Is patient modesty being honored or outraged in clinical practice? High time to introspect

Modesty of a patient may influence her or his health-care utilization. Doctors have been accused of unprofessional conduct after unchaperoned examinations. This article is an attempt to discuss the ethical issues and practices related to outraging of patient modesty on the basis of the published literature. Based on this, recommendations have been made.

A female who has never been naked in front of a stranger has to strip at times for medical reasons. She has a feeling of fear, anxiety, embarrassment, and even anger of being viewed and touched by a nonrelated male. That stranger could be a doctor, a male nurse, or any other health worker present at the time of the ongoing medical procedure. Medical procedures such as an injection in the hip, an administration of an enema, catheterization, cervical cancer screening or mammography, vaginal delivery, C-section, and other surgeries like hysterectomy are common among females. Lack of female staff could be the reason for such procedures to be carried out by males. However, the mental stress due to her illness is further subjected to fear and embarrassment in doing so. The first gaze or touch of a doctor can bring relief to his/her patient, but on the same time, it could be a feeling of uneasiness and discomfort. Many women have named modesty as the reason they do not obtain medical procedures and are not comfortable with a man in that physical proximity. A female patient feeling uncomfortable with a male health-care provider, may not access further medical treatments and follow-ups, and may yield poor treatment outcomes.

Cultural and religious beliefs of a female are responsible for the gender preference of health-care provider. Patients have also voiced dissatisfaction with modesty issues for men and women.[¹] Although acceptance under certain limiting situations for a health-care provider of the opposite sex to treat a patient have been tolerated,[²] the overall acceptance of opposite gender provider has been traditionally disliked at the minimum and refused at the extreme measure.[³]

Purnell's model for Cultural Competence provides a theoretical framework for measuring cultural competence in any culture and proposes twelve different domains of culture that need to be considered when studying a specific cultural belief system. The domains are concepts related to country of origin, communication and language, family roles and organization, workforce issues, biocultural ecology, high-risk behaviors, nutrition, pregnancy and childbearing practices, death rituals, spirituality practices, health-care practices, and health-care practitioner concepts including gender preferences.[⁴]

The Indian Medical Council Act 1956 or the concerned State Medical Council Act clearly states that “Abuse of professional position by committing improper conduct with a patient or by maintaining an improper association with a patient renders a physician liable for disciplinary action.”[⁵]

Since the time of Hippocrates, a sexual relationship between doctor and patient has been prohibited as there is dysfunctionality in this asymmetric relationship, which has been labeled as polymorphic incest.[⁶] It is well known that the patient's confidence is linked to the perception of the limits of medical practice, which are both important for the therapeutic relationship. A sexual relationship between doctor and patient is forbidden in several countries by an ethical code.[⁷]

In São Paulo city, 150 cases against male doctors alleging sexual harassment were registered with the professional council. Male professionals (96.6%) committed abuse against female patients (90.3%) during adulthood (77.7%). Concerning the specialties, most charges were found for gynecology and obstetrics (24.67%), general surgery (5.33%), pediatrics (4.67%), cardiology, medical clinic, and psychiatry (4%), and urology and traumatology (3.33%).

Sexual harassment has also been reported among women doctors and nurses, has become a common practice in India. In a report, none of the victims who were sexually harassed by their coworkers or by their patients and relatives had heard of a Complaints Committee for Redressal of their grievances.[⁸⁹]

Modesty is not just being covered up or wearing specific clothing, it is about respect. A provider who takes cultural modesty into account is someone who shows respect and caring in the highest degree.[¹⁰] Modesty may influence health-care utilization. Chinese and Islamic women have cited modesty as the reason they do not obtain cervical cancer screening or mammography for cancer care.[¹¹¹²]

Recently, the Supreme Court defined Modesty as “The essence of a woman's modesty is her sex.” An insult to the modesty of the woman is an essential ingredient of this offense. If a man exposes his person in an indecent way or uses obscene words which he intends that it should be heard or his obscene drawings should be seen, he is held to be an offender under section 509 of IPC.[¹³]

Providers should take this into account when discussing private issues, for example, making sure the door is closed, recognizing signs of discomfort when talking about sensitive individuals, and asking the individual if she would like another person present. Some cultures actually require a family member to be present even during noninvasive physical examinations. The code of medical ethics also says that a female attendant should be present when a male doctor examines a female patient. The key question health-care professionals can ask in handling such issues is “Is there anything I should know about your privacy or modesty concerns before I conduct an examination?”[¹⁴]

There is no supportive statistics from India about the problem outraging the modesty of female patients by male doctors; however, incidences are reported in the media. Indian Doctors have been accused of unprofessional conduct after unchaperoned examinations.[¹⁵¹⁶¹⁷] Eight percent of the women sampled by Webb and Opdahl reported experiences where doctors had conducted a gynecological examination in a “less than professional manner.”[¹⁸] Unprofessional behavior involved overexposure of the woman's body; inappropriate comments, gestures, or facial expressions and being examined in an unusual position.

Most women want the offer of a chaperone and feel uncomfortable asking for one if it is not offered. Most teenagers want a chaperone during intimate examination, and a family member may be the preferred choice. Many women prefer having a third party present when the examining doctor is male; fewer if the examining doctor is female. For women, a female nurse is generally the preferred choice as a chaperone, would be accepted as a routine part of the clinical examination, and is generally viewed as having a positive supporting role during the examination.[¹⁹]

“The elephant in the room study”[²⁰] in 2010 explored the awareness of sexual boundary violations (SBVs) and non-SBVs in the doctor–patient relationship in India and highlighted the need for culturally relevant guidelines in India. Further in 2011, “The Bangalore Declaration Group” submitted a request to the Medical Council of India (MCI) that the topic of boundaries in the doctor–patient relationship be introduced in the medical curriculum.[²¹] The MCI incorporated the topic in the regulations for graduate medical education.[²²²³] Several behaviors of health-care providers toward their patients have been termed boundary violations by psychotherapists. These behaviors include hugging, dining with, self-disclosing to, making house calls, exchanging gifts with, engaging in nonsexual social activities, lending books to patients during treatment, and sexual intercourse during treatment.[²⁴] The guidelines for doctors on sexual boundaries in the doctor–patient relationship were first drafted by the Bangalore Declaration Group and subsequently worked on by the Indian Psychiatric Society Task Force on Boundary Guidelines.[²⁵]

Based on the above reports, I recommend the following policies:

1. Examinations need to be conducted in an atmosphere where the patient's cultural and religious beliefs are taken care of. The privacy and modesty of the patient should be respected and preserved. This should be not a prerequisite but a goal
2. A conversation should be initiated by the health-care provider before conducting the examination with the patient regarding his or her attitude toward modesty. Written informed consent offering him or her an authorized chaperone should be obtained
3. The health-care provider and patient should never be alone together in a closed place where sexual intercourse could occur or where even such an accusation could be made
4. Patient should be given the liberty to refuse for a chaperone of the opposite gender. Providing a chaperone of similar gender to the patient would minimize the chances of an unprofessional behavior
5. If a chaperone is to be provided, a separate opportunity for private conversation between the patient and the physician should also be arranged. The physician should avoid asking questions related to sensitive issues during history taking in the presence of the chaperoned examination.
6. Complaints Committee for Redressal of grievances in every hospital should be established
7. It should be clearly mentioned in the appointment letter of the hospital personnel that abuse of professional position by committing improper conduct with a patient or by maintaining an improper association with a patient would render him or her liable for disciplinary action
8. Rules regarding respecting patient privacy and modesty must be adhered to the chaperones also
9. Preplacement and interplacement counseling sessions regarding medical ethics should be organized at least annually.