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Keywords:

  • Chaperones;
  • intimate tests;
  • research;
  • transvaginal scanning

Abstract

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion and conclusion
  7. Acknowledgements
  8. References
  9. Appendix

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.


Introduction

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion and conclusion
  7. Acknowledgements
  8. References
  9. Appendix

The General Medical Council (GMC) has advised that a chaperone should be offered to patients undergoing intimate examinations. Alternatively, they should be invited to bring a friend or relative.1 The Royal College of Obstetricians and Gynaecologists (RCOG) has followed this up with detailed advice to their members about vaginal examinations.2 In addition, the Royal College of Radiologists (RCR) has recommended that patients undergoing investigations such as transvaginal ultrasound (TVS) should be offered the opportunity to have a chaperone of the appropriate gender who should ideally be a healthcare practitioner.3

Reasons for recommending chaperones include reassurance to patient of the professional nature of the examination, protection to both patient and doctor against false accusations and time efficiency when the chaperone is used as an assistant.4 There are several arguments against the use of a chaperone and these include issues of confidentiality and hampering communication between patient and physician. It can also give rise to mistrust, but there can also be issues of extra staffing, funding and coordination.4 These pressures are even greater in the research setting and in the context of large screening trials such as the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS).

The advice from professional organisations is in response to complaints from patients who feel that doctors have behaved inappropriately during intimate examinations. It is meant to protect patients and doctors. However, recent publications suggest that it may not reflect the view of most women with regard to intimate examination.5,6

Regarding investigations such as transvaginal scanning, there are no reports in the literature of women's opinions either in the clinical or research setting. A pilot survey was therefore undertaken to determine the views of healthy women in the context of a screening trial as this has profound implications on trial design and resources.

Methods

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion and conclusion
  7. Acknowledgements
  8. References
  9. Appendix

The study was carried out in the context of the UKCTOCS, which is a multicentre randomised control trial involving 13 centres in England, Wales and Northern Ireland. The trial involves 202 000 postmenopausal women aged 50–74 years of whom 50 000 are randomised to annual screening with TVS for 6 years. The trial has ethical approval from the multicentre regional and local ethics committees, and all participants signed a consent form. There is an extensive quality-of-life study running parallel to this trial, one aspect of which involves sending women a psychosocial questionnaire if they required a repeat test following their annual screen. In 2003, a random sample of 250 women were sent the five-item study questionnaire (Appendix 1) together with this routine psychosocial questionnaire. No separate introductory letter was sent. The participants were from different trial centres. No volunteers were contacted following receipt of the questionnaire.

Results

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion and conclusion
  7. Acknowledgements
  8. References
  9. Appendix

Two hundred and fifty women were sent postal questionnaires between June and August 2003, of which 234 women (93.6%) returned the completed datasheet, which is consistent with the high return rate for the routine psychosocial questionnaire in UKCTOCS. All the returned questionnaires were usable. Two hundred and eight of the 234 women had undergone a TVS and 26 a transabdominal scan (TAS). All women were postmenopausal with a median age of 62.1 years (range of 50.4–74.3 years), 97.8% were white women, 37 were nulliparous and 69 women had previously had a hysterectomy.

Of the 208 women who underwent TVS, 204 (98.1%) were scanned by female ultrasonographers (Table 1). A female chaperone was present during the procedure for 11 women (5.2%) including the four who were scanned by male ultrasonographers. Overall, 198 women (95.2%) stated that they would prefer not to have a third person present during the scan. This included 10 of the 11 women who had chaperones. Two women commented that they would prefer a chaperone if the ultrasonographer was male, and 175 women (84.1%) expressed a preference for a female ultrasonographer.

Table 1.  Results of study questionnaire
 TVSTransabdominal ultrasound scan
Scanned by female ultrasonographerScanned by male ultrasonographerScanned by female ultrasonographer
No. of women204426
No. of women who were chaperoned742
Gender preference of ultrasonographers
Male000
Female172320
Either2916
Missing information30
Prefer another person to be present during the scan
Yes502
No194424
Missing information50
If yes, preference
Friend/relative101
Hospital staff401
Reason for presence of another person
Company101
Chaperone100
Ask questions for me200
Ask questions and company101

Of the 26 women who had TAS, two preferred the presence of another person during the scan, for company and to ask questions on their behalf rather than for the purpose of chaperoning. One of these women did have a hospital staff member present. Twenty women (76.9%) preferred a female ultrasonographer.

Overall, 222 women (94.8%) stated that they would prefer not to have a third person present. Of the seven women who wanted a third person to be present, only one stated chaperoning as the reason. One hundred and ninety-five women (83.3%) expressed a preference for a female ultrasonographer.

Discussion and conclusion

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion and conclusion
  7. Acknowledgements
  8. References
  9. Appendix

The majority of healthy postmenopausal women undergoing transvaginal scanning as part of a screening trial prefer a female ultrasonographer but do not want a chaperone present during the scan. This finding highlights an important issue with regard to recommendations from professional organisations. The advice given is often in response to highly publicised legal cases and complaints from a small minority of patients. This response may not be in tune with what the majority of the population who undergo the examination actually want from the service.

The stipulation that chaperones should be offered imposes an enormous burden on clinical practice and clinical research. It has led to significant organisational, staffing and financial pressures in continuing trials in the UK and generated concern and worry among clinical researchers. This report on women’s personal preferences will help reassure researchers that trial participants, on the whole, prefer not to have a third person present during transvaginal scanning.

Of the women who underwent TVS, 95% stated that they would not like another person to be present. This is in keeping with recent reports on pelvic examinations in the clinical setting. Of 1000 women attending family planning clinics in Scotland, 89% did not particularly want a chaperone during a pelvic examination by a female practitioner.5 In a similar study from community-based family planning clinics from Manchester, 85% of 126 women preferred to be alone with the female doctor or nurse during an internal examination.7 This has been reported in the primary care setting as well, with 89% of women preferring not to have a chaperone when undergoing an intimate examination with their GP of the same sex.6

It is not clear what factors contribute to these preferences. An earlier study in the general practice setting in 1992 reported that women preferred chaperones if they were undergoing intimate examinations by male physicians or if they had no previous experience of such an examination.8 This is in contrast to the findings of a more recent Scottish study where a higher proportion of women below the age of 25 years, those who had not been pregnant and those with no experience of pelvic examination, indicated that a chaperone might or would make them embarrassed. In the Manchester study, there was no significant difference in preference based on age, ethnicity or previous experience. In our report, only 7 of 234 women expressed a preference for a chaperone, making it difficult to explore contributory factors. It must be noted that the present cohort consisted of women over the age of 50 years, many of whom would have previously undergone a vaginal examination or an investigation such as a cervical smear.

Several surveys to assess the physicians’ practice to offer chaperones for intimate exams have also been conducted, both in general practice and hospital settings. To determine variations in use of chaperones for pelvic examinations (Pap smear) based on sex, age, number of examinations performed and geographic location, a self-administered questionnaire was mailed to 5000 randomly selected members of the American Academy of Family Physicians, with a response rate of 71%.9 Of the returned questionnaires, 2748 were rendered usable. Significantly (P < 0.00001) higher proportion of male physicians (84.1%) used a chaperone in comparison with female practitioners (31.4%). Also significant was that physicians using chaperones were younger (P= 0.01) and performed fewer Pap smears per month. A regional variation was also reported in their use (P < 0.00001). A UK hospital-based survey of 175 lead consultants from genitourinary medicine clinics reported that 96% of male doctors would always use a chaperone for genital examination of female patients in comparison to 59% of female physicians. In contrast, during examination of male patients, only 28% of male and 41% of female physicians used a chaperone.10 A similar questionnaire survey on the use of chaperones by 54 residents (response rate of 87%) during pelvic, breast, testicular and rectal exams reported the major determinant of chaperone use was related to the gender of the examiner.11 More male residents used chaperones for examination of breast and pelvis than female residents. In addition, a chaperone was more likely to be used for a pelvic than a breast examination especially by male residents. On exploring the primary reason for a chaperone, 60% of male residents used them for legal protection. In comparison, none of the female residents used chaperones for medico-legal issues, although 59% stated using them primarily for technical assistance.

The stated reason for the presence of a chaperone is to protect doctors and patients. The assumption is that nursing staff acting as a chaperone can safeguard against unnecessary humiliation or intimidation of patients.12 However, there are numerous instances where this has failed. In the recent cases of Rodney Ledward (gynaecologist) and Clifford Ayling (GP), the presence of a nurse as a chaperone did not protect patients from abuse.13 The reality is that few chaperones have the skill or ability to confront a doctor during the examination when the abuse occurs. The critical issue here is to rid the professions of the few practitioners who act unprofessionally. Similarly, there are instances where chaperones have failed the practitioner and seemingly false allegations have been made and upheld.14

In the current study, five of the seven women who favoured chaperones stated that they would prefer hospital staff. Although the GMC suggests that in addition to a health professional, a patient’s friend/relative could act as a chaperone, this may not always be appropriate especially when there are issues of confidentiality.

In this survey, female ultrasonographers scanned 98.1% of the women. This is reflective of staffing in the NHS where the preponderance of ultrasonographers performing transvaginal scans are women. Most of the men who perform transvaginal scans are male gynaecologists as opposed to ultrasonographers.

The study highlights that of greatest consequence to the women undergoing scans is the gender of the person performing the procedure. Of women undergoing TVS, 84.1% preferred a female sonographer. Only 14.5% stated that they did not mind either sex. No one preferred a male operator. The majority of those who underwent TASs expressed similar preferences.

With the GMC and other professional bodies such as the RCOG and RCR advocating that a chaperone of the appropriate gender must be available for all intimate examinations, it is essential to find the right balance between imposing chaperones and allowing patient choice. It is clear that no single set of guidelines on intimate examination is applicable in all settings.4 When it comes to transvaginal scanning, the views of women need to be considered when making decisions about allocation of scarce resources between training and retaining female ultrasonographers and employing chaperones.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion and conclusion
  7. Acknowledgements
  8. References
  9. Appendix

The authors would like to thank all of the medical, nursing and administrative staff who have contributed to UKCTOCS and are particularly grateful to the women throughout the UK who have participated in the trial. UKCTOCS and the Quality of Life Study are core funded by the Medical Research Council, Cancer Research UK and the Department of Health with support from the Eve Appeal.

References

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion and conclusion
  7. Acknowledgements
  8. References
  9. Appendix

Appendix

  1. Top of page
  2. Abstract
  3. Introduction
  4. Methods
  5. Results
  6. Discussion and conclusion
  7. Acknowledgements
  8. References
  9. Appendix
  • image(Appendix.)

[ United Kingdom Collaborative Trial of Ovarian Cancer Screening ]