Chaperones may offer one solution to sexual abuse of patients by medical providers

Stacey Wescott/Chicago Tribune/TNS

Tearha Hill typically stands to one side of the room, with her eyes trained on the medical exam happening in front of her.

The licensed practical nurse watches the doctor. Every few seconds, she looks at the patient’s face, searching for signs of distress.

As a chaperone in the Women’s Health Clinic at Edward Hines Jr. VA Hospital, Hill is present for sensitive procedures including Pap smears, breast exams and pelvic exams, acting as a witness and helping to protect both patients and doctors.

“As a chaperone, we have to ensure patient and provider comfort — for safety, privacy and dignity,” said Hill, who serves in that role in addition to her regular duties.

Preventing patient sexual abuse is an issue that’s gained national attention amid the fallout from scandals such as Dr. Larry Nassar’s abuse of female athletes; the hundreds of allegations leveled at former University of Southern California gynecologist George Tyndall; and Columbia University’s acknowledged failures regarding gynecologist Robert Hadden, also accused of sexually abusing hundreds of patients.

In Illinois, the Tribune recently exposed how several large Illinois health systems allowed health care workers who were accused of sexually abusing patients to continue working, sometimes leading to additional harm.

In one of the most egregious local cases, at least 30 patients have accused gynecologist Fabio Ortega of sexually assaulting them. Several women alleged in lawsuits he assaulted them after NorthShore University HealthSystem – now known as Endeavor Health – already knew he was under police investigation. Ortega pleaded guilty in 2021 to sexually abusing two former patients and was sentenced to three years in prison; his medical license was permanently revoked. Endeavor has settled 21 civil lawsuits related to Ortega.

The Tribune found that Endeavor and other health systems have faced few consequences from state or federal regulators for allowing providers accused of sexually abusing patients to continue working. Sometimes, all regulators required was a plan to do better in the future. The Tribune also found that the state agency that regulates many medical licensees can be slow to take disciplinary action, and providers who worked outside of hospitals sometimes practiced for months while police investigated allegations against them, because of loopholes in state law.

In addition to addressing those issues, some medical experts and survivors of sexual abuse say broader use of chaperones may be one way to prevent misconduct.

“I would like to see rules put in place where this can’t occur to any other women,” said Victoria, one of the women who has sued Ortega and Endeavor, alleging the doctor sexually assaulted her during an exam in 2017. The Tribune is using a pseudonym for Victoria because the Tribune generally does not identify survivors of sexual abuse or assault without their permission.

Victoria told the Tribune she doesn’t know why a chaperone wasn’t in the room with her and Ortega, especially given that he was under police investigation at the time because of another patient’s abuse complaint. She contends in her lawsuit that she asked if her partner could be in the exam room with her and was told no.

Endeavor now has signs in at least some of its doctors’ offices telling patients they can request medical chaperones. In response to Tribune questions, Endeavor said in a statement that it offers chaperones for sensitive exams, such as those involving the breasts or genitals. Endeavor also said it requires any provider accused of abuse to work with a chaperone or be removed from care pending the outcome of an investigation.

Endeavor declined to comment on specific allegations from Victoria and other patients, citing patient privacy and pending litigation. It also would not say whether Ortega was removed from care or required to work with a chaperone after women complained about his behavior, and did not answer questions about when it began offering chaperones for sensitive appointments or whether the policy is related to Ortega.

In a separate statement, Endeavor said it had “enhanced and evolved” its processes and policies to support the reporting of abuse allegations in the years since Ortega worked for the organization. “We have absolutely no tolerance for abuse of any kind,” Endeavor said.

Protecting patients, doctors

In the past, the American College of Obstetricians and Gynecologists recommended that chaperones be used when patients or doctors requested them. But in late 2019, the college changed its position, recommending that chaperones be present for all breast, genital and rectal exams with a few exceptions, such as during medical emergencies. Often, nurses or medical assistants serve as chaperones in addition to their other duties.

“Given the profoundly negative effect of sexual misconduct on patients and the medical profession and the association between misconduct and the absence of a chaperone, ACOG now believes that the routine use of chaperones is needed for the protection of patients and obstetrician-gynecologists,” the college wrote in 2019.

The same document also provided a list of unacceptable behavior during exams, including watching patients undress, asking unnecessary questions about sexual history or sexual desires, and touching patients’ genitals with ungloved hands.

Administrative rules in Oregon and Alabama require chaperones be present, or at least offered, during many exams of intimate parts of the body. Georgia’s administrative rules state that not having a chaperone present during certain types of exams is considered unprofessional conduct, unless the patient specifically refuses a chaperone.

Illinois has no law requiring chaperones at sensitive medical appointments, but the Illinois Department of Financial and Professional Regulation, the state agency responsible for oversight of doctors and many other licensed health care workers, can mandate in some circumstances that providers use chaperones.

So-called chaperone orders must be issued for individual medical providers, including nurses and doctors, if they have been charged with certain crimes, including sexual offenses. Chris Slaby, a spokesperson with the agency, said the orders are one of its “strongest tools.”

The agency has in at least one instance required that a health care provider utilize an attendant while his license is on probation, state records show.

In the absence of criminal charges and a state-issued chaperone order, it’s up to individual health systems in Illinois to decide whether to offer chaperones, and their practices vary.

Veterans Affairs hospitals across the country require chaperones during certain types of appointments, though patients can decline a chaperone if they wish.

Sinai Chicago requires chaperones for all of its gynecological appointments, according to spokesperson Dan Regan. Representatives for Cook County Health and Rush University Medical Center said those institutions also use chaperones for sensitive gynecological appointments.

Other systems in Illinois offer patients the option. Obstetricians and gynecologists who work for Ascension Illinois have signs in their offices telling patients they can request chaperones. At Advocate Health Care and Northwestern Medicine, chaperones are available to patients upon request, spokespeople said.

The American Medical Association recommends that physicians have chaperones available to patients upon request and make sure patients are aware of the option.

The use of chaperones can present challenges for medical practices and health systems, according to the American College of Obstetricians and Gynecologists. Using chaperones might mean a health system has to hire more people or treat fewer patients.

Dr. Kavita Arora, an OB-GYN and recent past chair of the ethics committee for the American College of Obstetricians and Gynecologists, estimates that she sees about 20% fewer patients in a day when using chaperones than she could otherwise. But she thinks it’s worth it.

“It definitely impacts flow,” Arora said. “However, I think it’s really hard to put a price tag on the ethical and legal issues surrounding misconduct and boundary violations.”

Not a perfect solution

Some physicians and patients resist the idea of a third person being in the room during invasive exams.

Dr. Christine Ko, a dermatologist and professor at Yale University in Connecticut, said she was not allowed to refuse a chaperone when she went to Yale Health for a gynecology appointment in 2022. Yale Health requires chaperones at all sensitive appointments, including those involving breasts and genitals.

Ko said she thinks chaperones should be allowed but not required; she wrote an article about the topic last year for MedPage Today.

“It’s uncomfortable enough to be naked in front of one person,” Ko said. “To me, it changes the dynamic if I’m naked or exposed in front of two people.”

As a physician, she said, she also knows that patients sometimes confide important personal information to their doctors that they might not feel comfortable disclosing with another person in the room.

In addition, Ko said the hierarchical nature of medicine makes it hard for her to imagine a chaperone calling out a physician for inappropriate behavior in the middle of an exam.

The American College of Obstetricians and Gynecologists says chaperones should be “empowered to report concerning behavior through a process independent of the health care provider being chaperoned.”

Red flags during sensitive exams

The American College of Obstetricians and Gynecologists lists examples of inappropriate conduct during exams that include:

  • Watching patients undress

  • Failing to drape patients for privacy

  • Failing to obtain consent for sensitive exams, whether or not medical students are present

  • Touching a patient’s genitals with ungloved hands

  • Inquiring unnecessarily about details of a patient’s sexual history or sexual desires

  • Touching a patient’s genitals orally

The organization acknowledges that “although chaperones may deter or discourage sexual misconduct by physicians, sexual misconduct still can occur in their presence.”

That’s what Pamela Harris says happened to her. Harris, who gave the Tribune permission to use her name, filed a lawsuit in 2022 alleging that Dr. Ala Albazzaz fondled her breast during an in-home exam in January 2020, even though an attendant was present.

“I was in tears. I couldn’t believe that happened,” Harris said in a Tribune interview.

State records show that the Illinois Department of Financial and Professional Regulation suspended Albazzaz’s license in 1997 after the agency heard testimony from six former patients who alleged sexual misconduct.

Earlier, prosecutors had filed dozens of charges accusing Albazzaz of touching women inappropriately during exams, according to Tribune reporting at the time. He was acquitted of criminal charges in 1990 related to one patient’s complaint and acquitted again in 1995 following a jury trial based on four women’s allegations, after which prosecutors dropped the remaining charges, the Tribune reported.

The state agency restored Albazzaz’s license to probationary status in 2008 and has required him to work with a female attendant when treating female patients ever since, according to state records.

Harris told Wheeling police in January 2020 that an attendant was in the room when Albazzaz examined her but the attendant’s back was turned when the doctor touched her inappropriately, according to Harris’ lawsuit.

“She should have been an active participant,” Harris told the Tribune. “She should have been facing me, watching what he’s doing and assisting, and she did nothing.”

Police closed the case in September 2020, records show; no criminal charges were brought against Albazzaz.

Albazzaz did not respond directly to the Tribune’s requests for comment on Harris’ allegations. In a letter to a Tribune attorney, a lawyer for Albazzaz described those allegations as “false”; he also stated that the female medical assistant was “observing and assisting Dr. Albazzaz, for the entirety of his examination of the patient.”

Training varies

None of the documents obtained by the Tribune address what training the woman at Harris’ exam might have had to be an attendant.

The American College of Obstetricians and Gynecologists says chaperones should be trained “in the requirements of best clinical practices.”

Health systems contacted by the Tribune take varying approaches to training chaperones. A spokesperson for Rush said it requires all newly hired nurses, medical assistants and certified nursing assistants to participate in training that covers medical chaperoning.

Sinai Chicago and Cook County Health said they don’t require any chaperone-specific training.

The Hines VA, which requires chaperones during certain types of appointments, is developing a policy about chaperones, based on existing VA requirements, that will include additional training on what to look for and the importance of intervention, said Krystal Gilewski, who managed the Hines VA’s Women Veterans Program until December 2022, and still works for the organization.

Cheryl Stevenson, a licensed practical nurse who often chaperones appointments at the Hines VA, said serving as a chaperone is “something you learn, you pick up being a nurse.”

During a chaperoned exam, Stevenson said, she stands where she can see the patient’s face. If the patient looks distressed or uncomfortable, she’ll ask the patient if she’s OK, after which the doctor will typically pause.

Stevenson, who’s worked at the Women’s Health Clinic at Hines since 2015, said she’s never witnessed a physician do anything inappropriate. But if a doctor did cross a line she wouldn’t hesitate to speak up, she said.

“It’s not an issue where you feel uncomfortable or can’t say anything,” Stevenson said. “That’s not the case.”

One local doctor with Endeavor wrote about the increased push for chaperones in an op-ed for the Tribune that was published shortly after Columbia University and its affiliated hospitals announced a multimillion-dollar settlement based on patients’ complaints against former gynecologist Hadden.

Dr. Emmet Hirsch, an OB-GYN, wrote in the October 2022 piece that he couldn’t think of a better way to protect patients undergoing sensitive exams than by using chaperones. Yet he expressed concern that having a chaperone in the room might signal to patients that their doctors cannot be trusted. Hirsch is director of the OB hospitalist program at Endeavor in Evanston.

“And yet, the fact is that our patients need a level of protection we have not previously provided,” Hirsch wrote. “I accept the necessity of having chaperones in my exam room — but I do so with sadness. Sadness that my practice has changed and sadness that my colleagues and I can no longer be relied upon to do no harm to the people who have entrusted themselves to our care.”

Hirsch did not respond to a request for comment, and Endeavor Health would not make him available for an interview.

DePaul University student Samantha Moilanen contributed to this story.

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