Erection ethics

Abstract

Dear Dr Dermatoethicist: A female medical student rotating through dermatology performs a total body skin exam (TBSE) on a 73-year-old male patient with history of melanoma. During the exam, the naked male patient who was covered by a sheet states “I'm sorry; this hasn't happened in years” and brings to the attention of the medical student that he has an erection. The patient appeared embarrassed, made light of the situation, and feigned a laugh. How should the female student-physician handle this scenario?–Embarrassed Dear Dr Dermatoethicist: A female medical student rotating through dermatology performs a total body skin exam (TBSE) on a 73-year-old male patient with history of melanoma. During the exam, the naked male patient who was covered by a sheet states “I'm sorry; this hasn't happened in years” and brings to the attention of the medical student that he has an erection. The patient appeared embarrassed, made light of the situation, and feigned a laugh. How should the female student-physician handle this scenario? –Embarrassed Dear Embarrassed: Even in uncomfortable situations, physicians have a duty to provide the best, most sensitive care to our patients. In the instance of a male patient's inadvertent sexual arousal, this can be difficult and needs to be handled carefully and compassionately. The best strategy is to remain ostensibly unperturbed and continue the TBSE, so as not to deprive the patient of a thorough examination. Avoiding any part of the exam would not be in the best interest of the patient and doing so would compromise your beneficent duty to the patient. The goal to do no harm, the principle of nonmaleficence, would be violated if the exam were not complete. Physicians must be sensitive to their patient's embarrassment by demonstrating that what has transpired has not in any way threatened the patient–physician relationship. Reassurance and nonchalance are the best techniques. Ignoring the patients aroused state and continuing on with the exam is an appropriate option. If the patient appears particularly uncomfortable, consider reassuring the patient and offering to leave the room for a moment to enable the patient to recover his equilibrium. Performing this action might help to maintain the patient's sense of dignity and autonomy. In acknowledging the patient's erection, it is important to avoid any comment or action that could be misinterpreted as sexual harassment. Alternatively, if the patient is sexually inappropriate toward medical staff, the dermatologist might want to employ the use of a chaperone during the encounter to keep themselves safe and avoid any misconstrued actions. Chaperone policies have been shown to be helpful in supporting female patients undergoing genital exams, but the benefit of chaperones during male genital examinations is less clear.1Bignell C.J. Chaperones for genital examination: provide comfort and support for the patient and protection for the doctor.BMJ. 1999; 319: 137-138Google Scholar Additional health care staff in the room is costly for the practice2Wai D. Katsaris M. Singhal R. Chaperones: are we protecting patients?.Br J Gen Pract. 2008; 58: 54-57Google Scholar and might increase patient anxiety and embarrassment. This scenario can occur regardless of sex or age of the physician or student. Chaperone use is uncommon, but it is important to have discussions with patients regarding their preference.3Stanford L. Bonney A. Ivers R. et al.Patients' attitudes towards chaperone use for intimate physical examinations in general practice.Aust Fam Physician. 2017; 46: 867-873Google Scholar, 4Grandhi R. Grant-Kels J. Naked and vulnerable: the ethics of chaperoning full-body skin examinations.J Am Acad Dermatol. 2017; 76: 1221-1223Abstract Full Text Full Text PDF Scopus (3) Google Scholar Physicians and students have the right to feel safe in their workplace; if necessary, they should be given the opportunity to debrief with a senior colleague. The frequency of involuntary patient arousal occurring during a medical examination has not been documented but creates an uncomfortable circumstance for the patient and provider. The patient is already in an inherently vulnerable state, and it is our job to make them feel safe and provide good care, even in the setting of inadvertent arousal during a medical encounter. – Dr Dermatoethicist