Research Paper - (2007) Volume 15, Issue 6
1General Practitioner, Professor of Quality in Health Care, Department of Health Sciences, University of Leicester, Leicester, UK
2General Practitioner, Measham Medical Unit, Swadlincote, UK
4Health Services Researcher, Research Associate,Department of Health Sciences, University of Leicester, Leicester, UK
5Medical Law, Health Services Research Fellow, National Collaborating Centre for Primary Care, Royal, College of General Practitioners, London, UK
Received date: 6 July 2007; Accepted date: 21 August 2007
Background In the UK, the conviction of several general practitioners for sex offences against patients has led to recommendations on use of chaperones in general practice.Aim To determine (i) the preferences of patients for the presence of a chaperone and (ii) the use of chaperones in primary care.Design Qualitative review of published articles.Method A bibliographic search for articles published up to March 2007 reporting quantitative or qualitative studies of patients’ views on and professionals’ use of chaperones in primary health care.Results Five studies of patients’ views were identified, none being undertaken in more than three general practices. In two studies, 75–90% of respondents wanted a chaperone offered, but in a third only 35% of females and 10% of males wanted achaperone offered. In all studies, patients’ preferences for the presence of a chaperone varied depending on a variety of factors, including age and sex of the patient and doctor. Ten studies of the use of chaperones were identified and indicated that male general practitioners increasingly report routine offer and use of a chaperone for intimate examinations of female patients, but female general practitioners commonly do not.Conclusion The studies included in this review indicate that male general practitioners should adopt a policy of routinely offering a chaperone by a practice nurse for intimate examinations of female patients. Research into the role of chaperones is limited, and more evidence is needed about how and when offers should be made by male and female primary healthcare professionals, the views of certain patient groups including ethnic minorities, and the costs of ensuring the ready availability ofchaperones in primary care.
chaperones, patient safety, primary healthcare
The recent cases of twoUKgeneral practitioners (GPs) who were convicted of committing sexual offences against patients have raised concern about the need for chaperones during intimate examinations. In 2000, Peter Green was convicted of nine counts of indecent assault on five patients, and a subsequent review indicated that Green had not complied with his practice’s chaperone policy, and that the implementation of the policy had not been monitored.1 The review recommended auditing of chaperoning policies, training to raise awareness of staff to the issue, and local determination of the most appropriate staff to take on the role of chaperone. Clifford Ayling was convicted in 2000 on 12 counts of indecent assault relating to 10 patients. The subsequent independent statutory inquiry made several recommendations, including that: (i) patients should be able to choose whether to have a chaperone present; (ii) chaperoning should not be undertaken other than by trained staff; (iii) NHS trusts should develop a chaperoning policy; and (iv) breaches of the policy should be formally investigated through each trust’s risk-management or clinical governance arrangements.2 However, in addition to offering some protection to patients from sexual offences by doctors, chaperones can protect the doctor from unfounded complaints and help patients feel less embarrassed when undergoing intimate examinations.
The joint advice of the Royal College of General Practitioners and the British Medical Association’s General Practitioner Committee is contained in Good Medical Practice for General Practitioners,3 which recommends that ‘You should always arrange for a chaperone to be present if intimate clinical examinations are carried out in situations that are open to misinterpretation’. The Royal College of Obstetricians andGynaecologists has recommendedthat ‘Achaperone should be available to assist with gynaecological examinations irrespective of the gender of the gynaecologist’. 4 The General Medical Council (GMC) issued guidance in 2001, defining an intimate examination as involving examination of the breasts, genitalia or rectum.5 It advised that the reason for the examination should be explained, consent obtained, discussion kept relevant, a chaperone be offered or the patient invited to have a relative or friend present, the identity of the chaperone should be recorded in the records, and if the offer of a chaperone is declined this should be recorded in the notes.
Despite the advice of the professional bodies, however, some issues remain unclear. It may be difficult to always ensure that a chaperone is available in primary care,6 for example when attending patients in the home, and the costs of always providing a chaperone in all practices, including the small practice or branch surgery, is uncertain. Furthermore, patients’ pReferences for a chaperone may vary according to gender, age, ethnic group, the established relationship between the patient and the doctor or nurse, and other factors. Different doctors may also have different pReferences for the presence of a chaperone. Therefore, we undertook a review of current evidence with the specific aims to determine (i) the pReferences of patients for the presence of a chaperone and (ii) the use of chaperones in primary health care.
Searches for potentially relevant literature were conducted in the following 10 electronic databases: MEDLINE (1966 to March 2007), EMBASE (1980 to March 2007), the Cochrane Library (Issue 1, 2007), CINAHL (1982 to March 2007), AMED (1985 to March 2007), BNI (1994 to March 2007), PsycINFO (1987 to March 2007), DH-DATA (1983 to March 2007), ASSIA (1987 to March 2007), and Sociological Abstracts (1963 to March 2007). Search terms employed included ‘chaperone’ (and the alternative spellings: ‘chaparone’ and ‘chaparon’), ‘third party’, ‘primary care’, ‘primary health care’ ‘general practice’, ‘family practice’, ‘family physician’ ‘physician–patient relations’, and ‘physical examination’. Relevant MeSH terms were used where available, and these were combined with free text terms. MEDLINE In-Process was also searched (May 2007) for any relevant literature not yet indexed in MEDLINE. An internet search on the Google search engine was conducted using the term ‘chaperone’. No systematic effort was made to search the grey literature for unpublished reports. Details of all searches are available on request. The GMC’s definition of intimate examination was followed. The titles and abstracts of all identified articles were reviewed independently by two reviewers for relevance, and the full text of articles identified as relevant by at least one reviewer was obtained.
The articles were assessed for relevance, and the data extracted into tables by two researchers. A standard assessment tool was used to appraise the quality of the studies.7 Studies were included if they were reported in English and had been undertaken in primary care and had investigated the views of patients and/or primary care doctors or nurses on the role of chaperones. We included either qualitative or quantitative observational studies and also experimental studies, for example comparisons of the impact of chaperones versus no chaperones. Studies were excluded if they had been undertaken in secondary care because patients in these settings tend to be selected and may have more serious problems with associated greater anxiety and therefore potentially different views on the need for intimate examinations. In addition, clinics in secondary care and also family planning clinics may have more staff and examination rooms available, and hence fewer barriers to undertaking intimate examinations. The reference lists of included articles were also scanned to check for relevant articles not already identified by the searches.
A total of 85 articles were identified as potentially relevant.Of these, 71 were excluded because they were letters in response to articles or expressing the personal opinion of the author, general discussion articles, had been undertaken in specialist outpatient settings or were otherwise not relevant. No experimental studies were identified. Study quality was generally satisfactory, although most studies were limited in size and involved only small numbers of practices.
Five studies of patients’ views were identified, two from the UK, two from the US and one from Canada (see Table 1).8–12 All five involved the administration of questionnaires, although one also involved focus groups.12 Three studies were undertaken in single primary care practices, one in two practices and one in three practices. Three were restricted to women patients, but two included both men and women. Two studies were concerned with pelvic examinations only.8,9 In the three studies that specifically asked whether patients thought they should be offered a chaperone, the majority (75–90%) of respondents in two studies wanted a chaperone offered, but in the third study undertaken in a single US practice, only 35% of females and 10% of males wanted a chaperone offered. In all studies, patients’ pReferences for the presence of a chaperone varied depending on a variety of factors. Women were more likely to prefer a chaperone if the examining doctor was male,9,11 particularly those women who would prefer a female professional if possible, and if the examination was pelvic rather than breast.11 When being examined by the usual doctor, fewer patients expressed a preference for the presence of a chaperone.9,12 Men were less likely than women to want a chaperone present – 7% of males in one study,10 and up to 13% in another12 preferring a chaperone for intimate examinations. Patient age also influenced pReferences. In one study, younger female patients tended to prefer consulting female doctors for intimate examinations.11 In a US study older women were more likely to prefer a chaperone when being examined by either a male or female doctor,10 but in a UK study younger women and those who had not had a pelvic examination before were more likely to express a preference for a chaperone.9 Female teenagers were more likely than adults to prefer a chaperone with a male doctor, but the evidence about the pReferences of male teenagers is very limited.11 In two UK studies, the majority of respondents thought the chaperone should be a nurse,9,12 and in the most recent UK study 74% of respondents said that receptionists were not acceptable as chaperones.12
Table 1: Studies of the views of patients
Ten studies of the use of chaperones were identified, six from the UK, two from the US, one from Canada and one fromNigeria (see Table 2).13–22 Nine involved questionnaire surveys of samples of GPs (in two cases national samples)19,20 to investigate reported use of chaperones, and one was a qualitative study involving lesbian, gay or bisexual health professionals.18 One of the surveys was restricted to male doctors examining female patients,15 one to rectal examination,14 and one to cervical cytology,19 all the others involving male and female GPs and examination of male and female patients.The surveys indicate that an increasing proportion of male GPs report routine offer and use of a chaperone for intimate examination of female patients, but female GPs commonly do not use chaperones for the same examinations.13,15,19–22 In addition to sex of the doctor, factors associated with the greater use of chaperones included the examination of the genitals, undertaking a high number of cervical smears,19 the availability of a nurse in the clinic (to act as chaperone),22 and the doctor being older, of a non-white ethnic group or working from a smaller practice.20 Reasons given for not using a chaperone included intrusion on the doctor–patient relationship,21 confidentiality and availability of a chaperone.20 Lack of a chaperone was also reported as one reason for failure to perform a rectal examination.14 Practice nurses were the most common chaperones, although a family member or another member of the practice staff was sometimes used.13,20–22 The doctor’s sexual orientation and the patient’s awareness of that orientation may also be a factor in deciding whether or not to offer a chaperone.18
Table 2: Studies of the use of chaperones in general practice
There are relatively few studies about patients’ views on and professionals’ use of chaperones in general practice. Our review brings together the available evidence in order to provide guidance to practitioners and policymakers. The review has some limitations. Since we excluded studies not reported in English, relevant studies from some other countries may have been overlooked. The search was broad and we believe it included all relevant published articles, although we did not contact study authors to ask if they knew of other relevant articles. The studies themselves were limited in terms of numbers of practices involved and the predominance of questionnaires over more indepth qualitative methods. We excluded studies of the use of chaperones in settings other than primary health care since, while these studies might have thrown light on the views of specific patient groups, it would have been difficult to extrapolate this information to primary care. For example, we excluded studies of women attending family planning services; these services are almost entirely provided by female health professionals and the patient group involved – women of reproductive age – is only a subgroup of the mix of people attending primary health care.
A small number of researchers have recognised the importance of the issue and have conducted sufficient studies to support a policy of routine offer by male doctors to female patients of a chaperone when conducting pelvic examinations and taking cervical smears. The evidence also indicates that the chaperone should be a nurse rather than a non-clinical member of the practice staff, although more information is needed about patients’ views on family members as chaperones. It is also clear that some women do not want a chaperone to be present, and some do, irrespective of the sex of the doctor. This presents considerable opportunity for misunderstandings unless the pReferences of individual patients are established before examinations are undertaken. Moreover, it is not clear whether a patient’s preference not to have a chaperone should be over-ruled to reduce the risk of unfounded complaints against the doctor. The available evidence does not provide detail about how the offer of a chaperone should be made, for example whether it should be in writing during a consultation, at the time the appointment is made, announced in practice leaflets or on posters, or made verbally, nor what form of words should be used. The impact of the offer of a chaperone on the patient–doctor relationship also requires investigation.
There were relatively few studies of patients’ views, and they had been undertaken in a limited range of practices, a fact that may explain some of the differences in findings between studies. Research is required involving a wider range of patients, including those from ethnic minorities, particularly vulnerable patients and different age groups including teenagers. Most studies of the use of chaperones by GPs relied on respondents’ reports of their usual approach. Studies of what actually happens in practice are therefore required. Furthermore, qualitative studies are required to better understand the reasons for patients’ pReferences, the use of chaperones in the context of the doctor–patient relationship, and potential barriers and facilitators to their use. The development of practice policies on use of chaperones also requires evidence about the costs of ensuring the ready availability of a chaperone.
Until more evidence is available, practices should be advised to implement a policy of routinely offering a chaperone for intimate examinations. Research funders concerned about patient safety or patients’ experiences of care should commission additional studies to enable better understanding of: which patients may prefer a chaperone and when; in what manner to offer a chaperone; how concordant the views of patients and providers are; and how primary care services can be organised to ensure a chaperone is available when needed.
The completion of this review was supported by a grant fromthe Royal College of General Practitioners.
None.
