A third person is just a third wheel in a trusting doctor-patient relationship.
Yale-New Haven Hospital and affiliated clinics have a rule that a chaperone must be present for any examination of so-called "sensitive" areas, including breasts, genitalia, and perianal area. Having a chaperone present is mandatory, and in visits to my gynecologist at Yale, I have been told that I am unable to refuse one.
What proper chaperoning looks like is not clearly defined. During my examination, the chaperone has either stood behind a curtain (unable to see me) or has averted her eyes. Presumably, she looks away to provide some sense of privacy instead of watching the doctor and me (also a doctor) with an eagle eye. While I appreciate the consideration, the usefulness or protection provided by requiring a chaperone remains questionable.
Inefficient and Delayed Care
Many different kinds of physicians may need to examine the breasts, genital area, or perianal area of their patients. The gynecologist or urologist typically examines the genitalia, and certain procedures like colonoscopies definitely involve the perianal area. Additionally, primary care or pediatrician visits might include a breast exam; surgeons, oncologists, and dermatologists also examine these sensitive areas in some cases.
The list goes on. At many health facilities, all of these visits would need to involve a chaperone. Some medical organizations, such as the American College of Obstetrician and Gynecologists, recommend that a chaperone is present for all breast, genital, and rectal examinations; other bodies, such as the American Medical Association, endorse having medical chaperones available for patients to request during examinations.
Chaperones are touted as "best practice," but what is this based upon?
Advocates for chaperones claim that chaperoning provides comfort, safety, privacy, and security for both the patient and physician. While this can be the case when a patient wants a chaperone and feels comfortable with the chaperone they're given, I can personally attest to the fact that it's not always true when chaperones are required.
Another concern is whether the training of chaperones is appropriate and sufficient. Currently, there are no universal training requirements. Some states do not require chaperone training for those who are already healthcare professionals, but provide it for individuals without a medical license. For example, the state of Oregon has approved a 2-hour online training module offered by the University of California Irvine.
Data on the effectiveness of chaperones in promoting best care is mostly absent. Additionally, chaperones are not always easily available to doctors in daily practice -- including in my practice as a dermatologist -- and waiting for a chaperone can potentially delay care for patients who need to be seen and examined on short notice.
Given limitations of time and resources, we need more data on which interventions would truly increase both doctor and patient comfort, safety, and satisfaction before health systems implement rules requiring chaperones.
Chaperones Can Harm the Doctor-Patient Relationship
When I am the patient, I don't want a chaperone. As a patient who values her privacy, I prefer that as few people as possible have a view of my "sensitive" body parts. Studies support that, like me, some patients do not want a chaperone present. Notably, some patients who do desire a chaperone prefer family members or friends, not adding another medical professional who is a stranger to the room. Yet, many academic institutions or medical groups mandate that only healthcare workers can serve as chaperones.
In my opinion, chaperoning implies that doctors and patients cannot trust each other, which is truly harmful to the doctor-patient interaction. A chaperone, as a third party in the doctor-patient interaction, may only serve to increase the patient's vulnerability, encroaching on their privacy and confidentiality. Security and trust are necessary between doctor and patient in order to share personal information of any kind, particularly information related to sexual activity or mental health, as stigma is common.
Patients who trust their doctors have better health overall. It's not only patient trust that is important -- if doctors cannot trust patients, doctors cannot do their best job, which further disconnects doctors and patients.
Patient Choice Matters
To be sure, I wholly support having patient safety checks and other safety measures in place, and I agree that any patient who wants a chaperone should be able to have one. Medical visits can be scary to a patient. Whether having two healthcare providers (doctor and chaperone) involved in an intimate examination is less or more frightening is a matter of patient preference.
Given the power differential that can be present between patient and doctor, the choice of having a chaperone (and ideally, the choice of who the chaperone is) should be established before the patient enters the examination room. The healthcare system can then take responsibility for providing the proper chaperone based on the patient's desires.
Finally, it is important to interrogate who the chaperone is actually protecting: patient or doctor. There has been increasing violence against healthcare workers in the past decade. Some might suggest that a chaperone is protective, but that is only against unfair allegations of misconduct, not violence. If a chaperone is there for patient protection, the chaperone then should be someone who the patient knows and trusts. If the chaperone must be from the healthcare system, the patient should be able to get to know that chaperone and ideally have the chaperone present each visit, in its entirety, if so desired.
For health systems requiring chaperones, it's time to reevaluate the evidence and take into account patient preference.
Christine J. Ko, MD, is a professor at Yale University where she has been practicing dermatology and dermatopathology for over 15 years. She is also a public voices fellow with the OpEd Project, and author of the book, How to Improve Doctor-Patient Connection: Using Psychology to Optimize Healthcare Interactions.