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What can physicians do to ensure boundaries are respected and assist patients in feeling safe when a sensitive or intimate physical exam has to be performed? The College wishes to provide some guidance and resources for physicians in this article.

A sensitive/intimate examination or procedure (“sensitive examination”) includes the physical examination of, or a procedure involving, the:

• genitalia (regardless of gender),
• rectum (regardless of gender), or
• female breast or the breast of a patient who identifies as female.

A patient’s personal and cultural background, experiences, and gender issues may influence their own definition of a sensitive examination. As such, patients may include in their definition of a sensitive examination or procedure those that involve partial exposure or palpation of body parts in close proximity to intimate/sensitive areas, for example:

• exposure of undergarments,
• palpation of the groin or buttocks, or
• areas in proximity to the breast.

In addition, if the patient is asked to undress fully and put on a robe, or to undress from the waist down and cover with a sheet, this may also be considered a sensitive examination.

The competent and patient-centered performance of a sensitive examination requires both technical proficiency and superlative communication skills. The approach needs to be tailored to the patient's individual circumstances, taking into consideration such factors as their cultural background and needs, their level of knowledge and understanding of what is being proposed, and a trauma-informed approach to the exam.

Vulnerable patients (e.g., those who are known to be survivors of sexual abuse, intimate partner violence, and reproductive or sexual coercion; patients who are not fluent in English; or those who a clinician perceives to be particularly anxious) should be treated with empathy and the exam should be trauma informed.  In these cases, any examination should be treated as a sensitive examination.

1. a) Explain to the patient why an examination is necessary and give the patient an opportunity to ask questions.
2. b) Be vigilant for verbal or nonverbal cues which may indicate that the patient is uncomfortable or hesitant and take time to address this before proceeding.
3. c) Clearly explain what the examination may involve, in a way the patient can understand, so that the patient has a clear idea of what to expect, including any possible pain or discomfort.
4. d) Confirm that the patient understood the discussion. Obtain the patient’s consent to the examination and record it on the patient chart.
5. e) Even though not considered mandatory, offer the patient the choice to have an impartial observer/chaperone present during the examination. The physician should record any discussion about chaperones and the outcome in the patient’s medical record. If a chaperone is present, the physician should record that fact and make a note of their identity. If the patient does not want a chaperone, the physician should record that the offer was made and declined. If a suitable chaperone is not available or if either party feels the chaperone is unsuitable, or does not wish to proceed without a chaperone, offer to delay the examination or refer to a colleague, provided that the delay will not adversely affect the patient’s health (for example a medical emergency).
6. f) Allow the patient time and privacy to undress and dress, and keep them covered as much as possible to maintain their dignity. An appropriate garment and covers should be provided. Avoid adjusting or removing a patient's clothing without express consent.
7. g) Ensure as much privacy as possible in the examination location, both to visual and audible aspects.
8. h) Prior to, during and following a sensitive examination, the physician should ensure that any questions/remarks cannot be construed as demeaning, seductive or sexual in nature; and explain why any questions relating to sexual matters are being asked so the intent of the history-taking is not misconstrued by the patient. Avoid sexual innuendo, sexually suggestive humor, and sexually provocative remarks in professional settings.
9. i) Remain cognizant of the fact that the presence of students/learners also requires the patient’s specific informed consent. Medical students and trainees should be educated about the inherent power imbalance in the patient–physician relationship, avoidance of sexually offensive or derogatory language, risk factors for sexual boundary violations, and procedures for reporting suspected misconduct.

During a sensitive examination, the physician should:

1. a) Follow universal guidelines for use of Personal Protective Equipment (PPE), and always wear gloves.
2. b) Be gentle, sensitive, and empathetic.
3. c) Perform the exam with the minimum amount of physical contact required to obtain the information required for diagnosis and treatment.
4. d) Stop the examination/procedure if the patient so requests.
5. e) Pause the examination/procedure if there is a perception of undue pain or discomfort and review available options with the patient.
6. f) Pause the examination/procedure if any difficulty in completing the process is encountered, explain why any changes to the scope of the examination are necessary and seek permission before proceeding.
7. g) Limit any discussion relevant to the examination/procedure and refrain from making any unnecessary or personal comments.
8. h) Be cognizant of how past trauma and cultural background may affect the patient’s perceptions, reactions and understanding.  

After the sensitive examination:

1. a) Provide the patient with appropriate materials for cleaning and personal hygiene.
2. b) Allow the patient time and privacy to re-dress.
3. c) Discuss the clinical findings, again avoiding any language or remarks which may be misconstrued.

Pelvic examinations in clinical settings are becoming relatively infrequent due to advances in diagnostic tests. However, for many physicians and patients, physical examinations remain a vital part of consultations. The Canadian Task Force on Preventive Health Care (CTFPHC) recommends not performing a screening pelvic examination to screen for noncervical cancer, pelvic inflammatory disease, or other gynecological conditions in asymptomatic women. This is a strong recommendation with moderate-quality evidence. However, it should be noted that a pelvic examination is appropriate in other clinical situations, such as for diagnosis of gynecological conditions when women present with symptoms or for follow up of a previously diagnosed condition.

Applicable bylaws and policies:

College of Physicians and Surgeons of Saskatchewan policy: Sexual Boundaries

College of Physicians and Surgeons of Saskatchewan bylaw 7.1: Code of Ethics

College of Physicians and Surgeons of Saskatchewan bylaw 7.2: Code of Conduct

Resources and references:

CPSBC: Physical Examinations and Procedures video

CMPA: Recognizing boundary issues

SOGC: Guidelines

ACHA guidelines: Best Practices for sensitive exams

GMC: Intimate examinations and chaperones

MDU: Consent and intimate examinations

CPSBC:  Boundary Violations in the Patient-Physician Relationship

CPSO: Advice to the Profession: Maintaining appropriate boundaries

CPSA: Personal & Sexual Boundary Violations

CPSNB: Sexual boundary violations

CTFPHC: Recommendations for routine pelvic exams: Canadian Task Force on Preventive Health Care