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.