Patients’ preferences regarding physicians’ gender: a clinical center cross-sectional study

ABSTRACT BACKGROUND: Even with the significant growth of female representation within medicine, inequality and prejudice against this group persist. OBJECTIVE: To analyze patients’ preferences regarding the gender of physicians in general and according to different specialties, and the possible reasons behind their choice. DESIGN AND SETTING: Cross-sectional study at the Clinical Center of the University of Caxias do Sul, Brazil. METHODS: Over a three-month period in 2020, 1,016 patients were asked to complete a paper-based 11-item questionnaire. RESULTS: The majority (81.7%; n = 830) of the patients did not have a preference regarding the gender of physicians in general. The preference rate for same-gender physicians was 14.0% (n = 142/1,016), and this preference was more common among female than among male patients (17.6% versus 7.0%; odds ratio, OR = 2.85; 95% confidence interval, CI = 1.80-4.52; P < 0.001). When asked about their preference for the gender of the specialist who they were waiting to see, the overall preference rate for a same-gender professional was 17.2% (n = 175). Preference for same-gender specialists was higher for specialties essentially based on pelvic or breast examination (i.e. gynecology, urology, proctology and mastology), compared with others (33.4% versus 9.7%; OR = 4.69; 95% CI = 3.33-6.61; P < 0.001). CONCLUSIONS: The patients’ model for choice of their physician does not seem to involve physicians’ gender in general or in the majority of medical specialties. The data presented in this study may make it easier to understand patients’ preferences and concerns.


INTRODUCTION
Gender disparity is defined as a social phenomenon in which discrimination against others occurs due to their gender (male or female). 1 In the field of healthcare, women represent 70% of the worldwide workforce, and this percentage has increased sharply over recent years. 2 Currently, even with the significant growth of female representation in field of medicine, inequality and prejudice against this group persists. 3,4 It has been shown that female residents are notably more likely to be mistreated, both by patients and hospital staff, which may lead to higher rates of burnout syndrome and suicidal thoughts among this gender, compared with male colleagues. 5 The idea that patients will choose their healthcare provider based on gender is an issue that has been discussed in the literature, albeit to a limited extent. Some previous studies have shown that patients seem to have a predilection in favor of male physicians for general medical care. [6][7][8][9] Among the medical specialties of obstetrics and gynecology, most patients were found to report a female preference when selecting this specialist. 10,11 In contrast, other studies within the emergency department and orthopedic specialties revealed that there was neither any patient preference for the physicians' gender, nor any propensity towards same-gender physicians. 12,13 Some authors have argued that the reasons behind this divergence in the literature may encompass factors such as cultural and regional influences, as well as the specialty studied. 14,15 While the representativeness of women in medicine has already been widely discussed and studied, few publications have focused on patients' views on the topic. 3 The literature still lacks studies that have assessed patient reception in the light of the increasing numbers of women in the most varied medical specialties. Analysis on patients' preference for male or female physicians within clinical care is an important tool to be considered in studies on patients' perceptions, since this elucidates gender disparities regarding physicians in the field of healthcare.

OBJECTIVE
The aim of this study was to analyze patients' preferences regarding physicians' gender in general and according to different medical specialties, at a single center, along with the possible reasons behind their choice.

Study design and location
A cross-sectional study was conducted using a paper-based ques-

Demographic data
Among the 1,041 questionnaires received, 1,016 were complete and were therefore included in the analysis. The median and mean ages of the respondents were, respectively, 55.0 ± 10.  Table 1 shows the detailed demographic data on the participants.

Patient preference for physician gender in general
The majority (81.7%; n = 830) of the patients did not have a preference regarding the gender of physicians in general ( Table 2).
Men, in turn, were slightly more likely to prefer male physicians than were women (7.0% versus 4.0%; OR = 1.78; 95% CI = 1.01-3.14; P = 0.04). Figure 1 illustrates the reasons behind the preference for male or female physicians according to patient gender.
The most common reason for preferring same-gender physicians was "feeling more comfortable with them".
The mean age of the patients who preferred same-gender physicians was lower (49.3 years; 95% CI = 46.4-52.2) than that of those who did not have a preference (55.12 years; 95% CI = 54.1-56.1) (P < 0.001). The age group with the highest preference for same-gender physicians was the youngest group (< 44 years) ( Table 3). Those who had a level of education up to complete elementary school did not have a statistically significant difference regarding preference for physicians' gender, compared with those who had at least incomplete high school education (14.0% versus 14.0%, AOR = 0.70; 95% CI = 0.46-1.04; P = 0.08) ( Table 3).

Patients' preference for physicians' gender according to medical specialties
When asked about the gender of the specialist who they were waiting to see, the overall rate of preference for a same-gender professional was 17.2% (n = 175). For specialties that are essentially based on pelvic or breast examination (i.e. gynecology, urology, mastology and proctology), patients were more likely to prefer same-gender specialists, compared with other specialties (33.4% versus 9.7%; OR = 4.69; 95% CI = 3.33-6.61; P < 0.001).
Among specialties with more than 20 responses, the highest pref-

DISCUSSION
Our findings suggest that most of the patients did not have a preference regarding the gender of physicians in general. It was also demonstrated that preference for same-gender physicians was higher among female patients than among male patients. For specialties essentially based on pelvic or breast examination (i.e. gynecology, urology, proctology and mastology), compared with others, there was a marked preference for specialists of the same gender.
The proportion of women in the medical profession has increased over recent decades, and more markedly so over recent years. [16][17][18] According to data from the World Health Organization Thus, it appears that the gender-based inequality between physicians does not stem from differences in clinical and diagnostic skills. [25][26][27] Even though many of these challenges are still encountered by women when choosing a residency program, this scenario seems to be changing for the better. As Dineen et al. 13    preferences when selecting orthopedic providers, found that 14.5% of the patients preferred a female surgeon and that, among these respondents, 89.2% of them were women. In our study, the rate of predilection for a same-gender physician in general was 14.0%, and it was 17.2% when considering preference according to the specialty within which the patient was waiting for a consultation, and this was more frequently observed among females. We also observed that the age group with the highest preference for same-gender physicians was the youngest (< 44 years). The mean age among those who had this tendency was 49.3 years, versus 55.12 years among those who did not ( Table 3). The prevailing reason for preferring same-gender physicians was "feeling more comfortable with them" (Figure 1).

Figure 1.
Reasons for preference for male and female physicians in general according to patients' gender.  and interventional radiology (80.8%). 28,[31][32][33] Previous studies revealed that within specialties based around pelvic or breast examination (such as gynecology and obstetrics, mastology, urology and proctology), preference for same-gender physicians is indeed more frequent. [9][10][11]27,[34][35][36][37] In a systematic review of the literature, Janssen et al. 38 evaluated patients' preference in gynecology and obstetrics and reported that 20%-25% mentioned a strong preference for a female specialist. A cross-sectional study in which the aim was to assess gender preference for care providers among urology patients revealed that 42.8% of the patients preferred a male urologist. 37 A descriptive survey evaluating male patients'

Specialty Preference for same-gender specialists -n/total (%) All patients Female patients Male patients
preference regarding the gender of the physician performing rectal examinations corroborated this, through showing that 51.5% of the patients indicated a preference for a male professional. 9 On the other hand, in a prospective study regarding female preferences for breast surgeon choice, 59% of the patients had no preference for the surgeon's gender. 27 Our study pointed out that same-gender professionals attending in these fields were 4.69 times more likely to be chosen, compared with the situation in other specialties (33.4% versus 9.7%; OR = 4.69; 95% CI = 3.33-6.61; P < 0.001). Women were more than twice as inclined to choose same-gender physicians as were men (17.6% versus 7%) ( Table 3). We found that 41.5 % of female patients who came for consultations within gynecology had a same-gender preference, followed by proctology with 38.9% and mastology, 22.2%.
In urology, the results showed that 28.8% within the male group had a same-gender preference ( Table 4).
It is worth noting that these results surprised us. We had expected to find notably higher percentages within these medical fields. The most frequent reason given for same-gender preference, in relation both to specialties that are essentially based on examination of intimate body parts and to other specialties, was "feeling more comfortable with same-gender physicians", although this was much more prevalent for the former group than for the latter (84.9% versus 48.6%) (Figure 2). These findings are supported by existing data in the literature. Those studies revealed that femaleto-female medical consultations were thought to have a more patient-centered approach, thus promoting increased involvement, Figure 2. Reasons for preference of same-gender specialists for specialties that are essentially based on pelvic and breast examination, and for other specialties.
while male-to-male interactions were found to be shorter and more focused on the physician's recommendations and instructions. 14,15,39 We also found that the patients' educational level did not seem to play any important role in gender preference. As detailed in Table 3, those who had a lower educational level (up to complete elementary school) did not show a statistically significant difference with regard to preference for physicians' gender, compared with those who had reached a higher level (at least incomplete high school education) (14.0% versus 14.0%). Data regarding whether formal education is an influencing factor in patient predilection for their health professionals' gender are scarce in the literature.

Strengths and limitations
This was an original and innovative study, given that it assessed patients' preference for physicians' gender in a center with a wide variety of medical specialties. In addition, the number of respondents was high (n = 1,016), in comparison with similar studies. 6,8,29 Some patients found it difficult to understand the questions and respective answers if these did not represent the patients' beliefs. In this setting, the researchers tried to clearly explain the meaning of each expression to the respondents when applying the questionnaires. Our study was also prone to selection bias. Patients who supported gender equality may have been more likely to answer the questionnaire than others who did not. Our sample also mainly consisted of patients with a monthly income lower than two minimum wages, and this may have influenced their responses and would not be generalizable to other settings. Furthermore, some specialties may have been underrepresented, with few or no respondents due to lower volume of patients per month (such as orthopedics and cardiac surgery) or because no consultations were available within our center (such as psychiatry and neurosurgery). Lastly, we emphasize that the data presented here were limited to a single center in southern Brazil and should not be fully extrapolated to other regions of this country.

CONCLUSION
In summary, our study showed that, in general, the majority of patients (81.7%) did not have any preference for the gender of their physician. These data demonstrate that the attribute of gender is not uniformly important to all patients. Female patients seemed to prefer a same-gender physician more frequently than did their male counterparts (17.6% vs. 7%). When our patients were asked about gender preference for specialists, the rate of preference for a same-gender professional was 17.2% (n = 175).
For medical specialties involving pelvic or breast examination, there was a greater tendency towards preference for same-gender professionals than was noted in relation to other fields (33.4% versus 9.7%).
The current study provides a clearer comprehension of patients' preferences and needs. Healthcare providers may benefit from knowing their patients' educational levels and providing counseling when planning healthcare services. Considering that in Brazil the prevalence of disadvantages and discouragement due to gender is ubiquitous among female physicians and very uncommon among male physicians in certain medical specialties, these data may help to show a change in this scenario to a more equal patient preference.