MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

We probably all heard about the horrific stories related to Larry Nassar who, on January 24, 2018, was sentenced to 40 to 175 years in a Michigan state prison after pleading guilty to the sexual assault of numerous minors and US gymnasts. But few of us, I think, had any idea that these stories also relate to alternative medicine. This is an excerpt from an article in the LOS ANGELES TIMES.

… McKayla Maroney, the Olympic gold medalist who says she was paid $1.25 million by the United States Olympic Committee and USA Gymnastics to stop her from speaking out, put it flatly: “Dr. Nassar was not a doctor.”

No wonder the survivors chose to crush that word. “Doctor” was Nassar’s supreme and founding lie. It notarized him as a professional pledged to heal, and launched his 20-year child-molestation spree, gaining him a sturdy disguise, a complicity network, access to victims and a savage sense of entitlement.

What allowed Nasser to use the honorific? In 1993, he received a doctorate in osteopathic medicine from Michigan State University. MSU, of course, went on to protect and pay Nassar, the almighty and trusted doctor, as a faculty member for 20 years. Lou Anna Simon, MSU’s president, resigned this week amid charges that the university covered for Nassar and enabled him. USA Gymnastics, where Nassar also passed as a doctor, is similarly accused of giving safe harbor to a known criminal, while hushing and deceiving his victims. Under pressure, the group announced this week that the entire USAG board would resign.

Osteopathic medicine focuses on the joints, muscles and spine. Historically, though, osteopathy — its original name — was closely associated with a set of esoteric massage styles that some researchers now consider ineffective or worse. For its part, MSU’s College of Osteopathic Medicine still teaches these unusual manipulations — a special “benefit” unique to osteopathic medicine — describing them as a form of “hands-on diagnosis and treatment.”

Some historical context: Andrew Taylor Still, the founder of osteopathy, wrote of his medical discoveries in 1897: “I could twist a man one way and cure flux … shake a child and stop scarlet fever … cure whooping cough in three days by a wring of the child’s neck.”

Modern osteopathic medicine uses none of these techniques to treat infections — or anything else. But the specter of violence and child abuse that Still conjured in his early writings continues to haunt the fringes of osteopathic medicine. These practices include intravaginal manipulation. Fisting. This was the “medical procedure” Nassar performed on so many young girls.

According to his victims, Nassar’s attention wasn’t on their hamstrings or ACLs; instead, he focused on their anuses, breasts and vaginas. In January 2017, one victim spelled it out in her complaint: “Nassar digitally penetrated Plaintiff Jane A. Doe’s vagina multiple times without prior notice and without gloves or lubricant.” Other victims describe Nassar’s forcing his “dry fingers” into their anuses and vaginas. The violent fisting was excruciating. “I’d want to scream,” said Kassie Powell, an MSU pole vaulter. As Amy Labadie, a gymnast, put it: “My vagina was sore during my competition because of this man.”

Then came the gaslighting. When the girls blew the whistle, Nassar and his enablers tirelessly reasserted his privileges as a doctor. “We were manipulated into believing that Mr. Nassar was healing us as any normal doctor is supposed to do,” Capua testified. Just last year, the American Osteopathic Assn. released a statement to MLive.com, the Michigan news service, saying that intravaginal manipulations are indeed an approved, if rare, osteopathic treatment for pelvic pain…

END OF EXCERPT

I feel sick and am speechless.

But before my detractors point it out: yes, such monserous transgressions do occur in conventional healthcare too. And no, I am not implying that all osteopaths are criminal perverts.

38 Responses to Larry Nassar – doctor of osteopathy (“intravaginal manipulations are an approved osteopathic treatment”)

  • So the American Osteopathic Association have confirmed that intravaginal manipulations are an approved osteopathic treatment for pelvic pain. To me this is astonishing and rather sinister. One would hope that this intrusive ‘treatment’ is based on sound evidence – if not, it is ethically abhorrent. The AOA say that vaginal manipulation treatment is ‘rare’. Really? Given that osteopaths are permitted to carry out this treatment, how can they or anyone else know how frequently osteopaths choose to employ it? This is all very worrying – and potentially explosive for the osteopathic ‘profession’.

  • Professor Ernst wrote: “But before my detractors point it out: yes, such monstrous transgressions do occur in conventional healthcare too”

    That is true, however chiropractors, for example, appear to have a high sexual transgression rate. According to a California survey in 2004, when compared to medical doctors, chiropractors are:

    • 2x more likely to be involved in malpractice
    • 9x more likely to be practicing fraud
    • 2x more likely to transgress sexual boundaries

    Ref http://www.patheos.com/blogs/unreasonablefaith/2009/04/7-things-you-need-to-know-about-chiropractic-therapy/ (see 7)

    Although internal procedures are not unknown in investigations and treatments for low back/coccyx pain https://www.coccyx.org/treatmen/manual.htm it would seem that patients are at risk of being abused by MSK practitioners, in some cases without the abuser ever being held to account:
    https://www.mirror.co.uk/tv/tv-news/susannah-constantine-claims-sinister-chiropractor-11455333

    • Happy New Year everyone.
      I refer to the article you reference.
      Specifically in regards to disciplinary charges, 60% of medical practitioners disciplined were for negligence and substance misuse whilst 67% of disciplined chiropractors was for fraud and sexual boundary issues.
      From my perspective, medical negligence and substance misuse are more of an immediate public safety concern compared to chiropractic fraud and sexual boundary issues even though no professional misconduct is acceptable.

      Regarding manipulation and non-surgical remodelling of the spine, osteopaths in the USA should leave these interventions to the experts, chiropractors and specially trained physiotherapists, for example, Moustafa and Diab PhD at Cairo University and Graham Linck, Doctor of Physical Therapy in Las Vegas. https://myvegaschiropractic.com/

      • Hi Mr. Epstein.

        Apropos fraud and unacceptable professional misconduct…
        You never answered why you said you were managing patient(s) acute abdominal pain?

        I was hoping you’d finally tell us when you reappeared last time but it seems like every time I ask, you vanish for a while. I think I have asked three times. Or was it four?

        Maybe now you can tell us your position on chiropractors taking on/diagnosing/pretending to treat patients with signs of potentially serious conditions?

        Do you use a rotary sander like the worlds best Houston chiropractor who claims to be able to treat hiatal hernia, which is a condition that predisposes to oesophageal cancer if not properly managed?

        https://youtu.be/8dg0xEU8A44?t=3m58s

    • @ Blue Wode

      Do you still think “Osteopaths in the US are mainstream – essentially medical doctors with an interest in evidence based manual interventions.”

      • AN Other asked me: Do you still think “Osteopaths in the US are mainstream – essentially medical doctors with an interest in evidence based manual interventions.”

        Most are, as far as I know, but I continue to be puzzled as to why they didn’t train as medical doctors at outset and then specialise in orthopaedic, rehabilitation, or sports medicine.

        With regard to Larry Nassar, it is a matter of some concern (if the Los Angeles Times article is accurate) that Michigan State University’s College of Osteopathic Medicine (from which Nassar graduated with a Doctorate in Osteopathic Medicine in 1993) still teaches “unusual manipulations” – including intravaginal manipulation – and that the American Osteopathic Association approves of it despite a dearth of evidence.

        It would be interesting to know the sexual transgression rate of Doctors of Osteopathy, bearing in mind that we already know that the rate for chiropractors appears to be twice as high as that of medical doctors. Physiotherapists too. Does anyone know?

      • From a quick Google there are ~1 million practising physicians in the USA and ~60,000 chiropractors. So the raw numbers in your link (1550 physicians, 260 chiros) work out at adverse actions for sexual misconduct involving 0.155% of physicians and 0.42% of chiros. So chiros are 2.6 times as likely as physicians to engage in sexual misconduct?

      • @DC
        I don’t know what point you are trying to make here or why.
        But these are very interesting data.
        Do you have any explanation to why adverse action reports (I assume that is the same as allegations?) of sexual misconduct are about four times more common among chiropractors than physicians?!

        • I wrot my comment before Frank’s appeared and did the arithmetic in my head using coffee and toasted brioche (the bread was finished) After entering the figures into Excel my corrected result is 3.28 times more.
          this is based on the very generous data from the American Association of Chiropractors of 60.000 active chiropractors. According to the US Bureau of Labor Statistics, approximately 44,400 chiropractors were actively practicing in the United States in 2012. About a third of those practiced only part-time. If we, again generously, estimate that all-in-all there are 40.000 full time chiropractic services being delivered, then the estimate would rise to 4.9%.
          So my first guestimate of 4 times more allegations of sexual misconduct being produced by chiropractic services than physicians is not so far off.

          If we expand our rather unscientific estimate, this reference says that on average, a physician sees 20 patients per day. A chiropractor sees anywhere from 20 to 50 patients a day according to this source. If we guess that the average is somewhere in between and a chiropractor on average sees 35 patients or 1.75 times more than the physicians, then the number of allegations would still be more than twice as common per patient than that of physicians.
          Then we give the chiropractors credit for the rather more intimate nature of the chiropractic contact and guess that it explains half of the events as non-warranted, the chiropractors would still be attracting more allegations of sexual misconduct than physicians 😉

          Please take the above musings with a grain of salt, but DC’s comment still falls flat, any which way you massage these numbers.
          I guess they do not teach basic epidemiology in chiro-school?

          • Björn…”…but DC’s comment still falls flat,…”

            I only provided another source of information so I gave no idea what comment you are referring to.

          • Another perspective?

            California is often cited as one of the more rigorous states in overseeing doctors. But, according to the medical board, very few sexual misconduct complaints are reported to the board in the first place, historically under 200 a year. Even fewer result in a formal accusation against a doctor. And when discipline is found to be warranted — typically in fewer than 20 cases a year — the board tends toward leniency, sometimes granting a few years of probation even in instances of severe misconduct, according to a KHN analysis of medical board records.

            https://www.medscape.com/viewarticle/906978?nlid=126850_2048&src=WNL_mdplsnews_181228_mscpedit_imed&uac=18894MK&spon=18&impID=1846363&faf=1#vp_1

          • @DC
            We had to intuitively make the inference that you were, in true chiro’ spirit, trying to argue that physicians draw many more accusations of sexual misconduct than chiropractors. Others of the ilk have tried to throw this dud before.
            If it was truly your intention, which you did not elucidate, to hammer yet another nail in chiropractic’s coffin by referring to this bewildering representation of facts , then you may be somewhat smarter than most members of said congregation. But the ingenuity, if true, fell short of calling your target 😉

            Well, this incriminating evidence should give you yet another reason to diss the derogatory denomination.

          • From what I’ve read, reported sexual misconduct appears to be more of an issue in chiropractic than within most other professions…at least based upon compared percentages as being reported to respective agencies.

  • Please make a link to:
    http://edzardernst.com/2014/01/visceral-manipulation-you-couldnt-make-it-up/

    In this post I wrote a lot of comments about intra vaginal and intra anal manual manipulations reinvented by Frech and Belgian “osteopaths”.

    Such intravaginal techniques were used officially in European medicine for a certain time in the 19th century to prevent hysteria and then they declared it as nonsense. The early American osteopathic manuals referred to such techniques only with a sentence as part of European medicine but didn’t describe them precisely. You might find such techniques in the books of Thure Brandt massage and the French Gynecologist Henri Stapfer.

    They are part of the CORE subject Visceral Manipulation of European/Commonwealth osteoathic manipulator’s trainings (see my comments on: http://edzardernst.com/2017/08/osteopathy-making-a-mockery-of-academia-and-evidence-based-healthcare/

    There was a quite similar case with several court trials in Germany like the Nassar case and the case proceeded to the highest court BGH.

  • I have notified the Chairman of the BMA and the BMA’s media department of this most important posting – urging they comment urgently.

    Quite why no UK media outlet seems to have got on to the fact that in UK terms Nassar was an ostepoath, not a doctor, represents egregious incompetence and shoddy journalism.

    Disgraceful practice, but also disgraceful reportage.

    The issue with osteopathy, and chiropractic, is that the practitioners have failed, or not wanted to qualify as regular regulated practitioners (the regulations being designed to protect patients) – and drift off into their own little world as ‘wannabe doctors’, lured by the prophet motive as much as the profit motive. More so in the US (the land of the ‘free to do as you will’), than the UK. But even here we are now seeing ‘integrated practitioners’ trying to insert their fingers into the medical pie. It really must stop.

  • a very sad aspect of this is that there ore no osteopaths coming forward stating that intra-vaginal manipulation is or is not a legitimate technique.

  • Yes it’s really sad that osteopaths are silent here. Probably it’s a rational -albeit unethical- stance: they cannot deny that IVM is part of osteo practice, since even the American Osteopathic Association has admitted this – not to mention osteopaths’ websites referring to the practice; and they can hardly be seen denying its effectiveness or utility (this diffidence being exacerbated by the reality that, unlike those in science-based medicine, people in the world of CAM are mostly highly reluctant to criticise any aspect whatsoever of their favoured creed). But they don’t want to audibly defend IVM either – that would be to draw increased attention to a practice that is at best implausible and unsupported by evidence, and at worst a form of sexual abuse.

    • KevS and Edzard Please note my comment above and the link to other posts of mine related to VM (visceral manipulation) and to osteopathy.

      As I am a qualified osteopathic manual practitioner and certified by the health department of The Kanton Bern Switzerland according to the Swiss laws and as I was tought by the French physical therapist and Commonwealth osteopathic manual practitioner Barral and by other “leading” French “osteopaths” in intravaginal and intranal techniques even at the BSO in Maidstone I said that intravaginal and intraanal manual manipulations according to those theories of VM are idiotic and bogus and a lot of the VM techniques have a risk to cause internal bleedings. There is no evidence to VM at all.

      There are some intranal and intravaginal palpation procedures related to the medical standard of clinical examination (e.g. prostate) but not for treatment like in “visceral osteopathy”.

      • @Osteopathie Praxis im Klinikum Karlsruhe

        Speaking of osteopathy and intravaginal manipulations.

        I came across a title of an osteopathic thesis that elicits a degree of discomfort in the context of this discussion.

        Can you explain what “MET treatment via pelvis of medial tibial stress syndrome”

        The dictionary says MET means “Motivational Enhancement Therapy”

        How can an osteopath treat a lower leg problem via the pelvis?? Is it possible this may entail some kind of genital or anal manipulation??

        • Björn Geir “can you explain …” I don’t know the cited thesis but MET means Muscle Energy Technique and this is just Sherrington 1 and Sherrington 2 which is not osteopathy at all but normal physical therapy. The European/Commonwealth osteopathic manipulators or the OMT departments in the US use the term MET instead.
          In functional disorders of the movement apparatus one has to examine and to consider local regional and global functional patterns.

          May be this thesis is about the functional unit “leg” including the whole functional unit from toes to lumbar?

          If the inner organs or the pelvic floor or gemelli or other muscles of the pelvis are considered to have influence and should be treated by pressing via intraanal or intravaginal touch onto the muscles or to manipulate the coxys with a pinch grip than you are right they learn it and they do.

          I consider this as b…sh… not necessary to do at all. VM must be stopped!!

          Besides a medical examination for gyn or urology there is no need to put an “osteopathic finger” intranal or intravaginal.

          • The techniques Sherrington 1 and 2 were invented by Sir Charles Scott Sherrington

            … and …

            The Nobel Prize in Physiology or Medicine was awarded jointly in 1932 to
            Sir Charles Scott Sherrington (1857-1952)
            and Edgar Douglas Adrian.

            … and …

            that’s not “osteopathy” although they renamed it into MET… so far to the background of the thesis mentioned above

  • Björn Geir said:

    How can an osteopath treat a lower leg problem via the pelvis??

    Pft. Don’t you doctors know anything?

  • As an allopathic physician and cardiologist for 25 years I thought that I had seen it all regarding quackery. Most physicians are bemused by outlandish claims proffered by those who present their training credentials as proof that they can relieve pain and suffering. But clearly as the Nasser case demonstrates there is a much darker side. Unsuspecting patients often don’t have the sophistication to discern good, evidenced-based care from snake oil salesmen. I take particular objection to those who hide their training in chiropractic or osteopathy by using the title “doctor” in front of their name rather than displaying their graduate degree. Everyone is a “doctor” now, pharmacists, nurses, physical therapists, and psychologists to name a few. I don’t begrudge those who do good work, stay inside their lanes, and make it clear to the public what their training is.

    The story of chiropractic needs little elaboration. Many offer treatments that at best cause no harm. Reading the above descriptions of “osteopathic manipulations” however makes me take pause. It is as if by using medical terminology legitimizes fake treatments. I find the worst offenders of the doctor title being the chiropractors. It’s hard to know if they use this prefix because they don’t want the public to know that they are a DC, or if they are frustrated non-physicians.

    On the other hand I have more severe criticism of the osteopaths. They too often avoid the suffix of DO on their communications, unless it suits their purpose. Even worse is the profession itself. The osteopathic schools still teach “treating the whole body”, and offer manipulation as part of their curriculum. The case of Michigan State School of Osteopathy and Nasser should shine light on this 19th century barbarism. I agree with one respondent above that the osteopathic professional societies have been deafeningly silent on the issue. Shame on them.

  • I am shocked.
    It was only after reading these posts that I did some more research (Wikipedia and the internet more generally), and now understand that in the US, a practitioner who has a DO IS regarded as a ‘physician’ – a ‘doctor’.

    I can find no evidence of the American Medical Association drawing attention to the fact that Nassar was an osteopath – presumably because they are all lumped together as a ‘medical profession’.

    In the UK there is only one standard of practitioner who is a ‘registered medical practitioner’ (‘doctor’, ‘physician’) – one who is registered by the GMC. Osteopaths are not.

    I have now read a number of web entries from the American Osteopathic Association and similar, and can see no reason why an intending student would want to do a DO course and not an MD course – unless a DO is perceived as being easier to achieve (which some suggest, but which is the elephant in the consulting room).
    Suggestions that DOs are more ‘holistic’ should be set aside as MDs can be as holistic as they like.

    If a DO is the ‘same’ as an MD, why don’t all US physicians use ‘MD’?
    Perhaps with the addition of ‘DipO’ if they gain a post-graduate qualification in osteopathy.
    (‘DO’ initially designated ‘Diploma in Osteopathy’ but seems to have metamorphosed to ‘Doctor of Osteopathy’.)
    If there is a difference, that difference should be made clear, or patients cannot give informed consent.
    As was the case for many of Nassar’s patients.

    Has anyone an explanation of why there are two sorts of physicians in the US?
    I re-iterate – a MD could, if they wished, learn osteopathic techniques as a post-grad. Perhaps some do.

  • I am a former Physical Therapist and a current D.O. practicing Emergency Medicine. Yes I am board certified and went to a well regarded residency program.
    I am fully aware that pelvic floor therapy can be found in both PT and Osteopathic practices.
    Do I find this type of therapy odd and nearly useless, YES. But I cannot be judgmental of the practice considering I have virtually no experience. I feel strongly that this should be an indictment of the man and not the profession. Furthermore there needs to be considerable evaluation of this type of therapy going forward.

  • Who’d sign up for this research? Just like most surgery it will go on traumatising people without any research.

  • I am a DO, I am board certified in family medicine and sports medicine. I studied in NY. The difference these days between DO and MD education are almost non-existent. In fact now we are moving to a combined credentialing and licensing practices. In my residency and fellowship (at a hospital system with dual accredited residency tracts), the only difference between my MD friends and myself/other DOs was that we were MUCH more comfortable with MSK medicine and physical exam of the MSK system, the MD students had spent maybe the equivalent of 6 months more time in the hospital during medical school (during the accumulated time we were in OMM lab learning PT/PMR/Ortho essentially) so they were more comfortable navigating the hospitals systems and structure for the first year when we were interns.

    That’s it. We all did the same on boards, we all have the same level of competence. the DOs were more likely to gravitate towards MSK stuff – sports, PMR etc. The “whole body” mentality may have set us apart in the old days – but MD and DO schools now focus on treating the patient as more than the sum of their parts in equal measure I think.

    Larry Nassar is a monster, plain and simple. IVM is an esoteric historical footnote; that’s it. That’s what we were taught. We learned the theory of it, but not a single one of my instructors thought there was any merit to it and we were told very clearly that it was a part of history, like psychiatrists treating hysteria with orgasm, or mercury for syphilis etc. No one was actually supposed to do it and it was never presented as a technique for actual use.

    Pelvic exams are important, rectal exams are important -but any muscle or joint you can manipulate from the inside of someone’s rectum you can get from the outside as well – and if I do need someone to train their pelvic muscles becuase of a sports problem; there are exercises for that – I’m not using my hands.

  • Ask women with vaginismus or interstitial cystitis like my wife if manual treatment helps with the pain. Just because Larry Nassar did something outlandish and unthinkable doesn’t discredit a treatment that works. The preclinical years as a medical student are the same, regardless of DO or MD, save for the OPP (Osteopathic Principles and Practice) that are taught to osteopathic students.

  • Edzard wrote on Friday 28 December 2018 at 10:23: “the question is: why are the figures so high? I had always related the answer to the fact that chiros [like most other SCAM practitioners] learn no or very little about ethics in their schools.”

    Preston H. Long D.C, PhD., in his 2013 book, ‘Chiropractic Abuse: An Insider’s Lament’, devotes a chapter to chiropractic sexual misconduct. On pages 71-73 he writes the following:

    “In 2002, a newspaper reporter found that from 1998 through 2002, Oregon’s licensing boards received 30.5 sex-related complaints per 1,000 chiropractors and only 3 per 1,000 against medical doctors.[1] In other words, chiropractors were ten times as likely as medical doctors to have a sexual abuse complaint filed against them.
    -snip-
    While preparing this chapter, I asked several regulatory agencies, professional organizations, and malpractice companies about the incidence of sexual abuse by practitioners. None provided any data. But there are at least four reasons why I believe this is a bigger problem for chiropractors than for medical doctors: (a) medical schools are much more particular about whom they accept, (b) chiropractic treatment involves more ‘hands-on’ procedures that provide opportunities for intentional sexual boundary violations, (c) some chiropractors maintain cult-like relationships that may make patients more vulnerable to exploitation, and (d) the chiropractic profession tolerates certain techniques that can be tools for sexual abuse.
    -snip-
    The Federation of Chiropractic Licensing Boards includes sharing personal information, asking for personal favors, and seeking emotional support from patients on its list of ‘danger signs and behaviors to avoid’. [3]
    -snip-
    Some chiropractors believe that a painful condition of the coccyx (‘tailbone’) can be treated by inserting a finger into the patient’s anus and ‘adjusting’ (pulling on) the bone several times. This treatment has not been substantiated by scientific research and is not widely taught, but some regulatory agencies consider it within chiropractic’s proper scope. I am skeptical. In the hands of an unscrupulous chiropractor, coccygeal adjustment can become a tool for sexual abuse. Breast and vaginal examination are clearly outside of chiropractic’s scope. Patients who encounter either of these should terminate their relationship with the chiropractor and ask the licensing board to investigate.”

    Refs.
    1. Budnick N. Can’t touch this. Williamette Weelkly Online, Nov 27, 2002
    3. Ethics and practice. Federation of Chiropractic Licensing Boards Website, accessed Dec 2012.

    • You could also add (e) patients are less likely to report sexual misconduct by medical doctors.

      I wouldn’t take those numbers too seriously – they’re from the US. Patients are afraid of getting a “bad reputation” within the med community and losing whatever healthcare they have.

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