Clinical examination skills are a core component of clinical care. A graduating medical doctor is expected to be competent in physical examinations across all systems , and so understanding the limitations of student exposure to conducting examinations is important. Due to the conservative nature of society in KSA, training opportunities in the examination of the hernia perineum and external genitalia can be limited . The sensitive nature of these examinations for patients as well as the cultures of some students, opportunities to gain skills in this area may not be readily available  .
Deficiency in the clinical examination skills of female surgical residents of the male groin, genitalia and rectum has not been explored in the Arab and Muslim context, despite obvious cultural restrictions and religious traditions. The lack of training opportunities to gain skills in examining the intimate areas of patients resulted in a declined skill of both undergraduate and postgraduate students’ performance in hospital practice.
An increase in the numbers of female medical graduates in the last two decades in Saudi Arabia, has consequently led to an increase in the number of female surgical trainees. Currently, the proportion of female surgical trainees in KSA is estimated to be approximately 27% .
In our society, there may be considerable anxiety and embarrassment of female students and junior doctors regarding the examination of the male inguinal hernia and scrotum. Female students may be embarrassed or concerned about male patient discomfort and thus they may perform the examinations in an incomplete or rushed manner . However, whether this translates to a significant difference between male and female student exposure to clinical examinations is not explored enough.
2. Aim & Objectives
Our study, aims to assess the perception and confidence of female surgical residents in clinical examination of inguinal hernia and intimate of opposite sex in five hospitals, Makkah holy city. We also sought to shed light on the barriers and the impact of different teaching modalities that are currently used in undergraduate education.
The study is an observational cross-sectional design based on a self-administered close and open ended questionnaire. The questionnaire designed by the authors after focus group exercise were used to explore themes that trainees face related to gender bias and self-confidence on intimate examination of opposite sex. Eleven female surgical trainees of different level R1 - R5 (i.e., junior (R1, R2 and R3) and senior R4 and R5), participated in the focus groups, in addition to two female surgeons and the authors, then it was distributed to all the available female residents who fulfilled the inclusion criteria at the time of the study. The questionnaire (see the appendix) was distributed to all 80 female surgical resident trainees across the five Hospitals in Makkah, Holy city, Saudi Arabia. The study was carried out between the periods of September 2020 to July 2021 and involved all the available female surgical residents from level 1 - 5 (R1 to R5) who were enrolled in the Saudi Surgical board training programme. The selection criteria of the study used all the female members of the Saudi Board general surgical programme who were working in Makkah five hospitals training centers. All female residents (R1 - R5) who fulfilled the inclusion criteria were participated in this study. The questionnaire, included questions regarding the confidence and skills of the female residents in inguinal hernia and intimate examination of adult male, female residents’ perceptions regarding factors that may impact the development of clinical skills related to gender, the method of training in the undergraduate curriculum, the frequent of examinations performed during their undergraduate training and the educational environment. The questionnaire was also looking at attitudes to patient centered care, and learning experiences on hernia and intimate examination of opposite sex.
We analyzed the data with SPSS statistical software version 16.0 for Mac. Microsoft Excel 2004 version 11.5.5.
A total of sixty-nine 69 (86.25%) female surgical residents completed the survey out of 80 distributed questionnaires (Table 1). This study revealed that overall female residents were feeling not confident on examining the intimate of opposite sex and feel less than expected, 22 (31.9%) were not confident at all, 34 (49.28%) some time while 13 (18.84%) feel confident enough. 56 (81.2%) feel gender affect their intimate examination skills, while 13 (18.8%) never feel the gender effect on their skill (Table 3). Regarding the male patient refusal to give consent for examination, 36 (52.17%) of the participants said patient refused to be examined by the female residents, while 33 (47.83%) never have this experience. In this study 24 (34.8%) of participants mentioned they were less exposed to the hernia and intimate examination of male patient, while 30 (43.5%) participants were frequently exposed and 15 (21.7%) more frequently exposed. Among those who completed the survey 5 (7.2%) had never performed intimate clinical examinations before.
Related to the barriers which impacted the intimate and hernia examination, out of the 69 responded, 21 (30%) were relating it to Shyness/embarrassment,
Table 1. Female surgical residents and hospitals. Female Surgical Residents’ distribution across Training Centers in five hospitals in Makkah Holy city.
As appeared in this table, almost three quarters of female residents in our study reported to be junior residents in the first (R1) or second year (R2) and (R3) of their training programme.
Table 2. Surgical experiences of female surgical residents before joining the Training programme.
*The table showing the less time of all residents spend in surgical fields Before joining the training Board. The Red Color Rs: junior resedents; The Green Color Rs: Senior Resident.
while 27 (39.13%) to Cultural/religious and 17 (24.6%) due to lack of training and 3 (4.34%) to misunderstanding. The majority (55%) of the female residents who responded to our questionnaire acknowledged the reality of the strong support of their supervisors and mentors in their workplace (Table 3).
Medical school would seem the logical place to learn the art of the physical examination. In the last decade the intake of female to medical schools has increased greatly and averaged approximately 51%. Despite this, a disproportionate number of women continue to choose non-surgical over surgical specialties .
To our knowledge, this survey is the first of its kind in the conservative setting of Makkah holy city. We have shed light on the gender, tradition, religious and environmental barriers that continue to limit the training of female surgeons.
Table 3. Factors affecting clinical examination as perceived by female residents (regarding the self-confidence, gender effect, professional level, competence, and patient attitude).
Our results showed that, still the sensitive examination is a uniquely challenging part of the undergraduate curriculum and female surgical trainees. Most residency programs have a duration of about 3 to 4 years, with residencies such as surgical residencies being the longest, this is possibly not attractive for the females.
Dahlke AR et al. (2018) reported that female surgeons and trainees recounted their experiences of being perceived to be less competent or inferior to male counterparts by hospital staff and colleagues alike   , our survey revealed similar results 56 (81.2%). Bernardi K et al., (2020), found that the main source of harassment against female trainees was the faculty members and supervisor residents  , while in our study, it is quite clear, that the supervisors are strongly supporting and encouraging to the trainees (Table 3). In our study 48 (69.6%) of trainees have examined the male patient with inguinal hernia in their undergraduate training while 14 (20.3%) have never performed certain intimate examinations or inguinal hernia of opposite sex (Table 3).This can also be attributed to general overall decline in clinical examinations skills .
In spite of the variety of teaching methods for clinical examination, however, the bedside teaching is seen as one of the most important modalities in acquiring clinical skills for the medical profession, but its use is declining. Impediments to bedside teaching need to be overcome if this teaching modality is to remain a valuable educational method for durable clinical skills. 49 (71%) residents thought that their undergraduate training in this area was insufficient and that no training modality was superior to the other. In our study all participants reported they spend short period before they joined the training programme and may be cause for their deline in examination skill (Table 2).
In our study the gender is an issue factor for self-confidence and limitation of the clinical examination of intimate (Table 3), this is not similar to the study of Brown et al. 2013 who expressed that gender did not impact their careers. Instead, they believed that gender-based difficulties were sometimes results of individual choices. Others perceived that male surgeons struggled with the same expectations as women  .
Our study showed, that most of the participants 28 (40.5%) reported impacted clinical examination of the other sex to cultural/religious, while 21 (30%) related to Shyness/embarrassment and 20 (29%) were due to lack of training and misunderstanding. The cultural, tradition and religious background of the female residents had an impact on female residents coping styles. Female residents from cultures with even stronger taboos against interpersonal physical contact than are present in our conservative Makkah holy city culture were felt by the female surgical resident themselves to be more likely to avoid practicing all their physical examination skills as well as intimate physical examination skills  . In our study 36 (52.2%) of the spondees out of 69 participants reported refusal of the patients give the consent Table 3. While it can be argued that the medical student should take the consent as an important part of their training, we feel our system maximizes the learning opportunities while avoiding patients being examined against their wishes as may have happened in the Broadmore et al. study . Limitation of the study: The small sample size was due to that:
1) The study was carried out during the era of COVID19 period which restricted the number of patients attending the hospitals.
2) Only the female surgical residents enrolled in the Saudi Surgical Board from level 1 - 5 (R1 to R5) were included, and exclusion of all service surgical program which restricted the number.
Our study revealed the declined of female surgical trainees on opposite sex intimate examination. Also the study showed the clear effects of conservative cultures community traditions and religious believes in Makkah community. This study serves as a call-to-action to increase collective effort towards gender inclusivity which will significantly improve future health outcomes. Suggestion for future studies is: A larger sample size study is needed to explore this issue more. Other Saudi hospitals in the western region of Saudi Arabia should be involved.
Questionnaire to Female Surgical Residents in General Surgery
Name: …………………………… Hosp: ……………………..Graduate Ys:………… University ………………………
· Which of the following undergraduate training do you feel relaxed on intimate and hernia examination?
• Bed side teaching
· What do you think are the main barriers for you to gain hernia and intimate exam. Experience
• Short staying in hospital.
• Shortage of cases in hospital.
• Gender bias
• Patient refusal
• Lack of interest
· What do you think the good for undergraduate hernia training :
• More Time
• Female surgeons to teach.
• Substitute corporals to skill lab.
• Undergraduate more Training and self confidence
· How would you best describe your area of experience?
· How would you rate yourself in intimate hernia training?
Are there any other comments you would like to make about hernia / intimate training in undergraduate
· Has a patient ever refused to give you a consent for doing an intimate clinical examination?
· How frequent have you examined the male patient with inguinal hernia in your undergraduate training?
· How does gender affect your clinical examination of male intimate experience?
· Do you feel supported by your supervisor to conduct intimate clinical examination?
· Do you feel not confident to conduct intimate clinical examinations?
· Which of the following have impacted your clinical examination of the opposite sex,
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