When a patient refuses a chaperone

CHAPERONES play an important role in intimate examinations – providing support and reassurance for both doctor and patient. But what should you do if a patient declines to have one present and you are uncomfortable to go ahead without one?

Some important points to consider include:

• Why is the patient refusing a chaperone? Understanding their reasoning and discussing any concerns can help to resolve the situation.
• The urgency of the examination – could you arrange for the patient to be seen by another doctor who would be willing to see the patient without a chaperone?
• Record keeping – it’s important to clearly document all discussions and decisions.
• Be aware of and comply with your own local policy regarding chaperones.

Common scenarios

Let’s look at two scenarios based on advice calls to MDDUS:

Scenario A: A male doctor consults with a teenage patient who has brought her friend along for moral support. The patient insists that she would prefer her friend to remain with her during a required breast exam and refuses the offer of a practice chaperone. How should he proceed?

Scenario B: A female doctor consults with a male patient who requires a testicular examination but refuses a chaperone. This is the second consultation in which he has made personal comments about her appearance and she is worried that professional boundaries may be blurring. Should she carry out the examination?

Why might these doctors feel uncomfortable?

Some of the reasons doctors give for feeling discomfort in carrying out an intimate examination without a chaperone present are focussed around the vulnerability of a patient. For example:

• mental health problems
• patients who are known to have previously suffered rape or sexual abuse
• learning difficulties
• a child or adolescent.

Some are around the doctor’s own vulnerability.

Concerns might arise if the patient has a history of violent behaviour – particularly when consulting in an out-of-hours or domestic setting.

In addition, there may be concerns the patient has an interest in the doctor outside their professional relationship – as in Scenario B above.

Whilst allegations of inappropriate examination can be directed at both males and females, by both males and females, evidence suggests a higher rate of allegations against male doctors by female patients. The result could be a male doctor being generally reluctant to carry out intimate examinations on female patients. This could be the case in Scenario A, which presents the further (albeit unlikely) risk that the friend could corroborate a malicious allegation against a well-meaning doctor.

General Medical Council (GMC) guidance makes clear that a relative or friend is not an impartial observer and so would not usually be a suitable chaperone, but you should comply with a reasonable request to have such a person present as well as a chaperone. Doctors would be well advised to remember that chaperones can be used to safeguard the doctor’s interests, as well as meeting the primary objective of protecting the patient and maintaining their dignity.

Why do patients refuse chaperones?

Patients refuse chaperones for a number of reasons, the most common being increased embarrassment that another person will witness the examination. This can be a particular issue for male patients where a practice is unable to provide a male chaperone. Where that patient is being examined by a female doctor, he may also be reluctant to have a second female in the room. Difficulties finding an acceptable chaperone can be compounded in smaller or rural communities. There may be fewer clinical team members to choose from, or the patient may know the chaperone and doesn’t wish to offend. 

What does the guidance say?

In its core guidance, Good medical practice, the GMC states that doctors ”must provide a good standard of practice and care. If you assess, diagnose or treat patients, you must… where necessary examine the patient.“

In addition, its guidance on Intimate examinations and chaperones states that: ”If you don’t want to go ahead without a chaperone present but the patient has said no to having one, you must explain clearly why you want a chaperone present. Ultimately the patient’s clinical needs must take precedence.”

So if the need to examine the patient is clinically urgent this takes precedence over any concerns the doctor may have about a lack of chaperone.

The guidance also states that: “You may wish to consider referring the patient to a colleague who would be willing to examine them without a chaperone, as long as a delay would not adversely affect the patient’s health.”

It is likely that both of the situations described above are clinically ‘urgent’ but there are more options available to the doctor.

So what are the options?

1. It is important to understand why the patient is refusing a chaperone, as it may be that you could resolve these concerns to the patient’s satisfaction. For example, the concern may be about the identity or the role of the individual you are proposing as the chaperone. In this case, attempts should be made to agree an acceptable alternative with the patient.
2. In both scenarios above, the doctor must explain their concerns to the patient and, if the patient continues to refuse a chaperone, document the reasons for this. In the case of Scenario B this may be more awkward; particularly as the reason is that the doctor is becoming uncomfortable with the patient blurring the lines of the doctor-patient relationship. This highlights the prudence of early discussion about this concern in order to reduce the impact on the patient. Interestingly, a longstanding patient with whom you have a mutual rapport built up over a long period of time may feel increased vulnerability regarding intimate examinations. They may be more reluctant to accept a chaperone, feeling this is disloyal in some way to the doctor.
3. Consideration should be given to whether the examination needs to be carried out at that particular time. Could you arrange for the patient to go to another local service that day? Or could you arrange for the patient to come back and see another doctor – perhaps one of another gender - if the examination is not clinically urgent? If the choice of chaperone is problematic, a delay could allow time to find someone the patient would find more acceptable. In this circumstance, it is important to check that the patient is prepared to wait and understands the importance of returning, as complaints can arise in situations where a lack of chaperone availability has led to a delay in treatment. In one recent case, the doctor judged that the examination was not ‘clinically urgent’ but the patient claimed that they had experienced what they described as significant additional unnecessary suffering and distress as a result of not being examined – and therefore treated – earlier.
4. If you do decide to undertake the examination without a chaperone present and start to feel uncomfortable – stop, explain and document why. Arrange for the patient to be seen by a colleague if necessary.

Further information

Read these MDDUS advice articles:

• GP risk toolbox: chaperones
• dealing with unwanted advances from patients.

Liz Price is head of training at MDDUS