Thursday, October 28, 2010

Patient Gender Preferences In Healthcare


Modern medicine is assumed to be gender neutral, that is providers, nurses and assistants are equally able to offer their services to all comers no matter the genders involved. It is a tenet of our training. This had little relevance in the past when nearly all physicians were men and nearly all nurses were women. Times have changed. Nowadays medical students are nearly 50% women. Although the percentage of male nurses is also increasing, it is still low, likely over 10%. However the increase in male nurses may be due mostly to the recession and the loss of traditional male jobs rather than to any perceived need for more male nurses.

Changing practices in medicine can be exemplified by male urinary catheterization. Thirty plus years ago this was always done by physicians or male orderlies; nowadays it is usually done by female nurses. The reason for these changes is mostly financial as hospitals got rid of orderlies in favor of less expensive ‘transport aides.’ As all physicians were male, they of course treated all patients. Women providers of today have the same expectations of being able to treat everyone.

Yet no one has ever asked patients how they feel about this. Are patients gender neutral in their preferences? The answer is clearly no. The factors are complex and need analysis. The clearest division is with intimate care. Women have strongly gravitated to female Ob-Gyns. Ninety percent of Ob-Gyns in training are women and men are discouraged from entering the field. The younger the woman, the clearer is the preference for female providers. The results vary somewhat from study to study likely based on how the study was conducted. Older women are used to using male gynecologists and some are reluctant to admit they prefer women because those concerns were made light of in prior years. Yet in nearly all studies, at least 50% of women prefer female OB-Gyn care with no more than 10-15% preferring male care. References include: Obstetrics Gynecology Apr 2005, Vol 105, #4, p 747-750, Obstet Gynecol 99: #6, 2002, 1031-1035, and Plunkett, Beth et al. Amer J Obstet Gynecol, 186: #3, 2002, 926-928. An Australian study put the number at 70%.  I haven’t seen a study which looked just at adolescents, but clearly the percentage is even higher, approaching 90%. Women are not gender neutral in their preferences for intimate care.

Not surprisingly the preferences that men have are not as striking, but still present. A similar study asking men their gender preferences for a urologist has not been done to my knowledge. Yet 90% or urologists are men and many of the few practicing female urologists specialize in women’s problems. The percentage of female urologists is increasing, but nowhere near as dramatically as the number of female Ob-Gyns. Men are not demanding more female urologists to take care of them. In terms of routine male genital exams, men still show a preferences even though the exam is brief and generally done as part of a full physical. In one study 50% of men preferred a male physician whereas the rest had no preference. Other studies have said up to 70% of men have no preferences, but once again it is critical how these studies are performed. An anonymous questionnaire will give different results than a series of questions asked by a nurse. Most men are loathe to admit that they are embarrassed by receiving care from women. They are frequently made to feel humiliated if they do. Women can have this same problem but it is far more acceptable for a woman to be modest than it is for a man. A man is likely to accused of sexism or suspected of homoerotic tendencies if he refuses opposite gender care whereas a woman will just be considered modest. It is much easier for a man just to avoid receiving any medical care which men do in far higher numbers than women who are forced into entering the healthcare system early in their lives for contraception and obstetrical care.

There are other factors besides gender in determining how likely it is that a patient will prefer same gender care. As noted, age is the most important of these. Adolescents are far more likely to be embarrassed by intimate care. A choice should be offered them. This often happens nowadays for girls but rarely for boys. This may become less of a problem for boys in the future as many are used to care by female pediatricians. But as they move into adolescence, this should never be assumed. Conversely elderly patients routinely have less concern. Religion also plays a role especially with Muslims and other orthodox sects. A history of sexual assaults or homophobia may also account for preferences.

Up to now we have only considered gender preferences for providers, but of course this can also be extended to nurses, technicians and assistants. Patients do not look at these healthcare workers like they do physicians. Clearly women are far more likely to accept male physicians than male nurses or technicians. Men who wouldn’t see a female physician routinely accept female nurses. Of course they usually have no choice. But beyond that there is still a common prejudice against male nurses in that they may be considered not as nurturing as women or they may be considered gay. I don’t think that either of these prejudices have much basis in fact, but they keep many men from going into nursing. This is changing, but slowly. Men are clearly at a disadvantage here. Many men who need urinary catheterization would request a male to do it, but they are rarely offered a choice. It is difficult to insist on it as the man may be embarrassed by asking and the need may be urgent. Female nurses almost never offer a man a choice; the only common exception is when the nurse feels the patient will harass her and asks a male nurse to do it instead. In short when men are offered male nurses for procedures, it’s usually done for the nurse’s comfort, not the patient’s. Although there are male nurses who catheterize women, it is far less common and many male nurses will routinely ask a female nurse to do it. Intimate care in hospitals nowadays is usually done by CNAs, who are 98% women. This includes giving baths and showers. The only option a man has is to refuse the care; no male CNA will likely be found.

In summary, American medicine claims to be gender neutral but patients are not. This is essentially a fact we’re not supposed to know. Hospitals routinely publish a patient’s bill of rights, but I’ve never seen one which included gender choice. At best it may be implied by statements that the hospital will respect the patient’s values. Of course gender is a protected class under federal laws so hospitals are in a bind. Federal law does make exceptions (BFOQ) where matters of bodily privacy are involved so it is legal to request a specific gender for care. However hospitals cannot base employment on that in general with rare exceptions. Still and all, hospital employment policies are never based on giving patients a choice of gender; their major consideration is cost and availability.

Will this ever change? It’s not likely to change in the foreseeable future unless a lot more patients speak up about their preferences. Hospitals are only likely to make the change if they see it as in their financial interest. For example, if men routinely asked for a male technician for testicular ultrasound, hospitals would soon provide them just as they provide an all female staff for mammography. Ultimately you as a patient must make your preferences known.

Please add your comments.  Further discussion can be found on my companion blog. This slightly modified article has also been picked for publication on Kevin.MD, a widely read medical blog.

27 comments:

Anonymous said...

"Most men are loathe to admit that they are embarrassed by receiving care from women. They are frequently made to feel humiliated if they do."

I'm sure you're correct but I have never understood why so many men feel that way. What is more masculine than a man standing up for himself? I think it takes a much stronger man to fight for what he believes than to be bullied or intimidated into humiliating himself in front of a female nurse. I believe a REAL man won't let himself be forced to do something he believes is wrong. Am I the only guy that thinks this way?

Joel Sherman said...

Hopefully as more men read articles like this they will be prepared to stand up. Most people are just taken by surprise and say nothing.

Anonymous said...

I think its more than saying no to THAT nurse, we are bucking what society has said is right. Looking at civil rights and womens sufferage, many stood by feeling these practices were wrong, but said nothing as society as a whole seemed to support them. The other part of this I believe is historical. Historically men have been the sexist, the oppressor, women were the victim. Society still sees females as being the victim, it is hard for them to see the oppressor in that role. Society still as a whole is patriarcal, while that is changing the view is it is still a mans world, so how can a man be a victim in his own domain. A male will not only be seen as weak and sexist, they will be seen as wrong. We need to learn from women, use the processes they learned and stand up. I remember clearly when I was a child regardless of how much blood I shed I was expected to man up just like my father and pretend it didn't hurt, my sisters were free to cry, seek help and comfort. We have to move past that. The question I have are men by nature willing to organize or go it alone.
By the way, an outstanding article. I am printing and mailing to as many providers as I can. This is a great article and for those who don't feel comfortable, send it annom. its better than nothing....alan

Anonymous said...

Well done Dr. Sherman!
The matter-of-fact tone of the article lends credence to the subject, as well as being non-adversarial. Speaking on a touchy subject such as this is tricky, and you represented it very well.
Congratulations on reaching beyond the walls.

Suzy (swf)

Anonymous said...

Great job, Joel, on getting this article about patient modesty published on KevinMD. The first letter responding to it is from Dr. Maurice Bernstein. This the kind of advocacy lead by doctors that we need. Those who haven't read it can find the article at:
http://www.kevinmd.com/blog/2010/11/patient-gender-preferences-medical-care.html#more-48741
Doug/MER

Anonymous said...

(sorry I wasn't clear that I was referring to the KevinMD article)

swf

Jan Henderson said...

Great post, great subject, great blog. I’ve added you to my blogroll and look forward to future posts.

The only other person I’ve seen discussing this issue is Maurice Bernstein (mentioned above). He gets fascinating comments from patients on this subject at his blog on ethics.

Jan Henderson said...

Picking up on Alan’s comment above, there was an article last year in the NY Times (http://nyti.ms/lLMvm) on how ideas about masculinity kept “macho” men from seeing doctors (irrespective of the doctor’s gender). The conclusions were based on a large longitudinal study of about 1,000 men who graduated from high school in 1957.

“Men who strongly endorsed old-school notions of masculinity — believing the ideal man is the strong, silent type who does not complain about pain — were only half as likely as other men to seek preventive health care, like an annual physical, the study found.

“Even men with a high level of education, a factor that is strongly associated with better health and usually a predictor of longer life, were less likely to seek preventive health care if they strongly adhered to the ideal of the macho man. …

“The study may help explain the gender longevity gap, with women outliving men by about five years.”

I wonder if there's any correlation between these findings and men who avoid health care because of gender sensitivity.

Anonymous said...

"I wonder if there's any correlation between these findings and men who avoid health care because of gender sensitivity."

Many of us wonder that. Common sense says, "yes." The question is for what percentage of men is this valid? But there seems to be no interest in studying this issue, mostly, I think, because it isn't considered an issue. Also because of the implications if the study says that this is an issue for a significant number of men. The health care industry doesn't want to engage in a discussion about this.
Doug/MER

Joel Sherman said...

Thanks for all your comments. swf, I do try to present the material in a non confrontational way. I'm glad you think I'm succeeding.
Jan, I hope my next article will be on why 'we' avoid medical care. My biggest trouble with the topic is that there are very few articles, and even fewer studies.

Anonymous said...

"Most people are just taken by surprise and say nothing"

Right you are doctor. I had an experience around 20 years ago where I was put into that situation. I needed a "full" physical to travel abroad as a missionary. I was 19 and extremely naive about doctor and hospital practices and just earlier in the day of my physical I had learned how hernia and prostate exams were given.

As I was waiting with just my underwear and apron (gown) on a woman entered the room and fiddled around with a few instruments. She didn't have a name-tag on and never introduced herself. I assumed she was a nurse preparing for the doctor, until she told me to hop down and untie the gown. At that time of my life I never imagined they would send in a woman to give a prostate and hernia exam, and I was rendered speechless for about ten seconds.
I'm proud to say though that I politely mumbled something about being more comfortable with a man. She threw the mandatory hissyfit but she left and a man returned.

I learned at that time that medical "professionals" can't be trusted, but occasionally I'm happy to hear that ethical doctors like Dr Sherman and Dr Bernstein are around to help us figure out solutions for this all-too-common problem.

Albert said...

I wasn't quite sure where to post this, so as far as I'm concerned, please feel free to move it elsewhere. Yesterday (5/18/11) I was watching television and a commercial came on showing a young girl patient, about ten years old, sitting up in a hospital bed being tended to by here doctor. She was getting a needle in her arm and the doctor playfully distracted her attention by singing along with her a verse of the old "Name Game" song - you know - the one where you can take anyone's name and make silly rhyme choruses to it. Anyway, there was no commercial indicia displayed which led me to believe I was watching a commercial for St. Jude's Children's Hospital. As the doctor was finishing with the syringe and their short chorus ended he complimented the young girl on how well she accepted the treatment. It was at that very moment that the "Johnson & Johnson" logo appeared, with the silent legend "Nurses Heal"!!

It was not a St. Jude's commercial and it wasn't a doctor at all. It was a male nurse tending to the young girl! I saw the commercial once again before the day was out. I live in the New York tri-state area and I'm curious to know if anyone else has seen this TV spot running in other parts of the country.

There's no greater truth than the longest journey beginning with but a single step.

Albert

Doug Capra said...

Great note, Albert. Now, what needs to be done is this: Spread the word. Make sure that Johnson and Johnson gets as many hundred/thousand letters from men in general, their significant others, nurses of both genders. Let them know that what they're doing is well appreciated. That's part of that longest journey. We need to start taking the second and third steps.

Joel Sherman MD said...

Nice find Albert. I haven't seen the commercial yet. Can you tell us what show you were watching?

Albert said...

Hello, everyone. I'm embarassed to say I do not recall what programs ran the spot because I am an incurable channel surfer when watching TV, but suffice it to say J&J ran it during prime hours. I'm happy to report that you can view the spot on J&J's YouTube channel. It is part of their "Campaign For Nursing's Future."

Doug, my computer skills are pretty much limited to point and click. I could not find an E-mail address for J&J and I fully agree with you that J&J is entitled to hear our gratitude for putting the male nurse front and center. It was also not lost on me the wonderful empathy displayed by the nurse in this spot, and that it was a young girl being tended to.

These issues speak to the very core of what your blog is trying to accomplish. Not only is there a dire need for male nurses, there is also a dire need to bring back to speed the nurturing empathy in our nursing corps, something which is so vital to patient care, and something that has been so badly ravished by boundary and time restrictions.

Talk to you later. There are a couple of other spots on the J&J YouTube channel that I haven't seen. That's about to change.

Albert

Anonymous said...

Regarding Alberts post about that commercial, it was easy to find.

Here's a link to the commercial:
http://www.youtube.com/watch?v=2PVeOq60GcA

Olengrumpy said...

Tried to post this before..
Let me preface this query by saying how happy I am to see someone addressing this issue that I thought I was alone with..
I no longer want a woman to view or touch my genital area other than during an operation or ER situation.. Even then I'd like the option of a male..
My question has to do with legalities, and if I have the legal right under the law to demand a male when my genital area has to be touched in any way..
Thank you in advance and I'm sorry if I missed this answer..

Joel Sherman MD said...

Olengrumpy, there is nothing illegal about asking for a a male or female caregiver. It is not considered an out of bounds request such as a request for a caregiver of a specified race would be.
But though you can ask, caregivers are under no mandate to accede to your request. They may not have a same gender caregiver available which would impact mainly requests for male caregivers. They don't have to give a reason. But I hope most institutions would grant the request when they are able. However these requests can go awry for many reasons and are not always fulfilled even when promised.

Olengrumpy said...

Thank you for your response. As a curiousity, does a female have the legal right to have a female over a male?

Joel Sherman MD said...

The answer is the same as given above though a woman's request is more likely to be honored.

Anonymous said...

Olengrumpy, you have the ethical and legal right to choose who, and to what degree, someone participates in your healthcare and you don't have to justify your rationale to anyone. This includes the MD, PA, NP, nurse, assistant, tech, student, chaperone, observer, etc. With the exception of the ER, no one can be present or touch you without your Informed Consent, one of the basic bedrocks of medical ethics, that seems to be ignored on a regular basis because it inteferes with expediency and profit. Even if you had signed documents granting consent (i.e., teaching hospital), simply state you changed your mind. We're not inmates in the county jail but it certainly seems that medicine expects nothing but meek compliance; no longer in my case! The key, as Dr. Sherman mentioned, is the facility in question doesn't have to comply with your request. My advice is respectfully request, then insist, and if necessary demand. If that doesn't work, leave and go elsewhere.

Ed

Olengrumpy said...

Ed..
Thank you very much for taking the time to respond to my query..
My most important question is, is there actually a law in place, (on the books) that provide for this demand of having male with male, female with female? .
If there is such a law in place, can you direct me to that law as I would like to quote the law in any upcoming visits that will require genital examination?
Thank you again for your time, and to others who have responded as well, I read every one of them..

Anonymous said...

Olengrumpy, while I'm no attorney, I'm confident there is no law guaranteeing same gender intimate care in the United States. That said, you have absolute control over who participates in your healthcare and don't let anyone tell you differently.

Ed

Anonymous said...

I understand that in an emergency situation you may not(most likely)have your choice of gender care. I think for scheduled exams you should have the option ahead of time(not when the person appears at the last second)to state your preference. It may not be always possible but at least you could be asked. It may give some proof as to the amount of people who actually do have a gender preference.
What is the point in choosing a male doctor if all the procedures you will have done are done by or accompanied by women. Totally defeats the purpose. I'm sure if a women chooses a female gyn they won't have a 20 year old male med student working with her.
I wonder how many lives would be saved if a lot of men felt they would not be embarrased by having females present during exams. Probably more people in a year than were killed in the 911 attacks. They spent a trillion dollars fighting for that and nobody seems to address this problem of a lot of men not going to exams because of embarrassment. There attitude is that's your problem if your embarrassed we have seen it all before so you should adopt our ideals even though you pay for our salaries. If any other business had such disregard for customers they would go out of business. I guess when your blackmailed by your health or life they have that power.

Olengrumpy said...

This is a little off subject, but I would like an opinion, or, a possible referral to an appropriate site.
My reason for my questions is, I am elderly, have frequent urination, and cannot force myself to urinate for the purpose of testing in a reasonable amount of time..
I have been on pain medication for several years, I have until recently, been able to provide a sample for the mandated testing for what I assume is the use of street drugs..
As I could not give a sample in a reasonable amount of time my PCP said he will have to use a catheter to get a sample or I will not be given the medications.. I have tried to stop taking these because of the problems associated with them but I could tolerate the pain and the withdrawal was horrific...
My question here is how ethical is it for a doctor to try to use a catheter for this purpose?
I know this out of parameters here but I have become comfortable enough here to at least ask...
Thank You!

Anonymous said...

Who defines what the reasonable amount of time is? Frankly, he can wait all day until you're able to urinate normally. I would never agree to being catheterized for a simple drug screen; it's unethical, unprofessional, and possibly illegal for a physician to coerce you in this manner, IMO.

Ed

Olengrumpy said...

Thank you Ed. It is indeed your IMO that I am looking for.. I agree on every aspect of your response.. Thank you for reinforcing my own feelings..
Rich...