Attitude and practice of family physicians towards physical examination of patients of the opposite gender in primary health care centres in the Kingdom of Bahrain: a qualitative exploratory study

Abstract

Background

Physician attitudes towards patients of opposite genders may determine a lack of comprehensive care during patient encounters in primary care, and this has not been previously documented in the Arab Gulf region. This study investigated the attitudes and practices of family physicians about physical examinations of patients of the opposite gender in the Kingdom of Bahrain, specifically identifying barriers to performing physical examinations on patients of the opposite gender.

Method

Qualitative exploratory, in-depth interviews were conducted with 15 board-certified Bahraini family physicians at nine primary health care centres from all five regions of the Kingdom of Bahrain. The participants were selected by a purposive sampling designed to include all physicians eligible as per inclusion criteria. A semi-structured interview guide was used for the interviews in English (appendix.1). Interviews were recorded and transcribed verbatim. The data were analysed by thematic analysis.

Results

The study revealed four distinct and interrelated themes, including: 1) Influencers affect the practice of performing physical examinations on patients of opposite genders; 2) Effective communication and rapport-building with patients of the opposite gender before physical examination; 3) Physicians collaborate in the physical examination of patients of the opposite gender when needed; 4) Importance of a functional chaperone system in the primary health care centres to provide optimal care.

Conclusions

Family physicians identified cultural, religious, and medico-legal barriers to performing physical examinations on opposite-gender patients. They reported adapting to these challenges by finding workarounds, such as referring patients to physicians of the same gender or using a chaperone system. To address these challenges effectively, establishing a regular chaperone system and trainings on examination techniques may enhance physicians' skills and confidence in conducting physical examinations on opposite-gender patients.

Introduction

Gender can impact physical examinations, affecting patient-physician interactions, preferences, expectations, and satisfaction with medical visits [1]. The physical examination is a crucial step in a patient’s visit to a family physician, and its absence can adversely affect the outcome of the medical consultation. Several studies conducted in various countries, including Saudi Arabia, the United Kingdom, and the US, have identified gender-related biases and barriers that affect physicians' attitudes and practices in performing physical examinations. For instance, male residents were found to be more comfortable with testicular and prostate examinations [2], while female residents were more comfortable with pelvic and breast examinations [3]. It is also perceived by family physicians that patients tend to prefer same-sex physicians regarding sexual health matters. Implementing appropriate strategies based on knowledge about physician and patient gender disparities is crucial for delivering high-quality, gender-sensitive healthcare [4]. Overall, there is a strong association between physicians' confidence in performing an examination and the frequency of conducting it on patients of the opposite gender [2, 3, 5, 6].

One study done in the UK showed that student discomfort with learning intimate physical examination skills is common and can have ongoing repercussions for both students and patients [7]. In the UK, another study highlighted that medical students perceive a gendered culture of learning in clinical practice, impacting mentorship, learning opportunities, and relationships with nurses [8]. Furthermore, in a study conducted at a European graduate-entry medical school, researchers addressed the presence of gender inequities in peer physical examination experiences. They emphasized the need for educators to address these issues to ensure fair and inclusive learning environments for all students [9].

Physician gender can influence the patient's preference for certain types of consultations. Female patients generally prefer a female physician for intimate examinations, primary health screening, prenatal visits, and reproductive counselling, whether the physician is an obstetrician and gynaecologist or a family physician [10, 11]. However, the gender of the physician appears to play little or no part in routine gynaecological consultations [12]. Male patients, especially in urology, also prefer a same-gender physician for intimate examinations or urological surgery. A study in Malaysia found that female patients were more likely to consent to physical examinations performed by male medical students if they understood and accepted that future male physicians should have the skills to treat female patients effectively [13]. However, factors such as the physician's personality, professional background, gender identity, and religious and cultural beliefs can also influence patients’ choices for consultations [11, 14]. For instance, most Muslim patients select physicians of the same gender, especially for consultations requiring genital examination; however, in emergency situations, they may accept the available physician regardless of gender [11, 15,16,17,18]. Studies in primary care showed that gender-related specific communicative skills, particularly patient-centred communication, were more likely to impact patient satisfaction and compliance than the gender of the physician [19].

Studies have shown that female physicians are more likely to see female patients and perform more preventive services, including Papanicolaou testing and mammograms, than male primary care physicians when seeing female patients [20]. The rate of cancer screening variation is affected by variables such as the age and gender of the patient, as well as the physician’s gender. For example, male physicians tend to offer rectal examinations more often to male patients over 70 years of age, while female physicians offer more mammograms, pelvic examinations, and Papanicolaou testing to women over 50 years of age [21].

While previous studies have focused on patients' perspectives, few have documented physicians’ opinions [4, 22]. Despite the importance of physical examination, the habit of either skipping or referring the physical examination of opposite-gender patients has been noticed in the daily practice of the primary health care centres in the Kingdom of Bahrain [23, 24]. However, the subject of performing physical examinations on opposite-gender patients remains unexplored in the Kingdom of Bahrain. This study aimed to assess family physicians' attitudes and practices towards performing physical examinations on patients of opposite genders and identify potential barriers to these examinations in the primary health care centres in the Kingdom of Bahrain.

Methods

Study design

We conducted a qualitative exploratory study among a purposively selected sample of physicians within the primary healthcare centres of the Kingdom of Bahrain from May 2022 up to June 2023 in Bahrain. Participants who were board-certified family physicians of Bahraini nationality, fluent in English, and currently working in a public sector primary health care centre were eligible to be included in the study. No participant refused to participate in the study. The qualitative, in-depth interviews were conducted with Bahraini family physicians in the Kingdom of Bahrain in nine primary health care centres covering different regions of the Kingdom of Bahrain. The interviews were conducted by five physicians enrolled into a Clinical Master in Family Medicine program in the Arabian Gulf University.

Setting

The current population of the Kingdom of Bahrain is approximately 1.5 million, including 47.8% Bahraini and 52.2% non-Bahraini residents. About 61% of the population are males, 38.5% are females, and 74% are Muslims, with the rest adhering to other religions and beliefs. Since most patients seen in the primary health care centres are Bahraini citizens and are Muslims [23, 24], it is important to consider the cultural context, which is deeply rooted in Islamic principles. In this context, the traditional understanding recognizes only two genders. Therefore, in this study and in alignment with these cultural norms, we used the term 'gender' in its binary form as understood within this culture. References to the 'opposite gender' are made in accordance with this binary understanding and are relevant to the scope of our research.

Population and sample size

The study population consisted of Bahraini family physicians in the Kingdom of Bahrain. About 262 out of 353 (74%) primary healthcare physicians working in the public sector are female [24]. The initial sample size was set at 20 participants, but data collection was stopped at 15 physicians as data saturation was achieved (Table 1). The interviews were conducted with the family physicians in nine primary health care centres to cover at least one centre in each of the five governorates in the Kingdom of Bahrain using purposive sampling. First, a request was sent to all primary health care centres in the Kingdom of Bahrain with information about the study, including its title, aims and objectives, and specified interview schedule. The administrators of the respective primary health care centres were requested to disseminate the request among physicians and inquire about their willingness to participate. The physicians who expressed interest were included as voluntary participants in the study. Next, the interviews were scheduled with the consenting physicians.

Table 1 Sociodemographic characteristics of the study population Interviewee’s gender

Data collection

The data collection process involved semi-structured, in-depth interviews with 15 board-certified family physicians (nine females and six males) at various primary health care centers in Bahrain. After obtaining written consent, interviews were conducted in English, lasting approximately 30–45 min each. An interview guide with open-ended questions was used, and additional probes were added as necessary to explore emerging insights. Each interview was audiotaped, and notes were taken to capture nonverbal cues and observations. This approach ensured a comprehensive exploration of the research topic.

Data analysis

After the interviews, the research team manually transcribed the recordings verbatim, and the participants were given the opportunity to review the transcriptions and give feedback that was incorporated into the transcriptions. Initially, the interviews were read together to generate codes based on the research objectives. Once the data was coded, we reviewed the codes and organised them into categories in Microsoft Word table format manually. The codes were reviewed multiple times in consultation with the senior author, removing irrelevant or duplicate codes and adding new codes that emerged from our analysis. Next, the codes were collapsed into relevant categories, which were merged into coherent themes explaining the construct of the study’s objectives. (Fig. 1) This process allowed us to identify patterns and themes in the data, providing valuable insights about the study questions.

Fig. 1

Schematic showing codes, generated from the in-depth interviews

The co-investigators who were also involved in the data collection, and analysis in this research were themselves medical graduates and ready to be inducted as family physicians in health centres. Their own experience of gender related barriers in their previous work may have sensitised them to these issues during the interviews and analysis, however a collaborative approach in data interpretation involving senior authors reduced any bias involved. During the analysis phase, each team member shared his/her understanding of the meaning in the transcripts to reach a consensus about the information from the transcribed interviews. The authors then discussed and agreed upon a final meaning and interpretation and organised the data into meaningful codes under relevant themes. This collaborative approach ensured participation by all team members, demonstrating their distinct perspectives and insights in the research process. Throughout this research process, multiple iterations of the manuscript were meticulously drafted and reviewed by all members of the research team and senior authors. This inclusive approach extended from shaping the research question and conducting the literature review to refining the methodology and culminating in the finalisation of the research manuscript.

Results

We identified six distinct but interrelated themes to describe the attitude and practice of physicians towards the physical examination of opposite-gender patients in primary health care centres in the Kingdom of Bahrain. These included: 1) Local culture, and religious norms as barrier to physical examination on patients of opposite gender. 2) Physicians improvise to compensate for a lack of physical examinations. 3) Situations where physicians would not avoid conducting physical examinations. 4) Engaging and rapport-building encourages acceptance of examination on patients of the opposite gender. 5) Physicians regularly collaborate to conduct physical examination of patients of opposite-gender. 6) Functional chaperone system ensures optimum physical examinations.

Theme 1: local culture, and religious norms as barrier to physical examination on patients of opposite gender

The participants talked about the challenges they faced in performing physical examinations on opposite-gender patients which were mainly because of local culture and religious norms. They described that Islam is the predominant religion, and Islamic traditions inspire strict gender roles where women are usually modestly covered in traditional clothing therefore it required them to be careful in conducting these physical examinations involving touch between genders.

“There is a dark place there's a cultural issues and the female is always like you know there's sensitive stuff and it's not easy for them to talk and elaborate to if the doctor is different gender because of the stereotyping because of the association that we build in our mind if he's male” (Male physician, IDI 12)

Although female physicians reported performing general physical examinations on male patients without facing any significant refusals, male physicians stated they sometimes faced refusals from female patients due to religious, cultural, and fear of medico-legal repercussions because, according to the physicians, an act of touch itself might be considered by the patients an intimate act in local culture. A male physician mentioned that some female patients even refuse simple examinations that would require any exposure, such as measurement of blood pressure and examination of the ear. Hence, they prefer the presence of a chaperone for examining the parts requiring exposure, like the abdomen, back, and arms, to avoid any risk of medico-legal claims.

"I am not a very conservative person, but I live in a conservative society, so I respect that." (Male physician, IDI 23)

"We are Muslims, so sometimes even exposing the arms or legs, not even the private area, can be difficult. Some patients even refuse to have their blood pressure checked because it requires exposing their arm." (Male physician, IDI 22)

"And you are aware that we live in communities where she may accuse you." (Male physician, IDI 2)

Female physicians' own religious beliefs and culture were found to be a barrier in conducting examinations of sensitive areas of their male patients. They talked about how reluctant they were to examine sensitive parts, such as the genitalia, breasts, and anorectal area of their male patients. In addition to this, some female physicians felt that a male patient may want them to examine him for other motives, such as sexual harassment. On the other hand, patients from other cultures were found to be examined without any gender sensitivity. However, a female physician believed it was acceptable for her to examine the patients in some situations where the patients were not locals or non-Arabs with less conservative cultural norms.

"The only issue is that it's Haram. There is no allowance for me to do it; it is Haram. It is prohibited in Islam." (Female physician, IDI 14)

"Because of a previous experience, like when a male patient is being examined by a female physician, some harassment issues happen. So, we are told that if it's not an emergency, it's better to just skip it (the examination)." (Female physician, IDI 21)

Also because of culture reasons, preventive services such as breast examination prior to requesting a mammogram and vaginal examination prior to Papanicolaou testing, are conducted exclusively in women’s health clinics. However, it was acceptable for our female participants to request Prostate Specific Antigen blood test without performing a digital rectal examination.

"So, I am not allowed to request a mammogram for a female patient (which requires a breast examination prior to request). It's fine. It's been taken off my shoulders by the administration that I can't request such tests." (Male physician, IDI 20)

Although participants described that they never perform genital examinations on female patients due to concerns for modesty and cultural or fear of medico-legal repercussions damage to reputation, several male physicians in our study believed that they could overcome this barrier if they had confidence and skills in conducting such examinations.

"I think I am not experienced in this part, especially in gynaecological problems... I think my experience is lacking in that part because of the lack of practice. It is not something that I commonly see.” (Male physician, IDI 23)

Theme 2: physicians improvise to compensate for a lack of physical examinations

Physicians reported finding various improvisations and practices in performing physical examinations on opposite-gender patients to overcome the barriers. When it came to system-specific examinations, performing examinations on patients of the opposite gender was considered challenging, and the participants reported adopting various alternative ways to perform such examinations, such as auscultating the lungs only from the back of the patients on top of their clothes.

"People get used to being examined, having their chests listened to from their backs... also for skin examinations, for rashes; they would show you by saying, 'Just look at my hands (without touching).’’ (Male physician, IDI 2)

Another example of coping with these cultural barriers was where patients refuse examination by a physician of the opposite gender. Participants stated that they rely on detailed history to manage some cases without performing any physical examination, or if it is a condition that might be diagnosed by a photograph for instance for skin lesions, but kept emphasising the importance of examination in some cases if an urgent condition is suspected.

"There are certain complaints that we can treat with history-taking, and we don't need to examine the patient if there are no (red) flags; we can proceed without examination if the patient insists on refusing examination." (Female physician, IDI 17).

"And some of them would just take photos of the genital area, the private areas where he feels uncomfortable to examine, and he would show us.” (Female physician, IDI 10)

Theme 3: situations where physicians would not avoid conducting physical examinations

Some female physicians mentioned situations where they said that they would not avoid performing a sensitive examination on a male patient, such as when a patient has limited access to healthcare services, especially if a patient has a low socio-economic status, or it is difficult for him to reach health facilities, a presentation with a concerning medical history, when a male physician is not available in the same primary health care centre, or when a chaperone is present during the examination.

“Here, there are people from various social and economic backgrounds. Some are from the diplomatic area, while others are bankers, high-level managers, and (others are) labourers who have low income and rely on (public sector) medical services when they need treatment and examination.” (Female physician, IDI 10)

"... if anything, by error (or a) misunderstanding, got out, you never know what would happen next, okay? So be more cautious and limit what you need to do." (Male physician, IDI 20)

According to most physicians, physical examination is acceptable and prioritised regardless of the patient’s gender in an emergency situation because the emergency supersedes all barriers to performing physical examination on patients of opposite gender. Female physicians also clarified that they would also perform physical examinations on male patients with a presentation that is suspicious of appendicitis or acute scrotal pain and claimed that, as per the referral to secondary care guidelines issued by the Ministry of Health, any such patients must be referred to the emergency department. However, none of the interviewed male physicians recalled that he ever faced any emergency that required him to perform an examination of the female genitalia or breasts.

"I had one patient who came in with testicular pain, and I was, um, shy to examine him. I decided to examine the patient with my female colleague because there was no male physician available at that time. It turned out to be torsion." (Female physician, IDI 14)

“I never faced a situation like this, but if there is a necessity to do the examination, definitely I will go and do it." (Male physician, IDI 1) Physicians noted that all primary healthcare centres in the kingdom of Bahrain follow an emergency protocol that requires physicians in the primary health care centres to attend to the patient after announcing an emergency code.

Theme: 4: engaging and rapport-building encourages acceptance of examination on patients of the opposite gender

Both male and female physicians emphasised the importance of trust and patient comfort during physical examinations. By fostering open dialogue and building good rapport with the patients, physicians noted that they could address concerns, provide information, and empower patients to make informed decisions about consenting to physical examinations.

“If you build a good rapport, I doubt that a patient will refuse your examination." (Male physician, IDI 1)

Female physicians spoke of prioritising professionalism during consultation; however, they stated that patients may feel uncomfortable discussing sexual history due to cultural and personal reasons. However, this attitude also varies according to several factors, such as the nature of the complaint, the severity of the complaint, and the age of the patient. For example, if a female physician is seeing a young male patient for a school screening, she will be more comfortable taking a history to exclude sexual abuse.

Male physicians said that building rapport with female patients is essential and achievable in general complaints, while they recognise the influence of social stereotyping in a clinical setting. For example, females tend to hesitate to share details about genitourinary complaints due to cultural and religious factors. Some physicians have said that females are reserved when it comes to sharing their menstrual and sexual histories. They also recognisde their limitations as male physicians in being able to fully relate to or empathise with certain complaints a female patient may present with, such as dysmenorrhea.

“No matter how a female can explain it I'm not going to as a male I'm not going through what she's gone through.” (Male physician,IDI 12)

Physicians of both genders also stressed the need for obtaining permission, usually verbally, from the patient or, when relevant, from the accompanying guardian. However, due to cultural reasons, the accompanying person of a female patient may influence the decision-making of her undergoing a physical examination performed by a male physician; this usually happens when an accompanying family member refuses for a female member of their family to be examined by a male physician—a phenomenon rarely encountered in a setting of a male patient attending with a family member companion. Physicians of both genders stated the importance of acknowledging any limitations they may face empathetically and how important it is to discuss relevant topics regardless of their sensitivity. Overall, the interviewed physicians pointed out that effective communication improves patient care and willingness to undergo physical examination.

"But I think the issue is if the patient is not understanding the situation. I mean, the patient should be well educated about the situation and the need for an examination. The patient may refuse with the [misunderstood] background that it’s not needed, or it will not help in the diagnosis or in the management." (Female physician, IDI 11)

Theme 5: Physicians regularly collaborate to conduct physical examination of patients of opposite-gender

Physicians indicated that collaboration in referring opposite-gender patients for physical examinations occurs based on both their preferences and the patients'. Female physicians stated that they might refer male patients to male physicians for genital and anorectal complaints. Male physicians noted that they might refer female patients to female physicians for both non-sensitive and sensitive areas for physical examinations. This collaboration is usually out of courtesy and as described by physicians it is either by directly contacting a colleague to attend the clinic and performing the required examination, sharing the findings, or transferring the patient's care entirely to a same-gender physician. However, as some physicians explained, this often results in a patient occupying two appointment slots, overburdening the system.

"I'm losing two appointments if he is having an appointment with me and then he's not comfortable, so we'll have another appointment with a different physician. So, one patient takes two appointments. That can be taken by a different patient." (Female physician, IDI 17)

In situations where physicians of opposite genders are unavailable, physicians said that they may involve same-gender colleagues to chaperone, or they would refer the patient to another primary health care centre to be seen by a physician of the same gender. Though they mentioned that collaboration and communication are necessary for efficient care, some stated that they find it disruptive in busy clinics or during evening shifts.

“It depends, like if it’s a busy clinic, yes, it will disturb the process of seeing the patient. But mostly no.” (Male physician, IDI 22)

Physicians noticed that as the number of female physicians is much higher in primary health care centres, female patients would choose to be seen by a female physician; therefore, referrals from male physicians are less common in general, while male patients are less likely to have their appointments scheduled with male physicians; hence, the frequency of referrals for physical examinations is an average of about once or twice a month, as patients have the option to select their physician before booking their appointment either online or by the registration desk.

The physicians stated that if the selected same-gender physician is unavailable, the patient can request to be seen by a physician from the same team. In these situations, the physicians often try to adjust the appointments. All the physicians interviewed had the "Choose Your Doctor" programme implemented in their primary healthcare centres, except for one. Physicians stated that the programme implementation has resulted in fewer referrals as patients can select their preferred physician from the beginning. Despite this, physicians have not reported any change in their practice regarding the examination of patients of the opposite gender. However, the system does not account for booking overflow, especially within the scope of walk-in clinics, where physician availability is what determines the gender of the physician the patient will see.

"Nowadays, with the Choose Your Doctor program, the patient should be registered with their family physician or another physician in a group. Sometimes, but rarely, we face situations where there are no male physicians available in our group. In those cases, we can ask for help from another group." (Male physician, IDI 14)

Theme 6: functional chaperone system ensures optimum physical examinations

The presence of a chaperone during physical examinations of opposite-gender patients was acknowledged equally by both male and female physicians. The physicians mentioned that they routinely request nurses, medical students, colleagues, or even a patient's relative to act as ad hoc chaperones. Although the use of a chaperone was perceived by the interviewees as important for ensuring safety, addressing medical legal concerns, and overcoming personal and cultural barriers, they found themselves limited by a lack of a chaperone system.

"I do examine the important body areas. I do that, but with a chaperone. I ask one of the nurses, or if I find a medical student or another colleague, I ask her to attend the examination. I will do that." (Male physician, IDI 1)

Female physicians stated that they typically use a chaperone when examining the genitalia and anorectal areas, while male physicians may always need a chaperone for even system-specific examinations that require exposure, for instance, abdominal examinations on patients of the opposite gender. However, male physicians stated that they would never perform examinations on female genitalia even with a chaperone due to medicolegal, cultural, and religious reasons. Only one male physician mentioned his willingness to examine in the presence of a chaperone if the patient accepted.

"Breasts, I don't... I never examined the breasts, no matter what the patient said. Okay, per vagina, never. Sensitive areas, never." (Male physician, IDI 12)

While physicians found that most of their patients do not object to examinations with a chaperone present, some mentioned that having a chaperone during the history-taking part might make some patients uncomfortable, and they may not share details of the illness. Overall, the presence of an established chaperone system was agreed upon by participants as essential to facilitating the physical examination and overcoming barriers to examinations of opposite-gender patients.

"But I don't like the presence of a chaperone all the time. Sometimes we need the patient to open and talk, so whenever it's needed, I can call for someone to be available during the examination. So, a chaperone might help." (Male physician, IDI 23)

Discussion

The purpose of our study was to explore the attitudes and practices of family physicians in primary healthcare centres in the Kingdom of Bahrain about physical examinations of patients of opposite genders. Our research showed that the attitudes of male and female physicians vary depending on the type of examination, be it a general or sensitive examination. Moreover, the physician's own perspective was influenced by cultural and religious factors, concerns regarding potential legal accusations, and ultimately, the patients themselves. We also found that effective communication and rapport-building with patients before physical examinations are important to make the examinations acceptable for patients of the opposite gender. The study also highlighted that physicians often collaborate to adapt to the preferences of patients of the opposite gender when conducting physical examinations. A functional chaperone system in primary health care centres is essential to encourage patients and physicians to overcome gender-related hesitancy in their clinical encounters.

In regard to general physical examinations, such as abdomen and chest, we found that some male physicians face some difficulties in performing such examinations on opposite-gender patients, which was expected and consistent with a study from the US that showed a significant gender bias in the performance of the essential cardiac examination between male and female patients who presented with chest pain [5]. However, our study found that some male physicians also face difficulties, even in blood pressure measurements or ear examinations, as they require exposure to covered areas in hijab-wearing patients.

Regional studies and as well as our own interviews show that female patients often express a preference for same-gender physicians, particularly for intimate physical examinations, such as breast and genital examinations [11]. Almost all interviewed physicians explained how cultural and religious factors influenced patient preferences, with some female physicians noting that patients from non-Arab or non-Muslim backgrounds may be more open to opposite-gender examinations because of less conservative backgrounds. Among the most challenging examinations for male physicians were those involving the breasts and vaginal examination, while female physicians found anorectal and testicular examinations more difficult due to a lack of exposure and limited performance opportunities [21], which lead to “deskilling” among physicians [6], affecting their proficiency in conducting those certain examinations [3], which was noted in both the literature and our study. However, no literature addresses the obstacles encountered by male physicians when conducting these examinations. Additionally, male physicians were also worried about medico-legal repercussions and fear of false accusations from female patients, which could contribute to apprehension in performing intimate examinations, while some female physicians expressed concerns about ulterior motives and hidden agendas from their male patients who would request genital or anorectal examinations.

The attitude of not performing a physical examination on an opposite-gender patient changes in emergency situations or cases with "red flags" that warrant concern in the patient's history. Physical examinations are prioritised and are generally agreed upon by both patients and physicians, as evidenced by a study conducted in Saudi Arabia [17], and notably mentioned by all physicians interviewed in our study. It is important to acknowledge that our interviewed male physicians rarely encounter emergency gynaecologic cases requiring genital examinations. The authors understand that if physicians are well-trained to identify emergency cases and understand when a mandatory physical examination is necessary, referring patients to a physician of the same gender might not be a significant problem.

In the Kingdom of Bahrain, primary care physicians have adapted to the situation by employing certain practices to address challenges in conducting physical examinations on opposite-gender patients. They either transfer care or request a same-gender physician to examine patients of the opposite gender. For some, a detailed history-taking alone may be sufficient for diagnosis and management, eliminating the need for a physical examination. Additionally, in certain situations, photographs are used as a substitute for physical examination, particularly for assessing skin conditions. In this approach, either a colleague of the same gender as the patient attends the clinic specifically to examine the patient or to serve as a chaperone, or the patient's care is entirely transferred to a different physician of the same gender as the patient. However, it should be noted that the transfer of care can have certain drawbacks. It may result in double-booking of a specific time slot, leading to overcrowding, increased patient waiting times, and disruption of the clinic's workflow for some physicians; however, the need for transfer of care is not a daily occurrence.

Our findings are consistent with other studies showing that the presence of a chaperone during physical examinations makes the process easier and more comfortable for both patients and their physicians [18]. Although some physicians in our study noted that a patient may feel uncomfortable disclosing private details about their history and taking part in the consultation in the presence of a chaperone, male and female physicians in both literature and our study recognised the benefits of using chaperones, as they contribute to patient and physician safety and comfort while also safeguarding from medico-legal concerns [25, 26]. Also, it was found in our study that female physicians consistently utilised chaperones during examinations involving the male genitalia and anorectal regions, whereas male physicians expressed their hesitation to examine female patients' genitalia, even with a chaperone present, citing concerns related to medico-legal, cultural, and religious factors. Interviewed physicians reported that patients generally did not express any objections to having a same-gender chaperone present during the examination, which is supported by previous literature [25, 26]. It may even encourage both the physician and patient to perform the needed physical examination, regardless of gender differences. Chaperones in the Kingdom of Bahrain can include nurses, medical students, colleagues, or even the patient's relatives, highlighting the diversity of individuals who can fit in this role. However, a well-established systematic chaperone system was currently lacking in the Kingdom of Bahrain's primary healthcare system.

Patient satisfaction and cooperation were found to be higher with female physicians than male physicians in the specialties of primary care and gynaecology clinics. Some possible solutions to gender-discordant visits include investment in physician education through specialised training courses and administration of training courses in gender-specific communication [6, 27, 28]. By recognising and understanding the factors that can affect physicians' attitudes towards the opposite gender patients, and their consequences in medical settings, providers can prevent negative patient outcomes [22]. However, some members of the research team reflected that conducting a physical examination should be a basic part of a medical consultation, and physicians have an ethical obligation to perform one if the patient consents.

Regarding the effect of gender disparities in the patient-physician encounters, we found, in both the literature and our study, that respecting patients’ autonomy as well as explaining the importance of physical examination would prompt patient consent to physical examination by an opposite gender physician [13]. We also believe that these challenges to physical examination can lead to inequal care for certain populations leading to health inequalities. Therefore, health inequalities between genders can encourage prejudices and significantly impact clinical outcomes and patient satisfaction. Gender biases and discomfort in performing intimate examinations on opposite-gender patients can lead to inadequate care and missed diagnoses. These disparities underline the need for systemic changes, including better training for physicians to manage opposite-gender examinations confidently and sensitively. Addressing gender issues in is essential for reducing health inequalities and ensuring all patients receive high-quality, unbiased care [29, 30]. Moreover, studies show that patient-centred communication can improve compliance to the examinations despite of the opposite gender of the physician [19].

Limitations

Findings of the present study might reflect just the visible aspect of an iceberg as we lacked triangulation of information from the patients’ perspectives. This will decipher different attitudes according to the cultural background of the patient and might identify gaps in the health system delivery system. A quantitative inquiry enquiring about different determinants of attitudes for patients and health professionals will better identify the relative importance of different factors on this outcome (cultural versus communication versus health services conditions such as chaperone system). These research priorities are in our agenda for the future. Additionally, it should be noted that the study employed purposive sampling of family physicians.

Conclusion

In conclusion, the attitude showed by male and female physicians varied with the nature of the physical examination required. The physicians’ own perspective was linked to the influence of cultural and religious factors, as well as concerns stemming from potential legal issues and, ultimately, the patients themselves. Establishing effective communication and encouraging rapport with patients prior to physical examinations are crucial to enable the examinations agreeable for patients of the opposite gender. Family physicians often collaborate to accommodate the preferences of patients and physicians of the opposite gender when conducting physical examinations. A functioning chaperone system at the primary healthcare centre level is important in encouraging patients and physicians to overcome any hesitancy related to gender sensitivity during clinical encounters. We recommend further exploration into the perspective of patients about this matter, as well as their level of satisfaction with the care they receive.

Appendix 1

In-depth interview guide

Section A: introduction and opening statement

Greetings,

I am Dr. ––- from the Clinical Master of Family Medicine program at Arabian Gulf University.

We are working on a study that aims to explore primary health care physicians' attitudes about the physical examination of opposite-gender patients. Our objective is to explore possible reasons as to why a physician may not examine a patient of the opposite gender in the kingdom of Bahrain.

Ethical approval has been obtained by the Research and Ethics Committee at the College of Medicine and Medical Science at Arabian Gulf University and the Department of Primary Care in the Ministry of Health.

Please feel free to give your opinion, as it will remain confidential as described in the consent form. I have a consent form here, which I will read to you and which you can keep.

We will go through this first, and I will answer any questions you have. Are you ready to start?

Interviewers note: Please read out the information sheet to the participants and answer their questions. Next, read out the consent form, answer any questions, and ask the participant to sign it if they are happy to proceed.

Section B: general and demographic information

• Ask the participant to fill out the demographic data form and explain to him that it will be taken separately for statistical purposes.

• Reassure the participant that his name will be anonymous in this study.

Section C: body of the interview

Interviewers note: It is always better to start the interview with a very general and very open question. The broadness and openness of the question would give the informant the impression that you want detailed answers. Remember, the initial few minutes are very important to establish rapport between you and the participant. Apart from providing an assurance of confidentiality for the information you are going to collect; you should let your informant realise that you intend to engage in conversations and are not seeking yes-or-no answers.

Q1: Tell us about yourself and your journey so far as a family physician.

Q2: Can you tell me about your experience dealing with patients of the opposite gender?

• Can you tell us about your journey from medical school until now regarding physical examinations of the opposite gender?

• Describe to me the effect of patient gender on communication and building rapport.

• comfort based on concordance. (Any discomfort in discordance)

Q3: How comfortable are you performing a physical examination of the opposite gender?

• How often do you face refusal of a physical exam?

• any specific examination?

• Why do you think patients refuse physical examinations?

• How would you proceed if a patient refused a physical examination?

• How do you refer? (documented or collegial cooperation)

• Do you refer patients upon their request? or do you offer it?

• What about preventive services (pap smear, breast, and prostate examination)?

Q4: Explain to me what would prevent you from performing a physical examination on patients of the opposite gender?

• What would encourage you to perform a physical examination?

Q5: What advice can you give regarding this issue?

I am thankful to you for your participation in our study, and if you have any questions, please feel free to ask.