Physical Examinations

To the Editor: In their survey on pelvic and rectal examinations of psychiatric inpatients reported in the June 1999 issue, Varner and Hollister (1) found that these examinations are not done routinely, despite guidelines to the contrary from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). However, the authors do not discuss possible reasons for this pattern except for "the perception … that providing psychiatric care is not the same as providing primary care."

The question of why psychiatrists omit pelvic and rectal (as well as breast) examinations merits further consideration. I believe we frequently do so out of a legitimate desire to minimize possible psychological sequelae of such intimate examinations. Although it is true, as the authors state, that "psychiatric patients are expected to be given a physical examination," this fact often comes as a surprise to the patients themselves when they arrive for hospitalization.

By definition, a person being admitted to an acute psychiatric ward is in an emotionally precarious position; the performance or even suggestion of rectal, pelvic, or breast examinations may have significant impact on a patient's ability to recompensate, adjust to the inpatient setting, and trust new caregivers. I personally have had at least one patient decline voluntary hospitalization altogether after the suggestion of a pelvic examination.

These issues will be compounded in the frequent scenario in which the examiner-psychiatrist is of the opposite gender, is a stranger, has no specialty training in these examinations, and has just finished hearing the details of the patient's personal life. The psychological fallout may be doubly compounded if the patient has any history of sexual assault or other sexual issues—facts that may well not have surfaced during the initial admission interview.

No doubt rigorous, routine pelvic and rectal examinations on all patients will turn up occult disease in a few. In the aggregate, though, will the physical benefit outweigh the potential psychiatric morbidity? This difficult question may be amenable to careful clinical study. But lacking such objective information, psychiatrists must continue to assess the indications for such exams on a case-by-case basis. They may need to follow the "first, do no harm" ethic even if it is in conflict with JCAHO policy.