Intimate Examinations

Although the most common scenario is a female patient complaining about such an examination by a male doctor, care should be taken with all patients as well.

An intimate examination refers to an examination involving the genital, groin or anal region in any patient, and includes breasts in female patients.

Case history one

Dr Ocky was a GP whose work consisted mainly of pre-employment medical examinations. Ms Taylor, a 25 year old woman, attended him for a pre-employment medical for a position that involved a certain amount of physical work. Dr Ocky conducted his usual examination, which included a thorough examination of the patient’s chest, as she gave a history of asthma. He also conducted his usual examination of back flexion, which involved asking Ms Taylor to bend over in front of him. On this occasion Dr Ocky noted that Ms Taylor was wearing a G-string  and seemed a bit embarrassed. However this part of the examination was the final part, so he concluded the examination and provided his report.

A short time later Dr Ocky received a letter of complaint from Ms Taylor. She stated that:

‘I had no idea that I would need to remove my clothes for the pre-employment check. I was shocked and embarrassed that you asked me to remove my bra, and also when I had to bend over in front of you I nearly died of embarrassment. I have had pre-employment medicals in the past and the doctor has never asked me to take off my clothes, he has just poked his stethoscope down the front of my top’.

Dr Ocky contacted MDA National for assistance in replying to Ms Taylor’s letter. He considered her comments very seriously and was keen to avoid any future complaints of this nature. He was also surprised to learn that his colleagues conducted such examinations in a different way. Dr Ocky felt it was essential that he continue to examine his patients in the same way to do a thorough job and ensure that any physical problems were properly identified. However, he decided that in future when patients arrived for a pre-employment medical he would provide them with written information that included:

• the nature of the examination, including the fact that they would be required to strip down to their underwear, and remove their bra for a thorough examination of the lungs and heart; 
• modesty gowns were provided;
• a chaperone could be arranged; and
• if they were uncomfortable undergoing such an examination with a male doctor, they could rebook with his female colleague.

In his letter back to Ms Taylor, Dr Ocky apologised for her embarrassment, but outlined why the examination was conducted. He then informed her of the changes he was making to his practice as a result of her comments. He heard no further from Ms Taylor.

Case history two

Mr Young, aged 29 years, was referred by his GP to a rheumatologist, Dr Joint. Mr Young had a history of chronic back pain, which he attributed to a MVA some 5 years previously.

Mr Young attended his appointment with Dr Joint. He gave a history of pain and swelling of his right knee and ankle, stiffness and swelling of some of the joints of his fingers and very troublesome back pain radiating to his buttocks. His GP had been treating him with NSAIDs, which gave him some temporary relief, but the symptoms did not seem to be settling.

After taking a full history, Dr Joint instructed Mr Young to remove his clothing down to his underpants so he could perform the examination. Mr Young did not make any comment during the examination.

Dr Joint then told Mr Young that he was considering a number of possibilities that may be causing his continuing symptoms and he advised Mr Young to undertake some blood tests and further imaging and he would review him after those results were to hand.

Mr Young did not say much as Dr Joint outlined his treatment plan and then left.

A short time later, Dr Joint received a letter of complaint from Mr Young via the Medical Board. The complaint stated:

‘I was totally shocked when you examined my genitals. I found it a shameful and deeply embarrassing experience. You gave no explanation as to why you did it, and considering you are a rheumatologist and I had not told you about any symptoms in that area, it was a total surprise. I did not challenge you at the time, as I was so confused and embarrassed that I could not speak at all. The fondling of my genitals was not related to the presenting medical condition and was totally unnecessary. I am never coming back to see you and have asked my GP for a referral to another specialist’.

Dr Joint rang MDA National for advice on how to respond to the letter. He was very upset at receiving such a letter, especially as he considered that he had obtained a thorough history and performed a very thorough and appropriate examination. He had told the patient that he was going to examine his genitals, in his usual way.

The Medico-legal Adviser at MDA National assisted Dr Joint with his initial response. In this response, it was outlined that Dr Joint had advised Mr Young that he needed to perform a general, whole body examination of him to try and establish the cause of his joint problems. Dr Joint then proceeded with his examination in his usual systematic way, beginning with Mr Young’s back, then neck, limbs, joints, chest and abdomen. It was while he was examining the patient’s abdomen that he advised Mr Young that he needed to check ‘down there’. He felt that he had implicitly sought Mr Young’s permission in this process, and as Mr Young had not said anything, he had taken that as consent. Dr Joint had been considering the possibility of reactive arthritis and psoriasis when he had examined the genital area to check for balanitis and other rashes.

The Medical Board then wrote back to Dr Joint. They accepted the reason for the examination, but they alleged that prior to the commencement of the physical examination Mr Young was not advised that he was going to have his genitalia examined. Further, Dr Joint had not given Mr Young sufficient opportunity to consent to the examination of his genitals, and Dr Joint had not given Mr Young any explanation as to the reason why he needed to examine his genitals.

For the next four years this matter was the subject of further correspondence between Dr Joint, with the assistance of MDA National and external lawyers, and the Medical Board. Finally the Medical Board determined that they would take no further action in relation to this complaint.

However, the Medical Board asked Dr Joint that in future when conducting an examination of a patient, particularly an examination of the genital area he:

• explain the purpose of the examination to the patient;
• explain why it is necessary to examine the patient in that way;
• inform the patient of his intention to carry out the proposed examination; and
• ensure that the patient consents to examination in the manner proposed.

Although this matter ended without an adverse finding against Dr Joint, it was a very lengthy and stressful process for him.

Discussion

What may be obvious and routine to doctors i.e. examination of the genitalia, or removing the patient’s bra to listen to the heart and lungs, may come as an unwelcome surprise to patients.

Good Medical Practice: A Code of Conduct for Doctors in Australia states: effective communication between doctor and patient involves informing patients of the nature of, and need for, all aspects of their clinical management including examination and investigations, and giving them adequate opportunity to question or refuse intervention and treatment (Section 3.3.3). 1  It further states that good medical practice involves obtaining informed consent or other valid authority before you undertake any examination, investigation or provide treatment (except in an emergency) (Section 3.5.3).

All doctors are reminded to take care with such examinations regardless of the sex of the patient. Patients may be particularly critical of a doctor’s behaviour when undergoing a medical examination, which is an examination that has been requested by a potential employer, and not by the patient themselves.

It is particularly important to maintain a professional boundary and intimate examinations can be embarrassing or distressing for patients. Whenever you examine a patient you should be sensitive to what they may perceive as intimate. This is likely to include examinations of breasts, genitalia and rectum, but could also include any examination where it is necessary to touch or even be close to the patient.

Before conducting an intimate examination you should explain to the patient why an examination is necessary and give the patient an opportunity to ask questions, and also the opportunity to decline the examination. The patient should be given privacy to undress and dress and should be kept covered as much as possible to maintain their dignity. Do not assist the patient in removing clothing unless you have clarified with them that your assistance is required.

During the examination you should explain what you are going to do before you do it and, if this differs from what you have already outlined to the patient, explain why and seek the patient’s permission. You should also be prepared to discontinue the examination if the patient asks you to and keep discussion relevant without unnecessary personal comments.

Good medical care should not be compromised by fear of conducting intimate examinations, but doctors should ensure that patients are fully informed. All doctors are reminded to take care with such examinations regardless of the sex of the patient.

Reference

• Good Medical Practice: A Code of Conduct for Doctors in Australia 

Resources

• Maintaining Boundaries, General Medical Council UK 
• Patient Examination Guidelines. AMA