Intimate Examinations: Respect & Responsibility

A live webinar exploring intimate examination was held on 8 May 2019. Members who missed the live online session can access the full 40-minute webinar recording through their Member Online Services account. Others can find an excerpt of the first 12 minutes of the webinar here.  

Follow-up answers to questions posed by participants during the webinar

Who can act as an observer/chaperone?

  • What are your thoughts on having your personal assistant as an observer?
  • Can a patient request someone who accompanies them to be present in the examination?
  • Can a family member be allowed to be there to calm patient?
  • If a mother is present with a young woman is it reasonable to have the mother in the room during a rectal exam for PR bleeding if both agree?
  • Do video cameras in consulting rooms work as well as observers?

An observer should be a qualified health professional such as a registered or enrolled nurse, someone who is trained to understand their role as a support person for the patient, or someone chosen by the patient.1 In general, a family member can be present during the consultation if that is requested by the patient.

In a survey of 687 patients across 13 general practices in regional New South Wales, non-clinical practice staff such as reception staff or a practice manager were the least preferred option for an observer. Slightly more than half of respondents said they would feel ‘very uncomfortable’ or ‘uncomfortable’ with reception staff/practice manager having an observer role.2

Not every practice environment facilitates observers being able to be provided ‘on demand’. In these cases, it’s especially important to state on a practice information sheet that patients are welcome to bring their own person to act as an observer if they wish. Though be mindful that when lay people – who are often family members – act as observer, they can add difficulties to the process.3 Aim to just use observers during a physical examination, not the general consultation.3

Video camera recording of consultations is not an alternative to an observer. The Medical Board has declined doctors’ requests to use a video recording in place of an observer.


When is an observer recommended to be present?

  • Does a female doctor need to always offer an observer during physical exam?
  • CSTs/PAPs/PR/DREs are considered ‘intimate examinations’. Do we really need chaperones for the common and routine examinations?

The Medical Board of Australia, Royal Australian College of General Practitioners, Australian Medical Association, and MDA National all support using observers to protect both doctors and patients.1,4

Exploring the need for an observer with the patient is part of good medical practice.1 This is particularly relevant when examining minors or those unable to give consent and when performing obstetric and gynaecological/breast examinations – patients in these situations are particularly vulnerable to sexual abuse3 and misunderstandings. Interestingly, a survey of general practice patients in regional NSW found that respondents were significantly less likely to want an observer for Pap smears or male genital examinations with a doctor they didn’t know than with their regular GP.2

If you’re concerned about how a patient may react to physical contact, having another person present as an observer should be considered and is strongly recommended. It can be useful to think of using an observer as not being something you ‘ask’ the patient about but something that you just say is part of standard practice.


What if there is disagreement about an observer being present?

  • What if the patient refuses an observer saying that they already have trust in their doctor? Can it be an issue if the doctor still asks for one?
  • If a male patient requests a female doctor to do a genital examination, where it is unnecessary, what is the strategy to prevent medico-legal issues?

A person’s request for the presence of (or if a patient declines the offer to have an observer present) and/or gender of an observer should be respected and documented.4,5 If a suitable observer is not available the examination can be postponed if it’s not urgent and will not impact the patient’s health.4,6

Doctors should decline to perform examinations if they’re not clinically indicated. If a female doctor has the impression that a male patient is requesting an intimate examination when there’s dubious indication, then they should have an observer present. If the patient declines to have an observer, then the doctor can decline to perform the examination. The fact that the patient declined to have an observer should be documented.

Refer particular patients to another clinician if the situation is unmanageable or risky. Even if the patient resists, it’s often in their best interests to be treated by a different practitioner. Seek assistance from your medical indemnity insurer if a patient behaves inappropriately.


What can be said to help the patient feel comfortable?

  • If a female patient is depressed about her morbid obesity. For a male doctor, what is the appropriate language to encourage the patient?

Good communication is critical. Always explain the clinical need to touch each bodily area prior to commencing any examination and ensure that the patient understands the reason for conducting the examination, so that you have appropriately obtained their consent.3 It’s important that the patient has an opportunity to ask questions about the proposed physical examination.

Take time to understand and respect cultural needs and consider the individual needs and sensitivities of each patient. Talk to patients about why certain topics such as family history, household functioning or sexual matters need to be discussed during the consultation.

Use neutral and professional language.7,8  Think carefully about using terms of endearment/address that may be nonsexual to some people but not to others, e.g. “my dear”, “honey” or “love”.7 Personal comments (e.g. about a patient’s body, clothing) or sexually based jokes may seem harmless but they can be easily misconstrued by a patient8 and are generally unacceptable.



References
1. Medical Board of Australia. Guidelines: Sexual Boundaries in the Doctor–Patient Relationship. 2018. 
2. Stanford L, et al. Aust Fam Physician. 2017;46(11):867–73. 
3. Crowley P. In: Subotsky F, et al, editors. London: The Royal College of Psychiatrists; 2010. p. 114–26.
4. RACGP Position On The Use of Chaperones in General Practice. [cited 24 May 2019].
5. Paterson R. Independent Review of the Use of Chaperones to Protect Patients in Australia; 2017. 
6. AMA. Maintaining Clear Sexual Boundaries Between Doctors and Patients and the Conduct of Patient Examinations. 7 May 2019. 
7. Committee on Bioethics. Pediatrics. 2009;124:1685–8.
8. Vulnerable Patients, Safe Doctors. London: The Royal College of Psychiatrists; 2007.

 
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