Abstract
The aim of this study was to determine the experience and views of female patients when they were offered a chaperone by a male sexual health practitioner for a genital examination. Between November 2007 and January 2008, an anonymous survey was administered to female patients seen by male practitioners at Melbourne Sexual Health Centre. None of the 79 (95% CI 0–5%) patients who were offered a chaperone and declined one reported that they were uncomfortable declining the offer. The qualitative analysis showed that some participants appreciated being offered the option of a chaperone even if they did not want one and that the professional attributes of the practitioner influenced their decision not to have a chaperone. Only 8% (95%CI 4–15%) felt uncomfortable when asked if they would like a chaperone. The results reassure that when a female patient declines the offer of a chaperone within a sexual health clinic, the male practitioner can feel confident that this is the expression of the patient's wish.
INTRODUCTION
Previous studies have shown that between 26.8% 1 and 32% 2 of female patients report the desire for a chaperone during a genital examination when asked before seeing a male practitioner. However, these studies have generally asked this question before the woman has actually seen the practitioner. When we introduced a new policy which recommended that male practitioners ask female patients if they preferred that a chaperone be present, few female patients actually accepted this offer. It was unclear why so few women indicated they wanted a chaperone. We hypothesized that it might be due to two possible factors. First, women may have been uncomfortable accepting the offer of a chaperone because it suggested that the women mistrusted the practitioner. Secondly, they may have felt more comfortable with the practitioner after the history was taken, so that they no longer felt the need for a chaperone. If the first explanation was true then women should be asked prior to seeing a male practitioner and our centre would need to change its policy.
We therefore undertook an anonymous survey to determine the preferences of women for a chaperone after they had seen a male practitioner. In addition, we also wanted to investigate the female patients' experience of being offered chaperones by the male practitioners.
METHODS
This study was a cross-sectional survey of female patients attending Melbourne Sexual Health Centre between November 2007 and January 2008 who were seen by male practitioners. Male practitioners (doctors and nurses) invited female patients to answer an anonymous, self-completed questionnaire after consulting with that practitioner, whether the consultation involved a genital examination or not. At the time of the study it was recommended that male practitioners routinely offer a chaperone to female patients after taking the history and before the examination.
Female patients were eligible if they were being seen by a male practitioner and had sufficient English literacy to complete the questionnaire unassisted. Patients were asked to return the questionnaire in a locked survey box. The questionnaire was designed to ascertain the proportion of female patients that accepted the offer of a chaperone, their feelings when they were offered a chaperone by the male practitioner, and when they declined the offer. Free text comments on these were sought. The purpose of this was for us to gain additional insights into participant's thoughts and experiences associated with chaperones.
Questionnaire responses were entered and analysed with SPSS 15.0 (SPSS Inc., Chicago, IL, USA) for Windows. The free text responses were analysed for themes. Responses were reviewed independently by two researchers who arrived at similar thematic classifications, which were refined into five thematic categories. Approval for the study was obtained from the Alfred Hospital Human Research Ethics Committee.
RESULTS
During the recruitment period, there were 3610 clients seen of whom 1574 were females. Of the 1574 female clients, 348 were seen by male practitioners. Of these women, 236 were eligible and offered the questionnaires by the male practitioners. A total of 220 (93%) patients agreed to participate in the survey. Nineteen of the patients who agreed to participate in the survey did not complete the questionnaire. The data from 201 participants were analysed.
The mean age of the participants was 29 (range 17–58). Most of the participants had had prior genital examination and/or cervical smears (respectively, n = 176 [88%] and n = 171 [85%]) (Table 1). Only 35% (n = 70) participants were first time patients to the centre. Of the 201 who participated in the study, 167 (83%) were examined during the visit of whom 102 were offered a chaperone and 79 declined the offer of a chaperone. None of the 79 who were offered and declined a chaperone reported that they were uncomfortable indicating this to the practitioner. Patients who had colposcopy examination were required to have chaperone with them and were included in the number who accepted the offer.
Female patient attitudes to the use of chaperones when seeing male sexual health practitioners (n = 201)
*n = Participants who had genital examination
† n = Participants who were offered chaperone
‡Those coded as yes included colposcopy clients where a chaperone is always present
§ n = Participants who rejected the offer of chaperone
**Some missing data
Only 8% (n = 8) of the 102 women who were offered a chaperone were made uncomfortable by the offer which was similar to the percentage of all women in the survey (201) who felt they would be made uncomfortable being asked about a chaperone (9%, n = 18).
Qualitative analysis
Of the 201 participants, 41 (20%) provided comments which were classified into five thematic categories. Most of the comments were brief, relating to one theme. They comprised between one to three lines of text, with the maximum being five lines. Five related to two to three themes. While the majority of comments were related to chaperone issues there were some that provided feedback about services provided by the centre. Chaperone-related themes included:
Attributes displayed by male practitioners led to high levels of satisfaction with care
Fifteen participants wrote that they were very satisfied with the care they received from the male practitioners. They described the attributes displayed by the practitioners that led to this satisfaction.
‘It's difficult to say whether I would want a chaperone or not. Based on my experiences today (totally lovely, professional, and unthreatening) I wouldn't want one’.
And.
‘They always make you feel comfortable and they explain everything in detail’.
Interestingly, 14 of these comments described the anxiety experienced by the client when they knew they were going to be examined by a male practitioner (having previously thought that they would have preferred a female practitioner), which dissipated when the practitioner displayed attributes that reassured them of their competence and professionalism.
‘In the past I have liked female doctors for genital examinations but I have found on both occasions that I have visited that male doctors have been very professional and helpful’.
The participants also described how, based on their positive experiences, they now have no preference for a male or female practitioner.
‘Before the examination I would probably have thought I would prefer a female nurse/doctor, but after being treated by a male, it is not a problem. I now have no preference’.
And.
‘I found both male staff that I saw today to be both friendly and professional. That is the most important thing for me’.
Being asked about chaperones inspires trust in clinicians
Five of the participants described how being asked if they would like to have a chaperone present provided them with a feeling of trust in the male clinician which made them decide not have a chaperone.
‘It makes me feel more looked after when I'm asked for a chaperone. In the end when I have the feeling I can trust the doctor I feel better without an extra person during my examination’.
And.
‘Being asked if I wanted a chaperone made me feel more comfortable but I was happy to have the doctor only’.
Supporting the availability of a chaperone service
Thirteen participants supported the availability of the chaperone service although they preferred to undergo examination without having one present.
‘Personally I don't feel the need for a chaperone, but it's a good idea to ask in case!’
Some of the participants noted that the chaperone service may be important for cultural reasons although this did not relate to their situation.
‘This is a great idea especially considering that patients of different cultural backgrounds come into the clinic. It would put those with concerns at ease I think’.
Not supporting the availability of a chaperone service
There were only three comments that did not support the availability of a chaperone service. These participants felt that having a chaperone present increased discomfort associated with an examination and expressed that it was unnecessary because practitioners are trustworthy.
‘I've had an exam before with a chaperone and it was very uncomfortable to have someone standing there watching’.
And.
‘Chaperones are pointless. Why use them when we live in a society when we can trust our doctors’.
DISCUSSION
To our knowledge, this is the first study to seek the views of women about chaperones for genital examination after being seen by male practitioners. The study showed that female patients who declined the offer of chaperones made by male practitioners within a sexual health service were comfortable declining the offer. Furthermore, the qualitative analysis suggested that some participants valued being offered a chaperone even though they would not necessarily want one and that this offer reinforced feelings of trust in the professionalism of the practitioner. The participants also described attributes displayed by the male practitioners, which led them to decide not to have a chaperone present even though they had previously identified anxiety about being examined by a male practitioner. Few women experienced uncomfortableness when asked if they would like a chaperone.
This study has a number of weaknesses that need to be considered in interpreting our results. For example, the results are only generalizable to the specific study population. This included women examined in a sexual health centre who had sufficient English to answer the questionnaire and the results may not be applicable in other situations or among specific ethic groups.
Only 102 of the 167 women who were examined were offered a chaperone. This is consistent with the centre's non-directive policy of recommending an offer be considered rather than mandating it. If the answers to the 65 women who were examined but not offered chaperones were different from the 102, the results of our study may be incorrect. Several lines of data suggest that this is not the case. First, the answers to similar questions (e.g. being asked about a chaperone) were similar for the 102 as for the entire 201 in the study. Secondly, there were no free text comments about this even when the specific objective of the study was clear in the written explanation about the study.
On the basis of these findings we continue to recommend that male practitioners seeing female clients consider offering a chaperone to women when they are examined. The results reassure that when a woman declines the offer of a chaperone, the practitioner can feel confident that this is the wish expressed by the patient.