When is a person old enough to refuse treatment?

(Trigger warning for discussion of coercive medical care, rape analogy)

I am loving my outpatient pediatrics rotation. Really loving it. Even when they are snotty, crying, and uncooperative. I love it. I am a little scared of how much I love it. I don’t think I would waver from ob/gyn but…it’s tempting, I’m not going to lie.

One thing that would make it difficult for me to be a pediatrician is the difficult concept of informed consent to care, and autonomy of the patient, when it involves a pediatric patient. (I am really into informed consent and right of refusal even for practitioners.) It can be complicated enough when we’re talking about adults who are patients. With minors, it’s even more complicated.

I know that pediatrics is in its own even grayer area, since many children, especially very young ones, would refuse all sorts of diagnostic tests and care if it was up to them. Most kids don’t want vaccines. Or blood draws. There are plenty of kids who scream and cry if you want to look in their ears. Pediatrics would look a lot different if children were allowed to refuse.

There are cases where older children have refused care such as blood transfusions.

I saw a case recently that troubled me. My cousin Susan’s young daughter had symptoms of a urinary tract infection. (Details have been changed to protect privacy, as usual.) She had a fever and some sort of hesitancy or pain with urination that was hard for her to express because of her age. She also has a history of acute pyelonephritis with sepsis which required hospitalization, which is a pretty seriously complicated urinary tract infection (UTI). She was unable or unwilling to provide a urine sample. So, the practitioner decided to do a urinary catheterization so obtain a urine sample.

(Trigger warning here) It was a disturbing scene. It took two people to hold the screaming girl down, force open her legs, and the catheterization involved forcing an object into a structure in her vagina. She was whimpering and holding her vagina for a while after the procedure.

Sigh. I am not a medical professional yet. I fully understand why the medical practitioner wanted a urine sample to screen for bacteriuria. This practice is quite conscientious about not prescribing antibiotics when they aren’t necessary. Considering her history, she was definitely at risk for a complicated UTI. Waiting could have led to scarring of her kidneys, among other possible issues. Should she have been treated empirically? All of the antibiotics they could choose have side effects. A good clean catch from a catheter is ideal for a culture and sensitivity, for appropriate treatment. What if it was something else? Should they have sent her home with a urine collection bag taped to her? I don’t know. As I said, complicated. I was just disturbed by the fact she was offered a lollipop afterwards, as she sniffled and held her vagina. What kind of a message is this sending to this little girl? Does this, in some big picture way, contribute to acceptance of sexual assault, either by her in the future or by the witnesses?

Ugh. I am absolutely not questioning the ethics or the judgment of the practitioner in this case. It was obvious to me why she chose to catheterize the child. I am just saying I find it troubling, although justifiable.


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53 responses to “When is a person old enough to refuse treatment?

  1. Instead of forcing a traumatic procedure on someone so young, since she was symptomatic and a hx of complications, they should have just empirically treated with antibiotics.

    • MomTFH

      You know, I am tempted to agree. I am loathe to criticize medical treatment, however, since I am a student and I am not a licensed caregiver yet.

  2. Treating empirically was my thought as well.

    We did have to do a catheterization like this for a clean-catch sample on my eldest daughter once when she was young. However, she didn’t have the history of UTIs this girl did and her symptoms were much more inconclusive so I felt like it was needed. My daughter didn’t fight it like this but I hated every minute anyhow. And in the end, she didn’t have a UTI after all.

    But in a little girl like this, with a history like hers, who was reacting so badly to the procedure, it seems like it might have been better to just treat empirically rather than traumatize her like that. I understand why they didn’t, but I think I might have erred on the side of discretion here.

    A lot easier to make those decisions in theory than in practice, though.

  3. This is disturbing, and I think the doctors should balance the risks of the procedure (in addition to the rape-like actions required to perform it, it seems that performing a catheterization on an unwilling girl could have physical ramifications, as the girl defensively fights and moves away from her attackers, um, health-care providers — struggling could complicate the process I would think) with the benefits of knowing for sure what type of antibiotic to use. After all, wasn’t the whole point of having the catheterization to provide the best care with the least side effects? How is the “side effect” of a little girl being medically raped completely ignored as inconsequential? What if she feels like a rape victim, as though she were molested or sexually assaulted? Children who are sexually assaulted often have life-long problems as a result. What benefit of the “right” antibiotic overshadows that huge problem?

    No, I think there had to be a better way. Surely she could have been talked to more, or treated on the “best guess” antibiotic, or had it done without so much trauma. This summer, I had to hold my nephew down so his mother could get a splinter out of his foot, and he screamed and struggled as if we were cutting off his toes. Finally, I just couldn’t take it any more, and called a time-out, and **started talking to him** and switched from a near strangle-hold on him, to more of a cuddle. I told him I was sorry that I had to hold him, and explained what we were doing, and yadi, yadi, yada, and whaddya know, he calmed down, and though he still didn’t *like* getting the splinter painfully removed from his foot, he went along with it, and did not require me to hold him down. Surely something like that could have been done for this little girl. Surely.

    • So when you are a licensed care provider, you think that your natural human instincts to loathe this scenario will magically disappear? Or you will magically understand that no matter how this girl is reacting, the licensed care provider is “doing the right thing?”

      Of course you don’t, I just think it’s funny how you couch your reaction in the name of some future epiphany that has not yet been reached. This smells bad all around. There has to be a better way to handle this situation, even if the catheter is necessary.

      I used to catheterize spina bifida kids (girls only- the boy counselors did the boys) when I was 14 at a camp for handicapped children. I had my own quick crash course in anatomy. Granted, these kids were used to it, and they didn’t even feel it happening, but it still felt invasive to me, and I used to talk a lot about what I was doing and tell stories while I was doing it to make it seem less so. It’s all in the approach, and surely, like Kathy above said, there has got to be a better, more humanizing, empathic way for the licensed care providers to get what they needed from that little girl.

      • MomTFH

        Yeah, I don’t think it will go away. I just have had it gently pointed out to me in the past that it is not really appropriate for me to criticize physicians on my blog. So, I try to couch my, um, issues with certain treatment decisions with qualifications.

  4. emjaybee

    This is a hard one, but yeah, it does seem like, when a child’s genitals are involved and pain is involved, and they are old enough to be talked to, that should be tried first and for longer.

    Failing that…would giving a local anesthetic work instead? She was afraid it would hurt, and it probably did, especially if she was already inflamed, yes?

    Medical practitioners are, when possible, in the business of decreasing pain; fear increases pain; therefore, learning how to decrease or eliminate fear seems like it should be part of medical practice, not just as a nice “extra” but as a basic skill. Surely what we know about counseling trauma victims, for example, could be used to train practitioners in defusing tense and painful situations.

  5. QoB

    I agree with other commenters about the benefits of talking to the child, even if she was a toddler, about why this was necessary (if indeed it was, and I can’t speak with any medical authority either), how long it would take, etc. It’s not clear if this was attempted and if so, how long for.

    Also, do you generally use ‘vagina’ when ‘vulva’ is more appropriate? I know it’s common usage but it’s a little odd to see that on a med student blog.

    • MomTFH

      Yes, it was discussed with her, very gently. She was very young, however.

      And, the urethra is not part of the vulva. It is immediately above the vaginal opening. Urethra would be more accurate, not vulva, and vagina is more accurate than vulva. But, the point I was trying to get across was that, for a young girl, it was in the area of her (hopefully future) insertive sexual orifice.

      • Ethel

        Actually the exterior genitalia of a female is the vulva, the vagina is hidden within as is the urethra which sits below the clitoris. So, in fact, the urethra is smack in the middle between the clitoris and vagina which are all part of the vulva.

        Vulva is more accurate then vagina since we don’t see the vagina unless the legs are wide and the labia is spread, the vulva includes the whole bunch. Seriously, look up the definition – when we describe a woman’s genitals we talk about the outside not the birth canal unless specifically talking about the birth canal (vagina).

        • MomTFH

          I am confused about the hairsplitting on this topic. I have actually taught female reproductive anatomy. The urethra sits at the top of the vaginal orifice under the clitoris.

          Her legs and labia were spread. I was not discussing the outside of her genitalia.

          Here is one source on the topic. The urethra is in the vaginal vestibule.

          I am really not interested in turning this comment thread into an endless argument on what to call different parts of the female genitalia.

  6. Olivia

    As a parent, if the procedure was not immediately life threatening or damaging, I would have called it off. To me the risk of the antibiotics vs. the risk of real sexual trauma and/or lifelong distrust of medical professionls is a better option. When you are a doctor, would you want to risk that? How would you feel if forcing a procedure on a child meant that child cried and shook whenever zie came for a future appointment?

    My toddler has been held down to have an x-ray done a couple of times, but it only took her father to hold her and no one was touching her. Last night my daughter was protesting a diaper change so physically it felt unsafe to me. I decided to listen to her cries and respect that she didn’t want to be handled lik that at the moment. I feel like children’s trust can be broken so easily and early by people who “know what’s best”, we adults need to carefully weigh the risks and benefits of what we do them.

  7. I think that doctors (and a lot of other people as well) just get tunnel vision when it comes to things like this. Like my own story of my nephew — it’s not that I or his mother were being sadistic (in our view) or hard-nosed — we were just focused on the task at hand. For my part, I thought that it would just be a quick two-second thing to get the splinter out, if he held his foot still enough. It turns out it wasn’t (the wood was wet, so the splinter had to basically be scraped out, because it fragmented and practically dissolved when touched), but we had that one-track mind of, “the faster we do it, the quicker it will be over,” and without telling him what we were doing, really, we were just trying to do the best thing. But it turns out it wasn’t. And what would have been both better and faster, as well as less traumatic, was if he had been involved in the process and respected. I hope that when you’re a doctor, you will take this lesson with you always, and always be able to see people (whether you end up in pediatrics or OB or whatever) as *people* and not just *cases*; that this girl and others like her are first and foremost thinking, feeling individuals, and patients second. [I know it’s so easy to get in the zone, or get in a groove, where you’re just “doing your job” and you see your task at hand first, and the people second or not at all. I think back to when I worked at a pharmacy, and while we knew the people and were friendly, a lot of the time, it was just “the Glucophage” or “the Lopid” or “the Amoxil,” rather than Mr. Smith.] The world would be a lot better if we treated each other as we ought, as human beings, rather than as problems to be solved or ignored. [Preaching to myself, here. :-)]

    • Olivia

      The tunnel vision is such an acurate description for me, and a hard thing to overcome. I remember, when my babe was about 10 months old, struggling to pull a hair elastic out of her hair that was stuck. She was crying and trying to get away, and I called my husband to hold her. Afterward I had such a forehead slapping moment, “Why didn’t I just snip the elastic out? It’s only a few cents and not worth the struggle.” It was a real lesson to me to wake up and respect my daughter’s emotions.

  8. doctorjen

    This is really a very multilayered situation you have here. On the one hand, from a purely medical decision making point of view, it is really important to determine if this kid is having recurrent UTIs. If she is, she may well need further testing to determine cause, long term prophylactic antibiotics, maybe even a surgical procedure. If she is not, a cause for her symptoms needs to be determined and taken care of. While it seems like treating her with antibiotics “just in case” would be a good option, it only addresses this particular episode and doesn’t let you figure out the whole picture so you know what to do for her going forward. The doctor, knowing that, want to make an accurate diagnosis so that the child is treated correctly – this time, and to protect her future health.
    Second, is the issue of “consent.” In pediatrics, with young children who cannot properly understand the risks and benefits of a given procedure, test, medicine, we usually rely on parents to make decisions for their children, because of course, who better to be able to think about the child’s needs? Parents are trusted to act in the best interest of their children, unless there is a reason to suspect otherwise (and of course we could discuss for days when to suspect otherwise – when there’s abuse? when the parent just disagrees with a doctor?) In pediatrics, we talk, too, about the concept of “assent” where the child is old enough perhaps to understand enough to be able to say “ok go ahead” but not old enough to give true consent. This is often used in the research setting, for example, with things like enrolling children in clinical trials. I like to get assent from any child I can for anything I can, and I start with teeny babies in my practice doing what I can to gain trust and let the child participate in their decision making as much as possible. Parents laugh at me for saying to their six month olds “I’m going to check your ears, now, okay?” but in my practice, kids I’ve known from birth are rarely ever fearful of me, rarely ever cry or struggle during an exam, and usually by 3 or 4 are so used to being treated with respect and listened to, that they often can give me the entire history, and tell me what parts I need to examine! I think it’s vitally important to treat children as people, and respect their person as much as possible.
    Third, you have the issue of how best to perform an unpleasant, truly needed procedure, and how much struggling is okay? For example, every primary doc I know has had to briefly restrain a child to give a shot, or collect a strep culture, etc. Is that okay because the genitals aren’t involved? I’ve had kids that didn’t want me to look at them, let alone do any physical exam, and sometimes that really isn’t reasonable, and we assume if the child was old enough to understand, they would allow it, so we proceed as gently as possible over their protests.
    In a situation like this (or in a recent toddler I had with a large abscess that needed to be drained for example) another option is to do the procedure under anesthesia – but that has another big set of risks. We frequently catheterize adults without anesthesia, and we know it feels unpleasant for a while, but is generally well tolerated, and many folks (parents included) may well feel that the minor discomfort and fright from a procedure is a fair trade off to avoid the risks of anesthesia (which is scary by itself.) Also, in some areas anesthesia wouldn’t be available or practical – you need a urine specimen to make a decision now, not next thursday when the anesthesiologist has an opening.
    Sometimes you can make the situation better by explaining things, by moving slowly, talking softly, distracting, having parents be involved – and sometimes the child is too young or too frightened for any of that to help. I always, always tell a child what I’m doing and an age appropriate reason why, and always, if I’m doing a genital exam comment about how sometimes doctors need to do those kinds of things, and that mom is here to help protect him/her, and that it’s not ok for other people to look at/touch their private parts and they should always say no to anything that seems wrong to them and tell a parent right away (I know it’s a little hypocritical to be telling a child they can say no to other people, but not me – but I don’t want them to confuse a medical situation with other situations where they should be saying no.) I try to provide good pain relief whenever possible (making sure that abscess was really numb before opening it, for example) and whatever other soothing can be done (mom at child’s head talking softly to child, doing procedures in mom’s lap and arms instead of papoosing if at all possible, oral pain relief if appropriate/available)
    I’d like to say it’s possible to practice without ever traumatizing a child (or even an adult) but it isn’t true. We absolutely need to be sensitive to the patient’s experience always – ALWAYS, let me say it again. And I would never do something like this and minimize the child’s experience – I would always apologize for the necessity, acknowledge that they were physically hurt (same with shots, or any other procedure) and state briefly that why we needed to do it. And parents should absolutely be told every possible alternative, and exactly what to expect (and the child as well as much as they can understand) so they can truly make a decision. This is an area where sometimes it just sucks to be the doc – you don’t ever want to hurt someone, but sometimes there is a risk/benefit trade off that you just have to follow.
    You bring up a rape analogy in your OP, and it’s worth thinking about. Is there a difference between a procedure involving the genitals and an unpleasant procedure that doesn’t for very young children? I think there is (which is why I make a point of giving my speech to the child and parents about boundaries and telling parents and saying no, etc.) but I don’t know it kids always view it that way, at least early on. Pain is pain, to some extent – but when they get older there is definitely also the extra issue of embarrassment and discomfort from being exposed. I think you have to address it, and this is an area where letting the parents guide decision making might be helpful as to when they think for their particular child a certain procedure is just too traumatic.

    • MomTFH

      Thank you for your thoughtful and comprehensive reply.

    • Olivia

      I’m curious what you think about sedating a child who is extremely fearful and struggling?

      • MomTFH

        I think it can definitely be a reasonable solution, depending on the risk of the sedative, and the risks of doing the procedure versus not doing the procedure.

        • I was wondering the same thing, if the parents wanted to go forward with the collection, knowing that it could be very difficult, if a little sedation might have helped or been appropriate. Or maybe even some pain medication, if she’s refusing to voluntarily give a urine sample because it’s going to hurt? Not something I know much about, though.

      • danielle

        i had to be catheterized several times as a child and was always mildly sedated for the procedure (they called it making me “loosy goosey”, so very mild, not all the way out)
        they also would use topical anesthetic on my urethra so i wouldnt feel that initial pinch from the insertion.
        i do not remember ever having any negative reactions to my catheterizations using this method.
        i hope this practitioner reads these comments, though i am sure she was acting on what she felt was best, what she did was traumatic and WRONG. it is never ok to hold a screaming child down and force instruments into their “private” areas just to avoid giving abx unnecessarily. that child may now have life long issues with sex, health care providers, relationships and who knows what else. these types of things are not to be taken lightly.
        there are better ways to keep trauma to a minimum and i think some people lose perspective of how much their actions really can effect someone, especially a child.

  9. I can’t help but continue to think about this story, and came up with another question in the middle of the night: would it have been at all possible for her to have inserted the catheter herself (depending on age)? I’ve read of some midwives and doctors having women insert the speculum themselves for pelvic exams, because obviously, women can feel exactly what they are doing and can thus minimize the pain or discomfort that can come with the procedure. And I was wondering if something like that could have been done, to avoid holding her down and forcing the catheterization.

    • MomTFH

      I think that is a great suggestion. This girl was preschool age, however, so I don’t know if that would have been a possibility. I think trying that whenever possible, like your example with the speculum, is a good idea.

      • danielle

        i also wonder if she had really been told what would happen if she couldnt pee in a cup. at 4 i think she would be able to comprehend that if she could provide a urine sample she would avoid having someone stick something in her to get it.
        also, whats the harm in waiting for a few hours until there was no way to hold it in anymore?

  10. StorkStories

    Wow. This is an excellent topic for discussion.
    I can truly identify with this story as a nurse involved assisting with such procedures AND as a parent with my 3 yr old daughter needing a VCUG (Voiding Cystourethrogram) many times before diagnosing ureteral reflux. It is quite disturbing for many reasons. I think that as the medically knowledgeable parent, I was able to talk my daughter thru the procedure by explaining everything that was going to happen as it did. I was at her head and secured (like that wording better than “holding down”) her arms and torso, gently talking to her while another secured her legs and a third performed the cath. We used warm blankets on her thighs and a Novocaine gel..(small amt). There were two separate procedures for that which went as well as could be expected. She still cried out, I’m sure she still felt traumatized. I certainly did as the mother…. I hope she felt less so by our comfort techniques. Those two were done at my hospital where i knew all those involved.
    A third procedure was done at a large children’s hospital as part of a nuclear scan. Again I sat at her head explaining that this would be just like the other times etc etc.
    Only it wasn’t.
    The nurse doing the cath could not find her urethra and continued to probe and try while she screamed (not to mention contaminating the catheter!). I halted the procedure asking for a supervisor. I eventually insisted on gloving up and had do it myself on my own daughter so I could be sure it was done correctly and as gently as possible talking to her the whole time. I am angry today writing about it even though this was 19 years ago.
    We didn’t discuss pain management for infants and children or painful procedures much back then. There is a lot of research and recommendations about it now. I’m glad. Sedation is tricky with children because of many opposite reactions or dose related issues. I also feel it’s a viable option given the situation.
    I also had to assist an OB/GYN do a rape kit on 2 yo. about 10 years ago. UNREAL …. I know but true and horrible. It was obvious the poor child had been sexually assaulted. The doc had requested that it be done under anesthesia so the baby girl not feel ANYTHING or remember it and discussed all that with the mother. After the rape kit was collected, he had to a small repair. It was difficult for everyone in the room.
    The kit was positive and the assailant was convicted. (a relative)
    Sorry I don’t know if I really added much to your discussion, just shared my own stories. Thanks for listening 🙂

  11. I agree that something like this is upsetting (I witnessed the same thing on my peds rotation). It is hard to really form a solid opinion on it and other situations like this.

    I also know what you mean about wavering from OB/GYN. I have had such a hard time with the decision of what to do. I applied to a mix of OB and FM (I like FM because I can do both ob and peds!). I wish I would have done peds sometimes ha!

  12. Phledge

    I’m all for procedural sedation. Quite frankly, we use it for less traumatic encounters than this, and my instruction (theoretical, but valuable) has been to sedate any female child requiring a pelvic or extensive genital exam. I think the risks of sedation are far, far outweighed by the benefits in this situation.

    For what it’s worth, my cousin Susan’s daughter had a straddle injury requiring nothing more than a simple look and see, and the treating physician floated the idea of sedation. The 8-year old child said, “Nah, just don’t hurt me. And don’t stay down there too long. You have thirty seconds.”

  13. mommymichael

    I haven’t read all the above comments, but why was sedation not used? Or Versed at least?

  14. Katie

    I just came across this. I haven’t read all of the comments, but the original post was very, very triggering for me. I WAS that little girl. The things that were done to me have stuck with me my *entire* life. I can’t recall anyone ever asking if it was okay to touch me during a medical procedure, but I DO remember having six or seven nurses hold me down so I could be violated every 6 months. I DO remember having panic attacks at 4 or 5 years old whenever we went to my parents’ favorite restaurant (that just happened to be near the hospital that I was always at). I DO remember a regular office visit where the doctor got in my face and told me that I was a rotten little girl from screaming while they tried to insert a speculum. I also, very vividly, remember my parents just going along with it, no matter how upset they seemed, because some health care professional told them that it was NECESSARY.

    I bet they’d (my parents) rethink that in a heartbeat if they knew the long-term effects of their actions. I had severe kidney/urinary tract issues that were solved with surgery when I was 8 or 9. But that was 8 or 9 years of routinely having MY personal space violated, instruments/tubes/catheters forced in between MY legs while adults – the people that were supposedly trying to protect me. It took its toll. I’ll be 26 years old this year, am married, have two children, have been sexually assaulted (once in college and then directly after my second son’s birth by the OB that attended it). It’s still as fresh in my mind now as it was then.

  15. Todd

    We had a similar situation with my niece. We’ve always been very close and I love her like a daughter. Several yrs ago she and her dad were hit by drunk driver. Dad and drunk driver died, DN lived. She was only 6. Broken Humerus, broken Radius, four broken ribs, hemothorax. Surgery went okay but she cried alot when waking up (understandably)

    A day later she woke up after a intercostal nerve block numb but upset and crying. I picked her up to cuddle her and my partner saw dry blood on her gown. She said her privates hurt. When the nurse asked to take a look she got VERY upset. The more we tried to persuade her the more she panicked. She was clinging to me crying and begging us not them let them hurt her there again. The word ‘again’ was a red flag. After my sis gave consent DN was sedated. The nurse was surprised to find a tear in her hymen and blood around the catheter. She called a female urologist who said the torn hymen was from a catheter accidentally inserted into DN’s vagina. The catheter itself was too big and there was trauma to her urethra as well. She took it out and did diapers and EMLA cream.

    We feared she had been awake and possibly struggling during the cath. We asked around and found a nurse who told us everything. Due to fear of respiratory failure they had been cautious with DN’s anethesia and at the end of surgery she woke up to a tech breaking her hymen. She started crying and struggling. The tech ordered several nurses to restrain and pry apart the legs of my screaming and crying niece while he roughly forced the too big cath in and told her not to cry.

    We couldn’t believe it. How could he do that to her? I went to the desk with my partner and friend of the family and demanded to speak to the tech. When he appeared I began questioning him (rather agressively I admit) and I was not pleased with his attitude. He told us sometimes these things happen and we should be grateful they saved her. I started yelling near tears that it didn’t have to happen and he could have prevented it.

    He said “Urogenital trauma heals quickly. She probably won’t even remember. She’ll get over it.”

    My head was spinning, I was so mad I couldn’t even see. I don’t remember screaming “She’s gonna be scarred forever you F-ing pr*ck!!” just prior to punching him in the nose and getting a good kick into his ribs before my partner and friend pulled me away. I vaguely remember standing over the bleeding man and telling him if she suffered at all for what he did I’d sue him into the tenth layer of hell.

    She did suffer. She had nightmares about it, panicked at dr.’s visits and hated anyone touching her skin. Even me. 6 mos after the accident we fostered her because my sis had become an alcoholic and CPS took her. We immediately put her in psychotherapy and her therapist diagnosed her with PTSD. He later discovered the cath incident had traumatised her so much she needed counseling for sexual assault in addition to everything else. She felt like she had been raped. It became apparent when she freaked out after we brought her to the ER for a UTI. She was so nervous during the exam (big eyes, fast breathing, shaking) but she went along until he wanted to exaime her urethra and asked her to take her undies off. She launched herself off the table and into my arms crying “No! No!” Her hysteria became a panic attack so I took her to the hospital chapel and just held her for a long time. I remember looking down at my fragile traumatised little girl and wanting to bawl my eyes out.

    The monster who calls himself a medical professional essentially raped a 6 year old girl with a medical device. He blatantly broke the hyppocratic oath and senselessy violated my baby. There was no lawsuit. My sis was too overwhelmed by everything else and we couldn’t let a countersuit against me for assualt jeopardize getting custody.

    • MomTFH

      I am so sorry about your niece. It is such a shame when health care practitioners get desensitized about how serious some of these seemingly routine procedures actually are to patients.

      • joseph r. haag

        this is not a incident of a health care professional(???????????) becoming desensitized, but an incident of a medical professional(??????????) thinking they are God and can do no wrong. I read somewhere that some physicians think M.D. is short for medical deity. I shudder to think that there is a hospital around who would still employ such charlatans and bureaus who still license such trash. this guy was indeed fortunate this was not my niece he violated, for if it were, he would now be pushing up daisies in a cemetery.

    • A Canuck

      If I were her, I probably would have learned to really LOVE CRANBERRY JUICE, for I heard the stuff AVERTS and even CURES UTI’s and I am sure no one would have blamed me for loving that stuff, for it would have beat having to go through who knows what other sort of medical ordeal.

  16. Jennifer Z.

    I previously commented my experience of having procedures like this done to me at age two but asked to have it removed as I felt too vulnerable sharing so much personal info.

    To cover my case very quickly, I had vesicoureteral reflux (VUR) otherwise known as kidney/urinary reflux. It was corrected with surgery at age 2 and a half. I underwent several of these procedures, some I remember and some I don’t. Now that I’ve pieced everything together, I think the things I don’t remember are probably affecting me the most. I was re-triggered when I gave birth for the first time and I was treated extremely similarly by a CNM at the birth. Having early childhood trauma can be a risk factor for PTSD if the person experiences a secondary trauma, which is exactly what happened to me.

    I have a daughter now and she also has VUR (it is genetic). She just got her first unexplained fever and I had to fight for her to be sedated for her catheter. The doctor said no, that the risks were too high (and “death” is the only risk she gave me) until I suggested Nitrous Oxide. I had to wait 40 minutes for a Nitrous Oxide certified nurse to come on staff, but it was worth it as she was very relaxed and didn’t even seem to notice the procedure. She did fight the mask, but given the choice I would rather she fight a mask than a catheter. It also made the blood draw easier because Nitrous Oxide swells the veins. I think the nurses and doctors were won over because the nurses kept saying how smooth it went and then the doctor asked me to write a letter to the head of the ER asking that all nurses be certified in Nitrous Oxide so they can use it more often.

    I was upset later when I found this study: http://tropej.oxfordjournals.org/content/53/4/221.full which shows that using the clean catch method of urine collection for non-potty trained children is almost just as good using a catheter. I was not even given this choice in the ER, even waiting the 40 minutes for Nitrous Oxide. I now have sterile cups and wipes at home and will wait as long as it takes for a sample before bringing her into the ER. It seems doctors don’t offer this method because they want the immediate results of a catheter and are either unaware of the risk of trauma, or they don’t want to be inconvenienced to protect anyone from trauma. There is also the perceptions that parents don’t want to attempt this method – of course parents are not informed of the risks of trauma, and how many parents know before the catheter that their child will likely be held down kicking and screaming?

    The main thing I want to say though is that I have been reading around at discussion boards of parents with kids who have VUR. It is so horribly triggering to me, not only the experiences they describe (children screaming and crying – a room full of people holding them down – not wanting anyone to change their diaper or freaking out at the doctors office afterward), but also the attitudes the parents have about it. Most of them seem completely against sedation as they are convinced it is unsafe, even when shown this study that proves otherwise: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2443423/ They can not accept that a procedure such as a VCUG can be interpreted by the child as sexual abuse – they insist that since it is a medical procedure required for their health there is no way that the child could be traumatized by it – even when the child in question is under 3. They feel their child won’t remember it, that it is harder on them to watch than for their child to experience, or that their child is resilient and will get over it quickly.

    Since reading these parents attitudes, I have been researching and trying to find evidence that these procedures can cause trauma – short or long term. I can’t seem to find much of anything. I find people commenting to posts like this one and leaving their experiences, such as myself or Katie above, on various places around the internet. But so far I haven’t found any organized group of adults who were affected by this, or of adults trying to advocate for more sensitive care for children experiencing these procedures, or any studies showing the short or long term affects. I’m completely confused by this. When I look into childhood post traumatic stress disorder, invasive medical procedures is one of the things listed as a cause. But finding evidence for that seems impossible.

    If there is anyone reading this who knows of any research that shows a risk of trauma or of short or long term affects please let me know. If anyone knows of any groups that are advocating for better care for children, or that support adults that this happened to, please let me know. If you are an adult affected by these procedures, contact me if you want to discuss it.

    My email is mamaofoz @ gmail . com

  17. The thinking of the majority of patients

    I hate medical workers more and more virtually every time I read about them. It literally pisses me off to no end whenever I hear doctors and nurses voice their sadistic opinions on what they think is “right”. You doctors and nurses need to get the F*** off of your high horse. Have some f***ing SIMPLE respect for your patients. STOP abusing them they are human beings, in fact MUCH MORE-SO than YOU are even!!!!! (THEY STILL HAVE THEIR EMOTIONS INTACT). STOP traumatizing children!!!! You ever wonder why some people don’t visit the hospital as much as they “should”?? (times that amount by 100,000 and you should get the actual amount btw) It’s because you f***tards have the emotions of a robot. And what happened to this child, absolutely insane. It’s the equivalent to a police officer beating down a random 100% law-abiding citizen, after randomly telling them they are under arrest out of nowhere not explaining why, and not giving the citizen a chance to talk or question why (ask the officer if he thinks what he did was right, and what the f*** do you think he’ll say? something on the lines of what he did “had to be done”? sound familar??) Absolute insanity. You could have waited for a few g** damn hours and the poor girl would have urinated anyway. Whenever I hear of child abusers/molesters/rapist it makes me want to visit them with an axe and show them what it’s like when someone forces an unwanted act upon them. And I honestly have that same exact sick feeling right now. YOU SCAR CHILDREN PERMANENTELY BY DOING THINGS LIKE THIS. If you as doctors or nurses EVER think higher of yourselves than other people then you need to stop, wake the f*** up and realize how rediculous your mentality is. You attempt to fix physical health and completely disregard mental health CONSTANTLY when they are exactly the same to the patient! You need to go back to school and learn the basics on respect. 99% of doctors and nurses do. You know, I am willing to bet all of my money that the little girl thinks about what happened the majority of nights before she sleeps for a very long time. G** DAMN YOU F***ING DOCTORS MAKE ME SICK TO MY STOMACH. THE WAY YOU ACT LIKE STUBBORN BRATS. You think and say and act like you are always right! and scoff at anyone who questions you!!! then when you f*** up (notice: “when”) you claim you’re “only human”????? Bit of a contradiction, no??? It would surprise you (I’m sure) the amount of people who have my exact same outlook on the medical profession. I am NOT a rare case at ALL. All it takes is a simple google on the subject of patient respect to know so. Also it would surprise you to know how much of us know what you say when we are not there/conscious. Stop thinking you are always right because that is a physical impossibility. G** D***** Start respecting patients you arrogant m*********ers!!!!!!!!!!!!!!!! It’s simple!! What the f*** is wrong with you?! It’s simple human-to-human respect! F***!! Ughhhhhhhh you dumb f***s piss me and hundreds of thousands of other people off. Slap yourself in the face for me. Please. Thanks.

    p.s. you start by erasing the thought of you always being right in your mind.

    p.p.s. slap your self again a couple times. For all of those patients you disrespected through-out your career, please. Thank you. Respect your patients.

  18. When is a person old enough? Apparently never, according to the b**ches who attended me in post-op. They refused to remove it or call the doctor when I requested…instead ignored me wait three hours. I’m 64 years old and I also feel like I was raped, and I now hate doctors and nurses also. I can only imagine what the experience was like for that poor little girl. I hope the practitioner who raped her and the parent who allowed it burn in hell.

  19. This girl had the same experience as being gang raped; held down, undressed, legs spread, and things shoved in to her. Hopefully the doctor informed the parent that one of the side effects may be Post-traumatic stress disorder (PTSD). Did they make any arrangements for follow up psychiatric care?

    Let me turn the situation around: would it be ethical for a doctor to run a patient over with a car to try to diagnose a mental disorder let alone not provide any follow up care?????

    What person would disagree with the following statement; “It is my body and NO means NO”?

  20. wayne

    i swear if i even hear that dr.is forcing my little girls legs open and inserting any thing in her vagin, i would actualy end up in prison for brutaly killing someone. i bet that little girl fealt as if they were raping her and i never want my or any little girl to feel like that

  21. flyboy116

    Listen all you physicians, she should have been sedated. Stop thinking you can torture children and them get over it. You just instill in them the flee instinct that when they are old enough or strong enough no one will ever torture them again like that. When someone says stop, stop, even an adult. If not, get ready for legal action. The more of you who do this, the more prepared and determined patients get.

  22. Kamden

    The doctor and her mother basically raped her, psychologically speaking. Emperical treatments would’ve sufficed.

  23. HealthCare

    These doctors, with that extra effort, could of talked to the mother to get her child to pee in a cup. I would not be suprised if that horrific moment is forever engraved in her mind. I had an experience similar but not quite traumatic and I still remember 21 years later. I know the doctors are doing what they can, but they sometimes forget they are treating a human too, not just a body part.

  24. MomTFH

    I appreciate all the additional replies on this post. This is a troubling topic to me, and that’s why I felt and compelled to write about it. The American Academy of Pediatrics has an algorithm to help practitioners decide whether or not to obtain a catheter sample. In this case, this patient definitely qualified. Even if she was willing to provide a sample, clean catch samples are much less specific and sensitive.

    I am not trying to dismiss the fact that this is true trauma. These are complicated topics that warrant further discussion. I do not agree that the pediatricians in these cases are monsters, rapists or have no sense of empathy. I also do not think that most patients who are catheterized at this age will have long-lasting sexual trauma. But, I’m not an expert on sexual trauma. I’m not even an expert on medical ethics. I do know what it’s like to be a practitioner, and to have a standard of care that is problematic and which I am supposed to participate. The parents obviously plays an important role in this situation too, and can always refuse a catheterization. The article on this in UptoDate emphasizes how to present the risks and benefits to the parents when deciding how and when to obtain a sample. The parental attitude towards the idea of catheterization of the child is considered to be very important in this discussion.

    I don’t think many people would argue that children should have full autonomy and all of their health decisions. Again, a very difficult topic. If this child was not catheterize, but then was decided clinically to have pyelonephritis, what if she did not want IV treatment? Again, a difficult discussion.

    • jennicaz

      What about this article I posted above that shows that clean catch samples are only slightly less accurate than a catheter urine draw: http://tropej.oxfordjournals.org/content/53/4/221.full And for a potty trained child, which this was, it would not be a clean catch sample but a mid-stream sample, which are no less accurate than a catheter draw.

      I don’t think physicians and nurses are trying to be cruel and traumatize children, but at the same time, why are they not aware of the ample research showing that procedures such as these can cause trauma and how to minimize that trauma? Why wasn’t this child offered the things that the research shows can reduce trauma and panic in children during these procedures? Was she offered light sedation, such as versed or nitrous oxide? Was she allowed to sit up against a parent, with the parent’s arms around her, in a semi-sitting position instead of being pinned down on her back and held there by other adults (something shown to cause panic in children alone, without any procedure being involved). Was this child allowed ample time and counseling about giving a mid-stream sample? Was she treated with compassion and care by the medical staff before, during and after the procedure? Was there any distraction attempted during the procedure? Was a parent in constant physical contact with her? Was she given oinment to sooth her vulva afterward so she did not remain in pain? If these things were not done, why were they not done? Were the medical staff to rushed? Were they not aware of the ample research on preventing trauma? Did they not care? Did they think it didn’t matter because she would forget the experience anyway?

      And yes, a parent can always refuse a catheter urine draw. However, if you have a dehydrated non-potty trained child who is lethargic and has a fever, your options are limited, and not doing a catheter draw at that point could delay treatment for a kidney infection. Could medical staff maybe offer the option of a clean catch before this point? Or if a child is still hydrated enough to possible allow that to work? Why do they not offer sedation? Why do I as a parent seem to piss them off whenever I suggest we follow what the medical research shows to minimize trauma and panic in my child? And you know what happens when you inadvertently piss off the nurses? They become annoyed, rushed, and non-compassionate. And I wish they knew how vital they were to my child’s experience. I wish they knew that their attitudes alone can make or break an experience for my child. All of the procedures for my child where the nurses were caring and compassionate went okay, and the ones where the nurses were rushed and business like my child reacted to with great distress.

      I once asked a doctor how they plan to minimize the trauma my daughter may experience from the procedure. She shrugged and said, “we don’t… we will hold her down and hold her legs apart and she will scream and cry, but it will be quick”. That’s it, that is how they are trained to manage trauma in children. Why is that? Why are they not familiar with the literature? Why are they not offering me the clean catch option, the light sedation, etc.? Not one nurse has allowed me to sit behind my daughter and put her in a semi-sitting position as the literature advocates. Not one. The most I can do is put an arm under her head and hold her arms together with mine to ensure no one is pinning her to a table flat on her back. I’m truly perplexed by the lack of concern or knowledge about these issues among medical staff who treat these children every single day.

      Perhaps the amount of autonomy a child has over their own body is tricky in these situations to tease apart. However, it isn’t difficult to read the literature about how to prevent trauma in these kids and to utilize those tools. Why is that not being done?

  25. Q

    This happened to me as a child. It’s one of my few memories of that age and it’s been an incredibly traumatizing experience in my life. I’ve been mistreated a lot by medical professionals after that. I’ve been sexually assaulted multiple times. Once by a doctor. I don’t know if they’re linked, but that was a horrible experience and I am so angry at everyone who allowed it. I very much hope your child doesn’t experience this trauma.

    • Q

      Update, I’m in my 20s now and this happened when I was a young child (can’t remember my age at the time, I can remember the procedure but have no context clues as to when it happened). I’m now experiencing urinary incontinence, I don’t know if it’s related to the procedure in any way (something physical that somehow was aggravated? or just something psychosomatic), it’s absolutely constant. Not only is it embarrassing to be peeing all the time but it’s basically a constant reminder of what they did to me. It’s hell.

  26. As a child I was operated on for reflux at the age of 2. Due to this diagnosis I was REPEATEDLY subjected to catheterization for years. The scene was the same as described above: four to five nurses would pin me to the table, spread my legs, swab me with cold iodine as I whimpered and begged my mom not to let them do what I knew they were going to do, and then I was forcefully catheterize as my mother tried to “talk me through it.” This happened repeatedly for years, long after a clean. mid-stream catch would have been entirely possible. It happened because the urologist insisted it was the only way. After these episodes I, too, was given a lollipop. The kicker is, I never had UTI’s, I had bladder spasms. But just to “rule them out” I had to endure this over and over. Let me tell you the effects:
    Nightmares, flashbacks whenever I smelled rubbing alcohol or even heard a child crying in a grocery store, the belief that my parents were not my real parents but had kidnapped me and were trying to kill me, a HUGE sense of shame that still haunts me to this day. My husband doesn’t even know about these episodes and I refuse to discuss it with my mother. When my own daughter was diagnosed with the same thing, I allowed them to catheterize her and they tried over and over to find her urethra as her hysteria increased with each insertion. I finally stopped the procedure and went to Children’s Hospital but refused to let them catheterize her without sedation. I got a lot of resistance from the doctor there but insisted that sedation was the only way it was happening. My daughter was four and perfectly capable of peeing in a cup! There is absolutely NO reason for a child to be put through this and parents and health care professionals need to know the lasting effects of this procedure. It is NOT the same as a shot!

  27. Deine

    This is insanity. Powerful gang-raping vulnerable, “for her own good”. I so hope that after priests and media+politicians, doctors will be the next to be dragged through the dirt for child abuse.

  28. luxy

    These mengles should be jailed for torture, assault, child abuse.

    I victim of forced gyn exams too.

    As child and adult I was falsely accused, unjust punished, degraded helpless, beaten into false confessions, dependent, and all the religious leaders, doctors, unions, foodstamp office, mental health services, political parties, are empowering themselves, controlling us through fear, playing us against each other, none of them are fighting for my freedom health prosperity power. And some fighting against me.

    The story of that poor violated, tortured, little girl hurts my heart.

  29. Danielle

    As a 4 year old I received a 2 Voided Cystourethrograms due to reoccurring urinary tract infections. I am now 18 years old and suffer from Post Traumatic Stress Disorder (PTSD), anxiety, and depression. I remember vivid details from this procedure including being afraid, in pain, and being held down and having my legs forced open. Quickly after the procedures I began to act out and become destructive. My mother could not understand why and took me to see a child psychiatrist who diagnosed me with ADHD (neither the doctor or my mother even thought about the incident being a reason why I could have been acting out) and I was forced to take ADHD medications until I was in high school. The memories always haunted me but I still never spoke out about them until I was 17 years old. After 13 years of feelings helpless I finally came out to a therapist about what had happened and my feelings regarding the situation. Even though I go to therapy once a week, it is hard to forgive and forget about the situation. Simple things like going to the gynecologist or have sexual intercourse for me are always traumatizing events that drop me into a serious depression for about a week after. My therapist usually accompanies me to the Gynecologist just to get me through it emotionally but I still never feel safe. Now, I didn’t write all of this out as a sob story for you guys but merely a lesson. I don’t see a lot of stories or testimonies about this traumatic exam so I wanted to speak out as someone who has gone through this procedure. Even though this happened in 2001, I do believe that if the patient is showing distress that the appointment should be cancelled and they should reschedule for a later date so that they can talk about sedating the child. If I was a doctor and it was up to me I would use this as a LAST RESORT or for an EMERGENCY.

  30. Alan Dester

    The doctor and all others concerned should be sued for battery, rape and false imprisonment. they should also be reported to the medical council and struck off permanently

    • MomTFH

      This is not an inappropriate standard of care. It is actually the recommended management, and was done with the parent’s supervision. It’s a bit more complicated than that, unfortunately.

  31. Heather

    I was catheterized repeatedly as a child because of bladder reflux. The very first time, when I was 7, the male nurse accidentally inserted it into my vagina. I do believe it was an accident and I know that’s a very easy mistake to make. Yet I can’t erase the searing pain that left me screaming and sobbing. I was normally a very compliant child and never cried or struggled with having blood drawn or anything. I have struggled with the trauma from that incident for years. Gynecological exams are torture, and I recently found out I have a sexual dysfunction called vaginismus, which is essentially where your pelvic muscles immediately and involuntarily snap shut when a “foreign object” is headed their way (even if on a conscious level you want it). I couldn’t even put in tampons until I was in my 20’s. I remember crying hysterically with the same pain and fear when I tried. I’m by no means suggesting that nurse did anything unethical, yet the consequences for me were akin to those of people who were sexually assaulted as children. It’s hard for a 7-year-old to distinguish between the two. Thanks your article. It really struck a chord with me.

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