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2. Intimate examinations

2.1 The General Medical Council (GMC) advises that it is particularly important to maintain a professional boundary when examining or treating patients where intimate examinations may be involved as these examinations can be embarrassing or distressing for patients.

‘Intimate examinations can be embarrassing or distressing for patients and whenever you examine a patient you should be sensitive to what they may think of as intimate. This is likely to include examinations of breasts, genitalia and rectum, but could also include any examination where it is necessary to touch or even be close to the patient’.3

2.2 The following are examples of what would be considered to be intimate examinations. The list is not meant to be definitive and, as discussed above, what is ‘intimate’ can vary between patients and cultures.

i) Examinations or treatments of the male genitalia.

ii) Examinations or treatments of the female reproductive system or urethra (e.g. endovaginal ultrasound scans, brachytherapy for gynaecological cancers, urethrograms, cystography).

 Note:  Transabdominal ultrasound examinations may be considered intimate by some patients as may some standard X-ray procedures.

iii) Examinations or treatments of the rectum and anus.

iv)  Female breast examinations or treatments.

v)  Ultrasound examinations for deep vein thrombosis that include the groin.

vi)  Lateral projection of the hip using a horizontal beam technique.

vii) Accessing the femoral artery prior to angiographic procedures.

viii) Endorectal MRI.

ix) A standard transthoracic echocardiogram on a female is not considered an intimate examination but still requires sensitivity.9 Individual patients may, however, consider that for them it is intimate, as discussed above.

2.3 You should explain to the patient why the examination is necessary and give the patient an opportunity to ask questions. The explanation should include what the examination will involve in a way the patient can understand, so that the patient has a clear idea of what to expect, including any pain or discomfort. It will be more meaningful if the patient has had time to consider the procedure through the use of, for example, verbal or written information given to them when they are referred.3,4 The Medical Defence Union advises:

‘Careful communication with the patient is key to an effective consultation, as well as helping to avoid any misunderstanding that might trigger a complaint. A patient may not understand why a symptom in one part of the body may require an examination of another area and it is essential to explain why this is necessary. The patient might not have any knowledge of how the examination will be performed, and you should explain what is involved, any equipment you will use , and any discomfort they may experience'.7

2.4 The conduct of intimate examinations must be considered together with obtaining informed consent. There must be policies in place for situations when a patient does not have the capacity to give consent or is of an age where they are legally still considered to be a child. A full discussion of consent for vulnerable adults and children is beyond the scope of this document and reference should be made to advice published by local Trusts and Health Boards, the GMC and professional bodies such as the SCoR and RCR.1,2,3,4

2.5 Witnessed verbal consent will usually be sufficient for most intimate examinations4 including endovaginal ultrasound examinations (assuming 2.3 and 2.4 have been properly actioned). This should be recorded in the patient’s notes, electronic record or report.10 Local protocols should also be consulted.

2.6 Patients coming for intimate examinations or treatments may feel unsure or vulnerable regarding the examination or treatment they are to undergo. Examinations requiring partial undressing and possibly conducted in reduced lighting may increase this sense of concern. It is therefore always important to give a full explanation of the examination or treatment in terms that the patient can understand and to allay their fears by giving them an opportunity to ask any questions they may have and to have their questions answered.

2.7 Some patients may have ethnic, religious, cultural or other concerns with respect to being examined or treated by a person who is not of the same gender. The patient has the right to decline the examination or treatment and should not feel pressurised into continuing. If possible the examination or treatment should be conducted by a practitioner of the requested gender. If one is not available on the day of attendance the patient may have to be offered a new appointment.  For many patients, however, their main concern is that the examination or treatment is conducted in a professional and timely manner. Chaperone considerations will apply as discussed in section 3. 

2.8 Patients should be offered the opportunity to have a chaperone (section 3) irrespective of the practitioner’s gender and examination being undertaken. For professional integrity and safety, the practitioner should give equal consideration to their own need for a chaperone irrespective of the examination being undertaken or the gender of the patient.

2.9 For all procedures which involve touching the patient in a place that they may deem to be intimate, or where such areas might be exposed, it is essential that an explanation be given to the patient before the procedure commences. The explanation must include what part of the body will be touched and why it is necessary. For example, for an imaging examination of the hip, the radiographer might say:

‘I will need to feel your hip bones so that I can position you correctly and get a good picture of your hip.’

An example relating to radiotherapy is:

‘I need to do a vaginal examination to decide which the correct size brachytherapy applicator is for you.’

This may need to be done before the patient is asked to lie on the couch so that there can be no possibility of coercion. In this way, it is hoped that the likelihood of any misunderstanding is avoided.2

2.10 It is advisable to ensure that the patient agrees with, and understands the role of, staff that might be present during examinations or treatments, whether they are considered intimate or not. All staff present should also understand their role and it is good practice to keep the numbers present in the room as low as possible.

2.11 The patient should be given privacy to undress and dress and it is good practice to keep the patient covered as much as possible to maintain their dignity. Do not assist the patient in removing their clothing unless you have clarified with them that your assistance is required.3

2.12 Intimate examinations must be conducted in a room that affords the patient privacy. Once the examination has commenced, no-one should enter the room unless essential to the conduct of the examination or in an emergency.

2.13 You should explain what you are doing as you proceed with the examination and, if this differs from what you have already outlined to the patient, explain why and seek the patient’s permission.

2.14 Be prepared to discontinue the examination if the patient asks you to and be alert to any verbal or non-verbal signs of distress or discomfort. Be prepared to provide a chaperone if initially declined but later requested.

2.15 Keep discussion relevant and do not make unnecessary personal comments. Even if well intended, the wrong meaning can be inferred and can result in a serious complaint.3 It can occasionally be necessary during (for example) provocation endovaginal sonography to attempt to elicit the cause of a patient’s symptoms  during the examination and specific questions asked should be of a clearly technical nature.4

2.16 Give any results or further information to the patient after they have dressed again.

2.17 Depending on local policy, appointment letters may include information on the treatment or examination proposed and also (for example) information on training policy, equal opportunities policy,  chaperones and a request for the patient to advise of any  special needs.

2.18 Some patients may have great difficulty going through with the procedure. For example endovaginal ultrasound scans may be impossible for reasons such as vaginismus, radiation fibrosis etc. Patients may find rectal examination impossible either because of pain or sphincter spasm. The Royal College of Radiologists advise that it is, in most cases, appropriate to abandon the examination and discuss the problem and possible alternatives and solutions after the patient has dressed.4

2.19 Before you carry out an intimate examination on an anaesthetised patient, or supervise a student who intends to carry one out, you must make sure that the patient has given consent in advance. Consent must be in writing.3

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