Are chaperones a hindrance to patient privacy?

Chaperones are increasingly recommended for routine use in Western medicine.  There are semi-official recommendations in both the UK and USA.   The AMA has long had this.

The rationale for using chaperones is twofold.  In theory their primary purpose is to protect, comfort and assist the patient.  In reality though, the usual purpose is to protect the physician against claims of sexual assault or harassment.

Preferably, chaperones should be real professionals, ideally nurses, female or male.  They should function as a patient advocate and their presence should reassure and comfort the patient.  Medical assistants are far less able to do this and should never be used without them being given special training.  Unfortunately, many offices use anyone who’s available at the moment.  This could be secretaries or clerks.  They could be experienced at their jobs or young girls just out of high school.  I have never seen data delineating just what type of personnel each office uses as chaperones and how they are trained.  This information is sorely needed to evaluate the topic.  It is also not clear what percentage of these chaperones are introduced as such.  It is probably more common to pass them off as “assistants.”

There is no doubt that male physicians feel that they need to offer chaperones when doing pelvic exams on women.  Over 80-90% use them in the US. For other intimate exams, ie breast, male genitalia and rectal, the percentage drops off.    Not surprisingly male physicians use chaperones at a much higher rate than women do for opposite gender patients.   Women physicians plan on using chaperones for male genital exams no more than 20% of the time.

The use of chaperones by male physicians is driven by legal concerns.  This is not as evident for women physicians.   They more often site patient comfort and their need for assistance with the exam.  In truth what is the real legal risk for women physicians?  Suits and complaints against male physicians are common enough.  State medical boards deal with them every year.  However complaints against female physicians are nearly unheard of.  Their risk is so low that their presence cannot be justified to protect the physician in my opinion.  Some women may use them not to protect themselves against suits, but to ease their own discomfort with the patient.

It’s clear however that many patients aren’t comfortable with the presence of chaperones for a variety of reasons.  Surprisingly nearly 50% of women don’t want chaperones present even when male physicians do a pelvic exam.  For men, the figure is 80 to over 90% refuse chaperones when given a choice in most studies.  That is hardly surprising when you consider that almost all chaperones are women.  Men are almost never hired as medical assistants in an office setting.  In part, that’s because they won’t accept the low pay scale, but many offices won’t hire men because they can’t readily be used as chaperones for women patients whereas female assistants are generally used with both men and women.

Few men feel that the presence of extra female eyes is reassuring.  One statistic that is not readily available in the US is the percentage of physicians who actually ask their patients whether they want a chaperone present.  If the chaperone’s  presence is driven by legal concerns, many doctors don’t ask  as they plan on using them anyway.  Some women physicians may use them because they feel at risk of inappropriate behavior from their male patients.  Patients turn down chaperones for many reasons.  The presence of extra people watching intimate exams increases the embarrassment factor for many patients.  There is also a loss of privacy that patients may resent.  It is harder to discuss intimate problems when strangers are present. Factors such as the familiarity of the patient and physician come into play here.  New patients are less comfortable in these situations.   In short, it must not be assumed that patients want chaperones present.

Adolescents are a special case as they are more prone to embarrassment than adults.  Boys are particularly subject to embarrassment when the physician (male or female) brings in a women chaperone to watch.  And the chaperones are almost always women.  Doctors do this again for legal reasons as they are concerned about charges of assault.  At least one state, Delaware now mandates the presence of chaperones during intimate exams given by pediatricians.  This law was passed after an egregious case of a pedophile pediatrician who assaulted many children over the years.  The case is not unique; Connecticut had a similar case and I’m sure there are others.  Delaware’s law is unusual in that it does state that same gender chaperones should be used ‘when practicable.’

However in the average office, it is never practicable.  Pediatricians’ offices almost never have any male employees.   I believe the law is an overreaction to a rare problem; bad cases make for bad law.   This law forces the presence of women as observers to watch the exams of older adolescent boys, many of whom would be severely embarrassed.  Using a parent, usually a mother, would not be much better in many families.  In short this law substitutes inflexible provisions for common sense.

In my opinion, sensible provisions for chaperone usage should include:

  1. Chaperones should be offered to all patients for intimate exams.
  2. They should always be voluntary.  The AMA regulations above make no mention of this allowing physicians to use them against the patients’ wishes.  This is wrong.  If the physician is worried about liability, he/she can have the patient sign a waiver.
  3. Chaperones should be professionals.  The use of secretaries and clerks is not acceptable.  Medical assistants, i.e. unlicensed ‘professionals’ need to be specially trained.
  4. Chaperones should not be present during history taking segments of the visit, only during the intimate exam.
  5. Chaperones should be introduced as such, not labeled as assistants when none are needed otherwise.
  6. Chaperones should be same gender as the patient.   This always happens for female patients and almost never for men.  Any exceptions should be made clear ahead of time with the patient given the option to refuse.

In summary I believe that the large majority of chaperones are used solely to protect the physician without the patients’ wishes being taken into account.  They are a hindrance to patient privacy and betray an underlying lack of trust on either the physicians’ or the patients’ side.  I believe they are greatly over used in our litigious society.

Joel Sherman is a cardiologist who blogs at Patient Modesty & Privacy Concerns.

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