Home About us Editorial board Ahead of print Current issue Search Archives Submit article Instructions Subscribe Contacts Login 
  • Users Online: 361
  • Home
  • Print this page
  • Email this page
Cover page of the Journal of Health Sciences


 
 Table of Contents  
EDITORIAL
Year : 2018  |  Volume : 11  |  Issue : 2  |  Page : 105-107

Is patient modesty being honored or outraged in clinical practice? High time to introspect


Department of Community Medicine, Integral Institute of Medical Sciences and Research, Lucknow, Uttar Pradesh, India

Date of Web Publication18-May-2018

Correspondence Address:
Dr. Syed Esam Mahmood
C-5, Ahiliyabainagar, Kalyanpur, Lucknow - 226 022, Uttar Pradesh
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/kleuhsj.kleuhsj_50_18

Rights and Permissions

How to cite this article:
Mahmood SE. Is patient modesty being honored or outraged in clinical practice? High time to introspect. Indian J Health Sci Biomed Res 2018;11:105-7

How to cite this URL:
Mahmood SE. Is patient modesty being honored or outraged in clinical practice? High time to introspect. Indian J Health Sci Biomed Res [serial online] 2018 [cited 2018 Dec 19];11:105-7. Available from: http://www.ijournalhs.org/text.asp?2018/11/2/105/232695



Modesty of a patient may influence her or his health-care utilization. Doctors have been accused of unprofessional conduct after unchaperoned examinations. This article is an attempt to discuss the ethical issues and practices related to outraging of patient modesty on the basis of the published literature. Based on this, recommendations have been made.

A female who has never been naked in front of a stranger has to strip at times for medical reasons. She has a feeling of fear, anxiety, embarrassment, and even anger of being viewed and touched by a nonrelated male. That stranger could be a doctor, a male nurse, or any other health worker present at the time of the ongoing medical procedure. Medical procedures such as an injection in the hip, an administration of an enema, catheterization, cervical cancer screening or mammography, vaginal delivery, C-section, and other surgeries like hysterectomy are common among females. Lack of female staff could be the reason for such procedures to be carried out by males. However, the mental stress due to her illness is further subjected to fear and embarrassment in doing so. The first gaze or touch of a doctor can bring relief to his/her patient, but on the same time, it could be a feeling of uneasiness and discomfort. Many women have named modesty as the reason they do not obtain medical procedures and are not comfortable with a man in that physical proximity. A female patient feeling uncomfortable with a male health-care provider, may not access further medical treatments and follow-ups, and may yield poor treatment outcomes.

Cultural and religious beliefs of a female are responsible for the gender preference of health-care provider. Patients have also voiced dissatisfaction with modesty issues for men and women.[1] Although acceptance under certain limiting situations for a health-care provider of the opposite sex to treat a patient have been tolerated,[2] the overall acceptance of opposite gender provider has been traditionally disliked at the minimum and refused at the extreme measure.[3]

Purnell's model for Cultural Competence provides a theoretical framework for measuring cultural competence in any culture and proposes twelve different domains of culture that need to be considered when studying a specific cultural belief system. The domains are concepts related to country of origin, communication and language, family roles and organization, workforce issues, biocultural ecology, high-risk behaviors, nutrition, pregnancy and childbearing practices, death rituals, spirituality practices, health-care practices, and health-care practitioner concepts including gender preferences.[4]

The Indian Medical Council Act 1956 or the concerned State Medical Council Act clearly states that “Abuse of professional position by committing improper conduct with a patient or by maintaining an improper association with a patient renders a physician liable for disciplinary action.”[5]

Since the time of Hippocrates, a sexual relationship between doctor and patient has been prohibited as there is dysfunctionality in this asymmetric relationship, which has been labeled as polymorphic incest.[6] It is well known that the patient's confidence is linked to the perception of the limits of medical practice, which are both important for the therapeutic relationship. A sexual relationship between doctor and patient is forbidden in several countries by an ethical code.[7]

In São Paulo city, 150 cases against male doctors alleging sexual harassment were registered with the professional council. Male professionals (96.6%) committed abuse against female patients (90.3%) during adulthood (77.7%). Concerning the specialties, most charges were found for gynecology and obstetrics (24.67%), general surgery (5.33%), pediatrics (4.67%), cardiology, medical clinic, and psychiatry (4%), and urology and traumatology (3.33%).

Sexual harassment has also been reported among women doctors and nurses, has become a common practice in India. In a report, none of the victims who were sexually harassed by their coworkers or by their patients and relatives had heard of a Complaints Committee for Redressal of their grievances.[8],[9]

Modesty is not just being covered up or wearing specific clothing, it is about respect. A provider who takes cultural modesty into account is someone who shows respect and caring in the highest degree.[10] Modesty may influence health-care utilization. Chinese and Islamic women have cited modesty as the reason they do not obtain cervical cancer screening or mammography for cancer care.[11],[12]

Recently, the Supreme Court defined Modesty as “The essence of a woman's modesty is her sex.” An insult to the modesty of the woman is an essential ingredient of this offense. If a man exposes his person in an indecent way or uses obscene words which he intends that it should be heard or his obscene drawings should be seen, he is held to be an offender under section 509 of IPC.[13]

Providers should take this into account when discussing private issues, for example, making sure the door is closed, recognizing signs of discomfort when talking about sensitive individuals, and asking the individual if she would like another person present. Some cultures actually require a family member to be present even during noninvasive physical examinations. The code of medical ethics also says that a female attendant should be present when a male doctor examines a female patient. The key question health-care professionals can ask in handling such issues is “Is there anything I should know about your privacy or modesty concerns before I conduct an examination?”[14]

There is no supportive statistics from India about the problem outraging the modesty of female patients by male doctors; however, incidences are reported in the media. Indian Doctors have been accused of unprofessional conduct after unchaperoned examinations.[15],[16],[17] Eight percent of the women sampled by Webb and Opdahl reported experiences where doctors had conducted a gynecological examination in a “less than professional manner.”[18] Unprofessional behavior involved overexposure of the woman's body; inappropriate comments, gestures, or facial expressions and being examined in an unusual position.

Most women want the offer of a chaperone and feel uncomfortable asking for one if it is not offered. Most teenagers want a chaperone during intimate examination, and a family member may be the preferred choice. Many women prefer having a third party present when the examining doctor is male; fewer if the examining doctor is female. For women, a female nurse is generally the preferred choice as a chaperone, would be accepted as a routine part of the clinical examination, and is generally viewed as having a positive supporting role during the examination.[19]

“The elephant in the room study”[20] in 2010 explored the awareness of sexual boundary violations (SBVs) and non-SBVs in the doctor–patient relationship in India and highlighted the need for culturally relevant guidelines in India. Further in 2011, “The Bangalore Declaration Group” submitted a request to the Medical Council of India (MCI) that the topic of boundaries in the doctor–patient relationship be introduced in the medical curriculum.[21] The MCI incorporated the topic in the regulations for graduate medical education.[22],[23] Several behaviors of health-care providers toward their patients have been termed boundary violations by psychotherapists. These behaviors include hugging, dining with, self-disclosing to, making house calls, exchanging gifts with, engaging in nonsexual social activities, lending books to patients during treatment, and sexual intercourse during treatment.[24] The guidelines for doctors on sexual boundaries in the doctor–patient relationship were first drafted by the Bangalore Declaration Group and subsequently worked on by the Indian Psychiatric Society Task Force on Boundary Guidelines.[25]

Based on the above reports, I recommend the following policies:

  1. Examinations need to be conducted in an atmosphere where the patient's cultural and religious beliefs are taken care of. The privacy and modesty of the patient should be respected and preserved. This should be not a prerequisite but a goal
  2. A conversation should be initiated by the health-care provider before conducting the examination with the patient regarding his or her attitude toward modesty. Written informed consent offering him or her an authorized chaperone should be obtained
  3. The health-care provider and patient should never be alone together in a closed place where sexual intercourse could occur or where even such an accusation could be made
  4. Patient should be given the liberty to refuse for a chaperone of the opposite gender. Providing a chaperone of similar gender to the patient would minimize the chances of an unprofessional behavior
  5. If a chaperone is to be provided, a separate opportunity for private conversation between the patient and the physician should also be arranged. The physician should avoid asking questions related to sensitive issues during history taking in the presence of the chaperoned examination.
  6. Complaints Committee for Redressal of grievances in every hospital should be established
  7. It should be clearly mentioned in the appointment letter of the hospital personnel that abuse of professional position by committing improper conduct with a patient or by maintaining an improper association with a patient would render him or her liable for disciplinary action
  8. Rules regarding respecting patient privacy and modesty must be adhered to the chaperones also
  9. Preplacement and interplacement counseling sessions regarding medical ethics should be organized at least annually.




 
  References Top

1.
Kulwicki AD, Miller J, Schim SM. Collaborative partnership for culture care: Enhancing health services for the Arab community. J Transcult Nurs 2000;11:31-9.  Back to cited text no. 1
    
2.
Boggatz T, Dassen T. Learning the meaning of care: A case study in a geriatric home in upper Egypt. J Transcult Nurs 2006;17:155-63.  Back to cited text no. 2
    
3.
van den Brink Y. Diversity in care values and expressions among Turkish family caregivers and Dutch community nurses in the Netherlands. J Transcult Nurs 2003;14:146-54.  Back to cited text no. 3
    
4.
Purnell L. The purnell model for cultural competence. J Multicult Nurs Health 2005;11:1-15.  Back to cited text no. 4
    
5.
Code of Ethics Regulation; 2002. Available from: https://www.mciindia.org/ActivitiWebClient/rulesnregulations/codeofMedicalEthicsRegulations2002. [Last accessed on 2017 Aug 10].  Back to cited text no. 5
    
6.
Cohen C. Bioethics and sexuality in professional relationships. São Paulo: Associação Paulista de Medicina; 1999.  Back to cited text no. 6
    
7.
AMA Code of Medical Ethics; 2007. Available from: http://www.ama-assn.org/. [Last accessed on 2018 Jul 04].  Back to cited text no. 7
    
8.
Cohen C, Kelian RL, Oliveira RA, Gobbetti GJ, Massad E. Sexual harassment in the physician-patient interaction: Analysis of charges against doctors in the state of São Paulo. Clinics (Sao Paulo) 2009;64:1075-83.  Back to cited text no. 8
    
9.
Chaudhary P. Sexual Harassment at Work Place: Experiences of Women in the Health Sector. Population Council an International NGO.  Back to cited text no. 9
    
10.
Andrews CS. Modesty and healthcare for women: Understanding cultural sensitivities. Commun Oncol 2006;3:443-6.  Back to cited text no. 10
    
11.
Rajaram SS, Rashidi A. Asian-Islamic women and breast cancer screening: A socio-cultural analysis. Women Health 1999;28:45-58.  Back to cited text no. 11
    
12.
Facione NC, Giancarlo C, Chan L. Perceived risk and help-seeking behavior for breast cancer. A Chinese-American perspective. Cancer Nurs 2000;23:258-67.  Back to cited text no. 12
    
13.
14.
Marcia Carteret. Modesty in Health Care: A Cross-Cultural Perspective. Available from: http://www.dimensionsofculture.com/2010/11/modesty-in-health-care-a-cross-cultural-perspective/Council, anInternationalNGO. [Last accessed on 2018 Jul 04].  Back to cited text no. 14
    
15.
Doctor Accused of Sexual Harassment. Available from: https://www.timesofindia.indiatimes.com/city/lucknow/Doctor-accused-of-sexual harassment/articleshow/25282459.cms. [Last accessed on 2017 Oct 24].  Back to cited text no. 15
    
16.
AIIMS Turns Blind Eye as Women Face Sexual Harassment. Available from: http://www.indiatoday.intoday.in/story/aiims-turns-blind-eye-as-women-face-sex-trauma/1/146991.html. [Last accessed on 2017 Oct 24].  Back to cited text no. 16
    
17.
Sexual Harassment Charge against AIIMS-Patna Doctor. Available from: http://www.hindustantimes.com/india/sexual-harassment-charge-against-aiims-patna-doctor/story-oJmrpJqpNGdKm7Og2N5V0M.html. [Last accessed on 2017 Oct 24].  Back to cited text no. 17
    
18.
Bignell CJ. Chaperones for genital examination: Provide comfort and support for the patient and protection for the doctor. BMJ 1999;319:137-8.  Back to cited text no. 18
    
19.
Webb R, Opdahl M. Breast and pelvic examinations: Easing women's discomfort. Can Fam Physician 1996;42:54-8.  Back to cited text no. 19
    
20.
Kurpad SS, Machado T, Galgali RB. Is there an elephant in the room? Boundary violations in the doctor-patient relationship in India. Indian J Med Ethics 2010;7:76-81.  Back to cited text no. 20
    
21.
Bangalore Declaration Group. A consensus document requesting the medical council of India to take action on the issue of boundary violations in doctor-patient relationships. Natl Med J India 2012;25:96-8.  Back to cited text no. 21
    
22.
Reforms in Undergraduate and Postgraduate Medical Education. Vision 2015. Medical Council of India; 2011. p. 18. Available from: http://www.mciindia.org/tools/announcement/MCI_booklet.pdf. [Last accessed 2016 Nov 30].  Back to cited text no. 22
    
23.
Medical Council of India Regulations for Graduate Medical Education; 2012. p. 5. Available from: http://www.psgimsr.ac.in/wp-content/uploads/2012/pdf/others/mci-regulations-graduate-medical-education-12.pdf. [Last accessed 2016 Nov 30].  Back to cited text no. 23
    
24.
Jackson JR, DeCesare JZ. The Overly-Friendly Patient. Challenging Office Cases in Obstetrics and Gynecology. Jaypee Brothers Medical Publishers (P) Ltd; 2016. Available from: http://books.google.com. [Last accessed on 2018 Jul 04].  Back to cited text no. 24
    
25.
Kurpad SS, Bhide A. Sexual boundaries in the doctor-patient relationship: Guidelines for doctors. Indian J Psychiatry 2017;59:14-6.  Back to cited text no. 25
[PUBMED]  [Full text]  




 

Top
 
 
  Search
 
Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
Access Statistics
Email Alert *
Add to My List *
* Registration required (free)

 
  In this article
   References

 Article Access Statistics
    Viewed1995    
    Printed68    
    Emailed0    
    PDF Downloaded143    
    Comments [Add]    

Recommend this journal


[TAG2]
[TAG3]
[TAG4]