A survey of condom use among female sex workers in Northern Sydney; declining condom use for fellatio.

Condom use among female sex workers (FSWs) is dynamic. We conducted a survey, by anonymous questionnaire, of condom use among FSWs routinely attending our clinical service in Northern Sydney. Logistic regression models determined associations with inconsistent condom use. All 201 women approached completed a questionnaire. Chinese-born women comprised 67% of participants. The median age was 35 years. Clients requesting unprotected fellatio was reported by 95% of participants, and approximately two-thirds felt pressure to have unprotected fellatio and vaginal sex (VSI). Inconsistent condom use at work was reported by 74% for fellatio and by 24% for VSI. The strongest adjusted association with inconsistent condom use for fellatio was monetary inducement by clients (aOR = 40.7, 95% CI 4.87-340, p = 0.001). The only other significant adjusted association was age ≥ 30 years (p = 0.02). The strongest adjusted association with inconsistent condom use for VSI was also monetary inducement by clients (aOR = 56.1, 95% CI 9.26-340, p < 0.001). Other significant adjusted associations were Chinese-speaking participants (p = 0.03) and clients requesting unprotected VSI (p = 0.02). We report high levels of inconsistent condom use. Health promotion should assist FSWs, particularly those of Chinese ethnicity, develop skills in dealing with pressure for unprotected sex, particularly fellatio.

The impact of Grindr advertising on attendance and HIV testing by men who have sex with men at a sexual health clinic in northern Sydney.

Grindr is a geolocation smartphone application popular among men who have sex with men (MSM) to find sexual partners. We conducted a study to assess if attendance and HIV testing amongst MSM increased due to advertisements on Grindr that promoted our service. We measured clinic website hits by users clicking through from Grindr; we counted self-reported registrations that nominated referral from Grindr; and we compared new patient attendances and HIV tests in MSM with heterosexual men, for the 18 months preceding the intervention and the 18 months of the intervention. During the intervention the clinic's website received 11,799 unique hits from Grindr users. The average monthly rate of attendances by new MSM increased 70.3% from 19.0 to 32.3, compared with a 5.5% increase among new heterosexual men from 45.6 to 48.1. The average monthly rate of HIV tests among MSM increased 43.6% from 47.0 to 67.6, compared with a 3.9% increase amongst heterosexual men from 40.0 to 41.6. The MSM:heterosexual men rate ratio for new patient attendances changed from 0.42 to 0.67 (p < 0.001, adjusted for possible underlying time trends in each period), and for HIV tests this rate ratio changed from 1.18 to 1.63 (p < 0.001, adjusted for possible underlying time trends in each period). The effects of the intervention did not significantly change over the course of the 18-month intervention. This study suggests that advertising on Grindr was effective and durable as a means of increasing attendance and HIV testing rates among MSM in northern Sydney.

Rapid HIV testing increases testing frequency among gay and bisexual men: a controlled before-after study.

Background Rapid HIV testing was introduced at 12 clinics in New South Wales (NSW) for routine testing and promoted with social marketing. The effect of the availability of rapid HIV testing on testing frequency among gay and bisexual men (GBM) was evaluated. METHODS: An observational design using patient data from 12 clinics was used. The primary outcome was the mean number of HIV tests in 12 months. The intervention group comprised GBM who had one or more rapid tests from October 2013 to September 2014 and this was compared with two control groups; a concurrent group (no rapid test in the same period) and a historical group (attended between July 2011 and June 2012). Independent sample t-tests were conducted to compare mean number of tests among men in the intervention, concurrent and historical groups. Multivariate logistic regression was used to assess the association between rapid HIV testing and testing frequency. RESULTS: Men in the intervention group (n = 3934) had a mean of 1.8 HIV tests in 12 months, compared with 1.4 in the concurrent group (n = 5063; P < 0.001) and 1.4 in the historical group (n = 5904; P < 0.001); testing frequency was higher among men at increased risk of HIV in the intervention group compared with the other two groups (mean 2.2, 1.6 and 1.5 respectively; P < 0.001). Membership of the intervention group was associated with increased odds of having two or more HIV tests in 12 months (AOR = 2.5, 95%CI 2.2-2.8; P < 0.001) compared with the concurrent group, after controlling for demographic and behavioural factors. CONCLUSION: Introducing and promoting rapid HIV testing in clinics in NSW was associated with increased HIV testing frequency among GBM.

Early initiation of antiretroviral therapy for people newly diagnosed with HIV infection in Australia: trends and predictors, 2004-2015.

OBJECTIVES: To determine trends in and predictors of early treatment for people newly diagnosed with human immunodeficiency virus (HIV) infection in Australia. DESIGN, SETTING: Retrospective cohort analysis of routinely collected longitudinal data from 44 sexual health clinics participating in the Australian Collaboration for Coordinated Enhanced Sentinel Surveillance (ACCESS) program. PARTICIPANTS: Patients diagnosed with HIV infections, January 2004 - June 2015. MAIN OUTCOME MEASURES: Commencement of antiretroviral therapy within 6 months of HIV diagnosis (early treatment); demographic, clinical, and risk group characteristics of patients associated with early treatment; trends in early treatment, by CD4+ cell count at diagnosis. RESULTS: 917 people were diagnosed with HIV infections, their median age was 34 years (interquartile range [IQR]: 27-43 years), and 841 (92%) were men; the median CD4+ cell count at diagnosis was 510 cells/µL (IQR, 350-674 cells/µL). The proportion of patients who received early treatment increased from 17% (15 patients) in 2004-06 to 20% (34 patients) in 2007-09, 34% (95 patients) in 2010-12, and 53% (197 patients) in 2013-15 (trend, P < 0.001). The probability of early treatment, which increased with time, was higher for patients with lower CD4+ cell counts and higher viral loads at diagnosis. CONCLUSIONS: The proportion of people newly diagnosed with HIV in sexual health clinics in Australia who received treatment within 6 months of diagnosis increased from 17% to 53% during 2004-2015, reflecting changes in the CD4+ cell count threshold in treatment guidelines. Nevertheless, further strategies are needed to maximise the benefits of treatment to prevent viral transmission and morbidity.

Lymphogranuloma venereum presenting as penile ulcer in two HIV-negative gay men.

An epidemic of lymphogranuloma venereum among men who have sex with men (MSM) has persisted in Australia for over a decade and virtually all diagnoses are made from rectal samples. We discuss two cases of human immunodeficiency virus-negative MSM who presented with a penile ulcer. The diagnosis can be made by ensuring a swab of any such ulcer is tested for Chlamydia trachomatis.

Providing HIV results via SMS one day after testing: more popular than rapid point-of-care tests.

An inner Sydney sexual health service introduced the option to gay and bisexual men of receiving a negative HIV result by SMS to mobile phone one business day after venipuncture (rapid SMS). Men could also choose one of the other options: a point-of-care-test (POCT), by phone, or in-person (clinicians could also require in-person). We followed-up patients choosing the rapid SMS method to ascertain their satisfaction. During 12 months, 473 men had 591 HIV tests. Of these tests, 5.4% were POCTs, 9.1% were in-person, 24% were by phone, and 62% were rapid SMS. HIV POCTs declined from being 22% of result methods in the pre-study period to 5.4% during the rapid SMS intervention period (odds ratio 0.20, 95% CI 0.13-0.32, P < 0.0001). Phone/in-person results declined from 78% to 33% (odds ratio 0.14, 95% CI 0.10-0.20, P < 0.0001). SMS was sent by the next business day in 95% of cases; 96% of men were satisfied; and 95% would choose this method for their next test. Of 77 men who previously had an HIV POCT, 56 (73%) elected a rapid SMS result rather than having another POCT. The higher accuracy of conventional serology was commonly expressed as the reason for choosing rapid SMS for results.

Is cost a structural barrier preventing men who have sex with men accessing condoms? A systematic review.

A systematic review was undertaken to determine whether cost is a structural barrier preventing men who have sex with men (MSM) accessing condoms. Studies were examined from a range of countries where condoms have been distributed free to particular populations and also those where condoms were available at a cost to the individual. The study inclusion criteria were: published between January 1990 and September 2014 inclusive; published in any language, discussed cost as a barrier to condom use, discussed cost barriers to MSM accessing condoms and included a measure of outcome. Articles were systematically extracted from MEDLINE, Embase, PyschINFO and Informat using the five search terms; Male Homosexuality, Access, Cost, Cost and Cost analysis, Condoms. Sixty-four articles were initially identified and 11 included in the final review. The included studies used cost-utility analysis, qualitative, cross-sectional, cohort or randomised control trial design. Large-scale free distribution programmes and smaller targeted programmes showed positive correlations in reducing the burden of disease from HIV and other sexually transmitted infections through eliminating the issue of cost. Decreasing the cost of condoms, and providing them for no cost, appears to increase their utilisation amongst MSM and possibly reduce the burden from HIV and other sexually transmitted infections. Inequality and stigma remain important barriers to MSM accessing and using condoms particularly in the developing world.

Barriers to HIV testing and characteristics associated with never testing among gay and bisexual men attending sexual health clinics in Sydney.

INTRODUCTION: HIV diagnoses among gay and bisexual men have increased over the past decade in Australia. HIV point-of-care testing (POCT) was introduced in Australia in 2011 as a strategy to increase HIV testing by making the testing process more convenient. We surveyed gay and bisexual men undergoing POCT to assess barriers to HIV testing and characteristics associated with not having previously tested for HIV (never testing). METHODS: During 2011 and 2012, gay and bisexual men who were undergoing POCT at four Sydney sexual health clinics self-completed questionnaires assessing testing history and psychological and structural barriers to HIV testing. Bivariate and multivariate logistic regression was used to assess associations between patient characteristics and never testing. RESULTS: Of 1093 participants, 981 (89.9%) reported ever testing for HIV and 110 (10.1%) never testing. At least one barrier to testing was reported by 1046 men (95.7%), with only 47 men (4.3%) not reporting any barrier to testing. The most commonly reported barriers to testing were annoyance at having to return for results (30.2%), not having done anything risky (29.6%), stress in waiting for results (28.4%), being afraid of testing positive (27.5%) and having tested recently (23.2%). Never testing was independently associated with being non-gay-identified (adjusted odds ratio [AOR]: 1.9; 95% confidence interval [CI]: 1.1-3.2), being aged less than 25 years (AOR: 2.4; 95% CI: 1.6-3.8), living in a suburb with few gay couples (AOR: 1.9; 95% CI: 1.2-3.0), being afraid of testing HIV-positive (AOR: 1.6; 95% CI: 1.0-2.4), not knowing where to test (AOR: 3.8; 95% CI: 1.3-11.2) and reporting one or no sexual partners in the last six months (AOR: 2.7; 95% CI: 1.2-6.2). CONCLUSIONS: Barriers to HIV testing were commonly reported among the clinic-based gay and bisexual men in this study. Our findings suggest further health promotion and prevention strategies are needed to address the knowledge, attitudes and behavioural factors associated with never testing.

Rapid HIV Testing Is Highly Acceptable and Preferred among High-Risk Gay And Bisexual Men after Implementation in Sydney Sexual Health Clinics.

BACKGROUND: Rapid HIV testing (RHT) is well established in many countries, but it is new in Australia. We assessed the acceptability of RHT and its associations among gay, bisexual and other men who have sex with men (GBM) after implementation of RHT in Sydney sexual health clinics. METHODS: GBM were invited to complete an acceptability questionnaire before and after provision of the result of finger-prick blood RHT, comparing their experience of RHT with conventional HIV testing (CHT) involving venipuncture. Logistic regression was used to assess associations between patient characteristics and the preference for RHT over CHT next time they tested for HIV. RESULTS: Of 1061 GBM who received non-reactive RHT results, 59% found RHT less stressful than CHT and 34% reported no difference, and 61% found RHT more comfortable than CHT and 26% reported no difference. Nearly all men were satisfied with RHT result delivery (99%) and the RHT process overall (99%). Most men (79%) preferred RHT for their next HIV test and this preference was stronger in men who were aged 35-44 years (adjusted odds ratio [AOR] 2.49, p<0.01), reported they would test more often if RHT was available (AOR 1.66, p=0.01), found returning for results annoying (AOR 1.67, p=0.01), and found RHT less stressful (AOR 2.37, p<0.01) and more comfortable (AOR 1.62, p=0.02) than CHT. Men concerned about the reliability of RHT were less than half as likely to prefer RHT for their next HIV test (AOR 0.44, p<0.01). CONCLUSIONS: Most GBM preferred RHT to CHT next time and this preference was associated with finding RHT more convenient, more comfortable and less stressful than CHT. These findings suggest that in a clinic setting RHT should be considered to improve the patient experience and may potentially increase uptake and frequency of HIV testing.

Multi-centre evaluation of the Determine HIV Combo assay when used for point of care testing in a high risk clinic-based population.

BACKGROUND: Determine HIV Combo (DHC) is the first point of care assay designed to increase sensitivity in early infection by detecting both HIV antibody and antigen. We conducted a large multi-centre evaluation of DHC performance in Sydney sexual health clinics. METHODS: We compared DHC performance (overall, by test component and in early infection) with conventional laboratory HIV serology (fourth generation screening immunoassay, supplementary HIV antibody, p24 antigen and Western blot tests) when testing gay and bisexual men attending four clinic sites. Early infection was defined as either acute or recent HIV infection acquired within the last six months. RESULTS: Of 3,190 evaluation specimens, 39 were confirmed as HIV-positive (12 with early infection) and 3,133 were HIV-negative by reference testing. DHC sensitivity was 87.2% overall and 94.4% and 0% for the antibody and antigen components, respectively. Sensitivity in early infection was 66.7% (all DHC antibody reactive) and the DHC antigen component detected none of nine HIV p24 antigen positive specimens. Median HIV RNA was higher in false negative than true positive cases (238,025 vs. 37,591 copies/ml; p = 0.022). Specificity overall was 99.4% with the antigen component contributing to 33% of false positives. CONCLUSIONS: The DHC antibody component detected two thirds of those with early infection, while the DHC antigen component did not enhance performance during point of care HIV testing in a high risk clinic-based population.

What proportion of sexually transmissible infections and HIV are diagnosed in New South Wales' public sexual health services compared with other services?

BACKGROUND: In New South Wales (NSW), publicly funded sexual health services (PFSHSs) target the populations at greatest risk for important sexually transmissible infections (STIs) and so may make a large contribution to the diagnosis of notifiable STIs. We aimed to determine the proportions of STIs diagnosed in PFSHSs and notified to the NSW Ministry of Health in 2009, and describe geographical variations. METHODS: The number of notifiable STIs (infectious syphilis, gonorrhoea, HIV and chlamydia) diagnosed in 2009 was obtained for each Area Health Service (AHS) and each PFSHS. The proportion of diagnoses made by PFSHSs was calculated at the state and AHS level according to five geographical regions: inner and outer metropolitan, regional, rural and remote. RESULTS: The overall proportions of diagnoses made by NSW PFSHSs were syphilis, 25%; gonorrhoea, 25%; HIV, 21%; and chlamydia, 14%. Within each zone, the proportions of these STIs were (respectively): (i) inner metropolitan: 32%, 26%, 21% and 13%; (ii) outer metropolitan: 41%, 24%, 43% and 9%; (iii) regional: 62%, 15%, 23% and 10%; (iv) rural: 8%, 29%, <5% and 20%; and (v) remote: <5%, 43%, <5% and 29%. There was considerable variation in proportions of STIs between and within AHSs (<5-100%). CONCLUSIONS: NSW PFSHSs contribute a large proportion of diagnoses for syphilis, gonorrhoea and HIV, but less so for chlamydia. Across AHSs and zones, there was considerable variation in the proportions. These data support the role of PFSHS in identifying and managing important STIs in high-risk populations.

Unsupervised screening for chlamydia and gonorrhoea in backpacker hostels in Manly, Sydney.

Young international backpackers frequently have new sexual partners. We conducted a pilot project of unsupervised screening for chlamydia (Chlamydia trachomatis) and gonorrhoea (Neisseria gonorrhoeae) by self-collected specimens at two backpacker hostels in Manly, Sydney. The median age was 24 years for men and 23 years for women. A new sexual partner during travel was reported by 94%, of whom only 20% always using condoms. The prevalence of chlamydia was 11.9% (14.3% of 35 men and 10.2% of 49 women). No cases of gonorrhoea were detected. Half of the dispensed testing kits went missing or were tampered with, and there was spoilage of the receptacle bins, which persisted despite a redesign to a more secure and locked box. While populations such as young backpackers may be a priority group for sexually transmissible infection screening, we advise caution for projects contemplating an unsupervised model.

Providing HIV-negative results to low-risk clients by telephone.

BACKGROUND: In Australia, Health Department policies differ on the recommended method of providing HIV results. Traditionally, all results have been provided in person. Our aim was to trial provision of HIV-negative test results by telephone to low-risk clients attending sexual health services and to assess clients' preferences for delivery method. METHODS: During 4 months in 2009 at two sexual health services in Sydney, all clients assessed as low-risk for HIV infection were invited to receive their HIV result by telephone. Non-receipt of results was defined as failure to receive results within 30 days of the test being performed. RESULTS: Of 763 clients tested, 328 (43%) were excluded following risk assessment, 30 (4%) declined to participate and 405 (53%) were enrolled. Among enrolled clients, 86% received their HIV result by telephone within 30 days, 97% were satisfied with delivery of the result by telephone and 93% preferred telephone delivery for their next HIV result. Only one enrolled client returned a positive HIV result. Independent predictors of receiving results within the 30-day timeframe were clinic attendance for sexually transmissible infection screening (P=0.021), lack of anogenital symptoms (P=0.015) and not being a sex worker (P=0.001). CONCLUSIONS: In this study of telephone provision of HIV results to low HIV-risk clients, there were no adverse events and clients expressed satisfaction with the process plus a strong preference for telephone delivery of future results. There was a decreased rate of failure to receive HIV results compared with other Australian studies.

Sexually transmissible infections among female sex workers in Manado, Indonesia, using a multiplex polymerase chain reaction-based reverse line blot assay.

BACKGROUND: Sexually transmissible infections (STIs) remain highly prevalent, and HIV is increasing, among female sex workers (FSWs) in Indonesia. Our aim was to determine the prevalence of, and risk factors for, STIs among FSWs in Manado, Indonesia. METHODS: We recruited FSWs mainly at their workplace: they completed a questionnaire and provided a urine sample and self-collected vaginal swab. Samples were tested using multiplex polymerase chain reaction, followed by reverse line blot hybridisation. RESULTS: We recruited 221 FSWs, (median age: 25 years). During the previous 3 months, 30% reported never using condoms; only 2.7% always used condoms. Of 217 women with urine samples, 49% had a 'curable STI': 10.6% with gonorrhoea, 26.7% with chlamydia, 12.4% with Mycoplasma genitalium and 22.6% with trichomoniasis. Independent risk factors for gonorrhoea were: domiciled outside North Sulawesi (P = 0.001) and age 16-25 years (P = 0.02); for chlamydia: no prior history of STI symptoms (P = 0.003) and age 16-25 years (P = 0.02); for Mycoplasma genitalium: number of clients on last day of sex work (P = 0.004); for trichomoniasis: number of clients per week (P = 0.04). When these four infections were grouped as any 'curable STI', independent associations were: number of clients on the last day of sex work (P = 0.001), age 16-25 years (P = 0.02) and sex working for fewer than 2 years (P = 0.03). CONCLUSIONS: This is the first report of M. genitalium infection in Indonesia. The high prevalence of STIs and low condom use among these FSWs suggest their vulnerability to the HIV epidemic in Indonesia. They need enhanced interventions, including outreach screening, and periodic presumptive treatment.

Prevalence over time and risk factors for sexually transmissible infections among newly-arrived female sex workers in Timika, Indonesia.

BACKGROUND: HIV rates are escalating in Indonesia. At Timika in Papua, the world's largest gold mine employs many single and migrant men, who frequently have sex with female sex workers (FSWs). We investigated trends of sexually transmissible infections (STIs) in FSWs in Timika. METHODS: From 1997 to 2002, FSWs at clinics were recruited for their first STI screening. Sociodemographic and sexual behaviour data were obtained and laboratory tests were performed to diagnose STIs. RESULTS: From 1997 to 2002, 3086 FSWs were recruited. Prevalence of gonorrhoea varied from 11% to 19% (P = 0.71). Positive treponemal serology varied from 1.4% to 5.1% (P = 0.50). Trichomoniasis declined from 16% to 11% (P = 0.03). HIV infection increased significantly from 0.0% to 1.4% (P = 0.002). Chlamydia prevalence did not significantly change from 33% in 1997 compared with 41% in 1998 (P = 0.10). Consistent condom use was low, but increased from 8% to 16% (P = 0.001). Any STI was independently associated with younger age, high frequency of sexual activity, and not using contraceptives. CONCLUSIONS: The high rates of STIs, low condom use and increasing prevalence of HIV among these FSWs require enhanced interventions, and consideration of periodic presumptive treatment. A partnership with industry can aid and sustain an intervention program.

The prevalence of urogenital micro-organisms detected by a multiplex PCR-reverse line blot assay in women attending three sexual health clinics in Sydney, Australia.

This study used a previously described multiplex PCR-based reverse line blot (mPCR/RLB) assay to assess the prevalence and distribution of 14 urogenital pathogens or putative pathogens, namely Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium, Mycoplasma hominis, Trichomonas vaginalis, Gardnerella vaginalis, Ureaplasma parvum, Ureaplasma urealyticum, Neisseria meningitidis, Streptococcus pneumoniae, Haemophilus influenzae, herpes simplex virus types 1 and 2, and human adenovirus. First-voided urine specimens and endocervical and self-collected vaginal swabs from each of 216 women attending three sexual health clinics in Sydney, Australia, were tested and the results were compared with those of reference methods for each organism. One hundred and sixty-eight women (77.7 %) had at least one and 105 (48.6 %) had more than one target organism, most commonly G. vaginalis and Ureaplasma spp. The prevalence of each of the four known sexually transmissible pathogens was <5 %. Of the 216 women, 111 (51.4 %) reported at least one symptom consistent with genital or urethral infection, including discharge, pain or discomfort. Only G. vaginalis was detected more frequently in women with symptoms (P = 0.05). The specificity of the mPCR/RLB assay compared with that of the reference methods for each organism and for all specimen types was 100 %. The mean sensitivities of the mPCR/RLB assay compared with those of the reference methods for self-collected vaginal swabs, cervical swabs and first-voided urine specimens for all organisms were 99.3, 98.1 and 84.6 %, respectively; however, these differences were not significant. There were no differences in sensitivities between specimen types for C. trachomatis, N. gonorrhoeae, T. vaginalis and H. influenzae, although all were found infrequently. Overall, the mPCR/RLB platform was found to be an accurate testing platform in a sexual health clinic setting.

Genital piercing in association with gonorrhoea, chlamydia and warts.

A 26-year-old heterosexual man presented with urethral discharge and penile oedema, two days after having a Reverse Prince Albert penile ring replaced. Clinically, he also had genital warts at the piercing tract openings. Investigations revealed positive chlamydial and gonococcal infection of the urethra. The gonococcal isolate was found to be highly resistant to antibiotics and the genotype matched an isolate only once previously recorded in the international database. We discuss how the genital piercing might have affected this patient's multiple infections, the possible contribution of genital piercing to the penile oedema, as well as potential anatomical spread of warts associated with a genital piercing.

Prevalence of sexually transmissible infections (STI) among male patients with STI in Denpasar and Makassar, Indonesia: are symptoms of urethritis sufficient to guide syndromic treatment?

BACKGROUND: There are few data on sexually transmissible infections in men in Indonesia. We conducted a prevalence study and compared symptoms alone with clinical signs to manage urethritis. METHODS: We recruited symptomatic male patients at public clinics, and used standardised questionnaires, examinations and laboratory tests. RESULTS: We recruited 273 men and the prevalences were Neisseria gonorrhoeae 18.2%, Chlamydia trachomatis 10.1%, and positive syphilis serology 5.2%. Four cases of HIV were detected. Urethral symptoms detected 91.7% of N. gonorrhoeae and/or C. trachomatis, and positive predictive value (PPV) was 41.8%, compared with clinical confirmation (sensitivity 86.1%, PPV 37.6%). CONCLUSIONS: Most cases of syphilis were asymptomatic, supporting routine screening for syphilis. Urethral symptoms predicted infection with N. gonorrhoeae/C. trachomatis better than clinical signs.

An extra pair of eyes: do patients want a chaperone when having an anogenital examination?

BACKGROUND: Anogenital examinations can be embarrassing for patients and can leave clinicians open to accusations of professional misconduct. Little is known about the attitudes of patients in Australia towards the use of chaperones. METHODS: In 2006, we surveyed 480 patients attending two sexual health clinics in northern Sydney. Our aim was to determine their attitudes towards the use of chaperones for anogenital examinations. RESULTS: Of the 480, 58% were male and 42% female. Most women (64%) preferred a female examining clinician, whereas most men (68%) had no preference for gender of the examining clinician (P < 0.0001). While 32% of women wanted a chaperone if being examined by a male, 29% did not. Only 4% of women wanted a chaperone when being examined by a female. Only 1% of men wanted a chaperone irrespective of the sex of the examining clinician. Independent predictors of women wanting a chaperone with a male clinician were preference for a female clinician (OR 6.59, 2.48-17.5; P < 0.001) and preference for a female chaperone (OR 4.02, 1.44-11.2; P = 0.008). The majority of participants felt that they should be involved in the decision to have a chaperone. CONCLUSIONS: Although a substantial minority of women want a chaperone when being examined by a male, a similar proportion do not want a chaperone. If a woman requests a female clinician, she should be offered a chaperone if there is only a male examiner available. Further study is required to determine why some women want a chaperone and how to distinguish them from other women.