Understand rules on chaperones
The GMC has updated its guidance on intimate examinations and the role of chaperones. Dr Sally Old explains what you need to know.
Trust is central to the relationship between you and your patients and never more so than when you need to carry out an intimate examination.
These situations leave many people feeling uncomfortable and vulnerable. It is your responsibility to ensure the patient understands why the examination is necessary, that it does not cause them unnecessary pain or discomfort and that they are treated with respect throughout.
If you get it wrong, you could undermine your patient’s confidence in you and the wider profession.
It could also lead to a GMC complaint, which is likely to be stressful and has the potential to cause long term damage to the reputation of your practice and your livelihood. In the worst-case scenario, you might even be accused of sexual assault.
Unsurprisingly, the MDU regularly receives calls for medico-legal advice on this subject from concerned practitioners.
Common queries include whether a relative can act as a chaperone, whether a chaperone is necessary for non-intimate examinations and whether the doctor can insist on the presence of a chaperone when a patient doesn’t want one.
These points are covered in the GMC’s new version of Intimate examinations and chaperones which emphasises the importance of patients feeling ‘as safe and as in control of the situation as possible’.
Defining an intimate examination
These are generally considered to relate to the breast, genitalia and rectum, but the GMC says that they could include any examination ‘where it is necessary to touch, examine intimate parts of the patient’s body’ or ‘be close to the patient’.
Be aware that some patients have concerns about undressing or exposing parts of their body but are hesitant to speak. For example, patients who have suffered abuse or who are vulnerable for other reasons may need a chaperone in any situation where it is necessary to touch or be close to them.
The GMC also notes that an intimate examination can ‘take place in a variety of settings, including in- person and remote consultations, such as by video-link or other digital technology’ (paragraphs 3-6).
Before the examination
Clear and effective communication is essential when getting consent for an intimate examination, taking into account any barriers that might affect the patient’s understanding.
The GMC says before the examination you should explain:
Why a particular examination is necessary;
What it entails in a way the patient understands so they know what to expect, including possible pain or discomfort;
That they can ask for the examination to stop at any time;
The offer of a chaperone and what their role is.
In rare cases where you believe a patient lacks capacity, the GMC has guidance on decision-making and consent and treating patients aged 0-18 years.
Ensure patients’ privacy and dignity when they are undressing for an examination – and dressing afterwards – by using screens and gowns. Do not help the patient remove clothing unless they ask you to or you have checked if they want your help (paragraphs 7-12).
During the examination
When carrying out the examination, you need to:
Explain what you are going to do before you do it;
Explain if the examination will differ from what you have told the patient beforehand and get their permission;
Be alert to the patient showing signs of discomfort or distress;
Stop the examination if the patient asks you to. Consent to a procedure can be withdrawn at any time and for a number of reasons, and you must respect and comply with this as soon as you become aware;
Keep comments professional and avoid personal remarks (paragraph 13).
The MDU advises you to invite the patient to tell you if they feel uncomfortable, rather than assume that they will. If this happens, stop the examination to check whether the patient has questions, wants to stop the examination permanently or agrees for the examination to continue.
The purpose of a chaperone
A chaperone is there to be an ‘impartial observer’ during intimate examinations and patients should be offered this option ‘wherever possible’.
The guidance explains that chaperones need to be:
Sensitive and respect the patient’s dignity and confidentiality;
Alert to the patient showing signs of distress or discomfort;
Aware of the most appropriate route to raise concerns and do so if they are concerned about the medical professional’s behaviour or actions;
Trained for the role they are undertaking – they should usually be a health professional;
Familiar with the procedure/examination or briefed in advance and given chance to ask questions;
Able to stay for the whole examination and to see what you are doing, as much as practical, without obstructing the examination or interfering with the patient’s dignity.
While a relative or friend would not meet these criteria, a patient can still ask for someone like this to be there to support them, alongside a chaperone (paragraphs 16-20).
Examinations without a chaperone
If no suitable chaperone is available, you can suggest delaying the appointment, provided this wouldn’t adversely the patient’s health. Try to avoid putting pressure on the patient to proceed without a chaperone and reassure them they are not inconveniencing you.
If a patient wants to proceed with an intimate examination without a chaperone but you are unwilling, you should explain why you would prefer to have one present. If the patient remains adamant and you are uncomfortable, the GMC says you may consider referring them to another doctor if the patient’s health won’t be adversely affected.
All discussions about intimate examinations and chaperones should be documented in the patient’s record, including the identity and role of any chaperone who was present or if the offer was made and declined (paragraphs 21- 23).
Dr Sally Old (right) is a medico-legal adviser at the Medical Defence Union (MDU)