Chaperone: For or Against Doctors

On June 26th 2007 and October 16th 2008, Korean newspapers reported two separate incidents in which two women alleged that their male doctors sexually assaulted them during a gastroscopy and a gynaecological examination, respectively. As a consequence, an internist was convicted with sexually assaulting more than 3 of his female patients under sedation in a 2 month period, while a gynaecologist was charged with alleged sexual misconduct. Although both instances arose from different circumstances, both occurred when the patients were alone with the doctors, without supervision or assistance of any other medical staff. For example, a nurse who would effectively act as a chaperone. Chaperones have conventionally been used during intimate examinations: this refers to any examination involving the genital, groin, or anal region in any patient, including breasts in female patients, as well as other situations that may cause embarrassment or stress to patients. For example, when a patient needs to undress for a skin check.1 Unfortunately, it is a reality that there have always been healthcare professionals who abuse their positions of trust. Similarly, there have also been instances when patients falsely accused their doctors of sexual abuse, including rape.2 When accusations arise, there is potentially no way of discerning who is telling the truth without a witness in the room. It is also possible that patients may perceive an examination as abusive, because of a lack of understanding of the procedure, inadequate communication, or mental health issues. In today's medical environment, and both doctors and nurses routinely consult patients alone, particularly in emergency situations especially in Korea. Most local clinics allow male doctors to examine female patients without the presence or offer of a chaperone and vice versa. Such practice is surely beyond justification. Chaperoning can be considered as a risk management strategy when performing intimate examinations.1 The use of a chaperone may protect the doctor from allegations of inappropriate behaviour and misconduct, or from misconduct by the patient. The UK General Medical Council (GMC) states that the function of a chaperone is primarily to protect the patient,3 but the protection of doctors is surely also of benefit. The consequences of a false accusation, if no chaperone is present, can destroy a doctor's reputation and lead to suspension and removal from the specialist register, with loss of livelihood, and also possible criminal proceedings. A recent consultation in the UK advocated that the burden of proof for professional misconduct enquiries should be changed from the criminal to the civil, making conviction against a doctor more likely. For all these reasons, therefore, the role of a chaperone should be not only for the protection of the patient but also for the protection of both doctors and nurses. The American Medical Association (AMA) recommends that an authorised health professional should serve as a chaperone whenever possible.4 The GMC recommends that a family member or friend is appropriate but this is satisfactory if the only role is to protect the patient. It would not, however, protect the doctor, and possibly result in doctor's being less able to defend against false accusations. The British Association for Sexual Health and HIV (BASHH) genitourinary medicine (GUM)5 and Royal College of Obstetrics and Gynaecology (RCOG)6 do not, therefore, recommend family or friends alone. They rather advocate that a chaperone must be a third party, with nothing to gain by misinterpreting the facts, and of the same gender as the patient. Chaperones must act as safeguards for patients against humiliation, pain, or distress; must offer protection against verbal, physical, sexual, or other abuse; and should provide physical and emotional comfort and reassurance to patients during sensitive and intimate examinations or treatment. Furthermore, an experienced chaperone should be able to identify unusual or unacceptable behaviour by a healthcare professional, and also provide protection for the professionals against potentially abusive patients. The issue of chaperones needs to be considered in the context of protection of the doctor-patient relationship. The doctor-patient relationship is based on mutual trust and understanding, communication, and decision-making. Further research on this issue is needed to understand in greater depth the barriers and facilitators to the use of chaperones during intimate physical exams. It would assist the development of policy recommendations that better meet the needs of both practitioners and patients, especially in an increasingly litigious society.7 This author argues that trained chaperones used in timely appropriate circumstances can ensure the protection of doctors and their patients. Surely this is a real win-win strategy with the wisdom of hindsight.