Intimate examinations: use of chaperones in community-based family planning clinics

Client and Provider Perspectives on Quality of Care: A Systematic Review

CONTEXT

A central premise of the literature on healthcare quality is that improving the quality of care will lead to improvements in health outcomes. A systematic review was conducted to better inform quality improvement efforts in the area of family planning. The objective of this systematic review is to update a previous review focused on the quality of family planning services, namely, the impact of quality improvement efforts and client perspectives about what constitutes quality family planning services. In addition, this review includes new literature examining provider perspectives.

EVIDENCE ACQUISITION

Multiple databases from January 1985 through January 2015 were searched within the peer-reviewed literature that described the quality of family planning services. The retrieval and inclusion criteria included full-length articles published in English, which described studies occurring in a clinic-based setting to include family planning services.

EVIDENCE SYNTHESIS

Search strategies identified 16,145 articles, 16 of which met the inclusion criteria. No new intervention studies addressing the impact of quality improvement efforts on family planning outcomes were identified. Sixteen articles provided information relevant to client or provider perspectives about what constitutes quality family planning services. Clients and providers mostly identified the need for services that were accessible, client-centered, and equitable. Themes related to effectiveness, efficiency, and safety were mentioned less frequently.

CONCLUSIONS

Family planning services that account for both patient and provider perspectives may be more effective. Further research is needed to examine the impact of improved quality on provider practices, client behavior, and health outcomes.

An audit of chaperone use for intimate examinations in an integrated sexual health clinic

We performed an audit at the Edinburgh Chalmers Sexual Health Centre to examine if the use and documentation of chaperones complies with the guidance set out by the General Medical Council (GMC) and other regulatory bodies. The case-notes of patients seen in the non-specialist, morning clinics over a one-week period were studied. Only 20 of the 104 genital examinations undertaken were recorded as chaperoned. Only in five of the unchaperoned examinations was it documented that a chaperone was declined. Thus, a total of 24% patients had documentation regarding the presence of a chaperone or the offer of one. However, these results show that our department is certainly lacking in documentation of this, if not the use of chaperones itself. This falls short of the GMC guidance for good practice: primarily in place not only to protect patients from harm, but also to safeguard clinicians against false accusations of impropriety.

Use of chaperones by obstetricians and gynaecologists: A cross-sectional survey

The Royal College of Obstetrics and Gynaecologists (RCOG) recommends that a chaperone should be offered to every patient for an intimate examination. The use of chaperones has risen in primary care, but little is known about the practice of obstetricians and gynaecologists. Our aim was to determine the current attitudes and practices of Fellows and Members of the RCOG regarding chaperones during intimate examinations, both in public and private practice. A total of 800 Fellows and Members were asked to complete a 45-item questionnaire on their use of chaperones and how important a range of issues were in deciding whether or not to offer and provide a chaperone. A total of 449 questionnaires were returned. In summary, 23% of respondents never or occasionally offered a chaperone; 24% of NHS units have no agreed NHS policy and a further 16% did not know if a policy existed. In NHS practice, 77% used a chaperone with only 62% of women using a chaperone. Of those who did private practice, 34% never or occasionally offered a chaperone with 31% actually using a chaperone. In conclusion, obstetricians and gynaecologists use chaperones more than general practitioners but there is significant room for improvement. Chaperones are used more in NHS than private practice.

The Differing Views of Male and Female Patients Toward Chaperones for Genital Examinations in a Sexual Health Setting

OBJECTIVES

To determine the attitudes of male and female patients to the use of chaperones during genital examination within a sexually transmitted diseases clinic.

STUDY DESIGN

An anonymous, self-completed questionnaire was administered to patients attending the Melbourne Sexual Health Centre, Australia, between September and October 2006.

RESULTS

The participation rate among male and female patients was 60% (166 of 276) and 73% (153 of 210), respectively. Among male patients, only 7.3% and 6.0% expressed a desire for a chaperone when being examined by a male and female practitioner, respectively. Among female patients, 26.8% desired a chaperone if they were going to be examined by a male practitioner when compared with 5.5% for a female practitioner (P <0.001). Around one-third of male and female patients indicated they would feel uncomfortable having a chaperone present and this did not vary by the sex of the practitioner (P >0.48). For female patients being examined by a male practitioner, the desire for a chaperone was associated with having had a previous cervical smear (odds ratio, OR = 0.35, 95% CI: 0.12-0.98, P = 0.04) and feeling comfortable about the presence of a chaperone present (OR = 28.9; 95% CI: 11.1-75.0; P <0.001), but not age (P = 0.16) or previous genital examination (OR = 0.55, 95% CI: 0.21-1.45, P = 0.2).

CONCLUSIONS

In a sexual health setting, female patients undergoing genital examination by a male clinician should be asked whether they would like a chaperone to be present.

An extra pair of eyes: do patients want a chaperone when having an anogenital examination?

Background: Anogenital examinations can be embarrassing for patients and can leave clinicians open to accusations of professional misconduct. Little is known about the attitudes of patients in Australia towards the use of chaperones. Methods: In 2006, we surveyed 480 patients attending two sexual health clinics in northern Sydney. Our aim was to determine their attitudes towards the use of chaperones for anogenital examinations. Results: Of the 480, 58% were male and 42% female. Most women (64%) preferred a female examining clinician, whereas most men (68%) had no preference for gender of the examining clinician (P < 0.0001). While 32% of women wanted a chaperone if being examined by a male, 29% did not. Only 4% of women wanted a chaperone when being examined by a female. Only 1% of men wanted a chaperone irrespective of the sex of the examining clinician. Independent predictors of women wanting a chaperone with a male clinician were preference for a female clinician (OR 6.59, 2.48–17.5; P < 0.001) and preference for a female chaperone (OR 4.02, 1.44–11.2; P = 0.008). The majority of participants felt that they should be involved in the decision to have a chaperone. Conclusions: Although a substantial minority of women want a chaperone when being examined by a male, a similar proportion do not want a chaperone. If a woman requests a female clinician, she should be offered a chaperone if there is only a male examiner available. Further study is required to determine why some women want a chaperone and how to distinguish them from other women.

Postmenopausal women undergoing transvaginal ultrasound screening prefer not to have chaperones

The Royal College of Radiologists has recommended chaperones of the appropriate gender for those undergoing intimate scans. This has significant implications for clinical and research programmes. Two hundred and fifty women undergoing scanning in a screening trial were sent postal questionnaires to determine their views as to the presence of chaperones and the gender of ultrasonographers. Ninety-five percent of 198 women stated that they would not like another person to be present during transvaginal scanning. Of greater consequence to women was the gender of the ultrasonographer, with 83.3% expressing a preference for a female ultrasonographer. This needs to be considered in making decisions about allocation of scarce resources.

Attitudes towards pelvic examination and chaperones: a questionnaire survey of patients and providers

Some women find pelvic examinations distressing. Some doctors use this as an excuse not to do them. Most professional organizations recommend the presence of a chaperone for every pelvic examination. In family-planning clinics, usually staffed predominantly by women, the provision of a chaperone for every pelvic examination is a burden to the efficient running of clinics and may not be necessary. Views about pelvic examinations and chaperones were sought from 1000 women attending a family-planning clinic and 98 health-care professionals. The majority of women (59%) do not mind being examined, and when the examiner is female most women do not particularly want a chaperone. One-third of women (34%) actively object to a chaperone. Health professionals are not good at predicting women's feelings and expectations about pelvic examinations. Young women (under 25) and nulligravid women are more likely to find pelvic examinations distressing but not more likely to want a chaperone present. Chaperones should be offered to, but not inflicted upon, women undergoing pelvic examination. Younger women need a particularly sensitive approach. Providers should not be deterred from doing pelvic examinations if they are clinically indicated in the mistaken belief that women will object.

Chaperone use by residents during pelvic, breast, testicular, and rectal exams

We designed a questionnaire survey to study internal medicine residents' plans to use a chaperone during the pelvic, breast, rectal, and testicular examinations. We found chaperone use by male and female residents differed markedly, and neither group planned to use chaperones universally. When examining female patients, male residents overall were very likely to use a chaperone during a pelvic exam, but less likely for the breast exam and rectal exam. For the female resident, there was a significantly lower likelihood of using chaperones during the pelvic, breast, or rectal exams. There was a much lower rate of chaperone use during the sensitive portions of the male physical examination compared with the female examination, with somewhat higher use by female residents. We concluded that male and female residents differ significantly in their patterns of chaperone use. It would be valuable to develop guidelines for chaperone use to help residents understand the issues involved in the choices, and to protect the residents from the possible medico-legal consequences of forgoing chaperones.