Introduction
As part of important efforts to
provide person-centered care, the particular role of gender as an underlying
social determinant in shaping the interaction between clients and providers,
while often acknowledged, is still poorly understood. A definitive evidence
base has yet to be established and most current data derive from descriptive
studies, or evaluations of relatively small-scale interventions.
In this review, I address the question as to whether there
are differential patterns of care provided by male and female healthcare
workers to male and female clients and how gender-based discrimination might impact
on provider-patient interactions.
Gender-based discrimination refers to any unfair or unequal
practices based on gender identity, roles and relations and which prevents
women and men of different sociological characteristics and ages from enjoying
their human rights, particularly in the context of this article, the right to
health.
Methods
This article reports the results of
a literature review of peer-reviewed studies. Initial searches for research
studies and meta-analyses were carried out on Pubmed using combinations of key
words. Grey literature was identified through general Web searches on Google,
Google Scholar and more focused reviews of relevant Web sites.
The selection of the articles was guided by the following
questions:
1.
Are different patterns of
care provided by female and male health workers as a function the client's
gender?
2.
Do female clients show a
preference for a provider's gender?
3.
Are there harmful effects
of individual and institutional gender norms within the context of
client-provider interaction?
The following indices were used to define poor quality of
interaction:
·
lack of privacy and
confidentiality
·
poor communication between
providers and patients, in terms of verbal abuse
·
failure to communicate
medical and health related information fully
·
lack of a rights based
approach that fails to give patients information to enable them to make informed
choices and consent on the part of the provider
Initial database searches identified 118 articles from which
all titles and abstracts were reviewed by one reviewer. The period of review
was 1995 to 2009. 16 articles were finally identified for full text review.
Results
Differential patterns of care by male and female health workers:
Much of the data on the significance
of provider gender emerges from developed countries. Overall, findings point to
the fact that there are no gender differences in the nature and extent of biomedical
information provided during the consultation. Female physicians were found to
engage in significantly more active partnership behaviours such as ‘positive
talk’, psychosocial counselling, psychosocial question asking and ‘emotionally
focused’ talk. They also spend on average two minutes longer with clients as
compared with male physicians [1].
A number of studies has shown differences in treatment as a
function of patient or physician gender. For example, one observational cross-sectional
study carried out in Germany specifically examined the interactions between the
physician's gender and medical treatment of chronicle heart failure. This study
found that female patients were less likely to receive guideline-recommended
treatment than males. With the success of treatment lower in female compared
with male patients. The authors concluded that there was no difference in the
treatment of males or female patients by female physicians, whereas males
physicians used significantly less medication and lower doses in female
patients [2].
Other studies have demonstrated that the patient's gender
and physician's gender influence drug treatment in patients with heart failure
[3,4], where patients treated for myocardial infarction had different drug
treatments as a function of patient gender. In female patients, symptoms of
coronary heart disease were significantly more often misinterpreted than in
male patients. One reason for this could be a physician-related shift of
diagnostic thinking away from the consideration of an organic cause to a
psychogenic one, especially when symptoms are dependent on psychologically
stressful situations [5].
Client preferences for provider's gender
The significance of provider gender
has received most attention in Obstetrics and Gynaecology. Studies carried out
in the USA have found that only a minority of women felt strongly about their
provider's gender and provider choice was more a function of other attributes
such as experience, communication, style and technical expertise [6-8]. In
contrast, another study undertaken in the United Kingdom showed that women's
preferences change according to the particular problem or procedure in
question: a female health professional is not important to most women when they
are consulting about general problems, but is more important for screening for
mammography and particularly important for gynaecological health problems [9].
Other authors report similar findings when examining the preferences expressed
by women for male and female gynaecologists. In cases where women preferred
female gynaecologists, they were concerned with emotional factors and the
experience of female biology, while a few women who preferred a male considered
them to be more capable both emotionally and technically.
In highly patriarchal societies, the gender concordance
between provider and client is important because of social, cultural and/or
religious norms and practices which not only demarcate gender roles, but also
restrict social and physical contact between men and women [10]. A qualitative
study carried out in Cuba, Thailand, Saudi Arabia, and Argentina examined the
experience of women seeking antenatal care and found that female doctors were
preferred by Saudi and Thai women although Cuban women indicated being equally
comfortable with both male and female doctors, even when warned against male
doctors [11]. There is evidence, therefore, from a number of studies and
evaluations that patients may avoid presenting for care at specific facilities
because of the gender of the health care workers employed there. They may not
think it acceptable, or their families might not feel it acceptable, for them to
see health care workers of a given gender.
The effect of gender norms in provider-patient interactions
Most of the available literature which
has examined the effect of gender norms on provider-patient interactions is
descriptive, and focuses only on certain aspects of health, such as maternal
and reproductive health. It is important to consider how transgressing gender
norms can lead to a real breakdown in provider practice. This seems to be
particularly the case in reproductive health services and in cases of women
seeking help after gender-based violence. Patients may also avoid health care
workers because of the fear that professional staff will be judgmental of the
medical condition for which they are seeking help: for example: abortion,
contraception, treatment for sexually transmitted infections (STIs), feeling
that they have transgressed some societal norms to need to access these
services. For example, in one study carried out in South Africa, health care
workers were reported as making judgments of women who they felt should not be
having children either because they were too young, because they already had many
children, because they were too old, or not married, etc [12].
The abuse of patients by health care providers, which may
take many forms, is a critical issue. A range of factors, including gender
stereotyping are of relevance here. All patients, especially women and women
who are socio-economically disadvantaged on account of race, class, age or
property ownership status are particularly vulnerable to abuse. In relation to physical
abuse, there is a large internationally derived literature on the physical
abuse of women in labour by health care workers. As discussed earlier, verbal
abuse of patients is relevant here, particularly when patients are accessing or
trying to access reproductive health services [13]. The ways in which sexual
assault survivors were treated by health care workers in many countries are
often extremely judgmental in their nature and characterised by rude verbal
abuse of women often linked to factors associated with health care workers
presuming that women have transgressed certain gender norms.
While acknowledging the need to empower women of all ages at
the societal level, it is asserted that health systems are "core social
institutions". How people are treated in these core institutions forms an
important part of experience of what it means to be socially marginalized or disempowered.
Provider attitudes illustrated by the examples described above of poor and
young women's experience of verbal abuse and scolding when they try to access reproductive
health services, demonstrate some of the negative effects of gender
discrimination on provider-patient interactions.
Conclusions
There is a growing evidence base
across many countries and across many medical conditions in terms of diagnosis,
treatment as well as patient adherence and patient satisfaction, that gender
has a significant impact on provider-patient interactions. The impact of gender
stereotypes and biases within the provider-patient interaction has been shown
to be harmful for women as well as for men. With men, gender norms often make
it difficult for them to utilize health care or express feelings of
vulnerability. It is surprising, perhaps, that although there is a substantial
body of literature that concludes that gender is an important factor that
shapes the quality of care that patients receive, very few articles look in
detail at the patient-provider interaction and describe or theorize the way in
which gender impacts on this interaction. Indeed, no currently published
studies appear to have investigated whether patients are more passive in their
interaction with male providers compared with female providers. Likewise the
factor of whether the interaction of gender with class and ethnicity of the
provider influences the interaction remains uninvestigated, as does the
question of whether it is more important for patients to consult with providers
of their own race and ethnicity and gender or whether this is of secondary
importance.
With regard to communication, gender dynamics appear clearly
to affect the way patients communicate with health care workers as well as how
they understand and follow treatment. Other factors are issues of literacy and
language proficiency among women who tend to be less well educated and the
belief that the patient is unable to ask relevant questions, difficulties
mediated by a range of social factors, including gender. Sexual and
reproductive health services are particularly impacted by gender bias and
discrimination. Indeed, gender norms around sex and reproduction are
particularly strong and there is also evidence that being seen to transgress
gender norms elicits particularly strong reactions from health care workers. It
is suggested that health workers delivering these specific services are those
that need particular training and ongoing support on issues around gender. However,
addressing gender biases and discrimination calls for action on multiple levels
given the complexities of the patient-provider interaction.
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