THE PROVISION OF CHAPERONES DURING the genital examination of patients can serve a number of purposes. For the patient, the presence of a chaperone can be a source of support and reassurance. For the practitioner, an independent witness to the examination could be of value in the event of patient allegations over professional misconduct.
Recommendations on the use of chaperones during genital examinations vary considerably between countries. In the United Kingdom, General Medical Council guidelines stipulate that practitioners should always offer a chaperone when conducting a genital examination, and that if a male practitioner’s offer of a chaperone is refused by a female patient, the examination should be delayed until a female practitioner is available.1,2 Indeed, almost all genitourinary medicine clinics in the United Kingdom always offer a chaperone when female patients are being examined by a male doctor, and it has been argued that a failure to do so is unacceptable.3–5 By contrast, the American Medical Association asserts that it would be impractical to have a chaperone at all examinations and recommends that chaperones be available on patient request.6 In Australia, guidelines state that a practitioner should offer a chaperone if they believe it would put the patient at ease.7
Research into patients’ desire for a chaperone during genital examinations has primarily been conducted within family planning and general practice settings. Within these settings, most women do not want a chaperone when being examined by a female practitioner,5–7 but many do when the examining practitioner is male.8–12 By comparison, far fewer male patients express any desire for a chaperone.12 Few data, however, are available on the attitudes of patients toward the use of chaperones within sexually transmitted diseases clinics, where genital examinations are frequently undertaken. In a small survey of patients attending a genitourinary medicine clinic in London, more female patients accepted a chaperone when the practitioner was male, consistent with studies in other settings.13 The study did not, however, provide any information on patient’s views on the use of chaperones.
The aim of this study was to ascertain the attitudes of male and female patients toward the use of chaperones within a sexually transmitted diseases clinic and to examine the factors associated with having a preference for a chaperone.
This study was conducted at the Melbourne Sexual Health Centre (MSHC), the main public sexually transmitted diseases clinic in Melbourne, Australia. Between September 18th and the October 4th, 2006, male and female patients attending the MSHC who were triaged to see a doctor or nurse were offered a questionnaire by the triage nurse to complete before their consultation. The questionnaire was anonymous and patients were asked to return it to a locked survey box while waiting to be seen. At the time of the study, chaperones were not routinely offered to patients attending the center, although if a patient requested a practitioner of a certain sex, this request was met wherever possible.
The questionnaire defined a chaperone as another staff member who would be present during a genital examination and who could assist with the examination, provide support and reassurance, and be a witness so that the examination is conducted in a professional and ethical manner.
The questionnaire required the patient to provide the following information: their age, gender, whether women had ever had a cervical smear test, desire for a chaperone during a genital examination when the examining practitioner was male or female, their level of comfort with the presence of a chaperone during a genital examination, and their level of comfort in either requesting a chaperone, or being asked whether they would like to have a chaperone during their visit to the service.
Categorical variables were analyzed using the χ 2 test. Odds ratios (OR) and 95% CI intervals were calculated for variables associated with desire for a chaperone. Data were analyzed using SPSS (Chicago, IL) version 12.0.1. The study was given ethical approval by the Alfred Hospital Ethics Committee.
During the survey period, 166 (60%) of the 276 men and 153 (73%) of the 210 women who were given a survey completed it. The mean age for participating men and women was 32 and 29 years, respectively. Seventy-eight percent of men (n = 129) and 85% of women (n = 130) had experienced a previous genital examination. And 89% of women (n = 136) had undergone a previous cervical smear test.
The responses of men to the prospect of a chaperone according to the gender of the examining practitioner are shown in Table 1. There were no statistical differences in the desire for a chaperone according to whether the examining practitioner was male or female patient.
The responses of women to the prospect of a chaperone according to the gender of the examining practitioner are shown in Table 2. Although significantly more women desired a chaperone if they were going to be examined by a male practitioner when compared with a female practitioner (26.8% vs. 5.5%, P <0.001), the majority of women (73.2%) either felt neutral about or did not want a chaperone under such circumstances. Furthermore, even though a higher proportion of women indicated they would feel more comfortable having a chaperone present if the examining practitioner was male as opposed to female (31.1% vs. 14.2%, P <0.01), almost as many (29.8%) indicated that they would feel uncomfortable with a chaperone in such a situation.
Around half of men and women indicated that they would prefer to be routinely asked whether they would like a chaperone to be present. This was not significantly higher for women (Table 3). Over a quarter of men and women indicated that they would not be comfortable asking for a chaperone if one had not already been offered, and few (13.2%–14.5%) indicated that they would feel uncomfortable being asked if they would like one present.
Among female patients, the desire for a chaperone in the presence of a male practitioner was associated with: having had a previous cervical smear (OR = 0.35, 95% CI: 0.12–0.98, P = 0.04); feeling comfortable in the presence of a chaperone (OR = 28.9; 95% CI: 11.1–75.0; P <0.001); and agreement with the statement that a chaperone was important to ensure that the examination was carried out professionally and ethically (OR = 12.0; 95% CI: 5.1–28.0; P <0.001). Similarly, lack of desire for a chaperone in the presence of a male examiner was associated with feeling uncomfortable about a chaperone (OR = 0.19; 95% CI: 0.06–0.56; P = 0.001). The mean age of female patients desiring a chaperone when examined by male practitioners was 27.3 years when compared with 29.8 for those not desiring a chaperone (P = 0.16).
In this study, we found that men attending a sexual health service rarely wanted a chaperone during a genital examination, irrespective of the sex of the examining practitioner. By contrast, a substantial minority of women being examined by male practitioners indicated that they would want a chaperone present, though most women either felt neutral about this or indicated that they would feel uncomfortable with a chaperone in this situation. These findings highlight gender differences about patient attitudes toward examinations that are frequently undertaken in sexually transmitted diseases clinics. They also underscore the fact that a wide spectrum of views toward chaperones exists among both men and women.
Our study has several limitations. First, our study population included few teenagers (only 16% of female participants were aged <20 years), so the absence of any association between younger age and the desire for a chaperone may have related to this. Second, the results of this study are indicative only of the attitudes of patients attending a sexual health service and are not necessarily generalizable to other settings. It is likely that patients attending a sexual health service would expect to undergo a genital examination and that this would be done by a trained sexual health practitioner. These factors may make them less concerned about requiring a chaperone during examination. Furthermore, unlike in some other settings, breast examinations are not generally undertaken in sexual health services. This might also reduce the desire for a chaperone among females. We did not collect demographic information on participants beyond age and sex. However, in 2006, 57% of clinic attendees were female (mean age 30) and 43% male (mean age 33); 38% were born outside Australia, 14% spoke a first language other than English, and the most common reasons for presentation to the clinic were for genital symptoms (24%) and asymptomatic STI screening (14%).
Third, no data on ethnicity were collected, and it is uncertain how important cultural factors are in patient responses and to what extent findings might differ in other cultural settings. However, our results are broadly consistent with those from a London study where female genitourinary medicine clinic attendees were more likely to accept a chaperone when seeing a male practitioner.13 Fourth, although we felt that some explanation for the roles that a chaperone could play was warranted, this may have biased patient responses toward the desire for a chaperone.
The findings of this study have important implications for clinical practice and policy. They suggest that patients attending sexually transmitted diseases clinics should be asked whether they would like a chaperone to be present during the physical examination, particularly where a female patient is to be examined by a male practitioner. Furthermore, our findings indicate that women’s attitudes to the prospect of a chaperone vary greatly and that a policy that seeks women’s views is likely to result in greater patient satisfaction. Such flexibility would also lessen the burden on clinic staffing.
Of interest was the finding that there was no significant difference in the proportion of women who felt that a chaperone was needed to ensure a professional conduct, when the prospects of male and female examining practitioners were compared. In fact, such a concern did not appear to be the strongest predictor of a woman’s desire for a chaperone when faced with a male clinician. Rather, it was the patient’s level of comfort with the presence of a chaperone. Thus, there may well be differences between patient and practitioner perceptions around the value and justification for a chaperone.
Future research should aim to gain a fuller understanding of why patient feelings and attitudes toward chaperones vary so widely, with the view of improving service provision for patients. Any policy governing the use of chaperones will also need to take into account the views and needs of clinicians.
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