The question of whether or not to use the acupuncture points Ren-1(Hui Yin) and Du-1 (Chang Jiang) occasionally arises in many discussions between Chinese medicine practitioners.
The reason that these 2 points are so controversial is due to their sensitive anatomic location: Ren-1(Hui Yin) is located in the center of the perineum, the area between the lower opening of the vagina and the anus, and Du-1 (Chang Jiang) in the midpoint between the anus and the tip of the coccyx (the tailbone).
In general, one side of the discussion claims that these points are irreplaceable for treating certain pathologies, and the other side claims that the potential of harm by needling an intimate zone may be greater than its benefit.
Acupuncture in itself is an invasive method and when it's done in the genital region, along with the asymmetry in the relationship of therapist-patient, it can be compared to a gynecological examination. When I was taught about these points I already experienced my first bad experience in a gynecological examination that had left its mark on me. The link between the two was immediate, then it was clear to me from the beginning that just as I will not allow anyone to use these points on me, I will have to manage without them at my practice to avoid triggering patients with a history of sexual trauma or even being the cause of such a trauma.
However, as a student, doubting my experienced teachers and the classical texts was not an option, it started a few years later after I managed to treat a few dozens of women with chronic vulvar and vaginal pain successfully without any need for these particular acupuncture points.
We live in a post #metoo era: we know about body boundaries violations, sexual abuse, and that almost every woman has or will experience some form of sexual harassment.
Ancient China didn't know or care about what we know today, therefore in certain situations, even though these points exist and we have indications of how and when to use them, the question every Chinese medicine practitioner should ask before proceeding to needle or even suggest needling Ren-1(Hui Yin) and Du-1 (Chang Jiang) is: Do I Have the Right to Use Them?
My aim here is to first prevent women from having a negative or traumatic experience with acupuncture, but also to prevent decent fellow practitioners from unintentionally harming their patients when they act from their best intentions to help as they were taught by their teachers.
In this blog I will show that regulations of how to use these points cannot protect the patients or the practitioners. I will also show that there are other equally effective as well as safe and well-tolerated options. I suggest the classical texts should be reexamined from a modern point of view. Our success as practitioners is based on our knowledge and skill, but cannot be separated from the need to create a compassionate and safe environment for our patients to heal. I therefore believe we should deepen our understanding of the potential harm of these points and the understanding of the benefit of alternative points available to us.
To present this complicated issue clearly and professionally I’ve discussed it at length with two highly appreciated colleagues of mine:
The women's health expert: Annemarie Reilingh, a registered GZ-Haptotherapist, and a Holistic Pelvic Care™ Provider, additionally she teaches medical students how to perform a female friendly gynecological exam (GTW).
The Chinese medicine expert: my teacher Hila Yaffe and an investigator of classical Chinese medicine texts.
Part One - The Ethical & Legal Aspect:
In each of my articles, lectures, workshops, and private conversations, I mention and explain my objection to using the acupuncture points Ren-1(Hui Yin) and Du-1 (Chang Jiang) when treating chronic and acute vulvar and vaginal pain. In our conversation, Annemarie provided me with the accurate words to explain, convince, and prove that we might not want to use these points at all in any pathology.
She began with the already regulated laws in the Netherlands that exist following complaints about boundary violations, sexual abuse and/or confusion about intentions by healthcare providers, the two most important for this article are the complaint policy and informed consent¹:
Before any invasive and internal work, it is customary that the practitioner use an informed consent, a several components to ensure that the patient is adequately informed with the following to be able to make a decision:
What exactly is going to happen
Why is the practitioner doing that
What are the expected results?
What they cannot expect
What are the side effects?
What other options exist and what are their results
The patient gives her answer in writing not less than 24 hours after it was discussed, in this way she has time to think and discuss it with her partner, family, and/or friends. If any further questions arise they have to be discussed again with the health care provider before signing the consent, if she agrees she is always allowed to bring a chaperone.
Annemarie said, “as a practitioner, I feel that I always have to be able to explain and justify why I need to be in an intimate zone, are there ways that I can avoid this and maybe teach it to her in another part of the body?”
To answer the questions mentioned above, the practitioner must do thorough research to understand and know all aspects of the pathology in their area and other areas, to professionally and objectively weigh the harm against benefit, to see if it is best for the patient to get an invasive and intimate treatment or perhaps a method that they think would be less effective or with a slower healing process may actually be better.
A complaint policy
Every health care provider in the Netherlands is obliged to have professional insurance for complaints to assure that patients can be reimbursed in case of a damage. According to the Dutch law, as CAM providers, registered Chinese medicine practitioners are allowed to approach the genitals and needle the points Ren-1(Hui Yin) and Du-1(Chang Jiang) with a signed informed consent and obedience to the complaint insurance guidelines, but in case of a complaint, their professional insurance would probably not cover it even if they were highly professional, followed all the instructions without any sexual intention, because genital care is not reasonably expected by acupuncturists as it is by gynecologists or pelvic floor physiotherapists. In case their patient who gave her consent, at some point in her life for any reason feels violated because of this situation, the CAM practitioner would probably have to deal with this complaint and its results by themselves, unless they were cleared individually to be registered as invasive intimate care.
What about the rest of the world?
A quick google search revealed to me that guidelines for safe acupuncture of institutions such as the World Health Organization and a few Chinese medicine associations indicate the external genitals as one of the forbidden areas for using acupuncture techniques².
What’s happening during an intimate examination?
Annemarie explains that although in many cases intimate work might not be a problem, there is a considerable amount of women who experience it as invasive and find it difficult to speak up. Women often complain that it was fast, they did not have time to relax and catch a breath, they can experience tension and are unsure what to do if it hurts. Due to the intimate nature and position of the patient, women are not always aware of their experience at that moment. This can lead to confusion about the need and the intention of the intimate work, and they go home to process it in their own way.
Annemarie provides medical students clear guidance about fear, pain, and tension: how to recognize it and discuss it with patients when it comes up. In good examinations Annemarie expects that the woman is able to relax on the examination table, to prevent her from dissociate and inhabited her body, as it usually creates tension which is a culprit of many sexual issues in women, also, tension in the pelvic floor has a big part in many cases of vulvar and vaginal pain.
Relevant links of studies about the psychological aspect of pelvic examinations³.
Projection to acupuncture in the genitals:
“Only when I think about a needle in my perineum, ooh, I feel my pelvic contracts, no one is going to wake up in the morning and say: oh, I really feel like having my perineum punctured” says Annemarie apprehensively. At this point, I explain that according to other practitioners, with the right technique it shouldn't be painful, also, practitioners are using medical gloves and long needles to avoid direct contact, the woman is lying on her side covered with a sheet exposing only a small area and allowed to have a chaperone in the room.
Sounds highly professional, yet, we both immediately agree that there is no good way for it whether you are laying on your back with your legs open or laying on the side when someone is behind you focused on your perineum and palpating it to locate the point, such situation can easily make some women change their mind about the consent and feel violated.
Who makes the decision?
Asymmetry and hierarchy cannot be taken out of the situation, the patient assumes that the therapist is experienced in their pathology, therefore it is likely for a patient to choose a bad proposed option just because it was recommended by an expert, or a patient might be inclined to please the practitioner because of the asymmetry of the relationship.
Everyone thinks that their treatment is the best, but there are so many reasons for personal experience to be biased, therefore it can’t stand alone. In the same way, other’s personal experience is biased as well, but the patient should be informed that other health care providers claim that they can get good results without using the invasive approach. At home, after thinking about it and/or discussing it with someone else, the majority of patients would probably prefer the non-invasive approach, and if the therapist cannot provide it by themselves, they should refer to someone who can.
Practitioners should make sure that the choice is up to their patients and not up to them, and if there are other options then actually, there isn't anything to choose from. Other options don't have to be in the area or the experience of the practitioner, for that, before using an invasive approach they must do the research and find all existing possibilities.
Because of the high chances for women to feel violated during or after pelvic examination, in cases that an invasive treatment was chosen when there were alternative options, the indications and/or regulations of how to use these points are not relevant ethically and legally if eventually it would cause a sexual trauma because of the same reason: it could have been avoided.
Annemarie suggests that before recommending an invasive treatment, any practitioner should go through a personal process and understand why they want to treat women in their genitals, why they are so convinced that this is the only way, do they understand how vulnerable it is to work in this area, and recheck if they did enough research to understand the pathology and its treatments.
In the second part, Hila and I will present the classical and modern indications and contraindications of Ren-1(Hui Yin) and Du-1(Chang Jiang) with alternative safe and well-tolerated options.
¹Since the incidence of sexual violence is much higher in women I chose only writing about them, but according to the CDC, nearly 1 in 4 men experience sexual violence involving physical contact during his life, then the discussion should be about every person, any sex or gender (https://www.cdc.gov/injury/features/sexual-violence/index.html)
²WHO - world health organization: guidelines on basic training and safety in acupuncture 1999
ASAP Australian Society of acupuncture physiotherapists 2013 guidelines
The Acupuncture Society UK code of ethics:
Association of Acupuncturists of Alberta (Canada) guidelines
³psychological aspect of pelvic examinations: https://www.tandfonline.com/doi/full/10.3109/0167482X.2011.560692?src=recsys