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The perception and use of chaperones by Nigerian gynecologists
International Journal of Gynecology and Obstetrics 120 (2013) 46–48
Contents lists available at SciVerse ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
The perception and use of chaperones by Nigerian gynecologists Peter O. Nkwo ⁎, Chibuike O. Chigbu, Leonard O. Ajah, Onyemaechi S. Okoro Department of Obstetrics and Gynecology, University of Nigeria Teaching Hospital, Ituku-Ozalla, Nigeria
a r t i c l e
i n f o
Article history: Received 14 March 2012 Received in revised form 12 July 2012 Accepted 11 September 2012 Keywords: Chaperone Examination Gynecologist Nigeria Perception Practice
a b s t r a c t Objective: To determine how Nigerian gynecologists perceive and use chaperones during intimate gynecologic examinations. Methods: A cross-sectional survey of Nigerian gynecologists was conducted with the aid of self-administered, semi-structured questionnaires. Data were analyzed for descriptive and inferential statistics. Results: In all, 97.6% of respondents considered the use of a chaperone necessary during intimate gynecologic examinations and recommended that the Society of Gynaecology and Obstetrics of Nigeria (SOGON) should endorse the routine offer of chaperones for such examinations. However, just 35.9% of male physicians always or often used chaperones, while 76.9% of female physicians used chaperones only under special circumstances. No female physician always or often used a chaperone during pelvic examination. The main obstacles to the use of chaperones were scarcity of personnel to serve in this capacity (87.6%) and patients’ refusal to be examined in the presence of a third party (12.4%). Conclusion: Most Nigerian gynecologists use chaperones at least some of the time and also support a policy of routinely offering chaperones during intimate gynecologic examination while respecting patients’ right to decline this offer. Scarcity of personnel to serve as chaperones is the greatest challenge to the implementation of this policy. © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction The medical profession has always placed the interest of patients above every other consideration, hence the Hippocratic Oath and its subsequent modifications [1,2]. Although physicians are expected to possess high moral and ethical integrity, some occasionally fall short of these expectations. This failure could result from ignorance or moral weakness or both. Practice guidelines and ethical codes serve to remind physicians of their professional responsibilities to their patients and the consequences of suboptimal or negligent conduct. Generally, deviations from the ethical codes and practice guidelines constitute professional misconducts [3,4], such as negligence or exploitation. Sexual abuse or exploitation of patients is a recognized form of professional misconduct [5] that might occur during intimate gynecologic, rectal, and breast examinations. Examination of the erotic organs of the genitalia and breast may lead to sexual arousal on the part of the physician or the patient or both and could result in sexual misdemeanor. To prevent such a scenario, the presence of a third party or chaperone has been recommended for such intimate examinations [4–7]. The chaperone is usually a member of the healthcare team and is often, but not invariably, a nurse [4]. However, scarcity of nurses and other healthcare workers is often cited as a reason for the ⁎ Corresponding author at: Department of Obstetrics and Gynecology, University of Nigeria Teaching Hospital, Ituku-Ozalla, PMB 01129, Enugu, Nigeria. Tel.: +234 8033420542. E-mail address: [email protected] (P.O. Nkwo).
non-use of chaperones during intimate medical examinations [8]. Family members or friends of the patient have sometimes served as chaperones and might be preferred by some patients [8]. Whenever possible, however, an authorized healthcare worker should act as the chaperone [4]. The argument against the practice of chaperoning is that the presence of a third party could interfere with the physician–patient relationship, especially with regards to privacy and confidentiality [9]. As a result, some patients refuse to have chaperones when they undergo medical consultations and intimate examinations [9]. Furthermore, the hiring of additional personnel to serve as chaperones increases the cost of healthcare provision. Nonetheless, physicians have the responsibility to offer patients the use of chaperones whilst respecting their right to refuse chaperone use altogether or to choose who their chaperone should be [10]. Although there is no ethical code or practice guideline in Nigeria that explicitly recommends the use of chaperones for intimate gynecologic and breast examinations, Nigerian physicians are not immune to sexual misconduct during such examinations. Moreover, it is expected that physicians everywhere should be familiar with, and apply, evidence-based best practices irrespective of the location of their practice. As chaperone use is standard practice in many parts of the world, it would be useful to investigate how this approach is perceived and practiced by Nigerian gynecologists. The aim of the present study was to determine the perceptions and practice of chaperone use among Nigerian gynecologists, and to uncover constraints to the use of chaperones during intimate gynecologic examinations. The results were expected to serve as a useful
0020-7292/$ – see front matter © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijgo.2012.07.014
P.O. Nkwo et al. / International Journal of Gynecology and Obstetrics 120 (2013) 46–48
resource to the regulatory authorities in formulating policies on chaperone use in Nigeria.
Table 1 Distribution of respondents according to Nigerian health zone.a
2. Materials and methods A cross-sectional survey was conducted from November 14 to December 31, 2007, among Nigerian gynecologists listed in the register of the Society of Gynaecology and Obstetrics of Nigeria (SOGON) in 2006 [11]. Ethics approval for the present study was granted by the Research Ethics Committee of the University of Nigeria Teaching Hospital Ituku-Ozalla, Enugu, Nigeria. All participants provided verbal consent. A minimum sample size of 230 was determined using the Yaro Yamane formula, which calculates the minimum sample size for a finite population [12]. This sample size represents approximately 43.0% of the population frame of 540 Nigerian gynecologists. In order to ensure proportionate representation, the respondents were first stratified according to the 6 health zones of Nigeria. Next, 43.0% of the registered members of SOGON from each health zone were calculated to obtain the minimum sample size for the corresponding zone. The calculated minimum sample sizes for the health zones were as follows: south west = 75; south south = 59; south east = 48; north central = 27; north west = 14; and north east = 13. To increase the power of the study while maintaining the zonal proportionality of the participants, a maximum 20.0% increment of the calculated minimum sample size was allowed for each zone. Hence, the maximum expected sample size was 285. The expected range of participants from each zone was as follows: south west = 75–90; south south = 59–71; south east = 48–58; north central = 27–33; north east = 13–16; and north west = 14–17. The initial survey was conducted during an annual conference of SOGON in Benin City, Nigeria (November 14–17, 2007). A follow-up survey was done in zones where the minimum sample sizes could not be obtained during the annual conference. Self-administered, semi-structured questionnaires were used to obtain relevant information from the respondents. Data obtained included sociodemographic information; location of practice; opinion on the necessity of chaperone use during pelvic examination; frequency of chaperone use during pelvic examinations; and the availability of persons to serve as chaperones when requested. Respondents were asked to indicate reasons for their expressed opinions and perceived obstacles to routine use of chaperones during pelvic examination. The questionnaires were administered at the point of registration for the SOGON conference to consecutive consenting respondents from each of the 6 health zones. The names of those interviewed were marked with an identifier to avoid multiple administration of the questionnaire to the same persons in the event of a follow-up survey. Data were collected and analyzed using SPSS version 15.0 (IBM, Armonk, NY, USA). Descriptive statistics and Fisher exact test were used, as appropriate. The level of significance was set at a P value of 0.05 or below, with a 95% confidence interval. 3. Results A total of 270 questionnaires were administered; 250 were completed and returned, equivalent to a 92.6% response rate. The distribution of respondents by health zone is shown in Table 1. The respondents comprised 237 males (94.8%) and 13 females (5.2%). In total, 231 (92.4%) of the respondents were married, 13 (5.2%) were single, and 6 (2.4%) were widowed. Of the 250 respondents, 244 (97.6%) believed chaperone use to be necessary during pelvic examination, while 6 (2.4%) thought it unnecessary. All of the female respondents believed that chaperone use is necessary during pelvic examination. The frequency of chaperone use is shown in Table 2. Despite the majority belief that chaperone use is necessary during pelvic examination, only 85 (35.9%) of the male respondents always or
47
Health zone
Distribution
South west South south South east North central North west North east Total
78 62 53 28 16 13 250
a
(31.2) (24.8) (21.2) (11.2) (6.4) (5.2) (100.0)
Values are given as number (percentage).
often used chaperones. None of the female respondent always or often used chaperones; however, 3 (23.1%) female respondents used chaperones occasionally and 10 (76.9%) used chaperones only in special circumstances. The obstacles to routine use of chaperones for pelvic examination in Nigeria are presented in Table 3. The major obstacles were scarcity of personnel to serve as chaperones (n = 219, 87.6%) and patients’ refusal to be examined in the presence of a third party (n = 31; 12.4%). A significantly higher proportion of respondents from the north of Nigeria reported shortage of personnel as an obstacle to routine use of chaperones than their southern counterparts (98.2% vs 84.4%; P = 0.003). Conversely, a significantly greater proportion of respondents from the south than from the north reported patients’ refusal to be examined in the presence of a third party as a hindrance to routine use of chaperones (15.5% vs 1.8%; P = 0.003). All of the respondents reported that there were no national or local practice guidelines on the use of chaperones available in Nigeria. A total of 244 (97.6%) respondents agreed that SOGON should recommend routine use of chaperoning for pelvic examination, while 6 respondents (2.4%) disagreed with this viewpoint. The respondents were asked if the patient should be allowed to choose whether or not a chaperone is present during pelvic examination. In all, 137 (54.8%) of the respondents believed the patient should have a choice, whereas 113 (45.2%) disagreed. Among the female respondents, 8 (61.5%) believed that patients should be allowed to make a choice, while 5 (38.5%) believed they should not be offered a choice. A similar proportion of the male respondents were of the opinion that patients should be allowed a choice regarding the use of a chaperone (54.4%; P = 0.78 for male vs female respondents). 4. Discussion The present study found that the majority of Nigerian gynecologists believe chaperone use to be necessary during pelvic examination. However, it appears that male gynecologists use chaperones more frequently than their female counterparts. The findings of the present study compare favorably with those reported in the USA [13], Canada [8], and the UK [14,15], where practice guidelines and ethical codes specifically require physicians to routinely use chaperones during intimate physical examinations. The observed low use of chaperones by female physicians is also Table 2 Frequency of chaperone use according to sex.a Frequency of chaperone use
Male respondents (n = 237)
Female respondents (n = 13)
Always Often (≥50% of time) Occasionally (b50% of time) Only under special circumstances
30 (12.6) 55 (23.2) 76 (32.1) 76 (32.1)
0 (0.0) 0 (0.0) 3 (23.1) 10 (76.9)
a
b
Values are given as number (percentage). For example, examination of adolescent girls and those who have experienced sexual violence. b
48
P.O. Nkwo et al. / International Journal of Gynecology and Obstetrics 120 (2013) 46–48
Table 3 Obstacles to chaperone use according to Nigerian health zone.a Obstacle
Shortage of nurses Patient refusal of examination in presence of third party Total a
Health zone
Total
South west
South south
South east
North central
North west
North east
66 (84.6) 12 (15.4) 78
56 (90.3) 6 (9.7) 62
41 (77.4) 12 (22.6) 53
27 (96.4) 1 (3.6) 28
16 (100.0) 0 (0.0) 16
13 (100.0) 0 (0.0) 13
219 (87.6) 31 (12.4) 250
Values are given as number or number (percentage).
consistent with findings elsewhere [16–18], as well as with the reported lower acceptance of chaperone use by patients when the examining physician is a female rather than male [10,19]. The perceived low need for a chaperone when the examining physician is female seems to be based on the traditional belief that the risk of sexual exploitation is reduced with a female physician. However, physicians and patients need to be conscious of the increasing cases of same-sex sexual abuse and, therefore, treat all physician–patient relationships alike in the issue of chaperone offer by the physician. The balance of power in any physician–patient relationship remains largely in favor of the physician. Such imbalance could encourage misuse and abuse of power in the absence of a third party, irrespective of the sex of the patient and physician. The present study identified 2 major challenges to the routine use of chaperones; namely, lack of personnel and patients’ refusal to be examined in the presence of a third party. Price et al. [8] reported that the availability of nurses to serve as chaperones was associated with increased use of this approach. While shortage of personnel appears to be the major problem in the northern part of Nigeria, refusal to accept the presence of a third party during gynecologic examination seems to be the major problem of the south of the country. The different religious backgrounds of these 2 regions may explain this finding. The Islamic north is probably more likely to accept a third party during intimate medical examination than the Christian south. Furthermore, the educationally less-advantaged north is also more likely to experience a shortage of personnel in the healthcare service than the south. Refusal of the offer of a chaperone has been widely reported in previous studies [9,14,16,18,20]. Despite their refusal, patients are, however, reported to appreciate the offer as a demonstration of respect for them by the physician [10,14,18,21]. Reasonable practice should be to routinely offer chaperones for intimate physical examinations while respecting the patients’ right to accept or decline the offer. This approach is consistent with the opinion held by the majority of respondents in the present study that SOGON should recommend that physicians routinely offer chaperones for intimate gynecologic examinations while acknowledging and respecting the patients’ right to decline such an offer. Furthermore, some degree of legal protection may be provided if gynecologists routinely document all offers of a chaperone, as well as patients’ acceptance and refusal. This practice is not yet common in Nigeria. Anecdotal evidence suggests that the incidence of allegations of sexual harassment against male gynecologists in Nigeria may be increasing. Routine offer of chaperones and documentation of all refusals may be helpful in such situations. The total absence of any chaperone policy within the respondents’ practice facilities that was observed in the present study is understandable given that there is currently no national, regional, or state chaperone guideline in Nigeria. While the national medical regulatory bodies are expected to provide national chaperone guidelines, it would be desirable for individual gynecology units to develop and implement local policies in the interim. In summary, most Nigerian gynecologists use a chaperone at least some of the time and also support a policy of routinely offering chaperones during intimate gynecologic examination, while respecting patients’ right to accept or refuse this offer. The major challenges to
regular use of chaperones in Nigeria include lack of appropriate personnel and patients’ refusal to be examined in the presence of chaperones. It is recommended that SOGON formulates a policy of mandatory offer of chaperoning during intimate gynecologic examination but that recognizes patients’ right to opt out of chaperone use. Health facilities should be encouraged to provide appropriate personnel to serve as chaperones during intimate physical examinations. Conflict of interest The authors have no conflicts of interest. References [1] Edelstein L. The Hippocratic Oath: Text; Translation, and Interpretation. In: Veatch RM, editor. Cross Cultural Perspectives in Medical Ethics. Second edition. London: Jones & Bartlett Learning; 2000. p. 3–20. [2] World Medical Association. WMA Declaration of Geneva. http://www.wma.net/ en/30publications/10policies/g1/index.html; 2006. Accessed July 5, 2012. [3] General Medical Council. Maintaining Boundaries: Supplementary Guidance. http://www.gmc-uk.org/static/documents/content/Maintaining_Boundaries.pdf; 2006. Accessed September 9, 2012. [4] Royal College of Obstetricians and Gynaecologists. Gynaecological Examinations: Guidelines for Specialist Practice. http://www.rcog.org.uk/files/rcog-corp/uploadedfiles/WPRGynaeExams2002.pdf; 2002. Accessed July 5, 2012. [5] McMurray RJ, Clarke OW, Barraso JA, Clohan DB, Epps Jr CH, Glasson J, et al. Sexual misconduct in the practice of medicine. Council on Ethical and Judicial Affairs, American Medical Association. JAMA 1991;266(19):2741-5. [6] Griffith R. Intimate examinations and trained chaperones. Br J Health Care Manage 2009;15(7):337-42. [7] Coldicott Y, Pope C, Roberts C. The ethics of intimate examinations-teaching tomorrow's doctors. BMJ 2003;326(7380):97–101. [8] Price DH, Tracy CS, Upshur RE. Chaperone use during intimate examinations in primary care: postal survey of family physicians. BMC Fam Pract 2005;6:52. [9] Fiddes P, Scott A, Fletcher J, Glasier A. Attitudes towards pelvic examination and chaperones: a questionnaire survey of patients and providers. Contraception 2003;67(4):313-7. [10] Santen SA, Seth N, Hemphill RR, Wrenn KD. Chaperones for rectal and genital examinations in the emergency department: what do patients and physicians want? South Med J 2008;101(1):24-8. [11] Society of Gynaecology and Obstetrics of Nigeria (SOGON). 2005 Membership Directory. Nigeria: SOGON; 2006. [12] Uzoagulu AE. Practical Guide to Writing Research Project Reports in Tertiary Institutions. New edition.Enugu: Cheston Nigeria; 2011. [13] Johnson NR, Philipson EH, Curry SL. Chaperone use by obstetrician/gynecologists. J Reprod Med 1999;44(5):423-7. [14] Afaneh I, Sharma V, McVey R, Murphy C, Geary M. The use of a chaperone in obstetrical and gynaecological practice. Ir Med J 2010;103(5):137-9. [15] Loizides S, Kallis A, Oswal A, Georgiou P, Kallis G, Gavalas M. Chaperone policy in accident and emergency departments: a national survey. J Eval Clin Pract 2010;16(1):107-10. [16] Baker R, Mulka O, Camosso-Stefinovic J, Sinfield P, Costin N. Patients’ views on and professionals’ use of chaperones during intimate examinations in primary health care: A review. Qual Prim Care 2007;15(6):337-44 [(8)]. [17] Sinha S, De A, Williams RJ, Vaughan-Williams E. Use of a chaperone during breast examination: the attitude and practice of consultant breast surgeons in the United Kingdom. Scott Med J 2010;55(1):24-6. [18] Teague R, Newton D, Fairley CK, Hocking J, Pitts M, Bradshaw C, et al. The differing views of male and female patients toward chaperones for genital examinations in a sexual health setting. Sex Transm Dis 2007;34(12):1004-7. [19] Baber JA, Davies SC, Dayan LS. An extra pair of eyes: do patients want a chaperone when having an anogenital examination? Sex Health 2007;4(2):89-93. [20] Whitford DL, Karim M, Thompson G. Attitudes of patients towards the use of chaperones in primary care. Br J Gen Pract 2001;51(466):381-3. [21] Osmond MK, Copas AJ, Newey C, Edwards SG, Jungmann E, Mercey D. The use of chaperones for intimate examinations: the patient perspective based on an anonymous questionnaire. Int J STD AIDS 2007;18(10):667-71.
Contents lists available at SciVerse ScienceDirect
International Journal of Gynecology and Obstetrics journal homepage: www.elsevier.com/locate/ijgo
CLINICAL ARTICLE
The perception and use of chaperones by Nigerian gynecologists Peter O. Nkwo ⁎, Chibuike O. Chigbu, Leonard O. Ajah, Onyemaechi S. Okoro Department of Obstetrics and Gynecology, University of Nigeria Teaching Hospital, Ituku-Ozalla, Nigeria
a r t i c l e
i n f o
Article history: Received 14 March 2012 Received in revised form 12 July 2012 Accepted 11 September 2012 Keywords: Chaperone Examination Gynecologist Nigeria Perception Practice
a b s t r a c t Objective: To determine how Nigerian gynecologists perceive and use chaperones during intimate gynecologic examinations. Methods: A cross-sectional survey of Nigerian gynecologists was conducted with the aid of self-administered, semi-structured questionnaires. Data were analyzed for descriptive and inferential statistics. Results: In all, 97.6% of respondents considered the use of a chaperone necessary during intimate gynecologic examinations and recommended that the Society of Gynaecology and Obstetrics of Nigeria (SOGON) should endorse the routine offer of chaperones for such examinations. However, just 35.9% of male physicians always or often used chaperones, while 76.9% of female physicians used chaperones only under special circumstances. No female physician always or often used a chaperone during pelvic examination. The main obstacles to the use of chaperones were scarcity of personnel to serve in this capacity (87.6%) and patients’ refusal to be examined in the presence of a third party (12.4%). Conclusion: Most Nigerian gynecologists use chaperones at least some of the time and also support a policy of routinely offering chaperones during intimate gynecologic examination while respecting patients’ right to decline this offer. Scarcity of personnel to serve as chaperones is the greatest challenge to the implementation of this policy. © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved.
1. Introduction The medical profession has always placed the interest of patients above every other consideration, hence the Hippocratic Oath and its subsequent modifications [1,2]. Although physicians are expected to possess high moral and ethical integrity, some occasionally fall short of these expectations. This failure could result from ignorance or moral weakness or both. Practice guidelines and ethical codes serve to remind physicians of their professional responsibilities to their patients and the consequences of suboptimal or negligent conduct. Generally, deviations from the ethical codes and practice guidelines constitute professional misconducts [3,4], such as negligence or exploitation. Sexual abuse or exploitation of patients is a recognized form of professional misconduct [5] that might occur during intimate gynecologic, rectal, and breast examinations. Examination of the erotic organs of the genitalia and breast may lead to sexual arousal on the part of the physician or the patient or both and could result in sexual misdemeanor. To prevent such a scenario, the presence of a third party or chaperone has been recommended for such intimate examinations [4–7]. The chaperone is usually a member of the healthcare team and is often, but not invariably, a nurse [4]. However, scarcity of nurses and other healthcare workers is often cited as a reason for the ⁎ Corresponding author at: Department of Obstetrics and Gynecology, University of Nigeria Teaching Hospital, Ituku-Ozalla, PMB 01129, Enugu, Nigeria. Tel.: +234 8033420542. E-mail address: [email protected] (P.O. Nkwo).
non-use of chaperones during intimate medical examinations [8]. Family members or friends of the patient have sometimes served as chaperones and might be preferred by some patients [8]. Whenever possible, however, an authorized healthcare worker should act as the chaperone [4]. The argument against the practice of chaperoning is that the presence of a third party could interfere with the physician–patient relationship, especially with regards to privacy and confidentiality [9]. As a result, some patients refuse to have chaperones when they undergo medical consultations and intimate examinations [9]. Furthermore, the hiring of additional personnel to serve as chaperones increases the cost of healthcare provision. Nonetheless, physicians have the responsibility to offer patients the use of chaperones whilst respecting their right to refuse chaperone use altogether or to choose who their chaperone should be [10]. Although there is no ethical code or practice guideline in Nigeria that explicitly recommends the use of chaperones for intimate gynecologic and breast examinations, Nigerian physicians are not immune to sexual misconduct during such examinations. Moreover, it is expected that physicians everywhere should be familiar with, and apply, evidence-based best practices irrespective of the location of their practice. As chaperone use is standard practice in many parts of the world, it would be useful to investigate how this approach is perceived and practiced by Nigerian gynecologists. The aim of the present study was to determine the perceptions and practice of chaperone use among Nigerian gynecologists, and to uncover constraints to the use of chaperones during intimate gynecologic examinations. The results were expected to serve as a useful
0020-7292/$ – see front matter © 2012 International Federation of Gynecology and Obstetrics. Published by Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijgo.2012.07.014
P.O. Nkwo et al. / International Journal of Gynecology and Obstetrics 120 (2013) 46–48
resource to the regulatory authorities in formulating policies on chaperone use in Nigeria.
Table 1 Distribution of respondents according to Nigerian health zone.a
2. Materials and methods A cross-sectional survey was conducted from November 14 to December 31, 2007, among Nigerian gynecologists listed in the register of the Society of Gynaecology and Obstetrics of Nigeria (SOGON) in 2006 [11]. Ethics approval for the present study was granted by the Research Ethics Committee of the University of Nigeria Teaching Hospital Ituku-Ozalla, Enugu, Nigeria. All participants provided verbal consent. A minimum sample size of 230 was determined using the Yaro Yamane formula, which calculates the minimum sample size for a finite population [12]. This sample size represents approximately 43.0% of the population frame of 540 Nigerian gynecologists. In order to ensure proportionate representation, the respondents were first stratified according to the 6 health zones of Nigeria. Next, 43.0% of the registered members of SOGON from each health zone were calculated to obtain the minimum sample size for the corresponding zone. The calculated minimum sample sizes for the health zones were as follows: south west = 75; south south = 59; south east = 48; north central = 27; north west = 14; and north east = 13. To increase the power of the study while maintaining the zonal proportionality of the participants, a maximum 20.0% increment of the calculated minimum sample size was allowed for each zone. Hence, the maximum expected sample size was 285. The expected range of participants from each zone was as follows: south west = 75–90; south south = 59–71; south east = 48–58; north central = 27–33; north east = 13–16; and north west = 14–17. The initial survey was conducted during an annual conference of SOGON in Benin City, Nigeria (November 14–17, 2007). A follow-up survey was done in zones where the minimum sample sizes could not be obtained during the annual conference. Self-administered, semi-structured questionnaires were used to obtain relevant information from the respondents. Data obtained included sociodemographic information; location of practice; opinion on the necessity of chaperone use during pelvic examination; frequency of chaperone use during pelvic examinations; and the availability of persons to serve as chaperones when requested. Respondents were asked to indicate reasons for their expressed opinions and perceived obstacles to routine use of chaperones during pelvic examination. The questionnaires were administered at the point of registration for the SOGON conference to consecutive consenting respondents from each of the 6 health zones. The names of those interviewed were marked with an identifier to avoid multiple administration of the questionnaire to the same persons in the event of a follow-up survey. Data were collected and analyzed using SPSS version 15.0 (IBM, Armonk, NY, USA). Descriptive statistics and Fisher exact test were used, as appropriate. The level of significance was set at a P value of 0.05 or below, with a 95% confidence interval. 3. Results A total of 270 questionnaires were administered; 250 were completed and returned, equivalent to a 92.6% response rate. The distribution of respondents by health zone is shown in Table 1. The respondents comprised 237 males (94.8%) and 13 females (5.2%). In total, 231 (92.4%) of the respondents were married, 13 (5.2%) were single, and 6 (2.4%) were widowed. Of the 250 respondents, 244 (97.6%) believed chaperone use to be necessary during pelvic examination, while 6 (2.4%) thought it unnecessary. All of the female respondents believed that chaperone use is necessary during pelvic examination. The frequency of chaperone use is shown in Table 2. Despite the majority belief that chaperone use is necessary during pelvic examination, only 85 (35.9%) of the male respondents always or
47
Health zone
Distribution
South west South south South east North central North west North east Total
78 62 53 28 16 13 250
a
(31.2) (24.8) (21.2) (11.2) (6.4) (5.2) (100.0)
Values are given as number (percentage).
often used chaperones. None of the female respondent always or often used chaperones; however, 3 (23.1%) female respondents used chaperones occasionally and 10 (76.9%) used chaperones only in special circumstances. The obstacles to routine use of chaperones for pelvic examination in Nigeria are presented in Table 3. The major obstacles were scarcity of personnel to serve as chaperones (n = 219, 87.6%) and patients’ refusal to be examined in the presence of a third party (n = 31; 12.4%). A significantly higher proportion of respondents from the north of Nigeria reported shortage of personnel as an obstacle to routine use of chaperones than their southern counterparts (98.2% vs 84.4%; P = 0.003). Conversely, a significantly greater proportion of respondents from the south than from the north reported patients’ refusal to be examined in the presence of a third party as a hindrance to routine use of chaperones (15.5% vs 1.8%; P = 0.003). All of the respondents reported that there were no national or local practice guidelines on the use of chaperones available in Nigeria. A total of 244 (97.6%) respondents agreed that SOGON should recommend routine use of chaperoning for pelvic examination, while 6 respondents (2.4%) disagreed with this viewpoint. The respondents were asked if the patient should be allowed to choose whether or not a chaperone is present during pelvic examination. In all, 137 (54.8%) of the respondents believed the patient should have a choice, whereas 113 (45.2%) disagreed. Among the female respondents, 8 (61.5%) believed that patients should be allowed to make a choice, while 5 (38.5%) believed they should not be offered a choice. A similar proportion of the male respondents were of the opinion that patients should be allowed a choice regarding the use of a chaperone (54.4%; P = 0.78 for male vs female respondents). 4. Discussion The present study found that the majority of Nigerian gynecologists believe chaperone use to be necessary during pelvic examination. However, it appears that male gynecologists use chaperones more frequently than their female counterparts. The findings of the present study compare favorably with those reported in the USA [13], Canada [8], and the UK [14,15], where practice guidelines and ethical codes specifically require physicians to routinely use chaperones during intimate physical examinations. The observed low use of chaperones by female physicians is also Table 2 Frequency of chaperone use according to sex.a Frequency of chaperone use
Male respondents (n = 237)
Female respondents (n = 13)
Always Often (≥50% of time) Occasionally (b50% of time) Only under special circumstances
30 (12.6) 55 (23.2) 76 (32.1) 76 (32.1)
0 (0.0) 0 (0.0) 3 (23.1) 10 (76.9)
a
b
Values are given as number (percentage). For example, examination of adolescent girls and those who have experienced sexual violence. b
48
P.O. Nkwo et al. / International Journal of Gynecology and Obstetrics 120 (2013) 46–48
Table 3 Obstacles to chaperone use according to Nigerian health zone.a Obstacle
Shortage of nurses Patient refusal of examination in presence of third party Total a
Health zone
Total
South west
South south
South east
North central
North west
North east
66 (84.6) 12 (15.4) 78
56 (90.3) 6 (9.7) 62
41 (77.4) 12 (22.6) 53
27 (96.4) 1 (3.6) 28
16 (100.0) 0 (0.0) 16
13 (100.0) 0 (0.0) 13
219 (87.6) 31 (12.4) 250
Values are given as number or number (percentage).
consistent with findings elsewhere [16–18], as well as with the reported lower acceptance of chaperone use by patients when the examining physician is a female rather than male [10,19]. The perceived low need for a chaperone when the examining physician is female seems to be based on the traditional belief that the risk of sexual exploitation is reduced with a female physician. However, physicians and patients need to be conscious of the increasing cases of same-sex sexual abuse and, therefore, treat all physician–patient relationships alike in the issue of chaperone offer by the physician. The balance of power in any physician–patient relationship remains largely in favor of the physician. Such imbalance could encourage misuse and abuse of power in the absence of a third party, irrespective of the sex of the patient and physician. The present study identified 2 major challenges to the routine use of chaperones; namely, lack of personnel and patients’ refusal to be examined in the presence of a third party. Price et al. [8] reported that the availability of nurses to serve as chaperones was associated with increased use of this approach. While shortage of personnel appears to be the major problem in the northern part of Nigeria, refusal to accept the presence of a third party during gynecologic examination seems to be the major problem of the south of the country. The different religious backgrounds of these 2 regions may explain this finding. The Islamic north is probably more likely to accept a third party during intimate medical examination than the Christian south. Furthermore, the educationally less-advantaged north is also more likely to experience a shortage of personnel in the healthcare service than the south. Refusal of the offer of a chaperone has been widely reported in previous studies [9,14,16,18,20]. Despite their refusal, patients are, however, reported to appreciate the offer as a demonstration of respect for them by the physician [10,14,18,21]. Reasonable practice should be to routinely offer chaperones for intimate physical examinations while respecting the patients’ right to accept or decline the offer. This approach is consistent with the opinion held by the majority of respondents in the present study that SOGON should recommend that physicians routinely offer chaperones for intimate gynecologic examinations while acknowledging and respecting the patients’ right to decline such an offer. Furthermore, some degree of legal protection may be provided if gynecologists routinely document all offers of a chaperone, as well as patients’ acceptance and refusal. This practice is not yet common in Nigeria. Anecdotal evidence suggests that the incidence of allegations of sexual harassment against male gynecologists in Nigeria may be increasing. Routine offer of chaperones and documentation of all refusals may be helpful in such situations. The total absence of any chaperone policy within the respondents’ practice facilities that was observed in the present study is understandable given that there is currently no national, regional, or state chaperone guideline in Nigeria. While the national medical regulatory bodies are expected to provide national chaperone guidelines, it would be desirable for individual gynecology units to develop and implement local policies in the interim. In summary, most Nigerian gynecologists use a chaperone at least some of the time and also support a policy of routinely offering chaperones during intimate gynecologic examination, while respecting patients’ right to accept or refuse this offer. The major challenges to
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