Chaperones and intimate physical examinations: what do male and female patients want?

Abstract

Introduction: Many studies of patients’ perception of a medical chaperone have focused on female patients; that of male patients are less well studied. Moreover, previous studies were largely based on patient populations in English-speaking countries. Therefore, this study was conducted to investigate the perception and attitude of male and female Chinese patients to the presence of a chaperone during an intimate physical examination.

Methods: A cross-sectional guided questionnaire survey was conducted on a convenient sample of 150 patients at a public teaching hospital in Hong Kong.

Results: Over 90% of the participants considered the presence of a chaperone appropriate during intimate physical examination, and 84% felt that doctors, irrespective of gender, should always request the presence of a chaperone. The most commonly cited reasons included the availability of an objective account should any legal issue arise, protection against sexual harassment, and to provide psychological support. This contrasted with the experience of those who had previously undergone an intimate physical examination of whom only 72.6% of women and 35.7% of men had reportedly been chaperoned. Among female participants, 75.0% preferred to be chaperoned during an intimate physical examination by a male doctor, and 28.6% would still prefer to be chaperoned when being examined by a female doctor. Among male participants, over 50% indicated no specific preference but a substantial minority reported a preference for chaperoned examination (21.2% for male doctor and 25.8% for female doctor).

Conclusions: Patients in Hong Kong have a high degree of acceptance and expectations about the role of a medical chaperone. Both female and male patients prefer such practice regardless of physician gender. Doctors are strongly encouraged to discuss the issue openly with their patients before they conduct any intimate physical examination.

Introduction

In this current era when personal privacy is highly regarded, it may seem counterintuitive for patients to prefer the presence of a third party during an intimate physical examination (IPE). The presence of a medical chaperone, however, may offer comfort and psychological support for patients in protecting them against indecent behaviour, and is now an established good practice.¹ Conversely, in an increasingly litigious society, a chaperone may serve as a witness to protect doctors against false allegations.² Usually IPEs involve per-rectal, genital, or breast examinations, but may also include physical contact with any other part of the patient's body.

The majority of reports about patients' perceptions of a medical chaperone have focused on female patients^{3 4 5 6 7}; those of male patients are less well studied.^{8 9 10} A potential discrepancy may exist between the two groups. Santen et al¹⁰ reported that in the US, a great majority of male patients (88%) did not care about the presence of a chaperone, while half of the female patients would prefer to be chaperoned when examined by a male physician, and a quarter when examined by a female doctor. Moreover, previous studies have been largely based on patient populations in English-speaking countries. It has been suggested that the presence of a chaperone is a ‘western concept' that may receive a different degree of emphasis or acceptance in other parts of the world.¹¹ To the best of our knowledge, there has been no related report on patients in Hong Kong. In this study, we investigated patients' attitudes towards and experiences with the presence of a medical chaperone, and in particular, the relevant impact of patient and physician gender.

Methods Study design

We conducted a cross-sectional questionnaire survey of patients waiting for their consultations at the Accident and Emergency Department and the surgical out-patient clinic of a public teaching hospital over a period of 2 weeks from late February to early March 2015. Participants were recruited irrespective of age, gender or ethnicity, but were excluded if they were under 18 years of age, or did not understand English, Cantonese, or Mandarin. Participants from the surgical out-patient clinic included both new and follow-up patients from various subspecialties. Informed patient consent and approval from the Institutional Review Board of our institution were obtained.

Survey instrument

The questionnaire, written in both English and Chinese, comprised eight questions on demographics, and 19 questions on previous experiences with IPE, preferences for the presence of a chaperone, influence of gender of the examining physician, and the underlying reasons for their preferences. Participants selected their answers from predetermined options. In this study, IPE was defined as breast, pelvic, genital, and/or per-rectal examination. This was explained to the participants at the beginning of the survey. Guidance on the survey was provided by an investigator if requested by the participant.

Statistical analyses

Data were analysed using the Statistical Package for the Social Sciences (Windows version 22.0; SPSS Inc, Chicago [IL], US). Descriptive analyses were performed on demographic data and participant responses. Patient ages were grouped into age ranges ([lesser than]40, 40-59, and [greater than or equal to]60) for analysis. The independent variables were patient gender and other demographic variables (eg age, education level). The dependent variables were preference for the examining doctor's gender, presence of a chaperone with a male examining doctor, gender of chaperone with a male examining doctor, presence of chaperone with a female examining doctor, and gender of chaperone with a female examining doctor. Bivariate analyses using the Chi squared test were performed to compare the various independent variables against the dependent variables. Other variables based on participant responses—such as reasons behind chaperone preferences, previous experience of IPE, and tendency for litigation if felt harassed—were analysed against other variables as appropriate. Statistical significance was set at a probability level of 0.05.

Results

Participant profile and demographics

Of a convenience sample of 183 patients, 33 declined to participate and 150 patients were recruited. Of these patients, 83 (55.3%) were from the Accident and Emergency Department and 67 (44.7%) were from surgical out-patient clinics. Recruitment was done in both locations during the mornings or afternoons of 23, 24 and 26 February, and 2 and 6 March 2015.

There were similar numbers of women (56.0%) and men (44.0%). Their mean age was 50 (range, 18-87) years. The majority (75.3%) had completed a secondary or higher level of education. Over half (53.3%) were non-religious, and approximately 40% were retired. The majority of men (63.6%, 42/66) and women (71.4%, 60/84) were married. Almost all participants (98.0%, n=147) declared themselves as heterosexual (Table 1).

Table 1. Demographic data of participants (n=150)

Perception of intimate physical examination and preference for physician gender

In addition to our definitions of IPE, significantly more women than men also found chest examination of the respiratory system to be intimate (44.0%, 37/84 women vs 13.6%, 9/66 men; P[lesser than]0.01). Among the entire sample, upper limb, lower limb, and abdominal examinations were also considered to be intimate by five (3.3%), 14 (9.3%), and 19 (12.7%) participants, respectively. Overall, 42 (50.0%) women preferred a female doctor for IPE; only one (1.2%) preferred a male doctor (Table 2). The only significant determining factor for women preferring a female doctor for IPE was the absence of prior experience of IPE (P=0.04); notable but non-significant determining factors included younger age (P=0.09) and being unmarried (P=0.10). For men, 42 (63.6%) participants did not have any preference for physician gender and 21 (31.8%) would prefer a male doctor (Table 2). No significant determining factors for men preferring either a male or female doctor for IPE were identified.

Table 2. Participants' preferences for physician gender and the presence of a chaperone during intimate physical examination

Previous experiences of intimate physical examination and general preferences for chaperoned examination

Of the 150 participants, 115 (76.7%) reported previous experience of IPE: 42 were men (63.6% of male participants) and 73 were women (86.9% of female participants). A large majority (90.7%, 136/150) of the participants considered the presence of a chaperone appropriate during IPE, and 84.0% (126/150) felt that doctors, irrespective of gender, should always ask if the patient would like a chaperone. This contrasted with the experience of those who had had previous IPE of whom only 72.6% (53/73) of women and 35.7% (15/42) of men reported having been chaperoned. For those whose previous IPE was unchaperoned, 75.0% (15/20) of women and 44.4% (12/27) of men would actually prefer to be chaperoned. Interestingly, participants with prior experience of IPE, irrespective of gender, were significantly more likely to want a chaperone when examined by a male doctor (57.4% with vs 28.6% without; P[lesser than]0.01) but not a female doctor (28.7% with vs 25.7% without; P=0.87) when compared with those with no such experience. Most participants (72.7%, 109/150) regarded health care workers as suitable chaperones, and 52.7% (79/150) would also consider a family member, and 20.0% (30/150) a friend to be appropriate.

The most commonly cited reasons for preferring a chaperone included the availability of an objective account should any legal issue arise (61.3%, 92/150), protection against sexual harassment by the doctor (48.0%, 72/150), and psychological support (43.3%, 65/150) [Fig a]. The most commonly cited reasons for not having a chaperone included embarrassment (34.7%, 52/150); significantly more men (43.9%, 29/66) than women (27.4%, 23/84) considered a chaperone's presence embarrassing (P=0.03). Furthermore, 26.0% of the participants (39/150) felt that the presence of a chaperone would undermine their privacy (Fig b).

Figure. Reasons (a) for and (b) against the presence of a chaperone during intimatephysical examination

Women's preferences for chaperoned intimate physical examination

The majority of women (75.0%, 63/84) would prefer a chaperone to be present when being examined by a male doctor, and 79.7% (55/69) of female respondents preferred that chaperone to be female (Table 2). Even when being examined by a female doctor, 28.6% (24/84) would still prefer to be chaperoned (Table 2). Women aged between 40 and 59 years were significantly more likely than other age-groups to prefer chaperoned IPE when examined by a female doctor (P=0.04). Other demographic factors—including education level, income, religion and marital status—were not significantly associated with any particular preferences.

Men's preferences for chaperoned intimate physical examination

More than half of the men had no specific preference, regardless of physician gender. There was, however, a proportion who would want to be chaperoned when examined by a male (21.2%, 14/66) or female (25.8%, 17/66) doctor (Table 2). Men who wished to be chaperoned when examined by a male doctor were significantly more likely to also prefer being chaperoned when examined by a female doctor (P[lesser than]0.01). Of note is that a great majority of the men who preferred chaperoned IPE when examined by a male doctor indicated that chaperones could provide an objective account should a legal issue arise (85.7%, 12/14). There were no significant differences in terms of demographic variables between the ‘no preference', ‘no chaperone', and ‘prefer chaperone' groups, regardless of the examining doctor's gender.

Discussion

Our results highlighted the different views of male and female subjects in this locality. The majority of our female patients would prefer to be chaperoned when examined by a male doctor, and previous experience of IPE appeared to enforce such a tendency. This finding is consistent with those from other countries.^{4 8 12} Interestingly, and somewhat unexpectedly, a substantial minority of women would still prefer to be chaperoned when examined by a female doctor. Another noteworthy finding was that male participants who preferred a chaperoned IPE by a male doctor would also hold a similar preference when examined by a female doctor, and that their most commonly cited reason was the availability of an objective account in case of medicolegal disputes. This was despite concerns about personal privacy and feelings of embarrassment.

Our findings compare well with the situation in the United Kingdom¹³ and Australia¹⁴ where the majority of patients were aware of and would prefer the practice. When compared with a similar study conducted at the Emergency Department in the US, however, we found that patients in Hong Kong were more likely to prefer chaperoned IPE when examined by a doctor of the opposite sex (male patient[-]female doctor: 25.8% vs 2-3%; female patient[-]male doctor: 75% vs 45-47%).³ Other studies found that physician gender had a variable impact on female patient's preference for a chaperone.¹⁰Our findings suggest a generally higher degree of acceptance of, if not expectation for, the presence of a medical chaperone in Hong Kong, although differences in study setting, subject profile, and study definitions of IPE limit the validity of such comparisons.

The reported experiences of participants who have had previous IPE indicate that their expectations have not been met on a number of occasions. Several reasons have been suggested for the inadequate use of chaperones including, inter alia, the shortage of nursing staff to act as chaperones,¹⁵ and a general lack of awareness.¹⁶ This is certainly an area for improvement in our health care setting. In this regard, it is important to note that some patients would also consider examinations of the abdomen and limbs to be intimate, and that chaperones may still be preferred even when the physician and patient are of the same gender. The Code of Professional Conduct issued by the Medical Council of Hong Kong states that ‘an intimate examination of a patient is recommended to be conducted in the presence of a chaperone to the knowledge of the patient'.¹⁷ ‘Intimate examination' is not defined and there is no advice about the impact of gender. The United Kingdom General Medical Council (GMC) guidelines nonetheless specify that IPE may include ‘any examination where it is necessary to touch or even be close to the patient', and the requirement for a chaperone should apply whether or not the patient and doctor are of the same or opposite gender.¹Challenging situations may arise when there is a shortage of staff or when the patient refuses the presence of a chaperone. The GMC have provided some detailed guidance.¹

Our study has several limitations. First, the number of participants was relatively small and our findings may not be readily generalisable, particularly outside the public hospital setting, where patients are likely to be more familiar with their doctor and have more control over which doctor sees and examines them. The convenient sampling method that we adopted may result in systematic bias, skewed results, and potentially suboptimal generalisability of our findings. Second, our definition of IPE encompassed a range of different examinations, and it might be possible that participants have different preferences regarding each type. Third, our cohort consisted of relatively few young subjects (only 15% were aged [lesser than]30 years) and this might have affected our ability to demonstrate any impact of age. Last, as to the reasons for participants' preferences, our questionnaire only provided a short list of options rather than an open question and this could have limited the range of responses. Future studies may focus on patient's preferences in specific settings (eg primary care) as well as physician's practice in order to inform and promote public and professional awareness in Hong Kong.

Conclusions

Patients in Hong Kong have a high degree of acceptance towards the presence of a medical chaperone. Both female and male patients prefer such practice regardless of physician gender although individual patients may value the practice differently. Doctors are strongly encouraged to discuss the issue openly with their patients and offer the presence of a chaperone prior to any IPE; an alternative would be to put up a sign asking patients to notify the doctor or other staff if they prefer the presence of a chaperone during IPE.

Declaration

All authors have disclosed no conflicts of interest.

References

1. General Medical Council. Good medical practice (2013). Available from: http://www.gmc-uk.org/guidance/good_medical_practice.asp. Accessed 27 Nov 2015.

2. Wai D, Katsaris M, Singhal R. Chaperones: are we protecting patients? Br J Gen Pract 2008;58:54-7.

3. Buchta RM. Adolescent females’ preferences regarding use of a chaperone during a pelvic examination. Observations from a private-practice setting. J Adolesc Health Care 1986;7:409-11.

4. Patton DD, Bodtke S, Homer RD. Patient perceptions of the need for chaperones during pelvic exams. Fam Med 1990;22:215-8.

5. Fiddes P, Scott A, Fletcher J, Glasier A. Attitudes towards pelvic examination and chaperones: a questionnaire survey of patients and providers. Contraception 2003;67:313-7.

6. Simanjuntak C, Cummings R, Chen MY, Williams H, Snow A, Fairley CK. What female patients feel about the offer of a chaperone by a male sexual health practitioner. Int J STD AIDS 2009;20:165-7.

7. Sinha S, De A, Jones N, Jones M, Williams RJ, Vaughan-Williams E. Patients’ attitude towards the use of a chaperone in breast examination. Ann R Coll Surg Engl 2009;91:46-9.

8. Penn MA, Bourguet CC. Patients’ attitudes regarding chaperones during physical examinations. J Fam Pract 1992;35:639-43.

9. Osmond MK, Copas AJ, Newey C, Edwards SG, Jungmann E, Mercey D. The use of chaperones for intimate examinations: the patient perspective based on an anonymous questionnaire. Int J STD AIDS 2007;18:667-71.

10. Santen SA, Seth N, Hemphill RR, Wrenn KD. Chaperones for rectal and genital examinations in the emergency department: what do patients and physicians want? South Med J 2008;101:24-8.

11. Van Hecke O, Jones K. The use of chaperones in general practice: Is this just a ‘Western’ concept? Med Sci Law 2015;55:278-83.

12. Teague R, Newton D, Fairley CK, et al. The differing views of male and female patients toward chaperones for genital examinations in a sexual health setting. Sex Transm Dis 2007;34:1004-7.

13. Pydah KL, Howard J. The awareness and use of chaperones by patients in an English general practice. J Med Ethics 2010;36:512-3.

14. Baber JA, Davies SC, Dayan LS. An extra pair of eyes: do patients want a chaperone when having an anogenital examination? Sex Health 2007;4:89-93.

15. Price DH, Tracy CS, Upshur RE. Chaperone use during intimate examinations in primary care: postal survey of family physicians. BMC Fam Pract 2005;6:52.

16. Vogel L. Chaperones: friend or foe, and to whom? CMAJ 2012;184:642-3.

17. Medical Council of Hong Kong. Code of Professional Conduct. 2009. Available from: http://www.mchk.org.hk/Code_of_Professional_Conduct_2009.pdf. Accessed 30 Aug 2015.