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Sources of anxiety about pelvic examinations among adolescent females
JOURNALOF ADOLESCENTHEALTHCARE1984;5:105-111
Sources of Anxiety About Pelvic Examinations Among Adolescent Females S U S A N G. MILLSTEIN, P h . D . , N A N C Y E. ADLER, P h . D . , A N D C H A R L E S E. I R W I N , JR., M . D .
Sources of anxiety about pelvic examinations were examined in 84 female adolescents seen in an adolescent clinic. The most common concerns about the examination were: fear of the discovery of pathology; fear of pain; and embarrassment about undressing and about personal cleanliness. Adolescent concerns were highly associated with their level of anxiety prior to, during, and following the examination. The concern most highly associated with anxiety was fear of pain. Fear that the pelvic examination might be painful may be the most important concern to alleviate in the adolescent patient. The most frequent source of information abOut the pelvic examination was peers, and the most common specific message from peers was that the examination was painful. Provider messages were more diffuse and rarely mentioned the physical sensations associated with the procedure, which may have less impact on the adolescent than the specific warnings of peers.
KEYWORDS: Adolescence Anxiety Pelvic exams
From the Adolescent Medicine Unit, Department of Pediatrics, School of Medicine, University of California, San Francisco. Supported in part by MCT 000978 from the Maternal and Child Health Research and Training Branch, Bureau of Health Care Delivery and Assistance, Health Resources and Services Administration, Department of Health and Human Services, and Biomedical Research Support Grant, S07RR05755, Division of Research Resources, National Institute of Health. Presented in part at the Society for Adolescent Medicine Annual Meeting, New York City, October 1982. Address reprint requests to: Susan G. Millstein, Ph.D., Adolescent Medicine Unit, A-268, Department of Pediatrics, University of California-San Francisco, San Francisco, CA 94143. Manuscript accepted October 11, 1983.
The pelvic examination is an essential component of the physical examination for the sexually active female adOlescent. Clinical observations suggest that many adolescents are reluctant to have a pelvic examination and that they may delay seeking health care, in part, because of their anxiety about the procedure (1,2). Anxiety about specific medical procedures is known to affect the patient's willingness to comply with medical recommendations (3,4). With rising rates of sexually transmitted disease in adolescents, anxiety about a pelvic examination could present a significant problem. Efforts to reduce adolescent anxiety about the pelvic examination must take into account the reasons for the anxiety. These reasons may include: fear of the discovery of pathology; expectation of physical discomfort; and psychologic discomfort due to the invasion of body privacy by a stranger (5). Given the importance of the pelvic examination in this age group and the lack of any research delineating adolescent anxiety concerning the pelvic examination, we designed a study to assess the sources of anxiety.
Methods
Subjects
Eighty-four female adolescent patients of adolescent dinics in an urban, university-based, ambulatory care facility were studied. The clinics sampled included two adolescent gynecology clinics and one general clinic. Approximately 76% of the patients w h o were asked to take part in a "health survey" agreed to participate. No information was collected on pa-
© Societyfor AdolescentMedicine,1984 Publishedby ElsevierSciencePublishingCo., Inc., 52 VanderbiltAve., New York, NY 10017
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tients who refused, which would have allowed for comparisons between the two groups. The 84 subjects ranged in age from 14 to 20 years, with a mean age of 17.3 years (SD = 1.5). All subjects were menarchal with a mean gynecologic age of 4.9 years (SD = 1.9). Eighty-three percent of the subjects were sexually active. The racial-ethnic distribution was 39.3% Caucasian, 36.9% Black, and 23.8% of other backgrounds. The socioeconomic status (7) of most subjects was in the middle (38.8%) to lowermiddle class (57.1%) range. Forty-five (53.6%) subjects had a pelvic examination on the day of the Study. Reports in reference to the pelvic examination among these subjects thus represents immediate recollection. Five of these subjects had their first pelvic examination on the day of the study. The remainder had had an average of four previous pelvic examinations. Sixty-two percent of the subjects who had pelvic examinations on the day of the study specified that their visit was gynecologic in nature, 13.3% said they were at the clinic for a check-up, 13.3% gave other specific reasons for their visit, and 8.9% said they were at the clinic for a follow-up visit of unspecified nature. One subject did not specify w h y she came to the clinic. Among subjects who cited a gynecologic problem, 28.5% were at the clinic for birth control, 28.5% for reasons pertaining to pregnancy or abortion, 21.4% for vaginal infections, and 21.4% for other gynecologic problems. Thirty-nine subjects had had pelvic examinations on prior occasions and gave retrospective accounts of their last examination. Almost half of these subjects (47%) had their last examination within the month preceding the study, 26% within 2-6 months, and 24% within 6-12 months previously. Subjects who gave retrospective reports had had an average of two to three previous examinations.
Instruments and Procedure
Overview. Preexamination anxiety was measured in the adolescent prior to being seen by the healthcare provider. After the examination, subjects were queried about their sources of concern and affective responses to the pelvic examination. Postexamination anxiety was measured at the conclusion of the survey. Preexamination anxiety. State anxiety prior to the pelvic examination was measured w h e n subjects arrived in the clinic, prior to their appointment, by the Spielberger State Anxiety Inventory (STAI) (6). The STAI is a 20-item self-report inventory that measures
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transient fluctuations in anxiety as a function of the subject's perceived level of stress. Although tile STAI was administered to all subjects prior to their appointment, analyses of preexamination anxiety were only performed on subjects who said they expected to have a pelvic examination the day they entered the study.
Postexamination anxiety. With the exception of preexamination anxiety, all additional data on subjects was collected following their appointment. Postexamination anxiety was measured by a second administratiOn of the STAI. To assure that measures of postexamination anxiety represented anxiety in relation to the pelvic examination, analyses of postexamination anxiety were only performed on subjects who had a pelvic exam on the day they entered the study. Affective responses to the pelvic exam. Sources of concern about pelvic examinations were elicited through the use of seven scaled items. Each item asked subjects if they had felt a specific concern before their last pelvic examination and the degree to which it had been present. The concerns were: embarrassment about undressing for the examination; fear that the examination would be painful; fear that pathology would be discovered; whether she was clean enough for the examination; if she woUld have an odor that the clinician would discover; whether the examination would damage her genitals; and whether the clinician would discover something about her sexual practices through the examination. Affective experience of the pelvi c examination by the subjects was also assessed by a 90-item adjective checklist developed by the authors. Subjects were asked to check the adjectives that described how they felt during their last pelvic examination, Nine subscales representing positive and negative responses to the pelvic examination were created a priori. The subscales and estimates of their reliability (Chronbach's alpha) were: anxiety (0.87); vulnerability (0.85); anger /0:82); depressive affect-withdrawal (0.65); negative self-image (0,75); relaxation (0.80); involvement-active participation (0.73); mastery (0.75); and positive self-image (0.75). Account of the anxiety subjects experienced during their last pelvic examination was assessed by combining the ACL subscale on anxiety with a single item that asked subjects to rate on a 5-point scale ("not at all" to "extremely") how nervous they felt during the examination. The reliability of this scale was 0.87. In addition, subjects were asked to indicate, on a 5-point scale, how much pain they ex-
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perienced during their last exam ("none" to "great deal").
Background information.
Background information collected on subjects included: chronologic age; age at menarche; race; socioeconomic status; number of previous pelvic examinations; age at first intercourse; number of lifetime sexual partners; and the reason for their current clinic visit. In open-ended questions, subjects were also asked what they had heard about pelvic examinations and from w h o m they had received the information. Open-ended questions were coded by two raters Using a coding scheme that was developed prior to examining subject response (Table 1). Agreement between raters was 90%.
Results There w6re no significant differences in terms of age, gynecologic age, race, or socioeconomic status between subjects who had a pelvic examination on the day they were questioned and those who reported on prior examinations; with few exceptions, the results of the study were the same whether the subject gave a current or a retrospective accOunt. For this reason, analyses on pooled data are presented, except for the analyses on pre- and postexamination anxiety. In cases where differenCes between the groups emerged, the results are noted in the text. The average difference on study variables between the groups was 0.2 SD.
Sources and Types of Information about Pelvic Examinations
Most subjects had heard about pelvic examinations from more than one source. The most frequently mentioned soi,irce of information was friends (64.3%), followed by physicians (41.7%), mothers (39.8%), and others, primarily female relatives (32.1%). Subjects most frequently reported hearing information that focused on descriptions of the examination procedure and the importance of having pelvic examinations (Table 2), However, the type of information subjects heard varied considerably according to the source of the information. Messages from friends were notably negative: 66.1% focused on pain; self-consciousness; fear/anxiety; physical or psychological discomfort; or other negative aspects. The most common specific message from friends was that the examination was painful (14.7%). in contrast, messages from mothers and health-care pro-
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Table 1. Coding Scheme Used to Quantify a Subject's Information AboUt the Pelvic Examination Coding category
Sample response
DESCRIPTION OF PROCEDURE Nonsensory description s, "You !ay on a table, they put mention of instruments, in a speculum and look position on table, rectal around." exam IMPORTANCE AND/OR RATIONALEFOR PROCEDURE Statement of importance, "It's necessary to have one," reference to ruling out "they can tell if you are or discovering pathology healthy or if you have cancer." PHYSICAL SENSATION References to how a pelvic "They feel kind of funny~ examination feels they hurt, I heard what physically (painful, not they feel like." painful) PSYCHOLOGICAL STATE "They are embarrassing," Presence or absence of "yoU don't feel good about self-consciousness, embarrassment, fear, it," "you shoUldn't be scared to have one." anxiety or other psychological state General references to
COMFORT "It was uncomfortable."
comfort or discomfort that cannot be identified as physiologic or psychologic in origin SEXUAL ISSUES Any reference to issues "I heard how the doctor pertaining to sexuality could get into the patient, it was gross." PROVIDER ATTRIBUTES Reference to provider skill, "The doctor was really nice, attitude, or interpersonal did a good exam." communication OTHER POSITIVE INFORMATION "They are not bad." OTHER NEGATIVEINFORMATION "They are sick, weird." "I hate them."
viders focused primarily on descriptions of the procedure (30.6% and 44.7%, respectively) and its importance (36.1% and 28.9%, respectively). Subjects' Sources of Concern about the Pelvic Examination
As shown in Table 3, the subjects' most frequently endorsed concerns about the pelvic examination were those pertaining to fear of the discovery of pathology (72.6%), fear of pain (65.5%), embarrassment about
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Table 2. Information Adolescents Reported Hearing About a Pelvic Examination--Percentage of Descriptions from each Information Source on a Specific Type of Informationa Percent information source Type of information
Friend
Physician
Mother
Other
Total
Description of procedure Importance of procedure Physical sensations other than pain Examination is painful Examination is physically uncomfortable Self-consciousness or embarrassment about the examination Fear or anxiety about the examination Examination is not painful No fear or anxiety about the examination Other positive comments Other negative comments Other responses
10.3 7.4 4.4 14.7 5.9 2.9 8.8 0,0 0.0 2.9 33.8 8.8
44.7 28.9 0.0 5.3 2.6 0.0 0.0 10.5 2.6 0.0 0.0 5.3
30.6 36.1 0.0 0.0 2.8 0.0 0.0 8.3 5.6 5.6 8.3 2.8
6.7 13.3 13.3 20.0 0.0 6.7 6.7 6.7 6.7 6.7 13.3 0.0
22.9 19.7 3.2 9.6 3.8 1.9 4.5 5.1 2.5 3.2 17.8 5.7
68
38
36
15
!57
Responses (n)
aNumbers in cells represent the percentage of responses associated with each information source that focused on a specifie type of information (e.g., 10.3% of the messages adolescents heard about pelvic exams from friends focused on descriptions of the procedure). u n d r e s s i n g for the examination (57.1%), and concerns a b o u t personal cleanliness (46.4%). Subjects' concerns varied as a function of age, history of p r e v i o u s examinations, and sexual experience. Sexual experience was scored on a scale of 0-8. Subjects w h o were not sexually active (had not e n g a g e d in sexual intercourse) were given a score of 0. Sexually active subjects w e r e scored o n the basis of h o w m a n y different sexual partners they had ever had. Subjects w h o r e p o r t e d having more than 8 different partners (n = 2) w e r e given a score of 8. The older a subject, the m o r e likely she was to acknowledge h a v i n g concerns a b o u t o d o r (Pearson r = 0.30; df = 82; p = 0.003). Subjects with less sexual experience r e p o r t e d m o r e e m b a r r a s s m e n t about undressing for the examination (r = - 0 . 3 3 ; df = 78; p = 0.001) and m o r e concern that the examination w o u l d be painful (r = - 0 . 3 6 ; df = 76; p = 0.001) t h a n did subjects with m o r e sexual experience. Subjects w h o h a d h a d f e w e r pelvic examinations also r e p o r t e d greater concern a b o u t e m b a r r a s s m e n t (r = - 0 . 3 4 ; df = 80; p = 0,001) and pain (r = - 0 . 2 4 ; df = 80; p = 0.015) t h a n subjects w h o h a d a history of m o r e pelvic examinations.
Anxiety Prior to, During, and Following the Pelvic Examination M e a n levels of p r e e x a m i n a t i o n anxiety (37.86, SD = 10.11) w e r e not significantly higher than those rep o r t e d for n o r m a t i v e samples of high school re-
males, suggesting that anxiety levels prior to the pelvic examination were not excessively high. A m o n g subjects w h o expected a n d h a d a pelvic examination, the m e a n postexamination anxiety score was 35.38 (SD = 9.42), r e p r e s e n t i n g a significant decrease in anxiety from p r e e x a m i n a t i o n levels (paired t-test = 2.12; df = 33; p = 0.042), Subjects w h o did not have a pelvic examination also s h o w e d a pre- to postexamination d r o p in anxiety, b u t it was not statistically significant. There w e r e no significant differences in pre- or postexamination anxiety a m o n g subjects as a function of age, race, socioeconomic status, sexual experience, or history of pelvic examination. Reported anxiety d u r i n g the pelvic examination varied as a function of subjects' sexual experience and history of previous pelvic examinations. Subjects with limited sexual experience r e p o r t e d significantly higher levels of anxiety d u r i n g the examination than those w h o w e r e m o r e sexually experienced (r = - 0 . 2 0 ; df = 77; p = 0.038). M u c h of this association was d u e to the differences in anxiety r e p o r t e d b y subjects w h o w e r e sexually active and those w h o w e r e not (t -- 2.56; df = 82; p = 0.014). A m o n g subjects w h o h a d a pelvic examination on the day of the study, anxiety levels d u r i n g the examination differed as a function of the n u m b e r of previous pelvic examinations t h e y h a d u n d e r gone. Subjects with a history of f e w e r pelvic examinations r e p o r t e d h i g h e r anxiety t h a n those with more experience (sr = 0.49; p < 0.005). (Semipartial correlation, controlling for age, a n d sexual activity.)
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ANXIETY ABOUT PELVICEXAMS
Table 3. Number of Adolescents Expressing Specific Concerns About the Pelvic Examination Number of subjects Concern
Not at all
A little
Some
Great deal
Embarrassment about undressing
36
29
12
7
Fear of pain
29
22
19
14
Fear of discovery of pathology
23
26
18
17
Have a noticeable odor
57
17
6
4
Doctor would know about sex practices
62
6
9
5
Examination would damage female organs
69
9
4
2
Wonder about being clean enough for the examination
45
22
12
5
Relationship between Adolescent Concerns and Anxiety Because of the intercorrelations a m o n g subjects' concerns, an assessment of h o w each concern correlates with anxiety does not allow the relative importance of subjects' concerns to be determined. Consequently, multivariate analyses were performed 1) to determine w h e t h e r these adolescent concerns could be s u m m a r i z e d by a few themes or dimensions; and 2) to assess the relationship of these themes with adolescent anxiety. The first analysis was a factor analysis of subjects' concerns about pelvic examinations to assess whether the adolescents' concerns could be combined to represent a few themes or dimensions (8). The factor analysis yielded two factors that together explained 51.6% of the variance in subjects' concerns. (The correlation b e t w e e n Factor 1 and Factor 2 was 0.45.) The first factor (34% of the variance, eigenvalue = 2.45) included concerns about odor, personal cleanliness, a n d e m b a r r a s s m e n t about undressing for the examination. This factor seems to best represent subjects' concerns pertaining to self-consciousness about the examination. The item most highly associated with this self-consciousness factor was concern about personal cleanliness (Factor loading = 0.75). The second factor (16.7% of the variance, eigenvalue = 1.17) included concerns about pain, pathology, a n d d a m a g e to the genitals. This factor appears to be a more general factor of the potentially aversive consequences of a pelvic examination. The item most highly associated with this factor was fear of pain (Factor loading = 0.74). The second phase of analyses utilized these factors (self-consciousness a n d aversive consequences)
as i n d e p e n d e n t variables in a multiple regression analysis. Factor scores for each subject were computed by taking the m e a n degree of concern over the three items in each factor. The results of these regression analyses s h o w e d that high levels of concern about the pelvic examination, irrespective of its source, were significantly associated with higher levels of anxiety prior to (Multiple R = 0.51; p < 0.005), and during (Multiple R = 0.62; p < 0.001), the pelvic examination. High levels of overall concern were not significantly associated with high postexamination anxiety (Multiple R = 0.30). Examination of semipartial correlation coefficients s h o w e d that anxiety prior to and during the examination was most highly associated with having concerns about the aversive consequences of a pelvic examination (sr = 0.35, p < 0.05; sr = 0.52, p K 0.001).
Other Affective Responses to the Pelvic Examination A n u m b e r of other positive and negative reactions to the pelvic examination were assessed in addition to anxiety. The primary sources of information on the other responses were: 1) ACL subscales on depression, anger, negative self-image, vulnerability, relaxation, positive self-image, involvement-active participation, and mastery; a n d 2) a question to assess the a m o u n t of pain experienced during the examination. Subjects' reports of anxiety during the pelvic examination were highly correlated with reports of other negative feelings in subjects w h o h a d an examination. These included: anger (r = 0.53; df = 43; p
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0.001), vulnerability (r = 0.48; df = 43; p < 0.001), depressive affect (r = 0.33; df = 43; p = 0.012), and negative self-image (r = 0.27, df = 43; p = 0.034). Anxiety was not correlated with reports of relaxation, involvement, feelings of mastery, or positive self-image. Postexamination anxiety was correlated with reports of depressive affect (r = 0.43; df = 42; p = 0.002).
Reports of Pain During the Pelvic Examination Most subjects (74.1%) reported that they experienced some pain. High levels of preexamination anxiety were not significantly associated with reporting of more pain during the examination (r = 0.26; df = 33; p = 0.065), although trends were in the expected direction. Subjects w h o showed higher anxiety prior to the examination reported higher absolute levels of pain during the examination. Subjects w h o were most concerned that the examination would hurt did report more pain during the procedure than those w h o had less concern (r = 0.31; df = 82; p < 0.005). Subjects who reported feeling anxious during the pelvic examination also reported it was more painful (r = 0.45; df = 43; p < 0.001). Subjects w h o had their first pelvic examination the day of the study reported significantly higher levels of concern about pain than subjects with a history of previous examinations (t = 3.08; p < 0.005), and their concerns were highly associated with the report of pain during the examination (r = 0.53).
Discussion The results of our study suggest that while adolescent females in our sample did not exhibit pathologic levels of anxiety in relation to a pelvic examination, approximately one-third (32.6%) of those who expected to have a pelvic examination had anxiety levels at or above the levels associated with presurgical (9) and text anxiety (6). Anxiety in our sample of adolescents was also associated with a variety of other negative states including feelings of anger, vulnerability, depression, and negative feelings about themselves. This suggests that negative responses to the pelvic examination do not focus entirely on anxiety, but include an entire set of negative affective responses. Surprisingly, our relatively simple measure of anxiety correlated more often with expected variables than the STAI. More importantly, adolescents' responses to the STAI were highly associated with
JOURNALOF ADOLESCENTHEALTHCAREVol. 5, No. 2
their tendency to respond in socially desirable directions 1, while our measure was not. Such an association is problematic for any self-report measure. The question of whether this instrument is valid for this particular population in this type of setting should be raised, although data from this study cannot answer this question. Fear that the pelvic examination will be painful may be the most important concern to alleviate in adolescent patients. The higher the adolescents' level of concern about pain, the more likely she was to show high levels of anxiety prior to (r = 0.26), during (r = 0.51), and following (r = 0.26) the examination. Fear of pain may be a self-fulfilling prophecy; subjects who were most concerned that the examination would hurt were also most likely to report having pain during the examination. While it could be argued that the subjects' fear of pain was the result of having had a painful examination, the data suggest that the fear of pain may, in some cases, be the determining causal factor. Subjects who had their first pelvic examination the day of the study reported significantly higher levels of concern about pain than subjects who had a previous history of an examination(s), and those concerns were highly associated with a report of pain during the examination. Simply asking patients h o w painful they expected the examination to be may help identify those adolescents for w h o m the examination will be more difficult. The most common specific message these adolescents heard from their peers was that a pelvic examination is painful, and peers were mentioned most frequently as an information source. While health-care providers were an important information source for our adolescents, the providers' messages rarely focused on a sensory description of the procedure. Research on anxiety in relation to stressful or aversive medical procedures has shown that providing patients with information about the sensory feelings they will experience may decrease their level of anxiety about the procedure, while information about the procedure itself does not (10). Cognitive strategies such as imagery, distraction, or sensitization may also be used to decrease anxiety about aversive events (10). In the adolescent patient having a pelvic exam, particularly those w h o have had few or no previous examinations, discussing the physical sensations associated with the procedure and suggesting methods of cognitive control may
:All analyses controlled for this relationship.
April 1984
help to alleviate some of their anxiety about the procedure, and perhaps decrease their reluctance to be examined. The authors thank Elizabeth Rutzick, Maryanne Stewart, and Lee Ann Slinkard for their assistance in data collection, William A. Hargreaves, Bruce L. Stegner, and Alan Bostrom for their helpful comments during the study, and Martin Kamp for his support. We thank Diane Wells and Abe Bernstein for their editorial assistance, and Carol Dahlstrom for manuscript preparation.
ANXIETY ABOUT PELVIC EXAMS
4. 5.
6.
7.
References 1. Wells GM: Reducing the threat of a first pelvic exam. Am J Maternal Child Nurs 1977;2:304-6. 2. Kruetner AK: Examination of the adolescent female. In Kruetner AK, and Hollingsworth DR, eds., Adolescent obstetrics and gynecology, Chicago, Year Book Medical Publishers, Inc., 1978. 3. Radelfinger S: Some effects of fear-arousing communications
8. 9.
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on preventive health behavior. Health Educ Monographs 1965;19:2-15. Kegels SS: Why people seek dental care: A test of a conceptual formulation. J Health Hum Behav 1963;4:166-73. Fordney-Settlage DS: Pelvic examination of women; genitorectal examination of men. In Green R, ed., Human sexuality: A health practitioner's text, Baltimore, Maryland, Williams and Wilkins, 1979. Spielberger CD, Gorsuch RL, Lushene RE: State-trait anxiety inventory test manual. Palo Alto, California, Consulting Psychologists Press, 1970. HoUingshead AB, Redlich FC: Social class and mental illness: A community study, New York, John Wiley and Sons, 1958. Cattell RF: Factor analysis: An introduction to essentials. Biometrics 21:190-215, 405-35, 1965. Chapman CR, Cox GB: Determinants of anxiety in elective surgery patients. In Sarason IG, Spielberger, CD, eds., Stress and anxiety, Vol. 4, Washington, Hemisphere Publishing Corp: 1976. Thompson SC: Will it hurt less if I can control it? A complex answer to a simple question. Psychol Bull 1981;90:89-101.
Sources of Anxiety About Pelvic Examinations Among Adolescent Females S U S A N G. MILLSTEIN, P h . D . , N A N C Y E. ADLER, P h . D . , A N D C H A R L E S E. I R W I N , JR., M . D .
Sources of anxiety about pelvic examinations were examined in 84 female adolescents seen in an adolescent clinic. The most common concerns about the examination were: fear of the discovery of pathology; fear of pain; and embarrassment about undressing and about personal cleanliness. Adolescent concerns were highly associated with their level of anxiety prior to, during, and following the examination. The concern most highly associated with anxiety was fear of pain. Fear that the pelvic examination might be painful may be the most important concern to alleviate in the adolescent patient. The most frequent source of information abOut the pelvic examination was peers, and the most common specific message from peers was that the examination was painful. Provider messages were more diffuse and rarely mentioned the physical sensations associated with the procedure, which may have less impact on the adolescent than the specific warnings of peers.
KEYWORDS: Adolescence Anxiety Pelvic exams
From the Adolescent Medicine Unit, Department of Pediatrics, School of Medicine, University of California, San Francisco. Supported in part by MCT 000978 from the Maternal and Child Health Research and Training Branch, Bureau of Health Care Delivery and Assistance, Health Resources and Services Administration, Department of Health and Human Services, and Biomedical Research Support Grant, S07RR05755, Division of Research Resources, National Institute of Health. Presented in part at the Society for Adolescent Medicine Annual Meeting, New York City, October 1982. Address reprint requests to: Susan G. Millstein, Ph.D., Adolescent Medicine Unit, A-268, Department of Pediatrics, University of California-San Francisco, San Francisco, CA 94143. Manuscript accepted October 11, 1983.
The pelvic examination is an essential component of the physical examination for the sexually active female adOlescent. Clinical observations suggest that many adolescents are reluctant to have a pelvic examination and that they may delay seeking health care, in part, because of their anxiety about the procedure (1,2). Anxiety about specific medical procedures is known to affect the patient's willingness to comply with medical recommendations (3,4). With rising rates of sexually transmitted disease in adolescents, anxiety about a pelvic examination could present a significant problem. Efforts to reduce adolescent anxiety about the pelvic examination must take into account the reasons for the anxiety. These reasons may include: fear of the discovery of pathology; expectation of physical discomfort; and psychologic discomfort due to the invasion of body privacy by a stranger (5). Given the importance of the pelvic examination in this age group and the lack of any research delineating adolescent anxiety concerning the pelvic examination, we designed a study to assess the sources of anxiety.
Methods
Subjects
Eighty-four female adolescent patients of adolescent dinics in an urban, university-based, ambulatory care facility were studied. The clinics sampled included two adolescent gynecology clinics and one general clinic. Approximately 76% of the patients w h o were asked to take part in a "health survey" agreed to participate. No information was collected on pa-
© Societyfor AdolescentMedicine,1984 Publishedby ElsevierSciencePublishingCo., Inc., 52 VanderbiltAve., New York, NY 10017
105
0197-0070/84/$3.00
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MILLSTEINET AL.
tients who refused, which would have allowed for comparisons between the two groups. The 84 subjects ranged in age from 14 to 20 years, with a mean age of 17.3 years (SD = 1.5). All subjects were menarchal with a mean gynecologic age of 4.9 years (SD = 1.9). Eighty-three percent of the subjects were sexually active. The racial-ethnic distribution was 39.3% Caucasian, 36.9% Black, and 23.8% of other backgrounds. The socioeconomic status (7) of most subjects was in the middle (38.8%) to lowermiddle class (57.1%) range. Forty-five (53.6%) subjects had a pelvic examination on the day of the Study. Reports in reference to the pelvic examination among these subjects thus represents immediate recollection. Five of these subjects had their first pelvic examination on the day of the study. The remainder had had an average of four previous pelvic examinations. Sixty-two percent of the subjects who had pelvic examinations on the day of the study specified that their visit was gynecologic in nature, 13.3% said they were at the clinic for a check-up, 13.3% gave other specific reasons for their visit, and 8.9% said they were at the clinic for a follow-up visit of unspecified nature. One subject did not specify w h y she came to the clinic. Among subjects who cited a gynecologic problem, 28.5% were at the clinic for birth control, 28.5% for reasons pertaining to pregnancy or abortion, 21.4% for vaginal infections, and 21.4% for other gynecologic problems. Thirty-nine subjects had had pelvic examinations on prior occasions and gave retrospective accounts of their last examination. Almost half of these subjects (47%) had their last examination within the month preceding the study, 26% within 2-6 months, and 24% within 6-12 months previously. Subjects who gave retrospective reports had had an average of two to three previous examinations.
Instruments and Procedure
Overview. Preexamination anxiety was measured in the adolescent prior to being seen by the healthcare provider. After the examination, subjects were queried about their sources of concern and affective responses to the pelvic examination. Postexamination anxiety was measured at the conclusion of the survey. Preexamination anxiety. State anxiety prior to the pelvic examination was measured w h e n subjects arrived in the clinic, prior to their appointment, by the Spielberger State Anxiety Inventory (STAI) (6). The STAI is a 20-item self-report inventory that measures
JOURNAL OF ADOLESCENTHEALTHCAREVol. 5, No. 2
transient fluctuations in anxiety as a function of the subject's perceived level of stress. Although tile STAI was administered to all subjects prior to their appointment, analyses of preexamination anxiety were only performed on subjects who said they expected to have a pelvic examination the day they entered the study.
Postexamination anxiety. With the exception of preexamination anxiety, all additional data on subjects was collected following their appointment. Postexamination anxiety was measured by a second administratiOn of the STAI. To assure that measures of postexamination anxiety represented anxiety in relation to the pelvic examination, analyses of postexamination anxiety were only performed on subjects who had a pelvic exam on the day they entered the study. Affective responses to the pelvic exam. Sources of concern about pelvic examinations were elicited through the use of seven scaled items. Each item asked subjects if they had felt a specific concern before their last pelvic examination and the degree to which it had been present. The concerns were: embarrassment about undressing for the examination; fear that the examination would be painful; fear that pathology would be discovered; whether she was clean enough for the examination; if she woUld have an odor that the clinician would discover; whether the examination would damage her genitals; and whether the clinician would discover something about her sexual practices through the examination. Affective experience of the pelvi c examination by the subjects was also assessed by a 90-item adjective checklist developed by the authors. Subjects were asked to check the adjectives that described how they felt during their last pelvic examination, Nine subscales representing positive and negative responses to the pelvic examination were created a priori. The subscales and estimates of their reliability (Chronbach's alpha) were: anxiety (0.87); vulnerability (0.85); anger /0:82); depressive affect-withdrawal (0.65); negative self-image (0,75); relaxation (0.80); involvement-active participation (0.73); mastery (0.75); and positive self-image (0.75). Account of the anxiety subjects experienced during their last pelvic examination was assessed by combining the ACL subscale on anxiety with a single item that asked subjects to rate on a 5-point scale ("not at all" to "extremely") how nervous they felt during the examination. The reliability of this scale was 0.87. In addition, subjects were asked to indicate, on a 5-point scale, how much pain they ex-
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perienced during their last exam ("none" to "great deal").
Background information.
Background information collected on subjects included: chronologic age; age at menarche; race; socioeconomic status; number of previous pelvic examinations; age at first intercourse; number of lifetime sexual partners; and the reason for their current clinic visit. In open-ended questions, subjects were also asked what they had heard about pelvic examinations and from w h o m they had received the information. Open-ended questions were coded by two raters Using a coding scheme that was developed prior to examining subject response (Table 1). Agreement between raters was 90%.
Results There w6re no significant differences in terms of age, gynecologic age, race, or socioeconomic status between subjects who had a pelvic examination on the day they were questioned and those who reported on prior examinations; with few exceptions, the results of the study were the same whether the subject gave a current or a retrospective accOunt. For this reason, analyses on pooled data are presented, except for the analyses on pre- and postexamination anxiety. In cases where differenCes between the groups emerged, the results are noted in the text. The average difference on study variables between the groups was 0.2 SD.
Sources and Types of Information about Pelvic Examinations
Most subjects had heard about pelvic examinations from more than one source. The most frequently mentioned soi,irce of information was friends (64.3%), followed by physicians (41.7%), mothers (39.8%), and others, primarily female relatives (32.1%). Subjects most frequently reported hearing information that focused on descriptions of the examination procedure and the importance of having pelvic examinations (Table 2), However, the type of information subjects heard varied considerably according to the source of the information. Messages from friends were notably negative: 66.1% focused on pain; self-consciousness; fear/anxiety; physical or psychological discomfort; or other negative aspects. The most common specific message from friends was that the examination was painful (14.7%). in contrast, messages from mothers and health-care pro-
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Table 1. Coding Scheme Used to Quantify a Subject's Information AboUt the Pelvic Examination Coding category
Sample response
DESCRIPTION OF PROCEDURE Nonsensory description s, "You !ay on a table, they put mention of instruments, in a speculum and look position on table, rectal around." exam IMPORTANCE AND/OR RATIONALEFOR PROCEDURE Statement of importance, "It's necessary to have one," reference to ruling out "they can tell if you are or discovering pathology healthy or if you have cancer." PHYSICAL SENSATION References to how a pelvic "They feel kind of funny~ examination feels they hurt, I heard what physically (painful, not they feel like." painful) PSYCHOLOGICAL STATE "They are embarrassing," Presence or absence of "yoU don't feel good about self-consciousness, embarrassment, fear, it," "you shoUldn't be scared to have one." anxiety or other psychological state General references to
COMFORT "It was uncomfortable."
comfort or discomfort that cannot be identified as physiologic or psychologic in origin SEXUAL ISSUES Any reference to issues "I heard how the doctor pertaining to sexuality could get into the patient, it was gross." PROVIDER ATTRIBUTES Reference to provider skill, "The doctor was really nice, attitude, or interpersonal did a good exam." communication OTHER POSITIVE INFORMATION "They are not bad." OTHER NEGATIVEINFORMATION "They are sick, weird." "I hate them."
viders focused primarily on descriptions of the procedure (30.6% and 44.7%, respectively) and its importance (36.1% and 28.9%, respectively). Subjects' Sources of Concern about the Pelvic Examination
As shown in Table 3, the subjects' most frequently endorsed concerns about the pelvic examination were those pertaining to fear of the discovery of pathology (72.6%), fear of pain (65.5%), embarrassment about
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Table 2. Information Adolescents Reported Hearing About a Pelvic Examination--Percentage of Descriptions from each Information Source on a Specific Type of Informationa Percent information source Type of information
Friend
Physician
Mother
Other
Total
Description of procedure Importance of procedure Physical sensations other than pain Examination is painful Examination is physically uncomfortable Self-consciousness or embarrassment about the examination Fear or anxiety about the examination Examination is not painful No fear or anxiety about the examination Other positive comments Other negative comments Other responses
10.3 7.4 4.4 14.7 5.9 2.9 8.8 0,0 0.0 2.9 33.8 8.8
44.7 28.9 0.0 5.3 2.6 0.0 0.0 10.5 2.6 0.0 0.0 5.3
30.6 36.1 0.0 0.0 2.8 0.0 0.0 8.3 5.6 5.6 8.3 2.8
6.7 13.3 13.3 20.0 0.0 6.7 6.7 6.7 6.7 6.7 13.3 0.0
22.9 19.7 3.2 9.6 3.8 1.9 4.5 5.1 2.5 3.2 17.8 5.7
68
38
36
15
!57
Responses (n)
aNumbers in cells represent the percentage of responses associated with each information source that focused on a specifie type of information (e.g., 10.3% of the messages adolescents heard about pelvic exams from friends focused on descriptions of the procedure). u n d r e s s i n g for the examination (57.1%), and concerns a b o u t personal cleanliness (46.4%). Subjects' concerns varied as a function of age, history of p r e v i o u s examinations, and sexual experience. Sexual experience was scored on a scale of 0-8. Subjects w h o were not sexually active (had not e n g a g e d in sexual intercourse) were given a score of 0. Sexually active subjects w e r e scored o n the basis of h o w m a n y different sexual partners they had ever had. Subjects w h o r e p o r t e d having more than 8 different partners (n = 2) w e r e given a score of 8. The older a subject, the m o r e likely she was to acknowledge h a v i n g concerns a b o u t o d o r (Pearson r = 0.30; df = 82; p = 0.003). Subjects with less sexual experience r e p o r t e d m o r e e m b a r r a s s m e n t about undressing for the examination (r = - 0 . 3 3 ; df = 78; p = 0.001) and m o r e concern that the examination w o u l d be painful (r = - 0 . 3 6 ; df = 76; p = 0.001) t h a n did subjects with m o r e sexual experience. Subjects w h o h a d h a d f e w e r pelvic examinations also r e p o r t e d greater concern a b o u t e m b a r r a s s m e n t (r = - 0 . 3 4 ; df = 80; p = 0,001) and pain (r = - 0 . 2 4 ; df = 80; p = 0.015) t h a n subjects w h o h a d a history of m o r e pelvic examinations.
Anxiety Prior to, During, and Following the Pelvic Examination M e a n levels of p r e e x a m i n a t i o n anxiety (37.86, SD = 10.11) w e r e not significantly higher than those rep o r t e d for n o r m a t i v e samples of high school re-
males, suggesting that anxiety levels prior to the pelvic examination were not excessively high. A m o n g subjects w h o expected a n d h a d a pelvic examination, the m e a n postexamination anxiety score was 35.38 (SD = 9.42), r e p r e s e n t i n g a significant decrease in anxiety from p r e e x a m i n a t i o n levels (paired t-test = 2.12; df = 33; p = 0.042), Subjects w h o did not have a pelvic examination also s h o w e d a pre- to postexamination d r o p in anxiety, b u t it was not statistically significant. There w e r e no significant differences in pre- or postexamination anxiety a m o n g subjects as a function of age, race, socioeconomic status, sexual experience, or history of pelvic examination. Reported anxiety d u r i n g the pelvic examination varied as a function of subjects' sexual experience and history of previous pelvic examinations. Subjects with limited sexual experience r e p o r t e d significantly higher levels of anxiety d u r i n g the examination than those w h o w e r e m o r e sexually experienced (r = - 0 . 2 0 ; df = 77; p = 0.038). M u c h of this association was d u e to the differences in anxiety r e p o r t e d b y subjects w h o w e r e sexually active and those w h o w e r e not (t -- 2.56; df = 82; p = 0.014). A m o n g subjects w h o h a d a pelvic examination on the day of the study, anxiety levels d u r i n g the examination differed as a function of the n u m b e r of previous pelvic examinations t h e y h a d u n d e r gone. Subjects with a history of f e w e r pelvic examinations r e p o r t e d h i g h e r anxiety t h a n those with more experience (sr = 0.49; p < 0.005). (Semipartial correlation, controlling for age, a n d sexual activity.)
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ANXIETY ABOUT PELVICEXAMS
Table 3. Number of Adolescents Expressing Specific Concerns About the Pelvic Examination Number of subjects Concern
Not at all
A little
Some
Great deal
Embarrassment about undressing
36
29
12
7
Fear of pain
29
22
19
14
Fear of discovery of pathology
23
26
18
17
Have a noticeable odor
57
17
6
4
Doctor would know about sex practices
62
6
9
5
Examination would damage female organs
69
9
4
2
Wonder about being clean enough for the examination
45
22
12
5
Relationship between Adolescent Concerns and Anxiety Because of the intercorrelations a m o n g subjects' concerns, an assessment of h o w each concern correlates with anxiety does not allow the relative importance of subjects' concerns to be determined. Consequently, multivariate analyses were performed 1) to determine w h e t h e r these adolescent concerns could be s u m m a r i z e d by a few themes or dimensions; and 2) to assess the relationship of these themes with adolescent anxiety. The first analysis was a factor analysis of subjects' concerns about pelvic examinations to assess whether the adolescents' concerns could be combined to represent a few themes or dimensions (8). The factor analysis yielded two factors that together explained 51.6% of the variance in subjects' concerns. (The correlation b e t w e e n Factor 1 and Factor 2 was 0.45.) The first factor (34% of the variance, eigenvalue = 2.45) included concerns about odor, personal cleanliness, a n d e m b a r r a s s m e n t about undressing for the examination. This factor seems to best represent subjects' concerns pertaining to self-consciousness about the examination. The item most highly associated with this self-consciousness factor was concern about personal cleanliness (Factor loading = 0.75). The second factor (16.7% of the variance, eigenvalue = 1.17) included concerns about pain, pathology, a n d d a m a g e to the genitals. This factor appears to be a more general factor of the potentially aversive consequences of a pelvic examination. The item most highly associated with this factor was fear of pain (Factor loading = 0.74). The second phase of analyses utilized these factors (self-consciousness a n d aversive consequences)
as i n d e p e n d e n t variables in a multiple regression analysis. Factor scores for each subject were computed by taking the m e a n degree of concern over the three items in each factor. The results of these regression analyses s h o w e d that high levels of concern about the pelvic examination, irrespective of its source, were significantly associated with higher levels of anxiety prior to (Multiple R = 0.51; p < 0.005), and during (Multiple R = 0.62; p < 0.001), the pelvic examination. High levels of overall concern were not significantly associated with high postexamination anxiety (Multiple R = 0.30). Examination of semipartial correlation coefficients s h o w e d that anxiety prior to and during the examination was most highly associated with having concerns about the aversive consequences of a pelvic examination (sr = 0.35, p < 0.05; sr = 0.52, p K 0.001).
Other Affective Responses to the Pelvic Examination A n u m b e r of other positive and negative reactions to the pelvic examination were assessed in addition to anxiety. The primary sources of information on the other responses were: 1) ACL subscales on depression, anger, negative self-image, vulnerability, relaxation, positive self-image, involvement-active participation, and mastery; a n d 2) a question to assess the a m o u n t of pain experienced during the examination. Subjects' reports of anxiety during the pelvic examination were highly correlated with reports of other negative feelings in subjects w h o h a d an examination. These included: anger (r = 0.53; df = 43; p
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0.001), vulnerability (r = 0.48; df = 43; p < 0.001), depressive affect (r = 0.33; df = 43; p = 0.012), and negative self-image (r = 0.27, df = 43; p = 0.034). Anxiety was not correlated with reports of relaxation, involvement, feelings of mastery, or positive self-image. Postexamination anxiety was correlated with reports of depressive affect (r = 0.43; df = 42; p = 0.002).
Reports of Pain During the Pelvic Examination Most subjects (74.1%) reported that they experienced some pain. High levels of preexamination anxiety were not significantly associated with reporting of more pain during the examination (r = 0.26; df = 33; p = 0.065), although trends were in the expected direction. Subjects w h o showed higher anxiety prior to the examination reported higher absolute levels of pain during the examination. Subjects w h o were most concerned that the examination would hurt did report more pain during the procedure than those w h o had less concern (r = 0.31; df = 82; p < 0.005). Subjects who reported feeling anxious during the pelvic examination also reported it was more painful (r = 0.45; df = 43; p < 0.001). Subjects w h o had their first pelvic examination the day of the study reported significantly higher levels of concern about pain than subjects with a history of previous examinations (t = 3.08; p < 0.005), and their concerns were highly associated with the report of pain during the examination (r = 0.53).
Discussion The results of our study suggest that while adolescent females in our sample did not exhibit pathologic levels of anxiety in relation to a pelvic examination, approximately one-third (32.6%) of those who expected to have a pelvic examination had anxiety levels at or above the levels associated with presurgical (9) and text anxiety (6). Anxiety in our sample of adolescents was also associated with a variety of other negative states including feelings of anger, vulnerability, depression, and negative feelings about themselves. This suggests that negative responses to the pelvic examination do not focus entirely on anxiety, but include an entire set of negative affective responses. Surprisingly, our relatively simple measure of anxiety correlated more often with expected variables than the STAI. More importantly, adolescents' responses to the STAI were highly associated with
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their tendency to respond in socially desirable directions 1, while our measure was not. Such an association is problematic for any self-report measure. The question of whether this instrument is valid for this particular population in this type of setting should be raised, although data from this study cannot answer this question. Fear that the pelvic examination will be painful may be the most important concern to alleviate in adolescent patients. The higher the adolescents' level of concern about pain, the more likely she was to show high levels of anxiety prior to (r = 0.26), during (r = 0.51), and following (r = 0.26) the examination. Fear of pain may be a self-fulfilling prophecy; subjects who were most concerned that the examination would hurt were also most likely to report having pain during the examination. While it could be argued that the subjects' fear of pain was the result of having had a painful examination, the data suggest that the fear of pain may, in some cases, be the determining causal factor. Subjects who had their first pelvic examination the day of the study reported significantly higher levels of concern about pain than subjects who had a previous history of an examination(s), and those concerns were highly associated with a report of pain during the examination. Simply asking patients h o w painful they expected the examination to be may help identify those adolescents for w h o m the examination will be more difficult. The most common specific message these adolescents heard from their peers was that a pelvic examination is painful, and peers were mentioned most frequently as an information source. While health-care providers were an important information source for our adolescents, the providers' messages rarely focused on a sensory description of the procedure. Research on anxiety in relation to stressful or aversive medical procedures has shown that providing patients with information about the sensory feelings they will experience may decrease their level of anxiety about the procedure, while information about the procedure itself does not (10). Cognitive strategies such as imagery, distraction, or sensitization may also be used to decrease anxiety about aversive events (10). In the adolescent patient having a pelvic exam, particularly those w h o have had few or no previous examinations, discussing the physical sensations associated with the procedure and suggesting methods of cognitive control may
:All analyses controlled for this relationship.
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help to alleviate some of their anxiety about the procedure, and perhaps decrease their reluctance to be examined. The authors thank Elizabeth Rutzick, Maryanne Stewart, and Lee Ann Slinkard for their assistance in data collection, William A. Hargreaves, Bruce L. Stegner, and Alan Bostrom for their helpful comments during the study, and Martin Kamp for his support. We thank Diane Wells and Abe Bernstein for their editorial assistance, and Carol Dahlstrom for manuscript preparation.
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4. 5.
6.
7.
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