For my entire life as a physician, from medical school, through residency and now until this 22nd year in practice, I have subscribed to the idea that I should have a chaperone when performing breast, pelvic or rectal exams on women. I was taught to do this from the beginning, and I still do it.

Why is this? On some level, the woman being examined probably feels more at ease having another woman in the room when a man is there. There is a remarkable vulnerability and intimacy to those sorts of exams. But at least as important, the tradition exists to prevent any inappropriate sexual advances or behavior on the part of the provider and to serve as witness that they did not occur. It was an idea predicated on a traditional view of sexual attraction and behavior. Thus, men generally did not take chaperones when examining men, and women did not generally take them when examining women. In fact, I recall that women seldom were chaperoned when examining men. After all, we were taught, only men are sexually aggressive! And a female physician would never do anything like that!

Now, however, it’s a brave new world. And I wonder, what shall we do with the whole chaperone thing? First of all, it’s clear that both men and women are capable of illicit sexual behavior. And that’s just in the traditional straight sense. However, with ever evolving definitions of sexuality, how is our view of chaperones altered?

From what I have read online, one of the fundamental beliefs of LGBT, etc. physicians is that nobody feels they should be compelled to reveal their sexuality. Fair enough. But what does that mean in terms of chaperones? If a gay physician examines a straight man’s genitals, or performs a rectal exam on him, should that physician bring a male, or a female, chaperone? And what about the sexuality of the chaperone? If the gay physician has a male chaperone, shouldn’t we ensure that the chaperone is straight? And if the female chaperone is a lesbian, I suppose it would be better than having a straight female chaperone, as she might also find the exposed man sexually interesting. And if a lesbian physician performs a pelvic on a woman, it makes sense that she have a straight female chaperone. But would a gay male be just as good? A straight man certainly wouldn’t do.

Wait, what if the patient is gay? Would a lesbian physician need a chaperone? Or would a lesbian patient need for her gay physician to have a chaperone? And what about a patient, or provider, who is bisexual? Does that require two chaperones? Should chaperones be chaperoned? What a vast cauldron of lust might ensue if we kept adding chaperones to the mix! And would we explain the sexual melting pot to the poor patient, who reclines in stirrups or bends over the table, potentially unaware that he or she is the object of so much potential controversy, lust, and litigation?

Sexuality aside, what happens when patient, or physician, have alternate genders? And what if those genders have alternate sexualities? I mean, I’m a baby-boomer and a little behind, I admit. But it stands to modern reason that a man who self-identifies as a woman could be a lesbian who is thus attracted to women and comes sort of, you know, full circle. Can a female physician, who is a self-identified male, be trusted to examine, alone, a lesbian patient? Or indeed, a gay patient?

Dare we inquire, in medicine, about both gender and sexuality as it pertains to being alone with a patient? And should we update the charts of our patients regarding gender, which appears to be endlessly mutable, unlike what our culture believes sexuality to be, which is carved in stone? And is it the duty of the provider to discuss his or her own personal sexuality before performing such exams on patients?

And what happens when the accusations fly in any of these scenarios? Who will be liable when someone alleges that they were assaulted or touched by someone who was sexually attracted to them, but whom the patient never realized was of an alternate gender or sexuality? Who will be liable when the provider is the one faced with unwanted, and unforeseen, advances? And will we be concerned that chaperones can, themselves, be compromised by attraction or group allegiance? After all, that’s one reason we had females chaperone males; for fear, in part, that “the boys” would cover up misbehavior. Finally, is this an open field for litigation? Or simply an open field for more and more regulations in health care?

Of course, this is not to suggest that any of the above groups are particularly prone to sexual predation. This is not some “everyone but straight people are dangerous” assault on those who are different. However, neither is it safe to assume that those of alternate sexualities and genders are not prone to such behaviors. Most of us, even the whitest most male and straight, were not sexual predators. But for the good of our patients, it was always assumed that we might be.

We tend to believe that when we change societal norms, it’s always a liberation, always a move from uneducated to enlightened, from repressed to expressed. But as I ponder the issue of chaperones, I’m not sure. What I am sure of is this: equality means that everyone gets distrusted just as much as everyone else. Equality means no free passes for being unique, edgy, alternative or formerly oppressed. It means that we’re all equally capable of good, and bad, simultaneously.

We can make two possible mistakes. We can simply assume everyone wants to have sex with everyone else, all the time; which is untrue and could not be monitored at all. Or we can pretend that it’s all a joke, because ‘nobody would do something like that.’ That’s a fool’s errand indeed.

So I suspect it means we’ll be needing a lot more chaperones from here on out.

Edwin Leap is an emergency physician who blogs at edwinleap.com and is the author of The Practice Test and Life in Emergistan. 

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