Intimate Examinations
Ref No: BFCR(98)5
Draft guidance was issued by the General Medical Council in November 1996 to address complaints that they receive each year from patients who feel that doctors have behaved improperly or roughly during intimate examinations. The advice given to doctors at that time was summarised as follows:
- Explain to the patient that an intimate examination needs to be done and why.
- Explain what the examination will involve.
- Obtain the patient's permission.
- Whenever possible, offer a chaperone or invite the patient to bring a relative or friend.
- Give the patient privacy to undress and to dress.
- Keep discussion relevant and avoid unnecessary personal comments.
- Encourage questions and discussion.
This advice is issued by the Royal College of Radiologists with a view to amplifying the GMC advice with special reference to the radiological aspects of intimate examinations.
Many examinations, especially those affecting anatomical areas of the chest (female), pelvis and upper thigh are potentially stressful to the patient. Examinations directly concerning or related to the breasts, genitalia, anus or rectum are particularly intrusive and may make the patient feel exceptionally vulnerable. Although Members and Fellows are clearly aware of the need for sensitivity and delicacy in such situations, the GMC expects the College to offer detailed clinical guidelines which include the following procedures:
- transvaginal, trans-anal and trans-rectal ultrasound,
- scrotal, penile and perineal ultrasound,
- X-ray and ultrasound hysterography and hysterosalpingography,
- contrast enema examination and defaecating proctography,
- X-ray mammography and breast ultrasound,
- urethrography and cystography,
- endorectal MRI.
Other examinations involving the anatomical areas mentioned above must be considered within the scope of this guidance note, for example echocardiography and doppler femoral vein studies.
General considerations
Patients should be provided with private, warm, comfortable and secure changing facilities. All intimate examinations should be preceded by a careful and sympathetic explanation of the technique.
Patients should be offered the opportunity to have a chaperone of the appropriate gender present during the examination. This would normally be another health care practitioner. The requirements and wishes of ethnic minorities, other cultural and social groups should also be taken into consideration when appropriate for local circumstances. If the patient refuses the offer of a chaperone, a written record should be kept and the operator should consider any consequential risks prior to the examination being performed.
Clear informed verbal consent must be obtained prior to all intimate examinations.
The examination will normally be performed in a room that cannot be entered while the examination is in progress, except in an emergency.
The examination should be performed as gently and carefully as possible. All such procedures are performed consequent upon patient symptomatology and care must be taken to observe both verbal and non verbal signs to minimise patient discomfort. Occasionally, as in provocation vaginal sonography, it may be necessary to attempt to provoke the cause of the patient's discomfort. As this is often related to dyspareunia specific questions should be technical rather than of a sexual nature.
Other personal comments should be avoided during the course of the examination.
Special circumstances
The ethnic, religious and cultural background of some women can make intimate examinations particularly difficult, for example, Muslim and Hindu women have a strong cultural aversion against being touched by men other than their husbands. Muslim women should be allowed the opportunity to limit the degree of nudity by, for example, uncovering only that part of the anatomy that requires investigation by ultrasound or x-ray. Wherever possible, particularly in these circumstances, a female radiologist sonographer or other suitably trained healthcare practitioner should perform the examination.
Patients who experience difficulty with the procedure
Vaginal examination may be impossible for reasons such as vaginismus, radiation fibrosis etc; both sexes may find rectal examination impossible either because of pain (for example from an anal fissure) or sphincter spasm. In most cases it is appropriate to abandon such a difficult examination, invite the patient to dress and discuss the problem. Usually the examination can then be attempted later although some patients will require an alternative procedure such as transabdominal ultrasound or sedation prior to the procedure.
Patients with learning difficulties or mental illness
In these situations a familiar individual such as a family member or carer may be the best chaperone. A careful, simple and sensitive explanation of the technique is vital. Adult patients with learning difficulties or mental illness cannot devolve consent and consequently resistance to any intimate examination or procedure must be interpreted as refusal to give consent and the procedure abandoned.
Children
For children under the legal age of consent, they and their parents or guardians should receive an appropriate explanation of the procedure in order to obtain their co-operation and consent.
Training issues
Teaching intimate radiological examinations is particularly difficult. Agreement that a trainee can be present should be obtained from the patient prior to the examination and it should be made clear that there would be no disadvantage to the patient if they refused to have a trainee present. Patients are understandably reluctant to be examined by inexperienced individuals and the embarrassment and inexpertise of the trainee may convey itself to the patient. The procedure requires sensitive handling of the trainee as well as the patient. Trainees must observe not only the procedure itself but also the process of explanation, eliciting verbal consent and post-procedural discussion. Careful direct supervision of the performance of all aspects of the procedure performed by the trainee is necessary, until the trainer is confident that the trainee is capable of achieving a diagnostic examination in a sensitive and sympathetic fashion.
Consent
Informed consent is essential for all intimate imaging and interventional procedures. It will be more meaningful if the patient has had time to consider the procedure by, for example, information given to them, either verbal or written, when they are referred. Careful explanation of the procedure and the indications for its performance with an attendant verbal consent in the presence of the chaperone are required at the time of the procedure. It is the Royal College of Radiologists' view that written consent is not necessary for the majority of intimate examination procedures. The patient's right to refuse any procedure must be respected.
Approved by Faculty Board:
10th July 1998
Approved by Council:
31st July 1998
BFCR(98)5
Section on "Children" updated to take account of the Children Act - March 1999
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