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.

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.

Validation of the Fear of Pelvic Examination Scale (F-PEXS)--measuring students' fear of performing a pelvic examination.

INTRODUCTION: Medical students of both genders often show signs of fear before they perform their first pelvic examination. This situation puts a novice in a special setting of intimacy never experienced before and where different emotions may emerge. A specially designed questionnaire, the Fear of Pelvic Examination Scale (F-PEXS) has been developed to assess fear in this context. The aim of this paper is to describe the validation of the F-PEXS. METHODS: Undergraduate medical students (N = 100) answered the F-PEXS one week before, prior to and after a learning session with professional patients to assess levels of anxiety towards performing the pelvic exam. The validity of the scale was examined using item analysis, reliability assessments and analysis of the construct validity in comparing the F-PEXS with the Spielberger State and Trait Anxiety Inventory and Beck's Anxiety Inventory. RESULTS: The F-PEXS has very good reliability (Cronbach's alpha 0.96) and good construct validity. The mean score on the F-PEXS did not differ between gender either before or after the learning session. CONCLUSIONS: The F-PEXS can be used to assess students' fear of performing the pelvic examination, to evaluate new strategies for learning the pelvic exam and to evaluate the outcome of such interventions.

The first pelvic examination for an adolescent: is this rite of passage used to its full potential?

PURPOSE OF REVIEW: Adolescents' experiences of their first pelvic examination (external inspection, speculum examination and bimanual palpation) may have a marked influence on future experiences; why examination techniques and strategies for creating a positive experience of this situation need to be developed. This review addresses to what extent that ambition is reflected in recent literature. RECENT FINDINGS: The majority of articles on 'pelvic examination during adolescence' come from the United States, which skews the review's perspective. Several researchers recommend using investigations based on new technology rather than a pelvic examination when medical indications for a full examination are present. The profession's attitudes toward annual check-ups and pelvic examinations (in the United States) are currently debated, for teens as well as for adults.How to perform a first pelvic examination on an adolescent is not often discussed, nor are strategies for creating a positive experience of this event.The contexts in which a first pelvic examination is performed probably differ among societies. The Swedish and the US contexts are compared as an illustration; for example preventive healthcare and sex education is in Sweden the responsibility of schools, open for anybody and without admission fees. SUMMARY: Recent literature does not mirror a need for developing examination techniques and strategies for creating a positive experience of the first pelvic examination, nor for exploiting its maximal potential as a positive rite of passage.The ongoing US debate on indications for pelvic examinations and annual check-ups is even more relevant for adolescents, in whom contraindications need to be considered.

Gynecological patients learning to perform the pelvic examination: a win-win concept.

OBJECTIVE: This study explored gynecological patient perceptions of previous pelvic examinations (PE), a learning session about PE prior to a scheduled PE consultation, and the impact of the learning session on the PE during the consultation. STUDY DESIGN: Twelve informants were purposefully sampled from women with scheduled gynecologist appointments at a Swedish University Hospital. The learning session preceded the consultation and provided information on female genital anatomy and the PE, and the informant performed a PE on a mannequin. Individual qualitative interviews followed the consultation. The interviews were transcribed verbatim and analyzed using a constant comparative analysis to acquire a deeper understanding of the women's experiences of the learning session and the subsequent PE. RESULTS: Three categories were identified in the analysis: 'Harmonizing the bad with the good' category, which primarily concerned the informants' previous experiences of the PE. 'Gaining self-confidence through knowledge', which depicted the informants' experiences of the learning session. 'Mental preparation enables bodily recapture', which was the summarizing category of informant experiences of the scheduled PE. The core category, 'active involvement triggers empowerment', was created from the categories, and constitutes the core of the empirical material. CONCLUSION: The informants' active participation during the learning session increased their knowledge, generated self-confidence, triggered an empowering process, and promoted interaction with the examiner during their subsequent PE.

Proud, not yet satisfied: the experiences of abortion service providers in the Kathmandu Valley, Nepal.

OBJECTIVES: In Nepal, the change of the abortion law in 2002 extended the staff duties at family planning clinics to include performing induced abortions. This study investigated the experiences, opinions and attitudes of the staff about their work at safe abortion service centres in the Kathmandu Valley and identified areas in which the health care staff stated the need for improvement. STUDY DESIGN: Fifteen qualitative semi-structured interviews were conducted with doctors and nurses working with induced abortion at one hospital and five clinics in the Kathmandu Valley. The interviews were transcribed verbatim and analysed using the constant comparative method. RESULTS: The core category 'Proud, not yet satisfied' comprised a strong perception of providing an important service that is beneficial for women's health and a feeling of pride in providing quality service. Four related categories were identified: 'Beneficial legal framework', 'A will to reach out to all women', 'Frustration about misuse' and 'Dilemma of sex-selective abortion'. The respondents emphasised that improvements are necessary to (1) ensure that all women have access to safe abortion services; (2) prevent abortions from being used instead of contraceptives; (3) stop illegal medical abortions; and (4) deal with the dilemma of sex-selective abortions. CONCLUSIONS: Respondents were proud of and had positive experiences from their work. They stated they have the opportunity to secure women's rights and health; however, changes are needed to bring the quality of abortion care to a satisfactory level.

Unexpected enlightening of a "female world". Male medical students' experiences of learning and performing the first pelvic examination.

OBJECTIVE: To gain a deeper understanding of how undergraduate male medical students experience a pelvic examination learning concept and performing the first pelvic examination (PE) on a professional patient. STUDY DESIGN: A qualitative study. In-depth interviews with 12 male medical students' after their involvement in a learning session about the PE, with professional patients and a supervising gynecologist as instructors. The interviews were analyzed according to the constant comparative method, a variety of content analysis, to acquire a deeper understanding of the students' experiences and the ongoing social processes. RESULTS: The essence of the entire analysis was "Unexpected enlightening of a 'female world'" and was identified from the three categories; "Not just any exam", "Professional supportive interaction" and "Humble awareness". The male students' most prominent concern was how to establish a professional rapport with the patient in the PE situation. Beneficial active support from the professional patient and the gynecologist assisted the students to overcome inherent barriers and facilitated the examination procedure. The informants gained "inside information" from the patients' perspective of being examined leading to a new awareness about an earlier unknown "female world" that is what women might go through before and during a PE and an humble understanding of how vulnerable it is to be placed in the examination position. CONCLUSION: The beneficial PE learning concept promoted an unexpected insight in what a woman might experience during a PE, creating a humble awareness of this vulnerable intimate situation and ideas for how to establish professional rapport.

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.

Use of clinical simulations for patient education: targeting an untapped audience.

In most cases, the health professional has been the target for simulation based learning curricula. We have developed a simulation based curriculum for patient education. In our curriculum lay-women learn how to perform the clinical female pelvic examination using a manikin-based trainer. Learner assessments show that prior negative expectations turned into positive expectations regarding future pelvic examinations.

Performing the first pelvic examination: female medical students' transition to examiners.

OBJECTIVE: To gain a deeper understanding of how female medical students perceive and experience performing their first pelvic examination (PE). METHODS: A qualitative study. In-depth interviews after the students' involvement in a learning session about the PE, with professional patients (PPs) as instructors and a gynaecologist as supervisor. The interviews were analysed according to the constant comparative method to acquire a deeper understanding of the students' experiences and the ongoing social processes. RESULTS: "Transcending unspoken boundaries and taboos, a prerequisite for learning" was the essence of the entire material and was identified from two categories: "A didactic design facilitates the transition to examiner" and "Interactive support enables creative learning of interpersonal and palpation skills". CONCLUSION: Through interactive guidance from the PPs, the students overcame affective obstacles and achieved the aim of becoming an examiner. The favourable learning experience heightened their awareness of their own bodies and promoted a deeper interest in PEs, both as examiners and as patients. PRACTICE IMPLICATIONS: Engaging voluntary, healthy and knowledgeable women as instructors in the PE situation creates a safe learning environment and promotes interaction with students. Immediate feedback teaches students to integrate communicative and behavioural skills in a professional manner and to palpate the uterus.

Medical students learning the pelvic examination: comparison of outcome in terms of skills between a professional patient and a clinical patient model.

OBJECTIVE: To compare two models of learning the pelvic examination (PE) for medical students, with professional patients (PP) or with clinical patients (CP), by measuring perceived distress and learning outcome in terms of skills. METHODS: Prospective longitudinal study. Assessments of self-perceived distress on four occasions at the prospect of performing a PE. Evaluation of the learning session (LS) and clinical clerkship concerning outcome of palpation skills. RESULTS: During the LS, students in the PP model (PP students) received enough guidance from their coaches, were certain they had palpated the uterus and at least one ovary, and were less distressed afterwards compared with students who were instructed using the CP model (CP students). During the clinical clerkship, the PP students performed twice as many PEs as CP students did and had more often confirmed palpating the uterus and an ovary. CONCLUSION: PP students were more skilful in palpating the uterus and ovaries and performed more PEs during the clinical clerkship than did CP students. PRACTICE IMPLICATIONS: Engaging healthy and voluntary women as PPs takes time and effort. It is, however, worthwhile as it increases the confidence of students who perform PEs, makes them more competent, and ultimately improves their skills in performing the examination during their clinical clerkship.