Chaperones

The General Medical Council’s Intimate examinations and chaperones (2013) provides guidance on how to examine patients and respect their dignity and privacy. Whilst intimate examinations may be an everyday occurrence for doctors, they are rarely so for a patient and the experience can often be embarrassing and even distressing. It is important for doctors to approach intimate examinations in the correct way, for both the dignity and care of the patient but also because a serious or persistent failure to follow GMC guidance will put your registration at risk. The practice team should also be familiar with the guidance to understand the need to facilitate provision of a chaperone when appropriate.

Basic considerations

Intimate examinations are likely to include those of the breasts, genitalia and rectum. However, it is important to be sensitive to what each individual patient may think of as intimate and could therefore also include any examination where it is necessary to touch or even be close up to the patient.

Before conducting the examination you should take time to explain why it is necessary, what it is likely to entail and how long it will last. Include details of any part of the examination that you anticipate could cause the patient discomfort or pain, and give the patient the time and opportunity to ask questions before seeking their consent. Ensure you record your discussion and consent. Do not proceed with an examination if you think that the patient has not fully understood your explanation due to a language barrier or for any other reason.

Use of a chaperone (an impartial observer) should be offered to the patient when conducting an intimate examination (even if you are the same gender). The criteria for the use of a chaperone is dictated by whether the examination is considered intimate, or likely to be considered intimate, by the patient. A chaperone should usually be a health professional and have been appropriately trained to be sensitive and respect the patient’s dignity and confidentiality. They should be able to reassure a patient showing signs of distress or discomfort, and be familiar with the procedures involved in a routine intimate examination. A chaperone should also be prepared to raise any concerns about a doctor’s behaviour or actions.

The chaperone should be present during the entirety of an examination. A patient should be given privacy to undress and dress, and kept covered as much as possible to maintain their dignity. Do not help the patient to remove clothing unless they have asked you to, or you have checked with them that they want you to help. During the examination if the patient asks you to stop at any point, you must do so.

Ensure you record any discussion about chaperones and the outcome in the patient’s medical record. If a chaperone is present, you should record that fact and make a note of their identity. Should the patient refuse the offer of chaperone you should record that the offer was made and declined. If either you or the patient do not want the examination to go ahead without a chaperone present or have reservations over the choice of chaperone, you may offer to delay the examination to a later date so long as this would not adversely affect the patient’s health.

Should you desire the presence of a chaperone but the patient refuses, you must explain clearly why, but ultimately the patient’s clinical need takes precedence. You may wish to consider referring the patient to a colleague who would be willing to examine them without a chaperone, so long as the delay will not adversely affect the patient’s health.

An intimate examination conducted in a patient’s home can be problematic if no chaperone is available. Should the situation be urgent and there is enough information from the history to indicate the need for hospital treatment in any event, it may be appropriate to defer the examination until after admission, taking care to explain the decision to the patient and referencing this in the referral letter. Otherwise, if the offer of a chaperone has been made and accepted for a non-urgent case, examination should not be undertaken until a chaperone is present.

Remote Consultations

Should you feel an examination is required during a remote consultation it is essential to consider to how best to safely arrange this. Faced with a patient who may require remote examination you should first discuss the limitations of the medium and consider whether it is best to defer the examination until the patient can attend face-to-face. If delaying the examination could potentially cause further harm to the patient or delay further investigation, you may decide a remote examination is appropriate. Whatever you decide, it is important to document your reasoning within the medical records. Further guidance is available here Using chaperones in remote consultations | MDDUS

Record keeping

In all cases where a chaperone has been offered, record in the patient’s notes whether it has been declined or accepted. Record the name and designation of the chaperone. If you have discomfort in continuing an examination without a chaperone, your reasons should be recorded, and the GMC suggests that these reasons should be discussed with the patient. In making alternative arrangements for an examination, record these fully and include a risk assessment of the patient’s condition.

Additional caution and considerations may be required with:

• patients with learning difficulties or mental health problems
• patients with a history of sexual abuse or assault
• children or adolescents
• patients with a known history of violent behaviour.

Common pitfalls

• Allegations that the GP inappropriately touched the patient after the chaperone had left the room. The chaperone should remain until the examination is fully completed and the patient has dressed (having been given privacy to do so).
• A patient declines the offer of a chaperone, but the GP feels uncomfortable undertaking the examination without one. Should a patient decline the use of a chaperone but you feel uncomfortable undertaking the examination, you can refer the patient to a colleague but any delay must not adversely affect care and treatment. The GMC are very clear about this – the patient’s needs must take precedence. It is important for the doctor to take time to understand why a patient is refusing a chaperone.
• A patient wants a friend or family member to act as a chaperone. A family member or friend cannot act as a chaperone, as they are not an impartial observer, but the GMC states that the doctor should comply with the request to have them present, along with a chaperone.
• A chaperone offered is not acceptable to the patient. It may be that they know the chaperone’s identity and don’t wish to offend – this can often be the case in a smaller or rural community. It can help to explore their reasons for not accepting the individual and, if appropriate, you can offer to delay the examination in order to find a suitable chaperone.
• Allegations of inappropriate comments during an intimate examination. Keep discussions and conversation relevant, especially during an intimate examination. Attempts to alleviate possible embarrassment through the use of humour, for example, can backfire, being misinterpreted and leading to complaints.
• Allegations of inappropriate behaviour whilst the chaperone was outside the curtain. The chaperone should be able to observe the procedure.

Key points

• Chaperones should act as an impartial observer, providing reassurance and assistance to the patient if they show signs of distress or discomfort, and to raise any concerns over doctor’s behaviour or actions.

Further guidance

• GMC. Intimate examinations and chaperones: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/intimate-examinations-and-chaperones
• MDDUS – Using chaperones in remote consultations: Using chaperones in remote consultations | MDDUS

MDDUS Training and CPS resources: Essential knowledge for chaperones in general practice – check list: www.mddus.com/training-and-cpd/training-for-members