4. Discussion

Women experience undesirable feelings such as embarrassment and loss of control during gynecological examinations [19]. This study, which examined the relationship between gynecological examination anxiety, genital self‐image, depression, anxiety, and stress, was conducted with 281 women to demonstrate that gynecological examination anxiety is not merely a medical anxiety but consists of a structure related to body and self‐evaluation processes.

The study found that university‐graduate women had a more positive genital self‐image than high school‐graduate women. Although Herbenick et al. [42] found that genital self‐image was not associated with the education level, many other studies have reported similar findings [43–45]. The fact that working women have significantly higher average genital self‐image scores than nonworking women (Table 1) may not be explained by a single factor. This could be related to the group having a higher socioeconomic status, demonstrating stronger psychological resilience, and experiencing lower levels of negative emotions. Furthermore, unemployed women were found to have higher levels of depression compared to employed women. Studies show that depression levels are higher in unemployed women than in employed women [46, 47]. Working women experiencing less emotional distress may develop a more positive body image. Therefore, better emotional health may indirectly contribute to higher genital self‐image scores. Furthermore, the fact that university‐graduate women have a more positive genital self‐image suggests that increased health literacy, body awareness, and critical thinking skills associated with education contribute to a more accepting and positive perception of women’s genital areas. Similarly, the higher genital self‐image scores of working women compared to those of nonworking women suggest that increased social interaction and self‐efficacy perception positively influence genital self‐image.

Genital self‐image is an integral part of body image and reflects an individual’s attitudes, feelings, and related experiences regarding their own genitals [28]. Gynecological examination is described as involving the exposure of the body’s intimate areas in a vulnerable state and with a loss of control [25]. It has been stated that genital self‐image is a factor affecting the frequency of gynecological examinations [24]. In this context, it is an expected finding that those who regularly undergo gynecological examinations and those who have had a gynecological examination in the past year will have higher genital self‐perception scores. A decrease in women’s shame, anxiety, or negative evaluations regarding their genital area may reduce the perception of gynecological examinations as a threatening experience, which could support regular checkups. However, the possibility of a reverse relationship should not be overlooked. In particular, it is hypothesized that in some women with lower genital self‐esteem, frequent gynecological examinations may lead to a habituation process over time, reducing anxiety and shame levels. However, subgroup analyses examining these potential interactions were not conducted in the present study. Therefore, a more detailed investigation of the relationships between gynecological examination frequency, genital self‐esteem, and psychological variables is recommended for future studies.

In addition to these factors, age can also be an important determinant of how gynecological examinations are perceived. Studies support a trend that feelings of shame decrease with increasing age [25, 48]. It was found that 45.5% of the women in this study preferred a female physician for gynecological examinations (Table 2). A study by McLean et al. [49] showed that 96.8% of participants preferred female doctors for gynecological procedures. In the study by Karaküçük and Sönmez [50], it was determined that 56.5% of women preferred female doctors for gynecological examinations, and factors such as having completed primary education, embarrassment, and discomfort were influential in this preference. Women’s discomfort with their genital area may affect their choice of a doctor’s gender. The fact that women in this study who preferred male doctors for gynecological examinations had a higher level of genital self‐image compared to those who preferred female doctors suggests that having a more positive and secure self‐perception regarding the genital area may reduce gender‐based anxiety during examinations. Many studies report that women prefer female physicians for gynecological examinations [25, 51, 52] and that women experience anxiety due to the physician being male during gynecological examinations [25]. Relational dynamics, such as spousal demands, can also play a role in women’s physician preferences. In one study, approximately half of the women stated that their spouses influenced their preference for a female physician, while one‐fifth said they would not change their preference even without their spouses’ influence [50]. Societal cultural perceptions, spousal opinions, and religious factors can also influence choices regarding women’s private lives [50]. Another finding of this study is that women who preferred a female physician during gynecological examinations also showed higher scores for depression, anxiety, and stress. It is thought that this gender discrimination in doctor preference is not limited to cultural factors but may also be related to increased psychological sensitivity, which, in turn, may be associated with privacy, shame, or disease diagnosis.

Gynecological examinations are one of the treatment procedures that increase anxiety in women [8]. It is particularly noted that anxiety and stress are triggered when the sense of privacy is compromised [19]. Women who regularly undergo gynecological examinations have higher depression scores, while those who do not have higher anxiety and stress scores. The presence of an existing health problem or related symptoms indicates that increased sensitivity is more pronounced in this group. However, the fact that women who do not regularly undergo gynecological examinations have increased anxiety and stress levels may suggest that the avoidance behavior towards healthcare is based on anxiety and stress. Women who had gynecological examinations within the last year had higher depression scores than those who had them more than 3 years ago. This suggests that gynecological examinations may have been undertaken mostly due to an existing health problem or the presence of symptoms and that this increased depressive mood may be related to healthcare‐seeking behavior.

Another finding in this study is the weak and negative correlation between women’s genital self‐image and gynecological examination anxiety. This suggests that an increase in genital self‐image may reduce gynecological examination anxiety and that women with a more positive perception of their genital area experience less anxiety during the examination process. In this context, the low level of correlation indicates that gynecological examination anxiety cannot be explained solely by genital self‐image; other variables such as cultural factors, past traumatic experiences, and mental health may also play a role in examination anxiety.

The regression analysis indicated that previous negative experiences during gynecological examinations were associated with higher anxiety levels, whereas a higher genital self‐image was associated with lower anxiety. Age, education level, and other sociodemographic/clinical variables were not significantly associated with anxiety. Thus, gynecological examination anxiety appears to comprise both the experiential and subjective components of body perception. Negative experiences during gynecological or obstetric examinations may even cause women to avoid future gynecological visits [53, 54]. This is because negative experiences may have caused the woman to code the examination environment as threatening, involving a loss of control, or containing a violation of privacy. It can also be said that a woman’s self‐assessment and satisfaction level regarding her genital area influence her perception of gynecological examinations.

4.1. Limitations and Strengths of the Study

The findings of this study should be considered in light of certain methodological limitations. First, the collection of data online may have limited the sample to women with internet access or who can use social media; this may have reduced the generalizability of the sample and caused bias. Second, the collection of data through self‐report may also bring about social desirability or recall bias. Third, as the study included only married women, the findings may not be generalizable to single, divorced, or women in other types of relationships. Fourth, considering cultural characteristics, the results may not be directly generalizable to different sociocultural samples. Another limitation is that women’s anxiety about gynecological examinations was assessed solely on a scale basis, and qualitative data regarding the causes of anxiety were not collected. It is recommended that future studies include data that comprehensively evaluate participants’ perceptions and experiences regarding gynecological examination anxiety. Furthermore, the conversion of some categorical variables into binary categories may have led to a loss of information. Additionally, the limited explanatory power of the regression model suggests a multidimensional nature of gynecological examination anxiety. And finally, the fact that variables that may affect the results, such as the past negative gynecological experiences of the women included in the study, social and cultural values, and family structure characteristics, were not addressed in detail within the scope of the research, may lead to different interpretations of the findings. Despite these limitations, the study contributes to the literature by addressing the relationships between genital self‐image, psychological symptoms, and gynecological examination anxiety. It is recommended that the findings be supported by multicenter, longitudinal studies covering different sociodemographic groups in the future.

4.2. Implications for Clinical Practice

The findings of this study demonstrate that gynecological examination anxiety is related to genital self‐image and psychological symptoms. In clinical practice, it is important to evaluate women not only physically but also psychosocially. It should be considered that the risk of anxiety may be higher in women with a negative genital self‐image, high levels of depression and anxiety, or a history of negative examination experiences.

Empathic communication, adequate information, respect for privacy, and woman‐centered and trauma‐sensitive care approaches that take patient preferences into account can be effective in reducing examination anxiety. Timely referral to mental health services and early identification of at‐risk groups may help promote adherence to regular gynecological examinations.