Your exam, plus audience

The American Academy of Pediatrics has revised its recommendations [subscription required] about chaperones during physical exams, which has led me to ponder how I conduct my own clinical affairs.

An update to a 15-year-old AAP policy statement clarifies when it is in the best interest for both the pediatrician and patient to have a chaperone present in the room during a sensitive physical examination.

Use of Chaperones During the Physical Examination of the Pediatric Patient …  says that deciding to include a chaperone in the room during a rectal, genital or breast exam should be a mutual decision between the pediatrician and patient after the pediatrician has fully explained the reason for the exam, as well as what the patient can expect during the procedure.

[snip]

Adolescents or young adults may prefer to preserve their privacy from parents or guardians or may be embarrassed to have family members see them in what could be perceived as an awkward situation, said Edward S. Curry, M.D., FAAP, lead author of the statement and a member of the AAP Committee on Practice and Ambulatory Medicine.

However, if a patient is comfortable with having a family member or friend in the room, an additional chaperone — preferably a nurse or medical student — is still suggested.

Having a chaperone present in the room protects both the pediatrician and the patient. Although rare, false accusations of molestation have been made but typically were the result of somebody misunderstanding a procedure that was not explained completely, Dr. Curry said.

Similar to their discomfort with having a parent or guardian present during an examination, patients may be uncomfortable with having a chaperone in the room. If a patient chooses not to have a chaperone, the pediatrician may opt to forego the exam especially if the patient seems anxious or has developmental delays, according to the policy statement.

[snip]

Pediatricians can feel confident proceeding with the exam if they believe the patient is at ease without a chaperone in the room. However, it is important to document the decision in the patient’s medical records, according to the policy statement.

In fact, Dr. Curry recommends documenting everything, including the initial discussion, the decision about the chaperone, the name of the chaperone if one is present in the room and the outcome of the examination.

I found it interesting that there was no distinction made in their recommendations between male and female patients.  There is a big distinction between the two in practice.  (I believe my own experience is typical for most pediatricians.)

I specialize in the care of adolescents, and have performed hundreds of pelvic exams in my career.  I have done one without a female chaperone in the room exactly once, and only at the patient’s strident insistence, which I made her repeat in front of a witness and documented as being contrary to my usual practice and recommendation.  I never, ever, ever do one without a chaperone.  The patient is too exposed and vulnerable, and the mechanics of the examination are too sensitive for me to feel comfortable doing otherwise.  (Being as gay as the day is long would probably fail miserably as a defense were I to be accused of some impropriety.)  With the one noted exception, every patient has accepted this as a given.  Frankly, I would question any male provider who did not have female chaperones for pelvic exams as a matter of course.

Similarly, I always have a family member present for any examination of small children and any developmentally delayed adolescent males.  To do otherwise is unthinkable, as far as I am concerned.  Except in rare cases of suspected abuse (in which case a nurse should be present for the exam), I can think of no good reason for examining a child without a parent present, and parents should be very wary of any pediatrician who would want to examine their child without them.

However, it hasn’t been my practice to have a chaperone present for adolescent male physicals, which involve a genital exam.  For younger adolescents, I will usually ask if they’d like a parent present for the exam (while the parent is still present), and there’s about a 50/50 split between those who want a parent in the room and those who boot them out.  It is my stated preference to have a parent present for the examination, but I defer to the patient’s wishes.  For older adolescents, many show up for appointments without a parent at all (certainly true for those over 18), and I couldn’t recall the last time I had a parent present for an older, cognitively normal adolescent male’s exam if I wracked my brain all morning.

I imagine that most of my adolescent male patients would prefer to have their exams without a chaperone present, all the more so because just about all the staff who would be available to chaperone are female.  However, I have been wondering if my current practice does leave me more vulnerable than is entirely comfortable, and these new recommendations are sufficient catalyst for a small change.  I’m going to start offering chaperones for everyone, and documenting that they were declined (as I suspect they almost always will be).  It’s a little bit more time-consuming to do so, but it’s better to be safe than sorry.

Russell Saunders

Russell Saunders is the ridiculously flimsy pseudonym of a pediatrician in New England. He has a husband, three sons, daughter, cat and dog, though not in that order. He enjoys reading, running and cooking. He can be contacted at blindeddoc using his Gmail account. Twitter types can follow him @russellsaunder1.

3 Comments

  1. Gay as the day is long? heheh. I always liked “queer as a three-cornered wheel”, although I’ve only ever heard it once.

  2. when i was 12 i was in a group home and was told i needed a physical.there was a young lady who was a staff member and she said that she would be taking me to my appointment.i was being chaperoned by an unfamiliar female and i was a male.we talked and listened and to the radio on the way there.i thought she was just going to take me to the appointment and wait outside. we filled out some questions and both went into the exam room.i thought she would leave when the doctor came in. the doctor arrived for my exam and she was a woman. she came in and the two of them talked then she said to me take off my clothes. here i was in front of two woman i had never met before and removing my clothes. i was almost 13 and just started getting pubes.when she said that i must have looked scared and she said to leave my underwear on. so it wasnt that bad. there were two chairs i was sitting on one the lady on the other.i had put my clothes on the chair next to her.then i got up on the exam table. i was sitting on the table and my legs were facing the lady in the chair. the doctor was doing her normal things. then she said lay down. the two women were talking and she started pressing on my stomach and in one quick yank my underwear were around my ankles. i was in shock. she was standing at my chest talking to this lady who could see everything in full view. she now took my underwear off completely and put them on the chair with my other clothes. there i was completely naked in front of two women i didnt even know.and they were both getting a great show of me. it seemed to last a long time but i was probably over in a minute or two. then she said ok and i leaped up to get to my underwear jumped off the table and almost fell. the lady sitting in the chair caught me. yes i was still completely naked. she actually helped me put my underwear back on and my stuff was just inches from her face. on the ride home it was very quiet and we didnt talk about what happened.

    • Had a similar experience during junior high. My Mom decided to allow the school, which brought in a Dr. to perform physicals each year,to handle my physical as my regular pediatrician was unable to do it before the 2nd week of school due to being booked solid.I was told what time of the day to report to the nurses office, and did so.The Dr. was a middle aged female from the local medical college. The school nurse instructed me to undress down to my underwear. I assumed she would leave after getting my weight and vitals.But she stayed in the room.While laying on my back, the Dr. lifted the front of my briefs and felt my abdomen and lymph nodes. I was thinking that wasn’t so bad, that it was over. The Dr. then asked me to take off my underwear and she then put me in whats called the “frog” position.Completely exposed she then proceeded to do a complete genitalia exam. Hernia, penis( I was among the few back in the late 70’s who was intact), and testicles. I was devoid of any pubic hair or any other signs of puberty(late bloomer). Nonetheless i was totally embarrassed at being seen completely nude by two women who until that day I didn’t even know.

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