Chaperoning adolescents: A bygone era or modern medical necessity?

The word ‘chaperone’ has many different connotations. To an adolescent, it may imply an adult who supervises at a school dance or a date. To a scientist, it may imply a protein that assists in the folding and unfolding of other structures. To a doctor, it is often unclear. The definition, roles and responsibilities of medical chaperones are not well defined in Canada. As it currently stands, there is no uniformity as to how and when medical chaperones should be used for general and/or intimate examinations of adolescents. This lack of guidance has led to confusion, and wide variation and inconsistencies in physicians’ practices (1).

Intimate examinations involving the genitalia and/or breasts are often embarrassing and uncomfortable for patients of all ages, but especially for adolescents who are going through rapid changes in body structure, as well as physiological, psychological and social functioning. What may be considered a routine examination to physicians and nurses may not be perceived the same way by patients. For adolescents who are preoccupied with their changing bodies, self-conscious about their appearance and longing for increased privacy, any examination in which we ask them to remove clothing can potentially cause distress. As physicians who provide care to adolescents, our role should be to relieve their distress and advocate for the delivery of developmentally sensitive and confidential care that respects their need for privacy.

While the use of social chaperones may be resisted and resented by young people, the use of medical chaperones may not. Few studies have investigated adolescents’ preferences regarding the use of medical chaperones. They have suggested that younger adolescents are more likely to prefer to be accompanied during intimate examinations, whereas older adolescents, particularly males, are more likely to prefer to be alone (2). Adolescents’ choice of chaperone may also be more reflective of their age and sex, rather than physician or nurse characteristics (2,3). More importantly, individual differences among adolescents of the same age are pronounced (2). Decisions regarding chaperone use in adolescents may, therefore, require addressing the individual needs of adolescents, without parents present, to determine their preferences.

While physicians and nurses should be trying to better understand why patients make the choices they do regarding chaperones, the options, if any, currently offered to patients depend on the practicalities of who is available and willing to chaperone, as well as physician or nurse preference. As one might expect, many factors such as sex, sexual orientation, medicolegal influences and comfort in providing care to adolescents are associated with a physician’s decision to use a chaperone (1). However, should physician discretion, rather than policy, dictate practice in the use of medical chaperones? Adolescents need to be examined in an atmosphere characterized by sensitivity to their feelings and needs, respect for privacy and dignity, and patient choice. These issues are not discretionary.

Things become more complicated, however, when health care professionals and the public become aware that a patient has been abused or a doctor falsely accused. At these times, the idea of a mandatory chaperone appears, to both the public and the medical profession, to be undeniably necessary. The unfortunate reality is that there will be health care professionals who abuse their position of trust. Without a chaperone present, there is no way of discerning who is telling the truth when accusations arise. Patients may even perceive an examination as abusive through their lack of understanding, inadequate explanation or mental health problems. The consequences of a false accusation are very serious because they can destroy a doctor or nurse’s reputation and, possibly, their livelihood.

Traditionally, female nurses have acted as chaperones when male doctors have performed gynecological examinations on female patients. Clearly, times have changed. Increasing numbers of women are entering medicine and many more nurses are now male. In addition, as nurses’ roles expand, many more will be conducting intimate examinations alone. In today’s health care system, the best person to act as a medical chaperone is not always clear.

Guidelines on the use of medical chaperones have been published in the United Kingdom (UK) and United States (US) (4–6). The General Medical Council (UK) advises that a chaperone be offered to all patients undergoing an “intimate exam”, one involving the breasts, genitalia or rectum, regardless of the sex of the patient or doctor (4). The American Academy of Pediatrics policy statement on chaperone use states that in some cases, either the patient, the parent, the paediatrician or some combination of these persons, may wish to have a chaperone present; however, there are a variety of circumstances, including those in which the patient requests confidentiality, that would render the presence of a chaperone problematic (5). The American Medical Association advises doctors in the US to establish policies in which patients are free to make a request for a chaperone in each health care setting and that this policy should be communicated to patients either by means of a well-displayed notice or preferably through a conversation initiated by a nurse or physician (6). The American Medical Association also recommends that an authorized health professional serve as a chaperone whenever possible (6). This is, however, an expensive use of resources. As such, physicians working in clinics or office settings without nurses may opt to use receptionists as chaperones rather than perform the examination alone. Some may argue that this is inappropriate because it is beyond the scope of a receptionist’s roles and responsibilities. Regardless of who acts as a chaperone, the person chaperoning must be made aware of and feel comfortable with their role, as well as respecting patient confidentiality.

In Canada, there are no national guidelines on the use of chaperones for children or adolescents. The standards of practice vary from province to province. The College of Physicians and Surgeons of Ontario (CPSO) states that although third parties are not mandatory, their presence during an intimate examination may contribute to both patient and physician comfort (7). The CPSO also advises that patients should be offered the option of having a third party present and, in cases where a physician is unable to provide such a person, he/she should inform the patient that they may bring in a person of their choosing with them (7). However, if the purpose of a chaperone is to protect both the patient and doctor, the choice of chaperone cannot lie solely in the hands of the patient or his/her family. This could actually put doctors at more risk and make them less able to defend themselves against false accusations. Ideally, the decision should involve input from both the patient and provider.

Canadian paediatricians need to develop clear national guidelines on the use of medical chaperones, not only to protect Canadian adolescents and their health care providers, but also to improve patient satisfaction and to help decrease confusion and variability in individual physicians’ practices. As an essential first step in this process, an attempt should be made to better understand the needs and wishes of adolescents along with the needs of their health care providers. The results of this two-armed needs assessment will help inform the development of guidelines outlining the definition, roles and responsibilities of chaperones, who should act as chaperones and when a chaperone is needed.

Clearly, the need for a chaperone is not specific to the nature of adolescence, but to the nature of the examination. However, adolescents have unique developmental needs and characteristics that warrant study of this issue in their population. This is both a patient and doctor safety concern that deserves our timely attention.