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doi:10.1111/jog.12512
J. Obstet. Gynaecol. Res. Vol. 41, No. 2: 283–293, February 2015
Obstetricians and gynecologists: Which characteristics do Israeli lesbians prefer? Hadar Amir1, Ruth Gophen2, Yifat Amir Levy3, Joseph Hasson1, David Gordon1, Ami Amit1 and Foad Azem1 1 Sara Racine IVF Unit, Department of Obstetrics and Gynecology, Lis Maternity Hospital, and 3Neuroimmunology Laboratory, Department of Neurology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University and 2Gan-Meir Community Health Center, Tel Aviv, Israel
Abstract Aim: The aim of this study was to explore lesbians’ preferences when choosing obstetricians/gynecologists. Material and Methods: This cross-sectional study included 100 lesbian and 100 heterosexual women. A 40-item questionnaire assessed the correlation between a patient’s sexual identity and her specific preferences for obstetricians/gynecologists. Results: The top five most important parameters for both groups in choosing obstetricians/gynecologists overlapped greatly. Four of those were experience, ability, knowledge and personality. Only one parameter differed: lesbians ranked ‘sexually tolerant’ as the third most important characteristic while heterosexuals ranked ‘availability’ as the fifth most important characteristic. Lesbians rated ‘sexual tolerance’ significantly higher than heterosexuals (P < 0.001). More lesbians (56%) preferred female obstetricians/gynecologists compared to heterosexuals (21%) (P < 0.001). When compared to heterosexuals, more lesbians preferred female obstetricians/gynecologists for intimate and non-intimate procedures (P < 0.001). But within the lesbian population, a higher percentage of subjects showed a preference for female obstetricians/gynecologists only for intimate procedures. Lesbians used the following to describe their preference for female obstetricians/ gynecologists: feeling more comfortable; gentle; sympathetic; patient; more understanding of women’s health; better physicians in general; and more sexually tolerant (P < 0.001 vs heterosexual). However, when we looked only at the lesbian population, the majority did not exhibit a preference for a female obstetrician/gynecologist for any of these reasons. The main reason given by the 56% of the lesbians who said they prefer female obstetricians/gynecologists was feeling more comfortable. Conclusion: Overwhelmingly lesbians prefer sexually tolerant obstetricians/gynecologists regardless of their gender; however, only a small number of lesbian subjects in this study considered their obstetricians/ gynecologists as displaying this characteristic. Key words: characteristics, gender, lesbians, obstetricians/gynecologists, tolerance.
Introduction Sexual orientation is an important determinant in health issues. In the 1990s, the difficulties and needs of lesbians regarding their health started to attract atten-
tion in the USA and more research has been conducted on their sexual behavior and health since then.1 In 2000, ‘Healthy People 2010’, an initiative started by the US Department of Health and Human Services, recognized sexual orientation as a social determinant of
Received: January 23 2014. Accepted: May 29 2014. Reprint request to: Dr Hadar Amir, Sara Racine IVF Unit, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, 6 Weizman Street, Tel Aviv 64239, Israel. Email: [email protected]
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
283
H. Amir et al.
health in a 10-year public health plan.2 A recent report from the Committee on Lesbian Health Research Priorities of the Institute of Medicine (2011) recommended the development of a research agenda that included the determination of access to and use of health-care services among lesbian, gay, bisexual and transgender people (LGBT).3 Community-based health studies demonstrated that lesbians have unique health service requirements.4,5 For example, lesbians are more likely to have behavioral risk factors for breast and gynecological cancers, to be smokers, to have patterns of heavy alcohol use6–9 and to have higher levels of body fat.10,11 Despite higher-risk health behaviors, lesbians are less likely to receive preventive health care, such as clinical breast examinations, Pap smears and mammography.1,5,7,12–17 Various investigations have demonstrated that US and Canadian lesbians under-utilize health-care services, visit physicians less often than heterosexual women, and seek medical assistance only after they have relatively more severe symptoms.18–23 Sexual-minority women (including lesbians) that are breast cancer survivors respond more negatively to certain cancer treatments compared to heterosexual women.24,25 The acceptance of sexual and gender minority (SGM) groups over the last decade has increased considerably but structural and personal factors continue to affect their ability to obtain high-quality medical care. Many lesbians are not able to acquire employer-sponsored insurance coverage through their partner because most states do not recognized same-sex unions.26 Another factor is the relatively few providers who are knowledgeable about the specific health risks of the sexualminority female population, with current medical training including little information on this topic.27–29 The lack of respect on the part of office staff and healthcare providers is also an issue.30 Studies on health-care professionals revealed a preponderance of negative attitudes towards homosexuality and poor understanding and acceptance of same-sex relationships.31–33 These attitudes were shown to affect the treatment that they provide to them. Other studies suggest SGM individuals perceived the health-care setting as being threatening due to an unpleasant experience,30 resenting the providers’ assumption that the patient is heterosexual,34 thinking that disclosure of their sexual orientation to their physician would adversely affect the quality of their health care,20,21 and the stigma of being part of a sexual minority.35 Health issues in general, and more specifically those in obstetrics and gynecology, are intrusive and intimate
284
in most societies. Many studies have demonstrated that women responders to surveys from specific populations exhibit gender preference for female providers36,37 and for female obstetricians/gynecologists.38–43 Lesbians generally experience profound mental barriers to seeking health care and are even more reluctant to go to the obstetrician/gynecologist’s clinic.15 Israeli lesbians’ rights are considered the most enlightened in the Middle East. Homosexual acts between consenting adults in private is not illegal. Nevertheless, Israeli lesbians do not enjoy equal rights, and their rights are determined by means of specific courtroom decisions and in specific cities.44 In 2005, one groundbreaking decision ruled that a lesbian spouse could officially adopt a child born to her current partner who had conceived by artificial insemination from an anonymous sperm donor.44 As of 2006, Israeli law recognizes same-sex marriages performed elsewhere.44 Recent publications, however, have demonstrated the need for Israeli lesbians to acquire highquality medical care and the avoidance of routine health care by Israeli lesbians for the same structural and personal reasons as lesbians in the USA and other Western countries.45,46 The inverse association between a lesbian’s high level of risk factors and the low level of receiving medical care is an important issue. It calls for understanding and improving specific factors among medical providers that would enable and encourage lesbians to feel more comfortable and obtain the medical care that they require. The aim of the current study was to explore lesbians’ preferences, including gender, when choosing their obstetricians/ gynecologists and to investigate which factors need to be changed in the health system to promote greater accessibility and use of appropriate medical care by this population.
Methods This study was performed at the Gan-Meir Community Health Center, Tel Aviv, Israel and at the Ezra Community Health Center, Bnei-Brak, Israel, during a 6-month period in 2010. It was approved by the Tel Aviv Sourasky Medical Center’s Institutional Review Board. An anonymous questionnaire written in Hebrew was used to assess lesbians’ preferences in selecting their obstetrician/gynecologist. In light of the anticipated difficulty in recruiting lesbian women, we chose to perform the study in the Gan-Meir Community Health Center, which provides
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
Lesbians’ preferences in Ob/Gyn
services mainly to SGM patients. The Ezra Community Health Center was used to recruit the rest of the women. Gan-Meir Health Center provides only family ambulatory care, and the staff consists of certified family physicians. The Ezra Community Health Center provides every type of ambulatory gynecological/ obstetrical care, and the staff consists of board certified obstetricians and gynecologists. The questionnaires were distributed by a female family physician in the Gan-Meir Community Health Center and by a female obstetrician/gynecologist in the Ezra Community Health Center. These physicians provided detailed explanations about the study and the questionnaire. It is important to note that, unlike the USA and other Western countries, where the family physician performs routine pelvic exams and Pap smears, in Israel only obstetricians/gynecologists perform these procedures. Therefore, in Israel, women go directly to an obstetrician/gynecologist for routine gynecological examinations or for any other gynecological issues. Residents who belong to the ‘Clalit’ health-care organization (HMO) are entitled to the services of both centers. Only oral consent to participate was obtained in order to preserve anonymity. The women who agreed to participate filled out a self-administered, anonymous questionnaire in a secluded room and left the form in a designated box. The criterion used for participation in the study was that the subjects were at least 18 years old. After collecting 80 questionnaires in each clinic, the question related to sexual orientation was examined and seven questionnaires from bisexual responders were excluded. After collecting 100 questionnaires in each location, recruitment was stopped. We developed a questionnaire that incorporated items from previously validated instruments that assessed the correlation between the patient’s sexual identity and a specific gender preference for their obstetricians and gynecologists.38,39,42,47,48 We conducted a pilot study among 20 lesbians and 20 heterosexual women and revised the questionnaire before it was distributed to all the study participants. The final questionnaire was comprised of 40 items. The first part of the questionnaire concerned basic sociodemographic information, such as age, country of origin, extent of religiosity, marital status, education and employment status. This part included a question on self-identified sexual orientation to be answered by circling the word heterosexual, bisexual or lesbian. Those who identified as bisexual were excluded from final analysis due to small numbers (seven women). The second part
included questions about gender preferences for obstetricians/gynecologists when they required a gynecological examination, pregnancy follow-up, cesarean section, gynecologic surgery, or any consultation on an obstetric or gynecologic problem. The women were also asked about gender bias associated with specific obstetric/gynecologic procedures, such as embarrassment during a gynecological examination, and for specific characteristics of the obstetrician/ gynecologist, such as being sympathetic, patient, etc. The items in the second part were answered by circling the word male, female or none. Each participant was also asked to circle three out of a list of 16 characteristics that she considered to be the most important in choosing her obstetrician/gynecologist. All questions were answered in all questionnaires. Descriptive statistics were computed as median, mean and standard deviation (SD) for continuous variables and as frequencies for categorical variables. Significance was tested using the t-test, χ2 and Fisher’s exact test as needed. All statistical analyses were performed using sas for Windows 9.1.3.
Results Two hundred volunteers participated in the study. A total of 216 women were eligible overall: nine women declined to participate in the study (four from GanMeir and five from Ezra); and seven bisexual women were excluded. The participation rate was 96%. The sociodemographic characteristics of the responders are summarized in Table 1. The preferences between the two groups for a female or male obstetrician/gynecologist and for a female or male family physician are detailed in Table 2. The difference between a lesbian’s preferences for female obstetricians/gynecologists and for family physicians compared to heterosexual women was significant (P < 0.001). Even though 57% of lesbian responders had no gender preference for their family physician, 56% of them preferred a female obstetrician/ gynecologist. Interestingly, preferences for a female obstetrician/gynecologist matter to many more women, regardless of their sexual orientation, compared to a family physician. Lesbian respondents preferred female obstetricians/ gynecologists for intimate and non-intimate procedures compared to heterosexual women (P < 0.001, Table 3). Interestingly, within the lesbian population, a higher percent of lesbian responders showed a preference for a female obstetrician/gynecologist when it
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
285
H. Amir et al.
Table 1 Demographic characteristics of the 200 women who participated in the study Characteristic
Lesbian women (n = 100) n (%)
Heterosexual women (n = 100) n (%)
Age, mean (SD) (range) Origin Israel Other Religious status Secular Religious Marital status Single Married† Divorced Widowed Children Yes No No. of children, mean (SD) Education Primary school (9th grade) High school (12th grade) Community college/graduate with associate degree 4-year college degree or higher Employment Yes No
34 (8.31) (18–66)
36 (9.66) (22–65)
97 3
85 15
91 9
95 5
31 62 7 0
15 80 4 1
32 68 0.6 (1.03)
56 44 1.1 (1.17)
1 19 7
1 19 6
73
74
90 10
92 8
†Israeli law does not recognize same-sex marriages; therefore, lesbian women who are in a relationship with a partner were considered married.
Table 2 Gender preferences of family physician and obstetrician/gynecologist of 200 Israeli responders Physician
Family (%) Prefer male physician Prefer female physician No preference Obstetrician/gynecologist (%) Prefer male physician Prefer female physician No preference
Lesbian women (n = 100)
Heterosexual women (n = 100)
5 38 57
8 11 81
3 56 41
16 21 63
doi:10.1111/jog.12512
J. Obstet. Gynaecol. Res. Vol. 41, No. 2: 283–293, February 2015
Obstetricians and gynecologists: Which characteristics do Israeli lesbians prefer? Hadar Amir1, Ruth Gophen2, Yifat Amir Levy3, Joseph Hasson1, David Gordon1, Ami Amit1 and Foad Azem1 1 Sara Racine IVF Unit, Department of Obstetrics and Gynecology, Lis Maternity Hospital, and 3Neuroimmunology Laboratory, Department of Neurology, Tel Aviv Sourasky Medical Center, Sackler Faculty of Medicine, Tel-Aviv University and 2Gan-Meir Community Health Center, Tel Aviv, Israel
Abstract Aim: The aim of this study was to explore lesbians’ preferences when choosing obstetricians/gynecologists. Material and Methods: This cross-sectional study included 100 lesbian and 100 heterosexual women. A 40-item questionnaire assessed the correlation between a patient’s sexual identity and her specific preferences for obstetricians/gynecologists. Results: The top five most important parameters for both groups in choosing obstetricians/gynecologists overlapped greatly. Four of those were experience, ability, knowledge and personality. Only one parameter differed: lesbians ranked ‘sexually tolerant’ as the third most important characteristic while heterosexuals ranked ‘availability’ as the fifth most important characteristic. Lesbians rated ‘sexual tolerance’ significantly higher than heterosexuals (P < 0.001). More lesbians (56%) preferred female obstetricians/gynecologists compared to heterosexuals (21%) (P < 0.001). When compared to heterosexuals, more lesbians preferred female obstetricians/gynecologists for intimate and non-intimate procedures (P < 0.001). But within the lesbian population, a higher percentage of subjects showed a preference for female obstetricians/gynecologists only for intimate procedures. Lesbians used the following to describe their preference for female obstetricians/ gynecologists: feeling more comfortable; gentle; sympathetic; patient; more understanding of women’s health; better physicians in general; and more sexually tolerant (P < 0.001 vs heterosexual). However, when we looked only at the lesbian population, the majority did not exhibit a preference for a female obstetrician/gynecologist for any of these reasons. The main reason given by the 56% of the lesbians who said they prefer female obstetricians/gynecologists was feeling more comfortable. Conclusion: Overwhelmingly lesbians prefer sexually tolerant obstetricians/gynecologists regardless of their gender; however, only a small number of lesbian subjects in this study considered their obstetricians/ gynecologists as displaying this characteristic. Key words: characteristics, gender, lesbians, obstetricians/gynecologists, tolerance.
Introduction Sexual orientation is an important determinant in health issues. In the 1990s, the difficulties and needs of lesbians regarding their health started to attract atten-
tion in the USA and more research has been conducted on their sexual behavior and health since then.1 In 2000, ‘Healthy People 2010’, an initiative started by the US Department of Health and Human Services, recognized sexual orientation as a social determinant of
Received: January 23 2014. Accepted: May 29 2014. Reprint request to: Dr Hadar Amir, Sara Racine IVF Unit, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, 6 Weizman Street, Tel Aviv 64239, Israel. Email: [email protected]
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
283
H. Amir et al.
health in a 10-year public health plan.2 A recent report from the Committee on Lesbian Health Research Priorities of the Institute of Medicine (2011) recommended the development of a research agenda that included the determination of access to and use of health-care services among lesbian, gay, bisexual and transgender people (LGBT).3 Community-based health studies demonstrated that lesbians have unique health service requirements.4,5 For example, lesbians are more likely to have behavioral risk factors for breast and gynecological cancers, to be smokers, to have patterns of heavy alcohol use6–9 and to have higher levels of body fat.10,11 Despite higher-risk health behaviors, lesbians are less likely to receive preventive health care, such as clinical breast examinations, Pap smears and mammography.1,5,7,12–17 Various investigations have demonstrated that US and Canadian lesbians under-utilize health-care services, visit physicians less often than heterosexual women, and seek medical assistance only after they have relatively more severe symptoms.18–23 Sexual-minority women (including lesbians) that are breast cancer survivors respond more negatively to certain cancer treatments compared to heterosexual women.24,25 The acceptance of sexual and gender minority (SGM) groups over the last decade has increased considerably but structural and personal factors continue to affect their ability to obtain high-quality medical care. Many lesbians are not able to acquire employer-sponsored insurance coverage through their partner because most states do not recognized same-sex unions.26 Another factor is the relatively few providers who are knowledgeable about the specific health risks of the sexualminority female population, with current medical training including little information on this topic.27–29 The lack of respect on the part of office staff and healthcare providers is also an issue.30 Studies on health-care professionals revealed a preponderance of negative attitudes towards homosexuality and poor understanding and acceptance of same-sex relationships.31–33 These attitudes were shown to affect the treatment that they provide to them. Other studies suggest SGM individuals perceived the health-care setting as being threatening due to an unpleasant experience,30 resenting the providers’ assumption that the patient is heterosexual,34 thinking that disclosure of their sexual orientation to their physician would adversely affect the quality of their health care,20,21 and the stigma of being part of a sexual minority.35 Health issues in general, and more specifically those in obstetrics and gynecology, are intrusive and intimate
284
in most societies. Many studies have demonstrated that women responders to surveys from specific populations exhibit gender preference for female providers36,37 and for female obstetricians/gynecologists.38–43 Lesbians generally experience profound mental barriers to seeking health care and are even more reluctant to go to the obstetrician/gynecologist’s clinic.15 Israeli lesbians’ rights are considered the most enlightened in the Middle East. Homosexual acts between consenting adults in private is not illegal. Nevertheless, Israeli lesbians do not enjoy equal rights, and their rights are determined by means of specific courtroom decisions and in specific cities.44 In 2005, one groundbreaking decision ruled that a lesbian spouse could officially adopt a child born to her current partner who had conceived by artificial insemination from an anonymous sperm donor.44 As of 2006, Israeli law recognizes same-sex marriages performed elsewhere.44 Recent publications, however, have demonstrated the need for Israeli lesbians to acquire highquality medical care and the avoidance of routine health care by Israeli lesbians for the same structural and personal reasons as lesbians in the USA and other Western countries.45,46 The inverse association between a lesbian’s high level of risk factors and the low level of receiving medical care is an important issue. It calls for understanding and improving specific factors among medical providers that would enable and encourage lesbians to feel more comfortable and obtain the medical care that they require. The aim of the current study was to explore lesbians’ preferences, including gender, when choosing their obstetricians/ gynecologists and to investigate which factors need to be changed in the health system to promote greater accessibility and use of appropriate medical care by this population.
Methods This study was performed at the Gan-Meir Community Health Center, Tel Aviv, Israel and at the Ezra Community Health Center, Bnei-Brak, Israel, during a 6-month period in 2010. It was approved by the Tel Aviv Sourasky Medical Center’s Institutional Review Board. An anonymous questionnaire written in Hebrew was used to assess lesbians’ preferences in selecting their obstetrician/gynecologist. In light of the anticipated difficulty in recruiting lesbian women, we chose to perform the study in the Gan-Meir Community Health Center, which provides
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
Lesbians’ preferences in Ob/Gyn
services mainly to SGM patients. The Ezra Community Health Center was used to recruit the rest of the women. Gan-Meir Health Center provides only family ambulatory care, and the staff consists of certified family physicians. The Ezra Community Health Center provides every type of ambulatory gynecological/ obstetrical care, and the staff consists of board certified obstetricians and gynecologists. The questionnaires were distributed by a female family physician in the Gan-Meir Community Health Center and by a female obstetrician/gynecologist in the Ezra Community Health Center. These physicians provided detailed explanations about the study and the questionnaire. It is important to note that, unlike the USA and other Western countries, where the family physician performs routine pelvic exams and Pap smears, in Israel only obstetricians/gynecologists perform these procedures. Therefore, in Israel, women go directly to an obstetrician/gynecologist for routine gynecological examinations or for any other gynecological issues. Residents who belong to the ‘Clalit’ health-care organization (HMO) are entitled to the services of both centers. Only oral consent to participate was obtained in order to preserve anonymity. The women who agreed to participate filled out a self-administered, anonymous questionnaire in a secluded room and left the form in a designated box. The criterion used for participation in the study was that the subjects were at least 18 years old. After collecting 80 questionnaires in each clinic, the question related to sexual orientation was examined and seven questionnaires from bisexual responders were excluded. After collecting 100 questionnaires in each location, recruitment was stopped. We developed a questionnaire that incorporated items from previously validated instruments that assessed the correlation between the patient’s sexual identity and a specific gender preference for their obstetricians and gynecologists.38,39,42,47,48 We conducted a pilot study among 20 lesbians and 20 heterosexual women and revised the questionnaire before it was distributed to all the study participants. The final questionnaire was comprised of 40 items. The first part of the questionnaire concerned basic sociodemographic information, such as age, country of origin, extent of religiosity, marital status, education and employment status. This part included a question on self-identified sexual orientation to be answered by circling the word heterosexual, bisexual or lesbian. Those who identified as bisexual were excluded from final analysis due to small numbers (seven women). The second part
included questions about gender preferences for obstetricians/gynecologists when they required a gynecological examination, pregnancy follow-up, cesarean section, gynecologic surgery, or any consultation on an obstetric or gynecologic problem. The women were also asked about gender bias associated with specific obstetric/gynecologic procedures, such as embarrassment during a gynecological examination, and for specific characteristics of the obstetrician/ gynecologist, such as being sympathetic, patient, etc. The items in the second part were answered by circling the word male, female or none. Each participant was also asked to circle three out of a list of 16 characteristics that she considered to be the most important in choosing her obstetrician/gynecologist. All questions were answered in all questionnaires. Descriptive statistics were computed as median, mean and standard deviation (SD) for continuous variables and as frequencies for categorical variables. Significance was tested using the t-test, χ2 and Fisher’s exact test as needed. All statistical analyses were performed using sas for Windows 9.1.3.
Results Two hundred volunteers participated in the study. A total of 216 women were eligible overall: nine women declined to participate in the study (four from GanMeir and five from Ezra); and seven bisexual women were excluded. The participation rate was 96%. The sociodemographic characteristics of the responders are summarized in Table 1. The preferences between the two groups for a female or male obstetrician/gynecologist and for a female or male family physician are detailed in Table 2. The difference between a lesbian’s preferences for female obstetricians/gynecologists and for family physicians compared to heterosexual women was significant (P < 0.001). Even though 57% of lesbian responders had no gender preference for their family physician, 56% of them preferred a female obstetrician/ gynecologist. Interestingly, preferences for a female obstetrician/gynecologist matter to many more women, regardless of their sexual orientation, compared to a family physician. Lesbian respondents preferred female obstetricians/ gynecologists for intimate and non-intimate procedures compared to heterosexual women (P < 0.001, Table 3). Interestingly, within the lesbian population, a higher percent of lesbian responders showed a preference for a female obstetrician/gynecologist when it
© 2014 The Authors Journal of Obstetrics and Gynaecology Research © 2014 Japan Society of Obstetrics and Gynecology
285
H. Amir et al.
Table 1 Demographic characteristics of the 200 women who participated in the study Characteristic
Lesbian women (n = 100) n (%)
Heterosexual women (n = 100) n (%)
Age, mean (SD) (range) Origin Israel Other Religious status Secular Religious Marital status Single Married† Divorced Widowed Children Yes No No. of children, mean (SD) Education Primary school (9th grade) High school (12th grade) Community college/graduate with associate degree 4-year college degree or higher Employment Yes No
34 (8.31) (18–66)
36 (9.66) (22–65)
97 3
85 15
91 9
95 5
31 62 7 0
15 80 4 1
32 68 0.6 (1.03)
56 44 1.1 (1.17)
1 19 7
1 19 6
73
74
90 10
92 8
†Israeli law does not recognize same-sex marriages; therefore, lesbian women who are in a relationship with a partner were considered married.
Table 2 Gender preferences of family physician and obstetrician/gynecologist of 200 Israeli responders Physician
Family (%) Prefer male physician Prefer female physician No preference Obstetrician/gynecologist (%) Prefer male physician Prefer female physician No preference
Lesbian women (n = 100)
Heterosexual women (n = 100)
5 38 57
8 11 81
3 56 41
16 21 63
