Intended for healthcare professionals

Letters

Chaperones for genital examination

BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7219.1266 (Published 06 November 1999) Cite this as: BMJ 1999;319:1266

Chaperones should always be present

  1. Michael Croft, general medical practitioner
  1. West Herts Community NHS Trust PMS Pilot, Gateways Surgery, Shenley, Hertfordshire WD7 9LL 106750.317{at}compuserve.com
  2. The Doctors' House, Marlow, Buckinghamshire SL7 1DN
  3. Ella Gordon Unit, St Mary's Hospital, Portsmouth PO3 6AF
  4. North Mersey Community NHS Trust, Liverpool L2 5SF

    EDITOR—Bignell states in his editorial that “it is difficult not to proceed with a clinically indicated examination if the patient declines a chaperone, providing the physician feels comfortable in this situation.”1 I would say that this reads in much the same way as “it is difficult not to proceed with sexual intercourse if the man declines to use a condom, providing the woman feels comfortable in this situation.” The analogy is valid, I believe, as sexually transmitted disease (including HIV infection and unwanted pregnancy) carries much the same mortality as allegations of sexual assault, to patient and doctor respectively, however comfortable they may feel at the time.

    If clinical governance and risk management are to mean anything it surely must be that entirely preventable disasters such as allegations of sexual assault, exclusively associated with the performance of intimate but unchaperoned examinations, are consigned to history This should be done by a corporate policy that requires all intimate examinations to be carried out in the presence of a chaperone of the appropriate sex, unless exceptional circumstances prevail. Individual patients might not like this, but the safety of healthcare workers should not be subservient to patients' whims.

    References

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    We should offer a chaperone but not inflict one

    1. James Morrow, general practitioner (james{at}marlowdocs.demon.co.uk)
    1. West Herts Community NHS Trust PMS Pilot, Gateways Surgery, Shenley, Hertfordshire WD7 9LL 106750.317{at}compuserve.com
    2. The Doctors' House, Marlow, Buckinghamshire SL7 1DN
    3. Ella Gordon Unit, St Mary's Hospital, Portsmouth PO3 6AF
    4. North Mersey Community NHS Trust, Liverpool L2 5SF

      EDITOR—“For medicolegal reasons a third party should always be present during genital examination” is an unfortunate comment in an otherwise useful and balanced editorial.1 Such bald statements have a tendency to be quoted as established good practice by the uninformed.

      Whether a consultation takes place at home, in a general practice surgery, or at an outpatient clinic, the fundamental right of all patients (of either sex or any sexuality) is to maintain their autonomy and to make informed decisions for themselves. This must extend to the presence or absence of a chaperone, and we should respect their wishes.

      The offer of a chaperone is generally appropriate, although—particularly in general practice—it can offend some patients, who interpret it as a lack of trust in them by their doctor. When made, the offer of a chaperone must be exactly that—a genuine offer and not an unwanted imposition of a spectator for an already potentially sensitive consultation. Patients have a right to a professional examination without an uninvolved third party being present.

      Let us not submerge our professionalism in a rising tide of neurotic guidelines. Patient choice and rights must not be subservient to medicolegal paranoia. We should offer chaperones but not make them compulsory.

      References

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      Presence of chaperone may interfere with doctor-patient relationship

      1. Sarah Randall, consultant community gynaecologist,
      2. Anne Webb, consultant in family planning and reproductive health care (awebb{at}westkirby1.freeserve.co.uk),
      3. Meera Kishen, consultant in family planning and reproductive health care
      1. West Herts Community NHS Trust PMS Pilot, Gateways Surgery, Shenley, Hertfordshire WD7 9LL 106750.317{at}compuserve.com
      2. The Doctors' House, Marlow, Buckinghamshire SL7 1DN
      3. Ella Gordon Unit, St Mary's Hospital, Portsmouth PO3 6AF
      4. North Mersey Community NHS Trust, Liverpool L2 5SF

        EDITOR—After publication of a document on intimate examinations by the Royal College of Obstetricians and Gynaecologists,1 the Faculty of Family Planning and Reproductive Health Care considered important issues specific to its own discipline and subsequently issued guidance.2 Some of these issues have not been completely addressed by Torrence et al's study on the use of chaperones in genitourinary medicine3 or the accompanying editorial.4

        In gynaecology and genitourinary medicine a chaperone is usually used when the clinician and client are of different sexes. Most staff and clients in family planning clinics, however, are women, and we find that most clients do not expect or wish to have a chaperone. Clinics may have only two or three clinical staff present at any time, all of whom are usually seeing clients; in addition, many sessions are held in the evening, when other staff, who could have acted as chaperones, have left. Nurses are increasingly developing their own roles, working alone in nurse led clinics, where there is no one to act as a chaperone.

        This reinforces Torrence et al's comments that many clinics would not normally have sufficient appropriate staff to be able to offer a chaperone for every intimate examination without considerably lengthening waiting times for clients. This, or the option of returning when a chaperone is present, may negate any postulated benefit that this practice may offer.

        Family planning clinics often offer other specialist services, including psychosexual counselling. A fundamental principle here is the observation of the doctor-patient relationship, and the genital examination is a part of the assessment. The presence of a third person, a chaperone, may unbalance the interview, and patients may be unable to articulate their innermost fears or fantasies in the presence of the third person.

        The Faculty of Family Planning and Reproductive Health Care therefore produced the following pragmatic guidance for staff:

        • All clients should be advised that they may ask for a chaperone to be present

        • The healthcare professional must believe that the intimate examination is necessary and will assist with the patient's care

        • If a trainee is to undertake the examination s/he will be supervised

        • The client must be treated with dignity and respect

        • An interpreter or advocate will be present if requested

        • Verbal consent must have been given after appropriate explanation.

        References

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