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I did my first pelvic exam on Valentine's Day. And my first prostate exam. And my first testicular exam.

The genital exam was taught in an evening session where my classmates and I practiced on professional patients trained to teach us the necessary skills -- two hours for the female exam and another two for the male. As February 14 approached, I was filled with anxiety. This exam was by far my least favorite part of my own regular physicals, and I was unsure how I would respond now that I had assumed the physician's role.

I had spent the last one and a half years of our Patient-Doctor clinical skills course learning how to question patients about their sexual practices and concerns. I worked to become more comfortable with the issues we probed and the information we gleaned. I struggled to make my patients -- and myself -- feel comfortable discussing topics fraught with taboo. But now I crossed the physical boundary. It was no longer discussion in the abstract; I observed, examined, and palpated. My classmates also struggled with these issues. For the first time we had to extricate ourselves from our sexual associations, cultural values and personal beliefs about genitals and transform them into a purely clinical experience.

After watching a very clinical -- and very graphic -- video of the pelvic exam and practicing the exams on plastic male and female dummies in preparation for our teaching session, my classmate Scott said, "Will sex ever be the same for us again?" As we struggled to achieve clinical objectivity, sometimes the boundary felt blurred.

Our first exams were staggered to accommodate small student groups -- they had been running nightly sessions for months by the time my turn came. Those of us scheduled for later slots questioned classmates who had already gone through their training session. It really wasn't too bad, Masha reassured me. "You get so caught up in looking for the structures, you forget what you're actually looking at," she said. Her "patient" had bruises on her abdomen from students attempting a bimanual palpation of the ovaries. In focusing on the physical, some of my classmates lost sight of the person.

Andrea was thrilled with her first pelvic exam. She came into tutorial the following morning glowing from her experience. "I'm going to be a vagina doctor. I just know it. I'm going to be a vagina doctor!"

Despite my trepidation about the upcoming exam, Scott said he wasn't particularly concerned about the session. These patients were trained. They were knowledgeable about the exam, comfortable with being examined, and fully aware of our complete inexperience."The first exam doesn't bother me," he said. "It's the second that I'm worried about." He feared his first exam on a real patient.

When confronted with real patients, my classmates and I would be forced to grapple with our patients' perceptions of the exam and their issues concerning genitals, not to mention our own. Insecurities about our clinical inexperience would compound the struggle.

Patients are legitimately concerned that we physicians will fail in our attempt to extricate the sexual aspect of genitals from the clinical exam. In particular, women have become increasingly aware of the sexual harassment risks involved in the pelvic and breast exams. They routinely request female examiners, and in our lecture on these exams the physician recommended that we always perform them with a chaperone in the room. Even she, a woman, did not do them alone, unless she had already established a long-term relationship with the patient.

Yet the increasing desire for patients to protect their privacy frustrated some of my male classmates in their attempt to learn the female exam and gain clinical experience. The course description of the obstetrics-gynecology clinical rotation at one of the Harvard sites warned: "Many HCHP [Harvard Community Health Plan] patients strongly prefer a female physician and decline examinations by male students."

A fourth-year student complained, "If you're a guy, you just can't learn it. None of the patients will allow us to watch. If you ask first, they always say no. I didn't do a single gynecological exam and I watched only one birth during my entire ob-gyn rotation. So you have to be aggressive if you want to learn it," he said. Another male student disagreed. But he emphasized the importance of getting to know the patient, if possible, before starting the procedures.

If the boundaries between emotional and clinical, cultural and medical were difficult for us to draw at times, our patients also struggled to make the distinction. When entering the intensely private relationship of a physical exam, they sometimes blurred the distinction between a professional and personal relationship. Our patients flirted.

One of my classmates practiced a mental status exam on a thirty-five-year-old male patient. Clearly psychologically competent, the patient was bored with the simple exercises to determine memory, reasoning, and judgment. When my classmate pointed to her shoe and asked him to identify it, he said, "Nice foot, nice ankle, nice knees, nice thighs. Want me to go any higher?" She was taken aback.

"At the time I just sort of laughed it off. I didn't know what else to do. I sort of thought it was my fault, like maybe I hadn't set a formal enough tone. Maybe I was just too casual and jokey," she said.

An older male patient kept touching Renu's hair and brushing it back as she leaned over him with her ophthalmoscope to visualize the retina on the back surface of his eye. To do the exam correctly, the examiner had to be within inches of the patient. "You can come closer. I really don't mind," he told her.

"The worst part was that he clearly knew that I knew he was flirting with me. He was from another culture, and maybe that was more acceptable where he came from. But it was very uncomfortable. I didn't know what to do," she said.

My male patients often thought I, as a young, small woman, was cute. Some of the older men identified me with their granddaughters, and one patient even surprised me with a familial peck on the cheek as I left. But some of them used a distinctly more sexual tone. I preferred a slightly less formal tone in my patient relationships, but these attitudes made me uncomfortable. I never found a way to discourage this atmosphere from creeping into my patient experiences. I even accepted it because these men were often willing patients and didn't complain about the two-hour histories and physicals I subjected them to.

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