A second set of eyes

By Emily Margosian, Senior Editor, July 1, 2025

In dermatology, the physical exam is a core part of nearly every patient encounter, requiring mutual trust between patient and physician.

Chaperones are often used during skin checks of sensitive sites to ensure professionalism, protect against misconduct claims, and support clear communication between all parties present.

Despite widespread physician support for chaperones, some states have begun introducing legislation mandating the presence of chaperones during sensitive exams, including full-body skin exams (FBSEs). DermWorld talks to dermatologist state society leaders and medical ethicists about pros and cons of mandated chaperone legislation.

Protection for patients and physicians

In many cases, the presence of a chaperone serves two functions: reassurance to the patient of the professional character of the exam, and as an available witness to support a physician’s innocence should a misunderstanding or false accusation be made by the patient.

“Chaperones that are the same sex as the patient have been demonstrated to make some patients feel safer. Chaperones can also be protective of the physician as they are a witness to the encounter in the rare case a sinister patient is inappropriately litigious,” wrote Jane Grant-Kels, MD, FAAD, in a recent DermWorld Insights and Inquiries column. “Patients should be offered a chaperone so that they have a sense of control over their environment and feel safe. Where mandated, if a patient refuses a chaperone, limit the exam to avoid sensitive areas and document your chart as to why.”

“Patients should be offered a chaperone so that they have a sense of control over their environment and feel safe.”

According to Stephanie Fabbro, MD, FAAD, chair of the AAD Professionalism & Ethics Committee, statutory requirements can add a layer of protection for both physicians and patients as they establish a uniform, non-negotiable standard. “Dermatology exams can feel uniquely intrusive to patients compared to physical exams for other specialties, and having a chaperone may help the patient feel more comfortable,” she explained. “For the clinician, that removes the awkward situation in which a patient refuses the chaperone, and the physician must choose between honoring the refusal, thereby potentially increasing medicolegal risk, or declining care, which could come with other negative ramifications down the line. In my clinic, although not legally required, a chaperone is always necessary for each visit, and something each new patient must consent to as they review our office policies.”

“Generally, when I’m working with male residents who are doing a full-body skin check, I make sure that there is another woman in the room,” said Anna Bar, MD, FAAD, professor of dermatology at Oregon Health & Science University, and past president of the Oregon Dermatology Society. “I would take that step myself regardless of what the law says just because medical practitioners should feel protected against potential false claims.”

“I appreciate and wholly support having a chaperone present, because they also protect the physician as a witness to the encounter,” agreed Gregory Bourgeois, MD, FAAD, former president of the Alabama Dermatology Society. “In the extremely rare case where a patient ends up bringing some type of complaint to the practice, your chaperone can then serve as a third-party witness.”

Patient autonomy

While chaperones can offer protection for patients and physicians, some patients would rather the exam be performed privately, particularly if they are the same sex as their physician or if the chaperone is the opposite sex of the patient.

“Overly rigid rules could undermine patient autonomy and restrict the patient’s ability to discuss sensitive topics with their physician,” said Dr. Fabbro. “Some patients, such as survivors of trauma or patients from modest cultural backgrounds, may be less likely to pursue care in these settings. It is important to leave room for culturally sensitive implementation, for instance, allowing patients to request a same-gender chaperone or to have a chaperone of their own present as well.”

According to Dr. Bourgeois, there are scenarios where requiring a chaperone would result in an invasion of patient privacy. “If I’m examining one of my male patients, I can imagine they wouldn’t want a female medical assistant in the room with me when I’m doing a sensitive exam,” he explained. “Often, I have male patients who travel from outside our usual service area because they’re specifically seeking out a male physician for their whole-body skin exam.”

Cost

The requirement of a chaperone at every visit may also put an extra economic burden on a practice who must hire more assistance to comply.

“Given that extra staff are not always available to small practices and those in rural areas, it can potentially impact access if we’re pushing an unwavering requirement on normal routine medical care,” said Dr. Bar. “There have been many cuts to reimbursement that hamper doctors’ ability to hire enough extra staff to always have somebody available to stand in the room.”

“If you must have a chaperone in every room, while also prioritizing the patient’s preference, that can inevitably lead to staffing issues. For example, what if I need another male in the exam room because that’s the patient’s preference? While I want to put my patient’s preference first, what if I don’t have a male medical assistant?” explained Dr. Bourgeois. “It can be hard to hire male medical assistants — that demographic is hard to come by. This puts a burden on practices by mandating who you need to hire and can result in a quantity versus quality hiring decision. You can see the complication that creates.”

Current legal landscape

At present, there is no universal state law mandating chaperones for skin checks.

Most states, through medical boards or professional guidelines, recommend offering a chaperone for sensitive skin examinations, particularly those involving intimate areas, regardless of the patient’s gender or the physician’s gender. The AMA makes recommendations on chaperone use and policy in its AMA Code of Ethics. Most medical societies advocate that patients should be given the option to decline a chaperone if they wish.

So, what’s driving the push for more rigid legislation surrounding chaperone use? According to Dr. Bar, media coverage of outlier cases may be the culprit. “There have been a very small number of cases involving physician misconduct, but they get a lot of publicity. It’s an extremely rare event but is often heavily covered in the news,” she said. “I personally don’t know of any cases where a dermatologist has behaved improperly during a skin exam. Should that ever happen, then those people should be dealt with appropriately.”

While reports of physician misconduct remain low, several states have had recent legislative activity concerning mandatory chaperone use during ‘sensitive’ physical exams.

Alabama

In 2021, the Alabama Board of Medical Examiners (ABME) brought forth a new administrative rule (540-X-9-.08(11)). This proposed change primarily focused on strengthening the requirement for medical chaperones during patient examinations, particularly in situations where a patient might be vulnerable to potential sexual misconduct, and included mandatory chaperone use for sensitive exams like breast or genital examinations.

Dr. Bourgeois, who was president of the Alabama Dermatology Society at the time, submitted a letter to the ABME expressing opposition to the new rule. “It was clear for us that we were against the mandate. Not against having chaperones, but against the requirement that they be present for every full body skin exam, which would be considered an ‘intimate’ exam under this legislation,” he explained. “Our big concern was patients who may be uncomfortable with another party present. We wanted to be able to carve out an exception.”

“I think it could make it more uncomfortable for some patients if the law says there always must be a chaperone. I see the spirit of the law, but I think it’s a law made where a law doesn’t have to be.”

Oregon

In 2023, the Oregon Medical Board (OMB) adopted a new rule (OAR 847-010-0130) requiring OMB licensees to offer a trained chaperone to be physically present for all genital, rectal, and breast examinations. Under the law, medical professionals (such as a nurse, medical assistant, or resident) can serve as a chaperone once reviewed by the Oregon Medical Board.

“I think this law was originally intended for sensitive exams, potentially OB-GYN exams that could be a little bit more invasive than dermatology. However, the law was written as such that it was then being applied to dermatology exams as well. The real consequence of it is being borne by smaller practices,” said Dr. Bar, who served as president of the Oregon Dermatology Society at the time of the law’s proposal and submitted a letter expressing opposition to the rule.

“I personally have a large staff. When I’m at the hospital or academic center, I can usually find somebody to go in the exam room with me if needed. However, I worry about small practices that don’t have this type of staff readily available. Ultimately, it’s the patients who will suffer if we must skip an exam because we don’t have the necessary staff on hand to chaperone.”

Wisconsin

In 2023, the Wisconsin Medical Examining Board implemented new rules for physicians in private practice.

As of October 2023, physicians who are self-employed or work in practice settings that do not involve hospitals or employers must establish and comply with policy for the use of chaperones in non-emergency clinical exams of sensitive areas.

While the proposal does not require physicians to hire a medical chaperone for examinations of the breasts, genitals, or rectal area, the rule would create a presumption of guilt following a complaint filed against a physician if a chaperone is not present for such examination. If the patient declines a chaperone, additional paperwork and documentation in the patient’s record would be required.

Future implications

While stricter chaperone laws are limited to a handful of states, questions remain about potential downstream effects beyond the skin check if legislation of this type becomes more common.

“The spirit of patient safety and dignity being the most important thing to preserve was likely the impetus for this legislation,” said Dr. Fabbro. “However, many specialties perform procedures that could be considered intimate or potentially vulnerable. A few examples would include breast exams during mammograms or femoral artery access during a cardiac cath. Obviously, this would be impractical to enforce for all specialties, especially in the setting of understaffed clinics or underserved areas.”

“I think it could make it more uncomfortable for some patients if the law says there always must be a chaperone. I see the spirit of the law, but I think it’s a law made where a law doesn’t have to be,” said Dr. Bar. “Say that I need to get a colonoscopy and there are only male chaperones available that day. How far are we going to take this? How is it going to apply to other specialties? In most practices, patients still have the choice to opt in or out. If someone requests a chaperone, I will of course provide one. Legislators need to understand that if we want medical care to come first, placing all kinds of rules on who can and cannot be present during a patient encounter is going to make everyone’s life more complicated.”

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