It is not uncommon for complaints about medical practitioners
to allege improper or inappropriate remarks, insensitive examination, or improper touching. Regardless of the doctor’s intention, it is the patient’s perception of the doctor’s behaviour that may trigger a complaint.
The Medical Board of Australia’s Guidelines on sexual boundaries in the doctor-patient relationship1 recommend that doctors should discuss the value of a chaperone or support person being present during an examination if this will make the patient more comfortable. This involves considering the patient before you and being sensitive to their concerns.
When to use a chaperone
While many patients do not want a third person present during their examination, studies about patient preferences reveal2,3,4:
- Women are more likely than men to desire the presence of a chaperone.
- Most patients regard the offer of a chaperone as a sign of respect.
- Failure to offer the option of a chaperone removes choice from the patient and can reinforce perceptions of paternalism in the doctor-patient relationship.
- Patients are less likely to desire a chaperone if they consult their usual doctor.
- Most female teenagers want a third party present during an intimate examination, with a family member preferred.
- Female patients prefer a female nurse to act as a chaperone whereas men of all ages find the presence of a female nurse unwelcome.
The practice of medicine depends on trust and confidence between doctor and patient. Once trust and confidence have been established many doctors consider the routine presence of a chaperone unnecessary. Even so, it is good practice to offer to have a chaperone present when conducting an intimate examination on any patient.
When you are seeing the patient for the ﬁrst time or there has been insufﬁcient time to build up that trust and conﬁdence, the offer of a chaperone should be strongly considered.
Circumstances requiring particular caution
Various college guidelines and position papers5,6 recommend that an appropriate adult witness or chaperone should be present when examining children. In relation to young females (and young males) they should be encouraged to consent to a chaperone being present and if they decline the doctor should not proceed with the examination if uncomfortable with the situation.
Particular care should be taken when:
- A woman attends for the ﬁrst time with a problem requiring breast, anal, or genital examination.
- Conducting an intimate examination on any patient regardless of how long they have been your patient.
- A patient consults with you after hours and the practice is otherwise deserted.
- Conducting a medico-legal assessment on a person who is not a patient of the practice.
- The patient is intellectually, mentally, or physically impaired.
- A patient uses sexually explicit language, displays inappropriate feelings or exhibits sexualised behaviour.
- There is a history of sexual assault.
- The patient is from a non-English speaking background.
Communication and consent
Before examining a patient, a doctor should explain the nature of the examination or investigations required and obtain the patient’s consent before proceeding. This will assist in making the patient more comfortable and minimise the risk of the doctor’s actions being misinterpreted.
Once the explanation has been given and the patient understands what is involved, the offer of a chaperone may follow as a matter of course as part of the consent process:
e.g. Would you like to have the nurse present while I do this examination?
If the patient declines the offer, it should be noted in the patient’s medical record. The doctor should also make a note if a chaperone or support person is present and record their name.
Patients may complain about medico-legal assessments being conducted insensitively, roughly, or inaccurately. This is particularly so when the patient does not know the doctor, perceives the doctor as ‘working for the other side’, or when the purpose of the consultation is not adequately explained beforehand. A report that is adverse to the patient’s interests may also prompt a complaint.
Before conducting a medico-legal assessment, doctors should take care to explain their role, and the requirement of any examination. During the course of the examination it is important to continue to communicate with the patient. If the patient withdraws their consent while the examination is in progress, the doctor should cease the examination, and record the withdrawal of consent in the patient’s notes.
As with any other consultation a chaperone should be offered.
Who can act as a chaperone?
Arranging a chaperone can be difficult. The gender of the chaperone may be relevant and the use of untrained non-clinical staff such as receptionists is not recommended7. The RACGP position paper on the use of chaperones in general practice recommends that the chaperone be the same sex as the patient unless the patient requests otherwise and that the chaperone be trained. This recommendation mirrors the Medical Board of Australia’s Guidelines on sexual boundaries1 which state that if a doctor provides a chaperone, the chaperone must:
- be qualified e.g. a registered or enrolled nurse or appropriately trained so that the chaperone understands the support role they are performing on behalf of the patient;
- be of a gender approved by the patient or the patient’s support person such as a parent, carer, guardian or friend;
- respect the privacy and dignity of the patient.
If a patient’s friend or relative acts as a chaperone, care should be taken to maintain the patient’s privacy and dignity, as far as possible. The doctor should be careful not to reveal conﬁdential patient information in front of the chaperone. If a friend or relative acts as a chaperone ideally they should observe the examination.
In the UK the NHS Clinical Governance Support team has raised the possibility of virtual chaperones8. This involves the use of unmanned cameras and audio equipment to record consultations in place of having a third person act as chaperone. Any video or audio recording or monitoring of a consultation requires patient consent and the patient should be informed that the recording will form part of their medical record. As this method is not commonly used you should contact Avant before using this type of service.
What if a chaperone is not available?
If a patient requests a chaperone and a suitable person is not available, you may wish to offer to reschedule the appointment so that a chaperone can be arranged, or refer the patient to another doctor if they would feel more comfortable with a doctor who is of the same gender. If the consultation is deferred you should counsel the patient about the effect the delay may have on their health.
Remember, you have every right to refuse to conduct a non- urgent intimate examination unless you are satisﬁed with the arrangements.
Take home messages
- Chaperones are a useful way of avoiding spurious allegations of sexual misconduct.
- It is important to document all offers of a chaperone and the patient’s response, and if a chaperone is present, record their name in the medical record.
- Consider the patient before you and be sensitive to their possible need for a support person or chaperone. Be mindful of their age, gender, and ethnic background.
- Before examining a patient, always explain what you intend to do in detail, and the reason for it.
- Avoid performing intimate examinations when alone at a practice or in a patient’s residence.
- Both the doctor and patient have the right to insist on a suitable third person being present for intimate examinations.
- Medical Board of Australia Guidelines on sexual boundaries, 28 October 2011.
- Penn MA, Bourgnet CC. Patients’ attitudes regarding chaperones during physical examinations. J Fam Pract 1992;35:639-43.
- Whitford D. et al. Attitudes of patients towards the use of chaperones in primary care. British Journal of General Practice May 2001: 381-383.
- Teague R et al. The differing views of male and female patients toward chaperones for genital examinations in a sexual health setting. Sex Tran Dis 2007;34(12):1004-7.
- Royal Australian College of Physicians. Genital examination in girls and young women: a clinical practice guideline. August 2009.
- RACGP Position Paper: the use of chaperones in general practice. July 2007.
- Ooi C. When three is not a crowd. Medical Observer 23 August 2010.
- NHS Clinical Governance Support Team. Model Chaperone Framework. June 2005.
DISCLAIMER: This topic is not comprehensive and does not constitute legal advice. You should seek legal or other professional advice before relying on any content, and practice proper clinical decision making with regard to the individual circumstances. Avant is not responsible to you or anyone else for any loss suffered in connection with the use of this information. Information is only current at the date initially published.