Chaperones for genital examination

Never, sometimes, or always characterise the wide variation in individual doctors’ practice of using chaperones during genital and rectal examination. This variation is not confined to general practice.¹ In this week’s issue Torrance et al report a survey of chaperone policy in genitourinary medicine clinics (p 159).² Some clinics would appear to allow male doctors to examine female patients without the presence or offer of a chaperone. Such practice is surely beyond justification.

Some may argue that the use of chaperones is an area where physician discretion is more relevant than policy. Certainly not all patients choose to have a chaperone present during intimate examinations, and it may be difficult to provide chaperones in some settings. However, in this area of quality and clinical risk guidelines rather than discretion need to dictate practice.

What considerations should direct the use of chaperones? Several studies have sought patient preferences in primary and secondary healthcare settings,^3–7 although not in genitourinary medicine. The findings show remarkable consistency. Male and female patients differ markedly in their desire for a chaperone. Most women want the offer of a chaperone and feel uncomfortable asking for one if it is not offered. Most teenagers want a chaperone during intimate examinations, and a family member may be the preferred choice. Many women prefer having a third party present when the examining doctor is male, fewer if the examining doctor is female. For women a female nurse is generally the preferred choice as chaperone, would be accepted as a routine part of the clinical examination, and is generally viewed as having a positive supporting role during the examination. Men, however, particularly teenagers, find the presence of a female nurse as observer during genital examination unwelcome. Interestingly, a substantial proportion of patients in primary care didn’t mind if a chaperone was present or not,⁷ although this finding may reflect an older patient sample and familiar doctors.

These findings suggest some strong imperatives. Every woman having a genital or rectal examination should be offered a chaperone. Failure to offer one deprives patients of support they may want, and non-availability is an unacceptable excuse. It is unacceptable for a teenage woman to be alone with an unfamiliar male physician for genital examination. Moreover, it shouldn’t be assumed that a female nurse will be an acceptable chaperone for a man.

Genital examination is one area of medical practice where the sex of the patient and sex of the doctor have a significant influence on patient preferences. Clear differences exist in the preferences of male and female patients, and these can and should be accommodated. In genitourinary medicine it is difficult to argue against a female nurse routinely being present during the examination of women to support the patient and provide assistance to the examining doctor, regardless of the sex of the doctor. Assistance is rarely required in examination of male patients, who generally do not express a need for the support of a chaperone and are likely to feel embarrassed if one is present. Teenagers, however, are probably more apprehensive about genital examination than older patients. They are a major patient group in genitourinary medicine clinics, and their concerns need to be handled sensitively.

What other factors bear on chaperone use? Doctors have been accused of unprofessional conduct and sexual assault after unchaperoned examinations. Eight per cent of the women sampled by Webb and Opdahl reported experiences where doctors had conducted a gynaecological examination in a “less than professional manner.”⁴ Unprofessional behaviour involved overexposure of the woman’s body; inappropriate comments, gestures, or facial expressions; and being examined in an unusual position. Eight per cent of the lead physicians in genitourinary medicine clinics surveyed by Torrance et al were aware of allegations of unprofessional behaviour in their departments in the preceding five years.² For medicolegal protection therefore a third party should always be present during genital examination. It is, however, difficult not to proceed with a clinically indicated examination if the patient declines a chaperone, providing the physician feels comfortable in this situation. It would be prudent to document the patient’s decision for an unchaperoned examination. It should also be recognised that in a few consultations—for example, the assessment of sexual dysfunction—the introduction of a third party for the examination might negatively affect the doctor-patient relationship.

Variations and inconsistencies in doctors’ attitudes and practice in the use of chaperones have again been demonstrated. Examinations need to be conducted in an atmosphere characterised by sensitivity to patients’ feelings, care, support, and respect for privacy, dignity, and patient choice. Such qualities are not discretionary. Most female patients in genitourinary medicine expect, welcome, and receive support from the presence of a female nurse. Policy should acknowledge this as best practice. Whether chaperoning should be more frequent during male genital examination is less clear and needs further study. Action is needed where practice is suboptimal and clear policies need to be formulated. Patient preference, the need for assistance, and medicolegal considerations would seem to be the major determining factors.

Papers p 159