The Joint Specialty Committee for Genitourinary Medicine of the Royal College of Physicians has produced guidance on chaperoning in response to the General Medical Council (GMC) guidance on doctors performing intimate examinations.¹

The definition of intimate examinations includes examination of the breasts, genitalia, or rectum. It recommends that all patients undergoing such an examination be offered a chaperone, who may be a friend or relative. The GMC guidance is predominantly concerned with the comfort and protection of patients, while also serving a secondary role to protect doctors from false allegations. The Royal College of Obstetricians and Gynaecologists (RCOG) has published its own updated guidelines based on the GMC recommendations.²

Doctors have a duty to protect patients, and implementation of the GMC guidelines could also protect staff undertaking such examinations who might otherwise find themselves accused of inappropriate behaviour. Even if allegations are totally unfounded it is difficult, if not impossible, to refute them if a chaperone was not present. Genitourinary medicine clinics cannot ignore the national recommendations and the issue of insufficient funding should not influence best practice.

Potentially, there may be far reaching implications for the specialty not only for working practices but also for cost/staffing issues. However, patients may not accept a chaperone, making the costs difficult to quantify at the present time.

KEY ISSUES

• Clinics must offer chaperones according to the GMC guidance for all patients being examined by a doctor at every visit.

• Explain to the patient why an examination is necessary and give the patient an opportunity to ask questions.

• Explain what the examination will involve, in a way the patient can understand, so that the patient has a clear idea of what to expect, including any potential pain or discomfort (paragraph 13 of GMC booklet Seeking Patients’ Consent gives further guidance on presenting information to patients³).

• Obtain verbal consent to examination and be prepared to discontinue the examination if the patient asks you to.

• Offer a chaperone to all patients irrespective of the sex of the patient or their doctor.

• Ideally, the chaperone should be a nurse or nurse auxiliary who is assisting with obtaining specimens. If not possible then others of the team could be considered with the patient’s agreement—for example, receptionists, interpreters. Novel posts may need to be created. The RCOG recommends that for female patients the chaperone should ideally be female. The GMC has no recommendations on the sex of the chaperone. In practice, if the patient expresses a preference then this should be respected wherever possible.

• Family, friends, and partners should only exceptionally be the chaperone in a GUM setting for reasons of confidentiality, possible coercion, etc. Additionally, the secondary role of a chaperone—that is, protecting the member of staff from malicious accusations, would not be served and ability to defend a false accusation may be jeopardised. The RCOG guidelines include information from the Medical Protection Society stating that a family member does not fulfil the criterion of a chaperone, as he or she must be “someone with nothing to gain by misrepresenting the facts.”

• The chaperone should record in the notes their name and designation.

• Record in notes if chaperone offered but declined.

• If for any reason you cannot offer a chaperone, you should explain that to the patient and, if possible, offer to delay the examination to a later date. However, this may cause problems in view of the nature of the specialty. You should record the reason why no chaperone is available, and ifthe patient wishes to defer examination.

• Refusal of a chaperone. A chaperone should always be present when a male member of staff examines a female patient. If a female patient refuses a chaperone then the examination should be deferred until a female member of staff is available. If the examining doctor (irrespective of their or patient’s sex) believes a chaperone should be present, the presence of a nurse in order to facilitate swab taking or treatment is likely to be acceptable to the patient. If a male or female patient refuses a chaperone and the doctor is unhappy with this they should not proceed with the examination.

• A check box in the notes for each attendance will aid recording of data.

• Give the patient privacy to undress and dress and use drapes to maintain the patient’s dignity. Do not assist the patient in removing clothing unless you have clarified with them that your assistance is required.

• Avoid unnecessary personal comments during examination.

• Patients refusing examination should be offered self taken swabs or urine testing for chlamydia, and for gonorrhoea when available.

• Patients refusing examination/tests should be offered epidemiological treatment if clinically indicated.

DISCUSSION

For reasons of confidentiality and other issues specific to GUM services the use of relative or friends as a chaperone as advocated by the GMC, and appropriate for other specialties, is not a solution for GUM clinics. In implementing these guidelines costs may be significant. Where there is insufficient resource, trust management including the risk management/clinical governance lead should be informed. in reality, many patients may decline a chaperone, thus costs may not be as high as anticipated.

The GMC guidance covers doctors, but the issues are equally relevant to nurses, and this needs to be addressed as the role of the nurse expands. The Royal College of Nursing has produced guidance for nurses stating that patients should be offered a chaperone or be invited to have a relative or friend present with them during any examination or procedure.⁴

The impact of introducing these guidelines needs to be assessed with regard to numbers of patients accepting a chaperone, cost and staffing implications, and acceptability to patients. The guidance should be modified as appropriate. Consideration should be given to assessing the impact of implementation in relation to allegations against staff, by the collection of data nationally on an anonymous basis before and after its introduction. These guidelines are available in full on the MSSVD website.⁵