Abstract
Background
During the gynecological examination, women especially feel uncomfortable with the lithotomy position and experience shame and anxiety. This study aims to explore metaphors used by women who have experienced gynecological examinations.
Methods
This study is qualitative and phenomenological. The study group consisted of 90 women. Data were collected online using a data form in May-June 2021. It consisted of the sociodemographic characteristics of women and their metaphorical perceptions of gynecological examination. Data were analyzed and interpreted using a metaphorical analytical method inspired by Kochis and Gillespie. Metaphoric linguistic expressions, sequences, words, and sentences related to each other, were highlighted. The Consolidated criteria for Reporting Qualitative research (COREQ) checklist was used in the study report.
Results
The average age of the women was 37.29 ± 10.14, and 73.0% were high school graduates. Three different conceptual categories were created by associating each metaphor image with a certain theme concerning women’s perspective on gynecological examination. The characteristics compiled during the category development phase were used to collect 24 metaphors under a specific category. The metaphor revealed that the process, instrument (examination table), and affective aspects of the gynecological examination are in interaction. In this study was found that the main metaphor image for the gynecological table was a “fork,” the gynecological examination brought to mind “the pregnancy” because of the reason for the procedure, and most of the women used the metaphors of “ache/pain” for their gynecological examination experience.
Conclusions
The metaphors used for the gynecological examination expressions suggested that women’s experiences were negative. Such metaphors may reflect physical and emotional discomfort experienced during the examination. Health professionals’ understanding of these negative perceptions and their empathy may facilitate positive experiences for women and the detection and treatment of health problems.
Supplementary Information
The online version contains supplementary material available at 10.1186/s12905-025-03621-6.
Keywords: Gynecological examination, Metaphor, Pain, Worry, Shame
Background
A gynecological examination is a physical examination of the external and internal genital organs of a woman by a healthcare professional [1, 2]. The gynecological examination involves visual examination and palpation of the external genitalia, assessment of the vagina and cervix with a speculum, and assessment of the pelvic organs by bimanual examination [3, 4]. Gynecological examination is a vital part of women’s health. Most women experience gynecological examinations several times in their lifetime due to reasons, such as the presence of a symptom, labor, or pap-smear testing [5, 6]. Having regular gynecological examinations and screening tests at appropriate intervals once a year allows early diagnosis and treatment of genital diseases and cancers. Within this regard, the gynecological examination is a crucial procedure for protecting women’s health [1, 6, 7]. In studies conducted in Türkiye, the rate of women who have regular gynecological examinations ranges from 5.5 to 42.4% [4, 8–10]. Gynecological examination is a practice that causes anxiety in women and may even be terrifying at times. Hence, the rate of women who have regular gynecological examinations is not at the desired level [9, 10]. There are various factors influencing women’s decision of going for regular gynecological examinations. In the studies, it has been reported that women avoid gynecological examination due to reasons, such as loss of control over their body, the examiner being of the opposite sex, the presence of many people in the room during the examination, having a negative genital image, concerns about genital hygiene and vaginal odor and fear of pain during the pathological diagnosis and examination [4, 5, 8, 11, 12]. Anxiety and embarrassment experienced during the examination prevent women from going to regular examinations and cause them to apply to a doctor/health institution when they are unable to cope with their gynecological diseases [9]. Due to this situation, early diagnosis and treatment of gynecological diseases may be challenging or the chance of treatment may be missed [4, 9, 13]. In Türkiye, the majority of women are taught from a young age to cover, hide and conceal their genital organs, and they are expected to comply with this taboo throughout their lives. Thus, women experience intense feelings of anxiety and embarrassment during the gynecological examination [9, 10]. Women may feel discomfort, embarrassment, and anxiety, especially from the lithotomy position [14]. Besides, it is uncomfortable for women to see the genital area, which is perceived as private, by another person because the body must be naked from the waist down. In this regard, it is of great importance to investigate the gynecological examination experiences of women and the perception that these experiences create in their minds.
Metaphors
The word metaphor is derived from the French word “métaphore.” It is the use of a word or meaning other than its accepted meaning. Metaphor is a method that individuals frequently use in their daily lives, consciously or unconsciously, to easily convey events or words [15–17]. It is an indispensable part of everyday language and is used to give tangible qualities to intangible things [16–18]. Metaphors provide a comprehensive perspective of people’s mental images and reveal a much larger and more comprehensive meaning than they intended [19, 20]. People try to explain how they consider events and objects using different metaphors [15–17]. Each individual’s perception is unique, and they interpret the events taking place around them according to their own perceptions. Metaphors are also influenced by cultural differences and may vary depending on each culture [15]. Sontag’s seminal work, Illness as Metaphor, critically explores how diseases are imbued with metaphorical meanings in society, the impact of these metaphors on patients, and how they influence individuals’ perceptions of health and illness [21]. Martin argues that the language and metaphors used towards the female body have a profound effect on how women perceive their bodies and their reproductive processes [22]. Lakoff and Johnson, who developed Conceptual Metaphor Theories (CMT) based on cognitive linguistics, suggest that metaphor is common not only in language but also in thought and action in daily life [18]. Metaphors are also a qualitative research method used to reveal how the concepts to be analyzed are perceived. Metaphor analysis is an in-depth analysis based on the similes, metaphors, and idioms that the individual uses while speaking. Moreover, how often they are used can be determined numerically [23].
There is no published study investigating metaphors about women’s gynecological examination experiences in Türkiye. This study aims to find out metaphors as a way of describing the perceptions and norms held by women with gynecological examination experience. It is very important for health professionals to understand and know the metaphors of women’s gynecological examinations in order to improve women’s health in general. These metaphors can facilitate women’s understanding of their gynecological health and their self-expression. Health professionals’ understanding of these metaphors allows them to communicate effectively with women patients and better understand their needs. Correct and empathic communication about a sensitive issue such as gynecological examinations can prevent women from avoiding necessary examinations.
Methods
This phenomenological study is based on the analysis of examine metaphors used by women who had experienced gynecological examination.
Participants and settings
The data collection forms were shared via a Google Forms link from two online social networks, Instagram and Facebook. Forms were filled by 90 women who met and accepted the research criteria in May- June 2021. The participants who experienced gynecological examination and were over 18 years old and living in Turkey were included in the study. Women who are not of childbearing age and under the age of 18 were not included in the research sample. In the study, women of different educational levels and from different provinces in the reproductive age range were reached through maximum variety sampling. Metaphors about gynecological examinations may differ among women in different cities in Turkey. The reasons for these differences may be cultural, social and geographical factors, as well as education level, access to health services and personal experiences.
Procedure
All of the women who agreed to participate in the present study gave their consent by reading the information about this study before starting the online form and they filled out the data collection form. Completing the questionnaire was voluntary, and no incentives were offered. Once the questionnaire was completed, the system did not allow the user to submit additional entries. The average time to complete the online data collection form took 8–10 min. The data of this study were transferred to excel and copied verbatim.
Data collection form
It consisted of 10 questions to assess the sociodemographic characteristics of women and their metaphorical perceptions about the gynecological examination and was prepared by the researchers in line with the literature [4, 8, 9, 11, 12]. For the questions of the data collection form, opinions were taken from four specialists working in midwifery, obstetrics and gynecology nursing, public health nursing, medical faculty obstetrics and gynecology department. The data collection form is a structured form and consists of open-ended questions. Some examples of open-ended questions were as follows: “The gynecological examination table looks like……….,” “The woman who has a gynecological examination looks like…………,” “When I think of being examined on the gynecological table,………… comes to my mind.” Women were asked to write/explain the gaps in the questions. There was also an image of a woman on a gynecological examination table in the online data collection form. There were questions about perceptions regarding this image. The questionnaire form used in this study was created by researchers for this study (It is presented in the appendix).
Data analysis
The analysis was inspired by Kochis and Gillespie (2006) [24]. According to these authors, metaphor analysis can be performed in three steps. First, a text is read and reread to obtain a broad picture and gain an overall impression. In the second step, metaphoric linguistic expressions are identified and listed to find patterns or clusters, so-called entailments. The third step goes from the explicit surface manifestations of metaphoric linguistic expressions and their entailments to a broader underlying dimension of conceptual metaphors. In this step, the entailments form a conceptual metaphor that binds the entailments together.
The study analysis progressed according to the above three steps proposed by Kochis and Gillespie (2006). First, the analysis was conducted as an ongoing process, going back and forth in the data to obtain a picture of the whole. Each data forms was read and compared with the other data forms in light of the whole. In the second step, metaphoric linguistic expressions, such as words, phrases or sentences were identified and “thema tags,” were assigned in the margins of the text. These tags were then pasted into different data files. Metaphoric linguistic expressions, that is, sequences, words, and sentences related to each other, were highlighted. In the analysis of research data, reliability calculation was made for objectivity. In this process, first, two researchers in the research team (S.C.U. and S.İ.Ç.) independently coded the metaphors they produced and developed categories. These two researchers compared their categories and reached a consensus on the existing differences, and in the final arrangement, 24 metaphors and 3 conceptual categories were obtained. Then, this list of 24 metaphors and 3 categories was evaluated by the expert researcher in the field of qualitative approaches (A.Ç.) by matching metaphors-categories. Then, consensus and disagreements were determined and reliability calculation was made for the consensus value between coders (expected to be at least 80%) suggested by Miles and Hubermann (1994). This rate was calculated as 83.3% and the harmony between the researchers and the expert shows that the findings obtained are reliable. In the process of categorizing the metaphors, consensus was reached by three experts [23, 25]. In the presentation of the findings, P was labeled with the participant number (e.g., P10 and P25), the abbreviation f (frequency) indicates the frequency of labels and themes. The consolidated criteria for reporting qualitative research (COREQ) checklist was used in the study report [26].
Results
In this study, the average age of the women was 37.29 ± 10.14, and 73.0% were high school graduates. 91.2% of women are married, 93.3% have at least one child. All of them had experienced at least once to have a gynecological examination. Participants in this study were from 15 different provinces of Turkey.
Based on this study’s findings, women (n = 90) created 24 valid metaphors for the concept of gynecological examination (Table 1). The number of participants representing 24 metaphors ranged between two and 38, with the mean number of participants per metaphor around four. Thus, out of 24 metaphors, 20 were expressed by more than four (above average) participant groups, whereas only four metaphors were created by a group of less than four (below average) participants. The less than four metaphor images were crucifix (f = 3), family planning (f = 2), spiral (f = 2) and cold (f = 3). The dominant metaphor images produced by the group of 4 or more participants are written in bold in Table 1. In addition, the metaphors said by the participants are presented as a word cloud in Fig. 1.
Table 1.
Distribution of metaphors by categories (90 women)
| Categories (n = 3) | f (%) | Metaphors (n = 24) | f (%) |
|---|---|---|---|
| Gynecological examination imaging the gynecological table (as an instrument) | 47 (15.1%) | Fork 16, examination chair 10, dentist chair 7, long metal instrument 7, operating Table 4, crucifix 3 | 6 (25.0%) |
| The gynecological examination that brings to mind the reason for the procedure |
88 (28.3%) |
Pregnancy 20, birth 19, treatment/healing 18, health 8, relieved 7, abortion/loss of baby 6, illness/uterine cancer 6, family planning 2, spiral 2 | 9 (37.5%) |
| Gynecological examination, including affective expressions | 176 (56.6%) | Ache/pain 38, embarrassing 36, fear/anxiety 32, helpless 26, uneasiness 20, disgusting 8, stressful/nervous 8, disturbing 5, cold 3 | 9 (37.5%) |
| Total | 311 (100.0%) | Total | 24 (100.0%) |
*Note: Main metaphors (produced by three or more participants) are shown in bold. The numbers indicate the number (f) and percentage (%) of participants and metaphors in the categories
Fig. 1.
The word cloud of women’s gynecological examination metaphors
In analyzing the participants’ responses, we considered both explicitly metaphorical expressions and those that, while appearing literal, conveyed deeper subjective reflections. Given that our study aimed to explore participants’ perceptions of gynecological examination through open-ended questions, we employed a systematic interpretative framework to identify and classify metaphors. Some responses contained clear metaphorical imagery, whereas others, though seemingly literal, were categorized as metaphors if they conveyed symbolic, emotional, or comparative associations beyond their literal meaning. Even if certain statements do not align with conventional definitions of metaphor, they provide valuable insights into participants’ experiences and perceptions. This approach allowed us to capture the nuanced ways in which individuals conceptualize gynecological examinations.
Three different conceptual categories were created by associating each metaphor image with a certain theme concerning women’s perspective on gynecological examination. The characteristics compiled during the category development phase were used to collect 24 metaphors under a specific category.
The identified metaphors were grouped under three main conceptual category: (1) Gynecological examination imaging the gynecological table (as an instrument), (2) The gynecological examination that brings to mind the reason for the procedure and (3) Gynecological examination, including affective expressions. The main characteristics of the metaphors that make up this category are in Table 2.
Table 2.
Three conceptual categories of gynecological examination and their representing characteristics
|
Gynecological examination imaging the gynecological table (as an instrument) - The gynecological examination is one of the most challenging times on a female examination stretcher; it is a very bad thing. - Even thinking about the gynecological examination table is a terrifying thing. -Being examined on the gynecological table is very different; it cannot be said that there is another feeling like that. |
|
The gynecological examination that brings to mind the reason for the procedure - Gynecological examinations are the examinations performed while giving birth. - When I think of gynecological examination, I think of pregnancies, abortions, and gynecological diseases. - Gynecological examination means family planning and treatment. - If you have had a gynecological examination, it means you have been treated. - Gynecological examination is a challenging procedure for healing and well-being. |
|
Gynecological examination including affective expressions - The gynecological examination is a painful procedure as if your soul is dying. - The gynecological examination feels so bad, it’s embarrassing. - The gynecological examination is a cold, disgusting experience that causes goosebumps. - A gynecological examination is undesirable, it suffocates. - In the gynecological examination, the woman is worried and helpless like a sacrificial lamb. - Gynecological examination is a terrifying thing, it is uncomfortable. |
Category 1. gynecological examination imaging the gynecological table (as an instrument)
The participants mentioned this category 47 times (15.1%) in total, and six metaphors (25.0%) represented it. The main metaphor images in this category were a fork (f = 16), examination chair (f = 10), dentist chair (f = 7), long metal instrument (f = 7), and operating table (f = 4). In this category, one participant said, “I wish it had never been invented,” and made a sentence for the gynecological examination table, expressed in different images as an instrument, in connection with the following categories, reflecting her fear and uneasiness (P5, Age:31).
Category 2. The gynecological examination that brings to Mind the reason for the procedure
The second category was cited 88 times (28.3%) by the participants and represented by nine metaphors (37.5%). The dominant metaphor images in this category are pregnancy (f = 20), birth (f = 19), treatment/healing (f = 18), abortion/loss of baby (f = 6), illness/uterine cancer (f = 6), health (f = 8), and relaxed (f = 7). One participant emphasized that women must open their legs for examination by defining the gynecological examination as “opening the legs”, which brings to mind the reason for the procedure in this category (P18, Age:36). Besides, one participant defined gynecological examination as treatment, a healthy process and used the expression “As if a burden had been lifted on yourself” (P83, Age:33).
Category 3. Gynecological examination, including affective expressions
This category received the highest number of citations from the participants, 176 times (56.6%). This category is represented by nine metaphors (37.5%). The dominant metaphor images in this category are as follows: Ache/pain (f = 38), embarrassing (f = 36), fear/anxiety (f = 32), uneasiness (f = 20), helpless (f = 26), stressful/nervous (f = 8), disgusting (f = 8), disturbing (f = 5). In the third category, one participant said “as if my soul is dying,” (P20, Age:28) while another participant stated that she felt “like a sacrificial lamb” (P3, Age:42). Another participant described his uneasiness and fear by saying, “All goose bumps” (P5, Age:31). In addition, another participant explained his uneasiness about the examination and the table by saying, “Something I don’t want, I’m getting sick” (P61, Age:35). Another participant described having a gynecological examination as a “very different and unique” situation (P23, Age:45).
Discussion
This study aimed to find out the metaphors of women regarding gynecological examination experiences. Metaphors about gynecological examination experiences were divided into three different categories: gynecological examination, which imagines the gynecological table as an instrument, gynecological examination, which brings to mind the reason for the procedure, and gynecological examination, including affective expressions. It is considered that determining the metaphors of women about gynecological examination is important in terms of revealing how their examination experiences are.
Metaphorical expressions may contain differences depending on the cultural characteristics of individuals [18, 27]. The women included in our study used cultural expressions for the gynecological table (as an instrument) that imagined their gynecological examination experience. It was found out that the expression “fork,” which is commonly used for the gynecological table in Turkish culture, is the most frequently used metaphor to describe the experiences of the participants. This expression is used because the stirrups on which the legs are placed on the gynecological examination table are like forks. Other expressions used by women regarding the gynecological table are “dentist chair,” “operating table” and “a metal instrument.” The fact that the metaphors used for the gynecological table included cold and metallic expressions suggested that women’s experiences were negative. In this regard, the statement of one participant that “I wish it had never been invented” for the gynecological table is remarkably striking (P5). Studies underline that women find the gynecological examination table uncomfortable and the women participating in our study support the metaphors that include negative statements about the gynecological Tables [4, 13, 28, 29].
Metaphors used by individuals are shaped based on their experiences [20]. In Türkiye, women who have gynecological examinations are generally young women, whom we call the fertile age. It is seen that parameters such as education level, profession, and employment status do not affect the situation of having gynecological examinations. For the majority of women living in Turkey, gynecological examinations are a taboo. It is a health practice that is not done unless it is mandatory. The majority of women go to a health institution for a gynecological examination when they have a complaint or when they have to. Perhaps that is why the metaphor subtitle “The gynecological examination that brings to mind the reason for the procedure” brought mandatory health practices (birth, miscarriage, etc.) to women’s minds. Women frequently use the metaphors “pregnancy” and “birth” for their gynecological examination experiences, and it is seen that the metaphors define the reason for the examination and change depending on the experience. In studies conducted in Turkey [6, 8, 11, 12], the fact that women frequently go to gynecological examinations due to pregnancy and birth supports the metaphors that reveal the reasons for gynecological examinations of the women participating in our study. Another frequently used metaphor that brings to mind the reason for gynecological examination in our study is “treatment/healing”. The use of women’s “treatment/healing” metaphor suggested that women experienced gynecological examinations for therapeutic purposes. Women describe gynecological examination as a challenging process that brings health. The use of the expression “as if a burden has been lifted” for the examination experience emphasizes that the examination is a necessary process, even if it is challenging. This perception is consistent with findings in the literature, which highlight that women often associate gynecological examinations with discomfort but also acknowledge their importance for preventive health care [8–12]. The dual perception of such exams as both challenging and necessary emphasizes the need to address emotional and physical discomfort. By prioritizing innovative strategies to alleviate discomfort and anxiety, healthcare providers can significantly enhance women’s overall experience and encourage more consistent participation in preventive care.
As women’s gynecological examination involves special experiences, it can be challenging to express [28–30]. The use of metaphors is a comforting and easy way to describe experiences that are difficult to express [18, 31, 32]. The metaphorical expressions of the gynecological examination experiences in our study are remarkable in terms of reflecting the emotions felt by women during the examination. The fact that most of the women use the metaphors of “Ache/pain,” “embarrassing,” “fear/anxiety,” “desperation” and “anxiety” for their gynecological examination experience reflects the emotions felt during the examination. These metaphors suggest that women have had negative experiences. Studies have revealed that women often experience pain, embarrassment, stress, fear and uneasiness during gynecological examination [4, 12, 29]. The metaphors used by women for gynecological examination are similar to the emotions stated in the study results. In their study, Skär et al. (2020) stated that it is not possible to compare the examination of the genitals of women with the examination of other organs [33]. The fact that one of the women participating in our study expressed the gynecological examination as “very different and unique” emphasizes that this experience is special. The metaphor of “like a sacrificial lamb,” which reflects the emotions felt during the gynecological examination, is a very impressive expression. The expression “like a sacrificial lamb” reflects the feelings of fear and helplessness experienced by women during the gynecological examination. Metaphors used by women for gynecological examinations show that they have had remarkably disturbing experiences. Emily Martin argues that metaphors surrounding the female body often reinforce women’s social roles and submission to medical processes. Such cultural framing might contribute to women passively accepting these procedures, perceiving them as obligatory rather than empowering [22]. This perspective aligns with the metaphors used in this study, which emphasize negative emotions and a lack of autonomy during the gynecological examination.
Limitations
Although this study has original results, it also has some limitations. One of the main limitations is that the researchers were not able to contact the participants in face-to-face interviews during the data collection process due to the COVID-19 pandemic. In identifying metaphorical perceptions, richer data could be generated using face-to-face in-depth interviews. The inability to conduct in-depth interviews can limit access to rich data. For instance, the theme of embarrassment can be considered information that can be overcome during the in-depth interview with questions at the end. The lack of open-ended questions that would allow for in-depth analysis of the participants’ cultural characteristics was considered another a limitation of the study. Some expressions provided by participants in response to open-ended questions may reflect direct reasons for gynecological examinations rather than purely metaphorical imagery, which could be seen as a limitation in the interpretation of findings. Moreover, the study did not evaluate the participants’ cultural characteristics, which could have significantly influenced their perceptions and responses. Understanding cultural context could have provided a deeper and more comprehensive analysis of the findings. Future research should address these limitations by incorporating open-ended questions and assessing cultural factors to enhance the depth and scope of the study.
Conclusions
In this study, we tried to reveal women’s perceptions of gynecological examination through metaphors. Three different conceptual categories were created by associating each metaphor image with a certain theme concerning women’s perspective on gynecological examination. The metaphor revealed that the process, instrument (examination table), and affective aspects of the gynecological examination are in interaction. The metaphors used for the gynecological examination expressions suggested that women’s experiences were negative. The main metaphor image for the gynecological table was a “fork,” the gynecological examination brought to mind “the pregnancy” because of the reason for the procedure, and most of the women used the metaphors of “ache/pain” for their gynecological examination experience.
This study focuses on the need to develop models and theories that support women in Turkish society to express their experiences of a gynecological examination.
At this point, the following questions that need to be answered in further studies:
-Could the shape of the examination table be the real reason for women’s negative metaphors about the gynecological table in Turkish society?
- Is the embarrassment of women during gynecological examination associated with that the genital area is considered private in Turkish society?
-Could models and theories be developed to support women in Turkish society to express their experiences of gynecological examination?
Electronic supplementary material
Below is the link to the electronic supplementary material.
Acknowledgements
Not applicable.
Author contributions
All authors contributed to the study conception and design. Material preparation, data collection and analysis were performed by [SCU], [SIÇ] and [AÇ]. The first draft of the manuscript was written by [SCU], [SIÇ], [AÇ] and all authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Funding
None.
Data availability
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.
Declarations
Ethics approval and consent to participate
This study was performed in line with the principles of the Declaration of Helsinki. Consultation and advice were provided by the Ethics Committee at the Medical Faculty, Manisa Celal Bayar University, Turkey (Date:2021-20.478.486/983 number). Information on the purpose of this study, the fact that the participation was voluntary, the information would be kept confidential, and they could terminate this study if they wished, were given in the introduction part of the online data collection form. Each participant was appointed a unique code (P) to record and present their data; for example, P9 referred to Participant 9. Informed consent was obtained from all individual participants included in the study.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher’s note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.