Women's experiences of the gynecologic examination: factors associated with discomfort

Speculum self-insertion: an alternative method for gynaecological examination?

BACKGROUND

Speculum examination is an intrusive practice in the clinical care of women. It requires privacy and patients may experience discomfort or anxiety related to the procedure, which can result in delays or avoidance of necessary healthcare. Speculum self-insertion originated in the United States in the 1970s as part of the self-help movement. However, this clinical practice is largely unknown among healthcare providers and has rarely been assessed.

AIM

This study investigates the women's views and healthcare providers' experiences of the self-insertion method.

METHOD

A qualitative study was conducted between December 2021 and October 2022, including fieldwork combining semi-structured interviews (10 women) and focus groups associated with individual interviews of 13 healthcare providers. The data collected were independently coded by 2 authors and analysed using an inductive approach and grounded theory method.

RESULTS

Speculum self-insertion was described as a way to decrease discomfort and facilitate speculum insertion. Self-insertion was proposed as a means of allowing women to participate in the examination, reducing their vulnerability against power imbalances in the doctor-patient relationship. Both patients and healthcare providers have reported that speculum self-insertion is a method that can contribute to improving trust and communication during the examination.

CONCLUSION

The practice of speculum self-insertion during the consultation is an alternative to traditional practitioner insertion and may be offered to all women by any practitioner who wishes to use this technique.

Trauma-Informed Care Training in U.S. and Canadian Ob/Gyn Residencies

This is a cross-sectional study investigating the prevalence and nature of trauma-informed care (TIC) training in obstetrics and gynecology residency programs. In our sample, 20% of programs had annual TIC training, 53% had less than annual training, and 27% had no training at all. Only 25.3% of respondents were satisfied with their current training in interpersonal trauma and TIC. A lack of facilitators to conduct such training was the primary barrier to implementing TIC. Significant opportunity exists to improve TIC education for Ob/Gyn trainees.

Sexual and Gender Minority Patients' First Pelvic Examination Experiences: What Clinicians Need to Know

STUDY OBJECTIVE

The aim of this study was to identify factors that influence the first pelvic exam experiences of sexual and gender minority (SGM) adolescents and young adults who were assigned female at birth (AFAB).

METHODS

Using purposive sampling, we recruited SGM AFAB individuals, ages 18-24, who had had at least 1 pelvic examination. Semi-structured interviews and an iterative approach allowed for the emergence of factors influencing the first pelvic exam experience. Items included in the final code directory had a Krippendorff's alpha intercoder reliability score greater than 0.7. Interviews were analyzed using ATLAS.ti.

RESULTS

Thirty participants completed interviews. Fourteen participants identified as bisexual, 2 as gay, 1 as lesbian, 3 as pansexual, 8 as queer, and 2 as straight/heterosexual. Sixteen participants identified as cisgender, 9 as genderqueer/gender nonconforming, and 5 as transgender. Factors influencing the first pelvic exam experience were organized as patient- or clinician-level factors. The patient-level factors of gender identity, sexual orientation, history of sexual trauma, and participant's relationship to their body were central factors influencing the exam experience. Speculum insertion during the exam induced anxiety and pain for some. The clinician-level factors of gender, age, and race or ethnicity influenced the exam experience. Most participants preferred detailed communication. Participants offered recommendations to ensure gender-affirming, patient-centered care during the first pelvic exam.

CONCLUSION

SGM AFAB individuals identified patient- and clinician-level factors influencing their first pelvic exam experiences. This study underscores the need for changes in medical education and health systems to ensure that SGM AFAB individuals have their needs met and feel comfortable in reproductive health settings.

Danish women's preferences regarding gynecological examination support international recommendations: A cross-sectional study

OBJECTIVE

Gynecological examinations (GEs) are challenging for many women. Several recommendations and guidelines have emerged, partly based on common sense and clinicians' consensus. However, there is a lack of knowledge regarding women's opinions. Therefore, this study aimed to describe women's preferences and experiences in relation to GEs and investigate whether they are dependent on their socioeconomic status.

METHODS

In Denmark, GEs are typically performed by general practitioners or resident specialists in gynecology (RSGs) in gynecological hospital departments. This cross-sectional questionnaire and register study included approximately 3000 randomly selected patients who visited six RSGs from January 1, 2020, to March 1, 2021. The main outcome measurement involved women's preferences and experiences regarding GEs.

RESULTS

Overall, 37% of the women thought that a changing room was important, 20% preferred a garment to cover themselves, 18% preferred a separate examination room, and 13% thought that the presence of a chaperone was important. Compared with working and retired women, more women outside the workforce felt insufficiently informed, considered their experience with RSGs unprofessional, and found GEs painful.

CONCLUSION

Our results support existing recommendations regarding GEs and the related environment, confirming that privacy and modesty are factors to take into consideration as they are of concern for a relatively large group of women. Thus, providers should focus on women outside the workforce, because this group appears to feel vulnerable in this environment.

[Pelvic exam in gynecology and obstetrics: Guidelines for clinical practice]

OBJECTIVE

To provide guidelines for the pelvic clinical exam in gynecology and obstetrics.

MATERIAL AND METHODS

A multidisciplinary experts consensus committee of 45 experts was formed, including representatives of patients' associations and users of the health system. The entire guidelines process was conducted independently of any funding. The authors were advised to follow the rules of the Grading of Recommendations Assessment, Development and Evaluation (GRADE®) system to guide assessment of quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasized.

METHODS

The committee studied 40 questions within 4 fields for symptomatic or asymptomatic women (emergency conditions, gynecological consultation, gynecological diseases, obstetrics, and pregnancy). Each question was formulated in a PICO (Patients, Intervention, Comparison, Outcome) format and the evidence profiles were produced. The literature review and recommendations were made according to the GRADE® methodology.

RESULTS

The experts' synthesis work and the application of the GRADE method resulted in 27 recommendations. Among the formalized recommendations, 17 present a strong agreement, 7 a weak agreement and 3 an expert consensus agreement. Thirteen questions resulted in an absence of recommendation due to lack of evidence in the literature.

CONCLUSIONS

The need to perform clinical examination in gynecological and obstetrics patients was specified in 27 pre-defined situations based on scientific evidence. More research is required to investigate the benefit in other cases.

Anxiety Connected with Pelvic Ultrasound in Adolescents and Their Caregivers: Comparison of Transabdominal and Transrectal Approaches

STUDY OBJECTIVE

Transabdominal ultrasound (TAUS) is usually the first approach for diagnosis of reproductive tract complaints in all adolescents. However, there are instances when transrectal ultrasound (TRUS) is more feasible. Although TRUS is considered more invasive and distressing, evidence-based data are lacking. The aim of this study was to evaluate the level of anxiety in adolescents subjected to TAUS and TRUS and in their caregivers.

METHODS

In this cross-sectional study, data were prospectively gathered using 2 instruments: the adult or child version of the State and Trait Anxiety Inventory (STAI or STAIC) and a self-developed survey.

RESULTS

TAUS and TRUS are connected with high-level anxiety in patients and moderate anxiety in caregivers, as measured by the STAI/STAIC questionnaires. TRUS-related anxiety, fear, discomfort, and pain in adolescents are significantly higher compared with TAUS. The TRUS-related anxiety of caregivers, as well as the parent-estimated fear, discomfort, and pain of adolescents, is significantly higher compared with TAUS. Anticipated pain connected to TRUS is significantly higher than the post-exam, actually experienced pain. Pain and shame are the main reasons for adolescent anxiety connected with TRUS, whereas shame and unknown experience contribute to TAUS-related anxiety.

CONCLUSION

Given the high level of anxiety associated with both exams, additional support should be provided to patients scheduled for any pelvic ultrasound exam. Given the even higher level of adolescent anxiety related to TRUS, specialists should be encouraged to train in TAUS and make efforts to begin with this approach. Because increased caregiver anxiety could adversely affect a child's reactions, anxiety-reducing interventions should be oriented toward the caregivers as well as the patients.

Primary care Providers' approaches to cervical cancer screening in Muslim females

The utilization of the Papanicolaou (Pap) test and the human papillomavirus (HPV) vaccine has significantly decreased rates of cervical cancer and related mortality. Disparities in receiving these preventive screenings are scarcely studied in Muslim females. Our study explores primary care providers' (PCP) approaches to cervical cancer screening in Muslim females. We created a cross-sectional Qualtrics survey using convenience sampling of PCPs who perform Pap tests in central Ohio. Recruitment emails were disseminated via departmental email listservs. We had 200 analyzable responses and 78% of respondents reported having Muslim patients. Bivariate analysis was used to identify predictors of providers' approaches. Providers younger than 35 years obtained a sexual history from Muslim females less frequently, family medicine providers were more likely to obtain a sexual history from Muslim females, and gynecologists were more likely to offer the HPV vaccine to Muslim females. Providers who counseled patients about Pap tests (P<0.001) and HPV modes of transmission (P<0.004) were more likely to offer cervical cancer screening for Muslim females. Our findings suggested that providers' age and specialty may be predictors of proactive cervical cancer screening and prevention in Muslim females and that there is a gap between current guidelines and preventive clinical practices regarding the HPV vaccine and transmission counseling.

[Gynecological care among women reporting sexual violence: a qualitative study]

INTRODUCTION

Sexual violence can be followed by different levels of gynecological care. Our objective was to characterise gynecological care and to identify the related factors among women who had reported sexual violence.

METHODS

Twenty-five semi-structured interviews were conducted among adult women who reported sexual violence during childhood or as adults. Topics addressed included gynecological health, gynecological care and experienced violence, RESULTS: Interviewed women, aged 20-60, had a good professional integration and a high level of education. The violence had often been committed by a relative or acquaintance. For the women interviewed, the least use of gynecological care was motivated by a desire to avoid the gynecological examination. Among women who had regular check-ups, the desire to conform to the norm explained their need for gynecological check-ups, which was similar to that of women who had never been subjected to violence. Lastly, some care pathways were characterised by multiple recourse of gynecological care for complaints with identical motives. The women interviewed expected professionals to spontaneously identify the violence they had suffered and the gynecological consequences attributed to such violence.

CONCLUSION

Individual and interpersonal differences in levels of gynecological care use were related to the characteristics of the violence and its perceived effects on gynecological health. It would be interesting to extend this research by examining the care pathways of women with other socioeconomic characteristics. A quantitative study would measure the association between violence and the use of gynecological care.

Retrospective evaluation of operator bias in the performance of high-resolution anorectal manometry

BACKGROUND

Measurements obtained during high-resolution anorectal manometry (HRM) are subject to operator-patient interactions. For example, standardized enhanced instruction delivered by a single operator in a test-retest fashion did not consistently increase pressures generated during dynamic maneuvers. It is probable that factors other than verbal instruction effect communication during the procedure. To investigate this hypothesis, we retrospectively examined inter-operator variance in HRM results.

METHODS

The electronic health records at Mayo Clinic, Rochester, were used to identify patients who had undergone HRM in 2019 and 2020. The analysis focused on constipated patients. The instructions given to the patients they had examined, and the pressure measurements obtained during HRM, by 6 different nurse operators were compared.

KEY RESULTS

When performing HRM on their individual patients (range 126-673), the 6 nurses used similar instructions for each of the maneuvers and sensory testing thresholds. The proportion of patients with prolonged balloon expulsion tests and the rectal sensory thresholds were similar among operators. Significant variance was seen in the mean rectoanal pressures at rest, during squeeze, and during dynamic maneuvers. The proportion of patients with manometry results suggestive of a defecatory disorder differed between operators by 18% and 28% in women <50 and >50 years old, respectively.

CONCLUSIONS & INFERENCES

Operators obtain significantly different results during HRM despite using similar instructions to patients. Substantial differences in the proportion of patients with manometry findings suggestive of a defecatory disorder among operators may have a significant impact on the diagnoses and therapies offered to constipated patients.

The Relationship Between Sexual Assault History and Cervical Cancer Screening Completion Among Women Veterans in the Veterans Health Administration

Background: Sexual assault affects one in three US women and may have lifelong consequences for women's health, including potential barriers to completing cervical cancer screening and more than twofold higher cervical cancer risk. The objective of this study was to determine whether a history of sexual assault is associated with reduced cervical cancer screening completion among women Veterans. Materials and Methods: We analyzed data from a 2015 survey of women Veterans who use primary care or women's health services at 12 Veterans Health Administration facilities (VA's) in nine states. We linked survey responses with VA electronic health record data and used logistic regression to examine the association of lifetime sexual assault with cervical cancer screening completion within a guideline-concordant interval. Results: The sample included 1049 women, of whom 616 (58.7%) reported lifetime sexual assault. Women with a history of sexual assault were more likely to report a high level of distress related to pelvic examinations, and to report ever delaying a gynecologic examination due to distress. However, in the final adjusted model, lifetime sexual assault was not significantly associated with reduced odds of cervical cancer screening completion (OR 1.35, 95% CI 0.93-1.97). Conclusions: Contrary to our expectations, sexual assault was not significantly associated with gaps in cervical cancer screening completion. Three- to five-year screening intervals may provide sufficient time to complete screening, despite barriers. Trauma-sensitive care practices promoted in the VA may allow women to overcome the distress and discomfort of pelvic examinations to complete needed screening. ClinicalTrials.gov (#NCT02039856).

Privacy, Self-Esteem, Anxiety in Women Having Pelvic Examination

This study aims to determine the privacy perception, self-esteem and anxiety levels of women undergoing pelvic examination and influencing factors. This web-based cross-sectional study was conducted with 415 women who underwent pelvic examination. The data were collected using a Personal Information Form, the Body Privacy Scale for Gynecology and Obstetrics, the Rosenberg Self-Esteem Scale and the State Anxiety Inventory. It was found that self-esteem (R² = .055, p < .0001) and state anxiety (R² = .037, p: .004) were significantly related to body privacy perceptions. The results of the study showed that making a statement to the women before the examination positively affected their perception of privacy. It is recommended for health professionals to be trained on the importance of privacy and communication during pelvic examination to increase their awareness on the topic.

Addressing Anxiety and Fear during the Female Pelvic Examination

To review the anxiety and fear risk factors, pathophysiology, symptoms, screening and diagnosis while highlighting treatment considerations for women undergoing a pelvic examination.

Caring for affective subjects produced in intimate healthcare examinations

This article is about the feelings - affect - induced by the digital rectal exam of the prostate and the gynaecological bimanual pelvic exam, and the care doctors are or are not instructed to give. The exams are both invasive, intimate exams located at a part of the body often charged with norms and emotions related to gender and sexuality. By using the concept affective subject, we analyse how these examinations are taught to medical students, bringing attention to how bodies and affect are cared for as patients are observed and touched. Our findings show both the role care practices play in generating and handling affect in the students' learning and the importance of the affect that the exam is (or is not) imagined to produce in the patient. Ours is a material-discursive analysis that includes the material affordances of the patient and doctor bodies in the affective work spaces observed.

Utilization of a Mirror During Pelvic Examinations: Does it Improve the Patient's Experience?

OBJECTIVE

This study was conducted to assess the utility of a mirror in improving pain and vulnerability during a pelvic examination.

METHODS

In this prospective, institutional review board-approved, 2-cohort trial, all "new" patients presenting to a urogynecology office were offered to have a mirror or no-mirror present during their pelvic examination. Patients completed 100-mm visual analog scales regarding pain, anxiety, knowledge, control, embarrassment, and vulnerability before and after examination. The primary outcome was difference in level of pain and vulnerability between groups. Secondary outcomes included comparisons from baseline to postexamination scores within groups, patient satisfaction, and examination duration. A sample size of 68 participants in each arm was planned.

RESULTS

From April 2019 to May 2020, 147 participants were enrolled. Two participants were excluded, 145 were included in the final analysis; 74 in the no-mirror group and 71 in the mirror group. The average age was 55.9 (±13) years, and the groups were overall similar. There was no difference in primary outcomes of pain or vulnerability, but the mirror group showed improved levels of control (P = 0.006) and knowledge (P = 0.018) following examination. All participants reported high satisfaction, and those that selected a mirror reported strong preference for future use.

CONCLUSIONS

Patients who chose to use the mirror did not demonstrate a difference in pain or vulnerability scores; however, they exhibited benefit to their sense of control and knowledge after the pelvic examination. Although the mirror did not benefit all patients, this is a simple option that could improve the examination experience for some.Clinical Trial Registration:ClinicalTrials.gov, NCT03785548.

#metoo? The association between sexual violence history and parturients' gynecological health and mental well-being

PURPOSE

Sexual violence is a global health problem. We aimed to evaluate the association between self-reported history of sexual violence and parturients' health behaviors, focusing on routine gynecological care, and mental well-being.

METHODS

This was a retrospective questionnaire-based study, including mothers of newborns delivered at the "Soroka" University Medical Center (SUMC). Participants were asked to complete three validated questionnaires, including: screening for sexual violence history (SES), post-traumatic stress disorder (PDS) and post-partum depression (EPDS). Additionally, a demographic, pregnancy and gynecological history data questionnaire was completed, and medical record summarized. Multiple analyses were performed, comparing background and outcome variables across the different SES severity levels. Multivariable regression models were constructed, while adjusting for confounding variables.

RESULTS

The study included 210 women. Of them, 26.3% (n = 57) reported unwanted sexual encounter, 23% (n = 50) reported coercion, 1.8% (n = 4) assault and attempted rape, and 1.4% (n = 3) reported rape. A significant association was found between sexual violence history and neglected gynecological care, positive EPDS screening, and reporting experiencing sexual trauma. Several multivariable regression models were constructed, to assess independent associations between sexual violence history and gynecological health-care characteristics, as well as EPDS score. Sexual violence history was found to be independently and significantly associated with a negative relationship with the gynecologist, avoidance of gynecological care, sub-optimal routine gynecological follow-up, and seeking a gynecologist for acute symptoms (adjusted OR = 0.356; 95% CI 0.169-0.749, adjusted OR = 0.369; 95% CI 0.170-0.804, adjusted OR = 2.255; 95% CI 1.187-4.283, and adjusted OR = 2.113; 95% CI 1.085-4.111, respectively), as well as with the risk of post-partum depression (adjusted OR = 4.46; 95% CI 2.03-9.81). All models adjusted for maternal age and ethnicity.

CONCLUSION

Sexual violence history is extremely common among post-partum women. It is independently associated with post-partum depression, neglected gynecological care, a negative relationship with the gynecologist, and with reporting of experiencing sexual trauma. Identifying populations at risk and taking active measures, may reduce distress and improve emotional well-being and family function.

Environnement réconfortant et respect de l’intimité. L’organisation du cabinet médical pour la consultation gynécologique

INTRODUCTION

Social science concepts (intimate distance, personal space) suggest that the gynecological examination environment (GEE) might influence women&#8217;s feelings during the exam.Purpose of research: We explore this hypothesis by assessing women&#8217;s preferences for the GEE.

RESULTS

An opinion poll was conducted, without randomization to explore women&#8217;s point of view. In 2017, questionnaires were referred to women by 14&#160;general practitioners in the Lille region. Among 173&#160;answers, 73% granted importance to the medical setting, especially to a comfortable ambiance and an isolated place during an exam (to respect women&#8217;s privacy). Women expected at least: a separation of consultation/examination (77%), disposal of sanitary towels (80%), a place to leave clothes and underwear (74%), a changing area (56%). Fifty-five percent judged it unnecessary to cover the lower body. Concerning the examination table: comfort was satisfactory (93%), &#8220;calm and peaceful colors&#8221; were appreciated, but clamps should be improved.

CONCLUSIONS

The GEE is characterized by a balance of natural comfort and a sequentially delimited spatial configuration. The study revealed cultural and subjective dimensions of privacy. Physicians need to apply psychosocial competences to perform a person-centered gynecological exam.

Nonindicated pelvic examinations during contraceptive encounters: Prevalence and provider variations

OBJECTIVE

Despite evidence that mandatory pelvic examinations deter contraceptive use and are not clinically necessary, survey research suggests that clinicians regularly perform pelvic examinations prior to prescribing contraceptives. This study estimates prevalence of nonindicated pelvic exams during contraceptive encounters, and variation in prevalence by provider specialty.

STUDY DESIGN

Using a national sample of commercial claims data, we identified contraceptive encounters without concurrent indication for pelvic examination among females aged 15 to 49 from 2007 to 2017. We first calculated the nonindicated exam rate by provider specialty and patient age. Using data from 2017 and linear probability models with metropolitan statistical area fixed effects, we estimated the differences in adjusted rates of nonindicated pelvic examination by provider specialty. To assess trends by provider specialty, we used all years of data and interacted specialty with year.

RESULTS

Of 7.9 million identified contraceptive encounters, 81.8% had no identified indications for pelvic exam. Exams were billed at 17.7% of these visits (2007-2017), and this rate increased from 13.4% in 2007 to 20.7% in 2017. The largest increase occurred among encounters with an obstetrician-gynecologist. In 2017, obstetrician-gynecologists were 20.3 percentage points (95% CI: 19%-21%) more likely to perform a concurrent pelvic exam compared to family physicians.

CONCLUSIONS

Pelvic examinations during contraceptive visits increased from 2007 to 2017. Increases occurred across all provider specialties, but were largely driven by obstetrician-gynecologists, who oversaw over half of all contraceptive encounters and performed non-indicated pelvic exams at the highest rate.

IMPLICATIONS

This research provides real-world evidence that suggests pelvic exams are increasingly performed during contraceptive encounters and that patients regularly undergo a low-value, invasive examination while obtaining contraceptive care. Continuing education, reimbursement reform, and more evidence on the harms of non-indicated pelvic exams will be necessary to change clinical practice.

The first pelvic examination: A rite of passage for the women. A qualitative study about French women

Background: French general practitioners (GP) and gynaecologists can make use of recommendations when performing a patient's first pelvic examination. The indications and techniques for this examination are clear. The relational aspects and experience of the patients have been dealt with little.Objectives: To analyse and understand the experience of French women during their first pelvic examination to propose practice recommendations based on their experiences.Methods: Qualitative semi-structured interviews was conducted with 13 French women aged 18-30 years recruited from the surgery of a general practitioner using the snowball method. The data were analysed using an inductive method.Results: The first pelvic examination was considered an indispensable rite of passage into adulthood and the life of a woman. They wanted a preparation for a consultation devoted to the first pelvic examination, with a time that is adapted to each woman. A patient-centred practitioner was more important than the pelvic examination itself.Conclusion: Women requested for a general practitioner or a gynaecologist with a deeper understanding of a woman's experience to perform their first pelvic examination. We propose practical recommendations: the following 3 phases for the consultation: before the pelvic examination where the women and the practitioners may get to know one another; during the examination, which would involve the technical aspects and the associated procedures; and after the examination, where the patients and the practitioners review the experience and discuss prevention.

Prevalence of and Factors Associated With Receiving a Pelvic Examination or Pap Testing Under the Age of 21 Years

PURPOSE

Current guidelines recommend that individuals receive their first Pap test at age 21 years and only receive a pelvic examination before age 21 years for clinical indications. We sought to determine the prevalence and associated covariates of receiving a pelvic examination or Pap test before 21 years of age.

METHODS

We analyzed the 2013-2015 National Survey of Family Growth. We conducted bivariate analyses comparing individuals who had and had not had a pelvic examination or Pap test and multivariable logistic regression to identify factors associated with having a pelvic examination or Pap test under 21 years.

RESULTS

This study included 1,170 individuals. Of respondents, 30.8% received a pelvic examination and 25.1% received a Pap test before 21 years of age. Receiving a pelvic examination was associated with being sexually active (adjusted odds ratio [aOR]: 6.6, 95% confidence interval [CI]: 3.8-11.7), having ever taken contraceptive pills (aOR: 2.6, 95% CI: 1.6-4.1) compared with no contraceptive method, and being screened for sexually transmitted infections in the past 12 months (aOR: 12.6, 95% CI: 7.3-21.8). Receiving a Pap test was also associated being sexually active (aOR: 7.2, 95% CI: 3.7-14.0), having ever taken contraceptive pills (aOR: 3.0, 95% CI: 1.9-4.7) compared with no contraceptive method, and being screened for sexually transmitted infections in the past 12 months (aOR: 8.94, 95% CI: 5.12-15.61).

CONCLUSIONS

Contrary to contemporary guidelines, a notable proportion of individuals under the age of 21 years continues to receive pelvic examinations and Pap testing.

Differences in teaching female and male intimate examinations: A qualitative study

CONTEXT

Teaching intimate examinations to medical students has been recognised as difficult because of the anxious feelings that the students may experience. For their professional development, previously incorporated understandings need to be relearned: how to transgress boundaries that regulate intimacy and physical closeness, learning to examine and touch other peoples' bodies, and talking about things that are otherwise taboo.

OBJECTIVES

This paper compares how students learn to perform two intimate examinations: (i) the digital rectal examination (DRE) of the prostate, and (ii) the bimanual pelvic examination (PE) and analyses how norms and expectations affect how students learn to approach them.

METHODS

This study is based on ethnographic work: in-depth qualitative interviews with two urologists and nine medical students in semesters four, eight and 11 of a medical education programme in Sweden, observations of three learning sessions where 16 students performed the PE on professional patients, and 2 days of observations at a urology outpatient clinic.

RESULTS

The educational approach to the PE and DRE differ. The PE is taught as sensitive and to be handled with care, using a well-documented learning concept including interpersonal and technical skills. The patient's exposed position in the gynaecological chair, possible previous negative experiences of PE or sexual exploitation are taken into account. In contrast, there is no educational concept for teaching the DRE. The students perform their first DRE on a clinical patient. The DRE is also handled with care, but with less sensitivity. The patients' possible previous negative experiences are not discussed and are thus made invisible.

CONCLUSIONS

Well-established routines in performing the PE help doctors and students to be attentive to patients' emotions and previous experiences, and remind them to perceive the examination as sensitive. Aligning the teaching of the DRE with that of the PE will improve how the male prostate patient is approached.

Factors of importance for developing a trustful patient-professional relationship when women undergo a pelvic examination

We examined gynecological teaching women's perception on what factors are important for developing a trustful patient-professional relationship when women undergo a pelvic examination. A qualitative research design was conducted with repeated focus group discussions. Our results show that healthcare professionals' communications skills can strengthen a trustful patient-professional relationship. Treating women with dignity could make them feel less vulnerable and make the relationship trustworthy based on respect. Thus, having the ability to identify factors important for a trustful relationship may support healthcare professional's ability to strengthen women's health issues. A trustful relationship might also affect quality of care.

A conceptual framework for understanding iatrophobia

OBJECTIVE

Iatrophobia - fear of doctors, medical care, or the medical care system - is common among patients and can negatively impact their health-seeking behaviors and relationships with health care professionals. Despite this, academic literature on iatrophobia often fails to explore its nuanced causes.

METHODS

We establish a conceptual framework of iatrophobia, categorizing sources of fear that may create barriers to accessing medical care, and recommend a research agenda to address this phenomenon and understand its role in medical care.

RESULTS

The framework includes three categories of determinants of iatrophobia: patient fear of illness and the medical exam, patient fear of physician reaction, and patient fear related to barriers to care. These categories represent influences from individual to more system-related factors associated with the physician-patient relationship. Research examining iatrophobia should focus on understanding its prevalence, how patients cope with their fear, discussing iatrophobia in the physician-patient encounter, the sociopolitical contribution to iatrophobia, and how iatrophobia can be reduced.

CONCLUSIONS

Iatrophobia can be categorized into three primary domains, but it remains poorly understood.

PRACTICE IMPLICATIONS

A more thorough understanding of iatrophobia will help to contextualize its role amid other barriers to care and patient health outcomes.

Factors Influencing Adolescent and Young Adults' First Pelvic Examination Experiences: A Qualitative Study

STUDY OBJECTIVE

To understand the factors that influence individuals' experiences during their first pelvic examination. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We conducted semistructured interviews with adolescents and young adults, aged 18-24, who had received at least 1 pelvic examination. Interviews explored contextual factors of the first pelvic examination, including visit acuity and clinical setting and individuals' experiences with the pelvic examination itself and elicited recommendations on how to improve the examination experience. Interviews were transcribed and computer-assisted content analysis was performed; salient themes are presented.

RESULTS

Thirty participants completed interviews. Nineteen participants described their first pelvic examination experience as positive; 11 described this examination as a negative or neutral experience. Factors influencing the experience include the examination indication and acuity, examination location and physical space, provider features, relational and interpersonal features, and procedural aspects. Recommendations included: (1) establish rapport and educate before the examination; (2) establish practices to orient patients; (3) make no assumptions about identity; and (4) elicit continuous feedback.

CONCLUSION

Individuals' first pelvic examination experiences are influenced by a variety of factors. Although some factors are directly modifiable by providers, other factors that might not be modifiable are important to elicit to optimize the examination experience. These findings call for best practice guidelines and educational interventions to prepare providers to perform the first pelvic examination.

Factors Influencing Young Women's Preparedness for Their First Pelvic Examination

OBJECTIVE

To understand factors contributing to women's level of preparedness for their first pelvic examination.

METHODS

We conducted semistructured interviews with young women, aged 18-24 years, who had undergone at least one pelvic examination. This analysis explored 1) gynecologic and health care experience before the first pelvic examination, 2) preprocedure expectations and concerns, and 3) preprocedure knowledge about the examination. Interviews were transcribed and computer-assisted content analysis was performed; salient themes are presented.

RESULTS

Thirty women completed interviews. Thirteen women described feeling poorly prepared for their first pelvic examination and 17 women described feeling prepared for the examination. Factors influencing women's level of preparedness for their first pelvic examination included 1) age at first examination, 2) pre-examination knowledge of the examination, 3) medical trust or mistrust, 4) overall comfort with one's body, and 5) prior sexual experiences and trauma.

CONCLUSION

Preparedness for the first pelvic examination emerges as a subjective concept shaped and determined by the interplay of many factors. Although some factors such as age and personal sexual and reproductive health history may not be modifiable by clinical practice, other factors, including information that young women receive before experiencing their first pelvic examination, may be modifiable by clinical practice.

Sequence of Pelvic Examination Affects Patient-Reported Pain

OBJECTIVE

The purpose of this trial is to compare patient-reported pain based on the sequence of the pelvic examination and to assess the relationship between pain during the examination and quality of life, self-esteem, and sexual function.

METHODS

A randomized controlled trial of women presenting for annual gynecologic examinations. Women were assigned to either group A: a Q-tip touch test, speculum examination, then bimanual examination or group B: Q-tip touch test, bimanual examination, then speculum examination. The primary outcome was visual analog scales to assess pain at baseline and after each portion of the examination. Secondary outcomes were responses to questionnaires for self-esteem, quality of life, and sexual function.

RESULTS

Of 200 women who enrolled, 192 (96%) completed all visual analog scale data points. Each portion of the examination caused minimal pain over baseline in each group. Pain during the speculum examination was higher than pain during the bimanual examination in both groups (P = 0.007 and P < 0.001). Group B, however, had significantly higher pain scores after the speculum examination than group A (P = 0.044). The groups did not differ on bimanual pain scores (P = 0.76). Pain scores were not statistically different when analyzed by age, parity, sexual activity, sexual orientation, education, or previous hysterectomy. Within both groups, patients who documented having any pain after the speculum examination or the bimanual examination were also more likely to have lower quality of life scores (P < 0.001 and P < 0.001).

CONCLUSIONS

Pain associated with the speculum examination was lower in those undergoing speculum before bimanual examination. Speculum pain was greater than bimanual pain in both groups. Most patients reported minimal or no pain during the different portions of the examination.

Touching the private parts: how gender and sexuality norms affect medical students' first pelvic examination

Gynaecologists are in a position to challenge norms about gender and sexuality in relation to female genitals. Through their work they have the opportunity to educate patients, which is why teaching medical students to perform examinations in a gender sensitive way is significant. Medical students performing their first pelvic examination often experience the examination as uncomfortable because it is a body part that is connected to sex and to something private. This paper uses medical students' interpretations of performing their first pelvic examination as a means to discuss how cultural norms for gender, sexuality and female genitals affect these examinations. Issues raised include how cultural connotations of female genitals affect the pelvic examination, how female and male students relate differently to examining female genitals and the interpretations they make in relation to themselves. Findings show that the female genitals are perceived as a special body part connected to sexuality and intimacy. Students' gender also affects the interpretations they make during pelvic examinations. Norms of gender, sexuality and female genitals need to be challenged in the teaching and performance of pelvic examination in order to demystify this experience.

Challenges with delivering gender-specific and comprehensive primary care to women veterans

BACKGROUND

The growing presence of women veterans in Veterans Administration (VA) settings has prompted the need for greater attention to clinical proficiency related to women's health (WH) primary care needs. Instead of making appointments for multiple visits or referring patients to a WH clinic or alternate site for gender-specific care, a comprehensive primary care model now allows for women veteran patients be seen by primary care providers (PCPs) who have WH training/experience and can see patients for both primary and WH care in the context of a single visit. However, little is currently known about the barriers and facilitators WH-PCPs face in using this approach to incorporate gender-specific services into women veterans' primary care services.

METHODS

We conducted qualitative in-depth interviews with 22 WH-PCPs at one Midwestern VA Medical Center. All participants were members of one of four outpatient primary care clinics within the main medical center, one off-site satellite clinic, or two off-site community-based outpatient clinics.

RESULTS

Inductive thematic analysis identified six themes: 1) Time constraints, 2) importance of staff support, 3) necessity of sufficient space and equipment/supplies, 4) perceptions of discomfort among patients with trauma histories, 5) lack of education/training, and 6) challenges with scheduling/logistics.

CONCLUSION

Although adequate staff was a key facilitator, the findings suggest that there may be barriers that undermine the ability of VA WH-PCPs to provide high-quality, comprehensive primary and gender-specific care. The nature of these barriers is multifactorial and multilevel in nature, and may therefore require special policy and practice action.

Importance of demographic characteristics and nurses' role in women's perceptions and experiences of gynaecological examination

Introduction: Gynaecological examination is crucial for protecting the reproductive health of women. The purpose of the study was to explore the perception of women towards gynaecological examination, the importance of some demographic characteristics and the role of a nurse. Methods: A quantitative methodology was used for study purposes. A structured web questionnaire was applied on a non-random, convenience sample of women (n = 476). The questionnaire was published on the most popular Slovenian web forums. Prior to the main research project, a pilot study was conducted on a sample of 10 women. The statistical analysis included descriptive statistics, t-test, Pearson's and Spearman's correlation coefficient. Results: Results of the study show a statistically significant correlation between the respondents' residential environment (t = -2.436, p = 0.015), the level of educational attainment (rs=-0.153, p = 0.001) and the presence of discomfort and fear before the gynaecological examination. The role of a nurse in reducing the level of discomfort and fear before (t = -0.931, p = 0.352) and during (t = -0.888, p = 0.375) the gynaecological examination was not proven statistically significant. Discussion and conclusions: Besides the demographic characteristics, a number of personal and societal factors influence women's attitudes towards gynaecological examination and the associated discomfort and fear. The study suggests that further qualitative studies are needed to gain a deeper understanding of how women experience a pelvic examination.

Pelvic examination experiences in women with and without chronic pain during intercourse

INTRODUCTION

Although pelvic examinations (PEs) are an important component of women's health, some women experience difficulty during PEs due to anxiety and pain. These difficulties may be heightened in women with chronic pain during sexual intercourse. Some evidence suggests that this population experiences pain and distress during PEs, but their experiences in this context have not been empirically investigated from a multidimensional perspective.

AIMS

The aims of this study were to compare the PE experiences of women with and without pain during intercourse and to examine predictors of negative experiences in each group.

METHOD

Women with vulvovaginal pain (n = 90), pelvic pain (n = 89), and women without current intercourse pain (n = 207) completed an online survey including sections assessing demographics, gynecological and medical history, and PE experiences. Respondents completed questionnaires assessing vaginal penetration cognitions and body image.

MAIN OUTCOME MEASURES

Participants rated their most recent PE on numerical scales for pain, embarrassment, anxiety, and the overall quality of the experience.

RESULTS

Women with pelvic and vulvovaginal pain during intercourse reported significantly more pain and anxiety during their most recent PE compared with the no pain group, and women with a higher number of lifetime gynecological diagnoses reported significantly more pain. Multiple regression analyses indicated that various predisposing, examination-related, and psychological factors predicted specific PE ratings in each group.

CONCLUSIONS

The results provide empirical support that PEs are more physically and emotionally difficult for women who experience chronic pain during intercourse. These findings have important clinical implications, as PEs are a critical part of complete reproductive care and play an essential role in the assessment/management of sexual pain, including Genito-Pelvic Pain/Penetration Disorder.

The impact of sexual abuse in patients undergoing colonoscopy

Background

Sexual abuse has been linked to strong effects on gastrointestinal health. Colonoscopy can provoke intense emotional reactions in patients with a sexual abuse history and may lead to avoidance of endoscopic procedures.

Objective

To determine whether care around colonoscopy needs adjustment for patients with sexual abuse experience, thereby exploring targets for the improvement of care around colonoscopic procedures.

Methods

Questionnaires were mailed to patients (n = 1419) from two centers within 11 months after colonoscopy. Differences in experience of the colonoscopy between patients with and without a sexual abuse history were assessed and patients' views regarding physicians' inquiry about sexual abuse and care around endoscopic procedures were obtained.

Results

A total of 768 questionnaires were analyzed. The prevalence of sexual abuse was 3.9% in male and 9.5% in female patients. Patients born in a non-western country reported more sexual abuse (14.9%) than those born in a western country (6.3%; p = 0.008). Discomfort during colonoscopy was indicated on a scale from 0 to 10, mean distress score of patients with sexual abuse was 4.8(±3.47) compared to 3.5(±3.11) in patients without a sexual abuse history (p = 0.007). Abdominal pain was a predictor for higher distress during colonoscopy (β = −0.019 (SE = 0.008); p = 0.02, as well as the number of complaints indicated as reason for colonoscopy (β = 0.738 (SE = 0.276); p = 0.008). Of patients with sexual abuse experience, 53.8% believed gastroenterologists should ask about it, 43.4% said deeper sedation during colonoscopy would diminish the distress.

Conclusions

Sexual abuse is prevalent in patients presenting for colonoscopy. Patients with a sexual abuse history experience more distress during the procedure and indicate that extra attention around and during colonoscopy may diminish this distress.

Sex differences in health care provider communication during genital herpes care and patients' health outcomes

Research in primary care medicine demonstrates that health care providers' communication varies depending on their sex, and that these sex differences in communication can influence patients' health outcomes. The present study aimed to examine the extent to which sex differences in primary care providers' communication extend to the sensitive context of gynecological care for genital herpes and whether these potential sex differences in communication influence patients' herpes transmission prevention behaviors and herpes-related quality of life. Women (N = 123) from the United States recently diagnosed with genital herpes anonymously completed established measures in which they rated (a) their health care providers' communication, (b) their herpes transmission prevention behaviors, and (c) their herpes-related quality of life. The authors found significant sex differences in health care providers' communication; this finding supports that sex differences in primary care providers' communication extend to gynecological care for herpes. Specifically, patients with female health care providers indicated that their providers engaged in more patient-centered communication and were more satisfied with their providers' communication. However, health care providers' sex did not predict women's quality of life, a finding that suggests that health care providers' sex alone is of little importance in patients' health outcomes. Patient-centered communication was significantly associated with greater quality-of-life scores and may provide a promising avenue for intervention.

Receipt of cervical cancer screening in female veterans: impact of posttraumatic stress disorder and depression

PURPOSE

We evaluated receipt of cervical cancer screening in a national sample of 34,213 women veterans using Veteran Health Administration facilities between 2003 and 2007 and diagnosed with 1) posttraumatic stress disorder (PTSD), or 2) depression, or 3) no psychiatric illness.

METHODS

Our study featured a cross-sectional design in which logistic regression analyses compared receipt of recommended cervical cancer screening for all three diagnostic groups.

RESULTS

Cervical cancer screening rates varied minimally by diagnostic group: 77% of women with PTSD versus 75% with depression versus 75% without psychiatric illness were screened during the study observation period (p < .001). However, primary care use was associated with differential odds of screening in women with versus without psychiatric illness (PTSD or depression), even after adjustment for age, income and physical comorbidities (Wald Chi-square (2): 126.59; p < .0001). Specifically, among low users of primary care services, women with PTSD or depression were more likely than those with no psychiatric diagnoses to receive screening. Among high users of primary care services, they were less likely to receive screening.

CONCLUSION

Psychiatric illness (PTSD or depression) had little to no effect on receipt of cervical cancer screening. Our finding that high use of primary care services was not associated with comparable odds of screening in women with versus without psychiatric illness suggests that providers caring for women with PTSD or depression and high use of primary care services should be especially attentive to their preventive healthcare needs.

A guide to performing pelvic speculum exams: a patient-centered approach to reducing iatrogenic effects

PURPOSE

Current training in the United States for pelvic speculum examinations (PSEs) has a primary focus on the physician-centered goal of visualizing the cervix but may not inform practitioners of potential iatrogenic effects. Such oversight leaves trainees unprepared and unskilled in preventing and addressing adverse outcomes. This article incorporates a literature review into a step-by-step guide to aid the teaching of PSEs.

SUMMARY

Iatrogenic effects of PSEs may include mild discomfort, extreme pain, anxiety, psychological (re)traumatization, and sexual pain disorders. A literature-based guide is presented to identify patients at risk for adverse outcomes, set up the exam room, set up the patient, perform the exam, calm distressed patients, and avoid exam-interfering behaviors.

CONCLUSIONS

Although PSEs can lead to adverse outcomes, awareness of the iatrogenic effects allows clinicians to utilize techniques to prevent or reduce negative effects. A method of incorporating techniques described in this article into teaching is provided.

Health care and female survivors of childhood sexual abuse: health professionals' perspectives

The present study explored health professionals' experiences with adult survivors of child sexual abuse in New Zealand. Face-to-face, semistructured interviews of up to an hour took place with 13 health professionals. The participants were asked about training, screening practices, their response to disclosures, and advice to other health professionals. A model-transition to ethical practice-emerged from the data, where delivering more sensitive health care to child sexual abuse survivors sits on a continuum from lack of awareness of child sexual abuse to delivery of care where all patients are comfortable. We recommend making sensitive care for all as the standard care of practice and providing training for health professionals on how to deal with disclosures.

The paradox of vaginal examination practice during normal childbirth: Palestinian women's feelings, opinions, knowledge and experiences

Background

Vaginal examination (VE), is a frequent procedure during childbirth. It is the most accepted ways to assess progress during childbirth, but its repetition at short intervals has no value. Over years, VE continued to be plagued by a nature that implies negative feelings and experiences of women. The aim of this exploratory qualitative study was to explore women’s feelings, opinions, knowledge and experiences of vaginal examinations (VE) during normal childbirth.

Methods

We interviewed 176 postpartum women using semi-structured questionnaire in a Palestinian public hospital in the oPt. Descriptive statistics were conducted; frequency counts and percentages for the quantitative questions. The association between the frequency of VE and age, parity, years of education, locale and the time of delivery was tested by Chi-squared and Fisher’s Exact test. The open-ended qualitative questions were read line-by-line for the content and coded. The assigned codes for all responses were entered to the SPSS statistical software version 18.

Results

As compared with WHO recommendations, VE was conducted too frequently, and by too many providers during childbirth. The proportion of women who received a ‘too high’ frequency of VEs during childbirth was significantly larger in primipara as compared to multipara women (P = .037). 82% of women reported pain or severe pain and 68% reported discomfort during VE. Some women reported insensitive approaches of providers, insufficient means of privacy and no respect of dignity or humanity during the exam.

Conclusions

Palestinian women are undergoing unnecessary and frequent VEs during childbirth, conducted by several different providers and suffer pain and discomfort un-necessarily.

Practice implications

Adhering to best evidence, VE during childbirth should be conducted only when necessary, and if possible, by the same provider. This will decrease the laboring women’s unnecessary suffering from pain and discomfort. Providers should advocate for women’s right to information, respect, dignity and privacy.

A history of interpersonal trauma and the gynecological exam

Cervical cancer is preventable, in part, by routine Papanicolaou (Pap) testing, but some women avoid routine screening. African American women have the greatest mortality among all groups of women in the United States. Personal reasons have been found to contribute to screening avoidance behavior, such as a history of sexual abuse and intimate partner violence. Fifteen African American women with a trauma history participated in personal interviews. The Interaction Model of Client Behavior was employed for exploring the women's social influence, previous health care experience, cognitive appraisal, affective response, and motivation associated with routine Pap testing. Study findings suggest that providers need to assess and provide accurate information about Pap testing and cervical cancer to increase patients' knowledge. Personally reflecting on one's approach to conducting a woman's gynecologic exam (and how it is performed) might prevent triggering unwanted memories, making that visit a positive experience and facilitating repeat screening behavior.

Sexual abuse history in GI illness, how do gastroenterologists deal with it?

INTRODUCTION

Data support an increased prevalence of sexual abuse (SA) among patients with gastrointestinal (GI) complaints. Sexual abuse causes multiple symptoms related to pelvic floor and stress mediated brain-gut dysfunctions. Treating these patients asks for a holistic approach, using centrally targeted interventions. However, gastroenterologists have never been surveyed regarding their practice patterns and constraints about inquiring into SA.

AIM

To evaluate whether gastroenterologists address SA in their daily practice and to evaluate their knowledge regarding the implications of SA in GI illness.

METHODS

A 42-item anonymous questionnaire was mailed to all 402 members of the Dutch Society of Gastroenterology (gastroenterologists and fellows in training). The questionnaire addressed SA and pelvic-floor-related complaints.

MAIN OUTCOME MEASURES

The results of this survey.

RESULTS

One hundred eighty-three of the 402 (45.2%) questionnaires were returned. Overall, 4.7% of the respondents asked their female patients regularly about SA; in males, this percentage was 0.6%. Before performing a colonoscopy, these percentages were even smaller (2.4% and 0.6%, respectively). When patients presented with specific complaints, such as chronic abdominal pain or fecal incontinence, 68% of the gastroenterologists asked females about SA and 29% of the males (P < 0.01). The majority of respondents stated it as rather important to receive more training on how to inquire about SA and its implications for treatment.

CONCLUSION

Gastroenterologists do not routinely inquire about a history of SA and they rarely ask about it before performing colonoscopy. There is a need for training to acquire the skills and knowledge to deal with SA.

National patterns in human papillomavirus vaccination: an analysis of the National Survey of Family Growth

Human papillomavirus (HPV) vaccine has shown effectiveness for girls and young women. Despite this, there are population disparities in vaccine utilization rates. The purpose of this study was to evaluate maternal correlates of HPV vaccination among their adolescent daughters using a nationally-representative population-based sample, emphasizing race/ethnicity-specific disparities and barriers. Mothers of 9-18 y-old girls having heard of HPV vaccine and completing the HPV vaccine survey module from the 2006-2008 National Survey of Family Growth (NSFG) (n = 444) were analyzed for maternally-reported adolescent HPV vaccination and maternal intent to vaccinate her adolescent daughter if no dose had been received. Correlates of uptake and intent were examined using multivariate logistic regression. 27% of mothers (n = 98) reported that their daughters were vaccinated against HPV. Independent correlates of vaccination included African-American race (adjusted odds ratio (AOR),0.29; 95% confidence interval (CI),0.11-0.77), and living below the poverty level (AOR,4.43; 95%CI, 1.53-12.82). 46% (n = 152) of mothers of non-vaccinated daughters intended to vaccinate them. Correlates of maternal intention included maternal pelvic exam history (AOR,0.06; 95%CI, 0.007-0.51), multiple male lifetime sexual partners (AOR,3.22 ; 95% CI, 1.34-7.76), religiosity (AOR,0.37; 95% CI,0.16-0.87) and acceptability of premarital sex among 18 y-olds (AOR,2.45; 95% CI, 1.16-5.20). In conclusion, HPV vaccination initiation among adolescent daughters of mothers participating in the NSFG continues to lag among African-American participants. However, no racial/ethnic differences in maternal intent-to-vaccinate her daughter were detected. Future interventions need to address specific maternal barriers to vaccine uptake and how these may differ from vaccine intention.

NorVold Abuse Questionnaire for men (m-NorAQ): validation of new measures of emotional, physical, and sexual abuse and abuse in health care in male patients

BACKGROUND

There are far more prevalence studies on abuse of females than on males as subjects of abuse. The NorVold Abuse Questionnaire (NorAQ) measures emotional, physical, and sexual abuse, as well as abuse in health care, in women and men.

OBJECTIVE

The aim of this study was to test the concurrent validity and test-retest reliability of the questions in the version of NorAQ administered to men (m-NorAQ) against the interview model.

METHODS

The validation was tested in a subsample (n = 86) of a male patient sample who had filled out the m-NorAQ (N = 1667). Respondents completed m-NorAQ twice and were then interviewed. Before the interview, respondents were instructed to answer questions based on personal experience. The interview consisted of 4 open-ended questions about lifetime experiences of emotional, physical, and sexual abuse and abuse in health care.

RESULTS

Results indicated that respondents in the subsample had discussed the experiences of abuse more often in both formal and informal settings than had subjects in the total patient sample. Measures of sensitivity for m-NorAQ were good to excellent (emotional abuse, 83%; physical abuse, 76%; sexual abuse, 68%; abuse in health care, 93%), as were those for specificity (emotional abuse, 72%; physical abuse, 92%; sexual abuse, 99%, abuse in health care, 90%); likelihood ratios were satisfactory (emotional abuse, 3; physical abuse, 9; sexual abuse, 46; abuse in health care, 9); and test-retest reliability measures were excellent (emotional abuse, 80%-95%; physical abuse, 77%-88%; sexual abuse, 91%-100%; abuse in health care, 84%-92%).

CONCLUSION

m-NorAQ showed good to excellent concurrent validity for the different types of abuse and excellent reliability for all questions about abuse. In spite of methodological challenges, validation studies must be conducted as a minimum precaution to ensure that an instrument accurately measures abuse as intended.

Sexual violence, posttraumatic stress disorder, and the pelvic examination: how do beliefs about the safety, necessity, and utility of the examination influence patient experiences?

BACKGROUND

Sexual violence and posttraumatic stress disorder (PTSD) have been linked to increased reports of distress and pain during the pelvic examination. Efforts to more fully characterize these reactions and identify core factors (i.e., beliefs about the examination) that may influence these reactions are warranted.

AIMS

This descriptive, cross-sectional study examines the relationship between sexual violence, PTSD, and women's negative reactions to the pelvic examination. Additional analyses highlight how maladaptive beliefs about the safety, necessity, and utility of the pelvic examination may contribute to these reactions.

MATERIALS AND METHODS

A total of 165 eligible women veterans were identified via medical record review and mailed a survey that assessed: (1) background information; (2) history of sexual violence; (3) current symptoms of posttraumatic stress disorder; (4) fear, embarrassment, distress, and pain during the pelvic examination; and (5) core beliefs about the examination. Ninety women (55% response rate) completed the survey.

RESULTS

Women with both sexual violence and PTSD reported the highest levels of examination related fear: chi(2) = 18.8, p < .001; embarrassment: chi(2) = 21.2, p < .001; and distress: chi(2) = 18.2, p < .001. Beliefs that the examination was unnecessary or unsafe or not useful were more commonly reported in this group and were associated with higher levels of examination-related fear and embarrassment.

CONCLUSION

Women with sexual violence and PTSD find the pelvic examination distressing, embarrassing, and frightening. Efforts to develop interventions to help reduce distress during the examination are warranted.

'You expose yourself in so many ways': young women's experiences of pelvic examination

The aim of this study was to identify and describe young women's experiences of pelvic examination (PE). Qualitative interviews were conducted with nine women aged 18-23 years, who had undergone at least one PE. Data were analysed using an interpretative phenomenological approach. Three general themes were identified: (1) relinquishing and regaining control, (2) facilitation of the situation by the examiner and (3) PE is an unpleasant necessity. These general themes had a common structure that represented the essence: an intimate situation. The women experienced PE as an intimate situation, which they associated with their sexuality. They felt exposed both bodily and mentally and were placed in a vulnerable situation. PE was considered as unpleasant but necessary to confirm their health. During the PE, the women felt that they lost control of the situation by exposing their intimate parts. To regain control, the women felt a need for continuous information from the examiner. The vulnerable situation could be made less vulnerable if the examiner built a trusting relationship and made the women feel secure and seen as individuals. A deeper understanding of the situation from the women's perspective could facilitate the examiner's performance of PE, leading to more positive experiences among young women.

Strong discomfort during vaginal examination: why consider a history of abuse?

OBJECTIVE

To study factors associated with strong discomfort during vaginal examinations (SD/VE) by means of four hypotheses.

STUDY DESIGN

A cross sectional postal questionnaire study, conducted at three Swedish departments of obstetrics and gynaecology and with a random population sample (n=4453).

MAIN OUTCOME MEASURES

The associations between a self-reported history of emotional, physical and sexual abuse and abuse in health care, flashbacks during the previous year, emotional contact with the examiner, and SD/VE during the index visit (discomfort estimated on a ten-point scale; six-ten=SD). Statistical analyses used were Chi-square, Binary logistic regression, and Pearson Correlation.

RESULTS

Eighteen percent of the women reported SD/VE. There was an association between SD/VE and a lifetime history of abuse. Having experienced combinations of abuse, especially combinations including emotional abuse and abuse in health care, was strongly associated with SD/VE. SD/VE was furthermore associated with flashbacks during the previous year, and negative emotional contact with the examiner during the index visit.

CONCLUSIONS

We conclude that women who unexpectedly react with SD/VE are more likely to have a background of abuse, and may even run a risk of feeling re-traumatised during the VE. A clinical implication is to consider a history of abuse in patients who react with SD/VE or experience negative emotional contact during the consultation.