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Few consultants would consider carrying out an intimate examination without a chaperone. Dr Sally Old, MDU medico-legal adviser, explains current best practice in the use of chaperones.
Chaperone is a decorous term, reminiscent of the propriety and mores of another age. In today's medical practice, though, the presence of an impartial chaperone during intimate examinations can provide both protection and reassurance for patient and doctor alike, and regardless of the gender of either.
The latest GMC guidance Intimate examinations and chaperones (2013) says that doctors should offer the patient the option of a chaperone wherever possible before conducting an intimate examination. The chaperone should usually be a trained health professional; friends or family members are not regarded as impartial. However, doctors should comply with 'a reasonable request' to have them present as well as a chaperone.
Guidance advocating chaperone use has also been published by other professional organisations, including the Faculty of Sexual and Reproductive Healthcare at the Royal College of Obstetricians and Gynaecologists and of course, the MDU.
A chaperone's principal responsibility is to protect patients from abuse. But they can also reassure or comfort patients during examinations that they might find embarrassing or distressing.
This is reflected in the criteria listed by the GMC which says that doctors must be satisfied that their chaperone will:
The presence of a chaperone during intimate examinations may also help protect doctors themselves from false allegations of abuse.
Even so, the MDU is aware of cases where doctors have been accused of unprofessional conduct or sexualised behaviour by patients despite the presence of a chaperone. For this reason, we strongly advise members to document both the presence of a chaperone and their identity (name and full job title rather than a generic phrase such as 'duty nurse') in the records, in line with the GMC's guidance.
If an accusation is made several years later and there is no record of who acted as chaperone during the examination, the likelihood of the doctor remembering the name of this crucial witness is slim.
Doctors routinely offer patients a chaperone before conducting an intimate examination but the circumstances in which a chaperone is required may extend beyond those which might conventionally be considered 'intimate' examinations, such as when the needs of the specific patient require it.
For example, for particularly vulnerable patients or those who have been the victims of abuse, it might be appropriate to offer a chaperone for other examinations too. The GMC says this could go beyond an examination of the genitalia, rectum or breasts to include "any examination where it is necessary to touch or even be close to a patient". In these circumstances, doctors will be expected to use their professional judgment about whether a chaperone should be offered, depending on the patient's previously expressed views and level of anxiety.
There may also be a misconception among some doctors that male patients do not require a chaperone. In fact, the gender of the doctor and the patient is irrelevant to whether a chaperone should be offered. The MDU's experience is that while most allegations of indecent assault are made by female patients against male doctors, this is not always the case and we have seen cases that involve other gender combinations.
A 2010 study canvassed the views of over 200 consultants from a range of specialties on the role of chaperones. All would request a chaperone when performing female intimate examinations, but when it came to male patients, 90% of genito-urinary doctors requested a chaperone compared with 39% of colorectal surgeons and only 28% of urologists.
The authors acknowledged previous studies which found male patients are less comfortable with the presence of a chaperone and suggested that the predominantly male consultants and male patients in urology may explain why a chaperone was considered unnecessary. However, as the report points out this is contrary to the GMC's view that doctors should give patients the option of having a chaperone present, whether or not they are the same gender as the patient. In short, the patient should have the opportunity to decide.
For many patients, the offer of a chaperone is a sign that their doctor respects them. But that response is not universal. Many are adamant that they do not want another person in the room while they are being examined. However, this can leave the doctor in an uncomfortable position, especially if the patient has behaved in a sexualised way.
The MDU is regularly asked whether doctors can refuse to conduct an intimate examination without a chaperone. In these situations, doctors should follow the GMC's guidance and explain why they would prefer a chaperone present. An alternative would be to refer the patient to a colleague who would be prepared to proceed without a chaperone but the patient's clinical needs must take precedence and this approach would not be appropriate if the delay would adversely affect the patient's health. If they go ahead with the examination without a chaperone, the doctor should make a note that one was offered but the patient declined.
The same option to delay non-urgent examinations applies if a patient wants a chaperone but no one is available, or they are simply unhappy with the choice, for example if they will only accept someone of the same gender. However, asking a patient to return another time could make them feel under pressure to proceed without a chaperone to avoid the inconvenience; cause an anxious patient distress; and perhaps prompt a complaint. This explains why it is preferable for trusts to publish a chaperone policy which covers these situations, helping to manage patients' expectations and encouraging them to make their wishes known at an early stage so it is easier to meet their needs.
Doctors can also help themselves by familiarising themselves with their trust's policy and working effectively with colleagues to ensure trained chaperones are available. For example, be aware that if your clinics frequently overrun into the evening, this could put a strain on the available chaperone cover. It would be advisable to make a note of patients' wishes when it comes to the presence of a chaperone so that it is easier to accommodate them should they need to return.
For many specialties, intimate examinations are part of day-to-day clinical practice but of course they are far from routine for patients, some of whom find them intrusive and upsetting. In spite of this, most people still trust doctors to examine them when they are at their most vulnerable. If they are to justify that faith, doctors must respect patients' right to request a chaperone but perhaps more importantly, treat each patient as an individual and heed their concerns.
A male ST4 trainee in obstetrics and gynaecology contacted the MDU for advice when a pregnant patient insisted on being examined by a female doctor, despite the offer of a chaperone. The doctor was unsure whether he had to agree to the patient's demands and was worried that this would mean an unacceptable delay in the patient's treatment as there were no female doctors available to treat her.
A patient does not have an absolute right to choose the characteristics of their doctor but in most cases, it is appropriate to accommodate a request for a practitioner of the same gender as the patient when this is possible. It might, however, also be appropriate to explain how practicable this might be for future care, particularly when urgent care might be required.
No examination should proceed without the consent of the patient. If there is an urgent clinical need for the examination and the patient does not wish to proceed even with a female chaperone, the GMC in Consent: patients and doctors making decisions together (2008) tells doctors that they should "explain [their] concerns clearly to the patient and outline the possible consequences of their decision" without putting pressure on them to accept this advice. For example, if it was felt there was a risk to the patient or an unborn child but no female doctor was available, the doctor should explain the possible consequences of any delay and carefully document the discussion.
More generally, it would be advisable for the hospital trust to inform patients in advance that the unit is staffed by a mixture of male and female staff and that chaperones will be provided where appropriate or when they wish. The trust could request that patients who will not accept the presence of a male doctor make their requirements known in advance and warn that there may be additional delay while waiting for a female doctor or other member of staff.
The patient's request has implications for resources and could put additional pressure on female colleagues. The doctor was therefore advised to raise the issue with the seniors in his department or his educational supervisor. The trust may already address this point in its chaperoning policy but if not, he could refer them to the MDU's response.
This is a fictional case compiled from actual cases in the MDU files.
This article originally appeared in the printed version of the April 2014 MDU journal entitled "Someone to watch over me"
This guidance was correct at publication . It is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.
All this is true, but it raises 2 questions that I have never seen properly addressed:-
Will it be made mandatory for Trusts to provide sufficient staff to chaperone? The current vogue for moving hospital sexual health services out into somewhere called "the community" relies on community services being seen as cheaper, but this is largely because we have very few HCAs, and our nurses have their own clinical work to do and are not available to run round the doctors. In a walk-in clinic at least half our consultations may need an intimate examination, if we needed a chaperone for every one we just could not cope with our present funding
If GPs employ their practice nurses to do cervical cytology, should they also employ a second nurse or an HCA to chaperone the nurse who is taking the specimens? Whose responsibility is it to make sure that this is done?
Lesley Bacon Consultant in Sexual and Reproductive Health, Lewisham, SE London
In my time as a Clinical Director for Obstetrics & Gynaecology I dealt with two complaints where Junior Doctors' careers have been saved by the presence of a trained nurse or midwife during the conduct of a vaginal examination. Now the Nursing hierarchy considers it infra dignitatem for such tasks to be delegated to nurses, though at the same time the nurse is able to multi-task (as only nurses can), listening to what is being said and reinforcing it to the patient who may question the nurse ahead of the doctor, answering telephone calls, helping with forms, all in all making the experience for the patient much more pleasant. The administrative hierarchy quickly jumped on board seeing an opportunity to save money by replacing the nurse with a "yellow pack" substitute who does not understand the examination and cannot help with the other tasks. Allowing the potential for careers to be sacrificed, making the consultation less multi-professional,team structured or patient friendly is allowing the pendulum to swing too far. I was once told that the only thing nurses were needed for in the outpatient clinic was to put on bandages, and they weren't needed in gynaecology!