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Sunday, July 11, 2010

Gender Preferences in Healthcare Part 2

Part 1 is full. Please continue posting here. I'll repost the last comment for continuity.
A summary article can be found on my companion blog.  This summary article has also been picked for publication on KevinMD, a widely read medical blog.

35 comments:

Joel Sherman said...

This was posted at the end of Part 1 by MER:

Anonymous has left a new comment on your post "Gender Preferences in Healthcare":

I post this link below as an example of the kind of stereotyping men put up with these days within the health care culture, and even from other men. Read the article, but especially read the responses. The male modesty issue is just one part of an entire attitude that responds to men's needs based totally upon cultural stereotypes. Here's the link:
MER

http://www.kevinmd.com/blog/2010/07/kidney-stone-pain-experienced-man-woman.html/comment-page-1#comment-137803

Joel Sherman said...

I have trouble knowing what to make of that article MER. It was written tongue in cheek. Don't know if he would have reacted to a woman patient the same. But he is correct that patients who over react to pain and demand narcotics are a big problem in the ER. Most of them are addicts and many are women.
Yet I agree that the article was sexist in that he made it into a gender issue, which it clearly was not. Many of the responses were very good.

Anonymous said...

That was my point, Joe. Pain isn't a gender issue. As far as tongue and cheek writing -- note how this kind of sarcastic writing is okay when you're writing about men. Note Dr. Orange. But try it with women and see what happens.

Men are sometimes quick to take on other men with a female audience. They think it makes them look "progressive" in the women's eyes. Granted, I've heard, too, that men, esp. those who rarely get sick, can be bears when they do get sick, crying out in pain. But I think this whole issue a personality issue. But the way this doctor was so quick to break out men as being wimps fit our issue. Can't you see the same doctor calling men wimps who won't put up with opposite gender care?
MER

Anonymous said...

PART 1 OF 3

Dr. Bernstein recently informed me a very relevant court case that has an interesting side note relevant to patient modesty and same gender care. The case is Brenda Chaney vs. Plainfield Healthcare Center. Essentially, the case boils down to a hostile work environment based upon race. Chaney is an African-American certified nurse assistant. It also involves what Chaney claims is her being fired due to her race.
Plainfield Healthcare Center claimed that they were allowed, under state and federal law, to allow patients to choose the race of their caregiver, just as they are allowed under the BFOQ rulings to allow patients to choose the gender of their caregiver. This case involved a patient who refused to be cared for by a Black certified nurse assistant, Chaney. The nursing home allowed this, refused to let Chaney access to this patient because of her race. This caused, according to Chaney, other workers to call her names and otherwise create a hostile work environment.
Plainfield tried to mitigate the work situation, but claimed patient choice of race was okay under state and federal law. And, what is of interest to us, Plainfield used the comparison of opposite/same gender care to defend their case. Plainfield connected race and gender, saying they were basically the same under the law, and that they were allowed to discriminate under the BFOQ laws. Here’s what the court wrote about these cases:
Plainfield contended that the following cases supported their position:
Jennings v. N.Y. State Office of Mental Health, 786 F.Supp. 376, 383 (S.D.N.Y. 1992); Local 567 Am. Fed’n of State, County, and Mun. Employees v. Michigan, 635 F.Supp. 1010, 1013 (E.D. Mich. 1986); Backus v. Baptist Med. Ctr., 510 F. Supp. 1191, 1193 (E.D. Ark. 1981); Fesel v. Masonic Home of Del., Inc., 447 F.Supp. 1346 (D. Del. 1978) (aff’d by
591 F.2d 1134 (3d Cir. 1979)).
MER

Anonymous said...

PART 2 OF 3

Here’s what the court wrote about these cases:
“Taken together, they hold that gender may be a legitimate criterion—a bona fide occupational qualification (“BFOQ”)—for accommodating patients’ privacy interests. It does not follow, however, that patients’ privacy interests excuse disparate treatment based on race. Title VII forbids employers from using race as a BFOQ, Rucker v. Higher Educ. Aids Bd., 669 F.2d 1179, (7th Cir. 1982), and Plainfield’s cases allowing gender preferences in the health-care setting illustrate why. The privacy interest that is offended when one undresses in front of a doctor or nurse of the opposite sex does not apply to race. Just as the law tolerates same-sex restrooms or same-sex dressing rooms, but not white-only rooms, to accommodate privacy needs, Title VII allows an employer to respect a preference for same-sex heath providers, but not same-race providers.

Note what the court said about privacy and “undressing” in front of a doctor or nurse. I would strongly suggest that if the court feels this strongly about the mere act of “undressing” in front of the opposite gender, they would certainly feel even more strongly about having intimate exams or procedures done by the opposite gender if it's not the patient's preference, esp. in non life-threatening or emergency situations.
MER

Anonymous said...

PART 3 OF 3

What’s the message for us?
First, the courts have shown their support for the patient’s right to choose same gender for intimate care. That’s clear. Second, that if men push this issue, and take it to court, hospitals and clinics will most likely be forced to hire male staff under the BFOQ laws. Right now most of the cases involve female patients. As I see it, under gender equity law, the courts can’t allow women to have choice of gender for intimate care without granting the same rights to men. Third, we should be moving in two directions as far as advocacy goes.
First, educating men that they do have these rights and that they shouldn’t be afraid, ashamed or intimidated into not claiming them if that’s their choice. Second, educating hospitals and clinics about these laws. My experience has indicated to me that there’s still a significant amount of confusing within hospitals and clinics as to the difference between race and gender regarding this issue. Show them cases like this and explain to them the implications.
But the key is getting men to stand up and confront this issue. Until that happens, not much else will happen to improve the situation.
You can find the court’s opinion and an audio file of the case here:
Official Circuit Court Opinion:  http://www.ca7.uscourts.gov/fdocs/docs.fwx?submit=rss_sho&shofile=09-3661_002.pdf
Oral Arguments (audio):  http://www.ca7.uscourts.gov/fdocs/docs.fwx?submit=rss_sho&shofile=09-3661_001.mp3
MER

Joel Sherman said...

I'm familiar with the case MER. It's well established that race is never a bona fide reason for exclusion in the workplace, though it can be used as affirmative action hiring quotas, which can cause a similar effect. The courts vary with how far gender can be taken, but they usually grant a BFOQ when exposure is needed. But the courts are not consistent on the latter. Just saw a case out of Nevada where an appeals court overturned a decision saying that all top correctional officers jobs in a women's prison could be reserved for women. But another court I believe in the Northwest upheld a similar regulation that 70% of CO's in a women's prison could be women.
To extend that legal atmosphere, you can not assume that the courts would allow gender preferences to men in healthcare because they grant it to women. Once again, decisions would likely be mixed. But you can be sure that institutions would much rather avoid these issues completely by making a show of equality.

Anonymous said...

Joel:

I see your point. But notice that the case we're referring to involves a state saying that their state law coincides with federal law regarding Title V11. This was a federal court that overruled that contention.
Are the cases you mentioned state courts or federal courts? If they're state courts, I can see it. The question is, what would happen upon appeal within a federal court.
Also, patients in hospitals cannot be considered as anywhere near the category of prisoner. And, there is a lack of female guards with in the prison system, compared with male guards -- so the courts are looking at some kinds of affirmative action strategies.
Hospitals are different. There's no lack of female nurses or cna's or med techs or other staff. They dominate. I think the differences are extreme.
But you are right in that this battle will have to be fought. Men can't just sit back and expect society to work this out on its own. That won't happen.
One situation that has always fascinated me is -- Why don't females have to register with the Selective Service when they turn 18? The answer is simple. First, we don't have a draft, so there is no crisis. Second, it's never been challenged all the way up to the Supreme Court. If it were tested, I don't see how women could get by without registering. As long as we have an all volunteer force, the issue probably won't be pushed. But you wait to see what will happen if the draft happens again. The question isn't whether women can do well in and belong in the military. Of course they can do well and belong. The question is whether it should be a choice for them and not for men. Under the gender equity laws, I don't see how they can have a choice and men can't.
The world is changing.
MER

Anonymous said...

Although the availability of gender selection in medicine isn't always available, especially for men when it comes to staff assisting doctors -- I think we need to realize that the basic philosophy that backs it up is embedded within the system.
This comment from KevinMD.com:
"A definition of patient centered care advanced by the Institute for Health Care Improvement (IHI) includes consideration of “patients’ cultural traditions, their personal preferences and values, their family situations, and their lifestyles. It makes the patient and their loved ones an integral part of the care team who collaborate with health care professionals in making clinical decisions… [and] ensures that transitions between providers, departments, and health care settings are respectful, coordinated, and efficient. When care is patient centered, unneeded and unwanted services can be reduced.”

That reads pretty clear to me. I don't see how that statement does not intrinsically include the whole modesty issue and patient preference of gender for intimate care.

So, patients need to go into hospital situations, not only speaking openly about their preferences and values, but also arming themselves with copies of definitions like the one I quoted above. Make your values know, then demonstrate that the ethics codes, core values of the hospitals already support your point of view. Demand that they make it happen, that they make the rubber meet the road.
You'll find the quote above at this URL:

http://www.kevinmd.com/blog/2010/08/abim-patient-centered-care-crucial-health-reform.html

MER

Hexanchus said...

MER,

I agree with your most recent post. The problem is that the principle of "patient centered care" is a relatively new concept that is still in it's infancy and not widely practiced yet. As time goes on hopefully more hospitals will adopt the concept.....

Joel Sherman said...

MER, still catching up on posts. Referring to your post of July 31, 2010 7:03 PM, the Nevada case was a federal appeals court. Here's one reference; you can find the original decision online as well. But federal decisions aren't consistent either. Different courts have decided differently within the system.
I disagree also that affirmative action is needed to increase the number of female correction officers. I think you'll find that many systems, New York city comes to mind, already have near 50% female CO's. If you include support staff like teachers and counselors, it's over 50% in many areas.

Anonymous said...

A comment from an allnurses.com
thread:
"I am an American Muslim and registered nurse. Men are very common in the nursing field in the middle east. In fact some years there are more men than women in nursing programs in Jordan. The reason for this has to do with the cultural preference for same sex nurses. It is not necessarily a religious preference and some cultures will be less tolerant of personal care given by the opposite sex."
The rest of the comment can be found at:
http://allnurses.com/general-nursing-discussion/treating-muslim-patient-429119-page4.html#post4466815
MER

Joel Sherman said...

Here's a twist. A Canadian hospital is offering coed patient rooms as a new benefit! They say it will speed patient placement so that patients can be transferred from the emergency room faster.
Hard to imagine an American hospital touting that as a benefit. Doubt that they could get away with it for even 3 months before the complaints pile up.

Anonymous said...

Correct me if I misread this, Joel, but this policy says nothing choice. It says that staff will be "allowed" to do this. Where does it say that patients will be asked whether they want this or not?
Doug/MER

Joel Sherman said...

That's my point Doug. The hospital will do this if they think they can move patients more efficiently. It doesn't say that a patient can veto the idea.
That's why I said I didn't think an American hospital could get away with it.

Anonymous said...

Why can't we be very honest. A man wouldn't want to share a hospital room with a woman and we say that makes sense? But 9 out of 10 times he is. The NURSE. Why is it wrong for one woman to be there but ok for the other? A woman is a woman.
Hospitals are soooo hypocritical!
Nurses are too. They don't see themselves as part of real world rules. Only the medical fantasy lies. When will they ever just be honest?

MarĂ­a said...

No, they're not honest they think they belong to a class of saints apart from the rest of this sinful world. Let's be fair: at least they mistreat their female patients as much as the males, contrary to popular belief, one of the traits they use to share is not compassion but superlative rudeness. That's why I don't intend to give them any business for the rest of my life.

Anonymous said...

Maria, I think the difference is much of the issue revoles around opposite gender, and with 90+% of nurses being female the issue is a little different for males. toss in societies general discounting of make modesty men do face additional issues in this area...not to day females don't face it, or it isn't as diffcult when it does, but there is a difference....alan

Anonymous said...

Great job, Joel, on getting your 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 both on our companion blog and at:
http://www.kevinmd.com/blog/2010/11/patient-gender-preferences-medical-care.html#more-48741
Doug/MER

Anonymous said...

Don't quite know where to post this Joel, but here it is:
I want to point out an interesting article about "empathy" written for health care professionals on KevinMD. It's very well done. Here'as a quote from it:

"Patients need understanding and guidance. They need to learn that it’s okay to ask questions and to take charge. They need to learn that they can be empowered, proactive and in charge of their health and well-being no matter who they are. While some patients are savvy, there are patients who feel intimidated to be assertive. They don’t know how to ask questions or to speak up, but they can learn. As professionals we can help them. We can guide them and encourage them to take to charge of their health care."

There are enlightened providers out there who recognize what I talked about in my last post. Note that this article is written by a nurse. They are much more in touch with this modesty issue that are doctors. Many recognize that the medical professionals need to take the lead in helping patients speak up and become empowered. Here's the link to this article:
http://www.kevinmd.com/blog/2010/11/deeply-connect-engage-patients-empathy.html
Doug/MER

Joel Sherman said...

This was posted to Part 1 which is full. I have moved it here.

Anonymous said...

Interesting thread on allnuses. An "doctor" writes this wife wants an all female team in the OR for a particularly embarrassing operation.
Most responders seem fine with this, saying to ask and that most facilities will accommodate. On page three of the thread a male gets on a brings up the opposite situation, a male asking for an all male team. Then a male nurse gets on and says he's never heard of such a thing but would have no problem making this accommodation for either men or women.
Throughout, there are interesting comments that suggest that this "doctor" could easily request this accommodation as a professional courtesy request, regardless. Near the end, a few posters suggest that this "doctor" is really a "troll."
So what happens. The thread is closed, apparently due to posters claiming the OP is a troll. The staff member does say that in most cases, esp. for elective surgery like this, cultural and modesty issues may be accommodated and patients should ask.
I still wonder why threads like this are closed. Does the system recognized that they will accommodate if possible but they don't want to advertise it? Do they realize that they can easily do it for women (except quite often for the surgeon), but are less able to do it for men? Is it that this thread turned from a women being accommodated to a man being accommodated?
Why was the thread closed? You can read it here:
http://allnurses.com/general-nursing-discussion/wife-wants-all-526491.html
Doug/MER
January 16, 2011 3:54 PM

Anonymous said...

Don't know exactly where to post this, but here it is:
Following is an important thread to read on allnurses that may help you understand some of the stuff you read there. Now, if you hate nurses, don't bother to read this. You can't be convinced. But if you're open minded, and realized that nurses are people just like everyone else,than read this. I don't condone some of the attitudes I find on the site, but there is a context for it.
http://allnurses.com/general-nursing-discussion/have-nurses-always-527358.html
Doug/MER

Anonymous said...

In the UK we have all female cosmetic surgery teams probably started with all the breast surgery and more genital surgery. If they can do that, why not all female gyn surgery or all male urology surgery? It's a no-brainer and would be a huge money-spinner. I would happily pay a premium with a guarantee of all female care if I was having "that" sort of surgery.
I'm amazed doctors haven't seen the gap in the market and jumped to fill it...
How difficult would it be?
http://www.trustplus.co.uk/all-female-surgical-teams
Jan

Joel Sherman MD said...

Two nice links recently posted on Bernstein.
The first concerns women's reactions to having a male mammography technician. In this survey 10-20% of women would refuse or not return. My wife expressed horror at thought of a male technician handling her breasts. But obviously the double standard is immense. Why not have the same reaction to female ultrasound technicians doing testicular ultrasound, a routine practice? Other references are given which I'll follow up on.
The second article is a general discussion of the gender of x-ray technicians giving statistics.

Doug Capra said...

Joel:
A few comments on that second article:

"I don't honestly think that patients, particularly very ill or injured ones, even notice whether a tech is male of female,"
Two comments:
1. It always fascinates me that in articles like these about "gender" -- I use quotes because these articles are generally not about both "gender" and their feelings about modesty -- but about female attitudes only -- the word "patient" is used with no gender attached to it. Thus, by using the word "patient," the implication is that we're talking about both male and female patients. But the articles are clearly only about women.
2. "I honestly don't think..." Attitudes toward men and their modesty are based almost totally on what medical professionals "think" they know about men. Studies, as you and I know, are relatively rare.
3. These kind of patients don't even notice the gender of the caregiver? Let's get real. The gender may or may not matter to them -- but that patients don't notice? This is the world view hammered into medical professionals. It's the "gender neutral," gender doesn't matter at all, philosophy. Gender plays no role at all attitude. Of course, it matters for women and intimate exams. They know that and have made accommodations. But even if it does matter for some men, accommodation isn't always available, or the "trick" is to "convince" or "ambush" the male into just going along with the program.

"...professionalism appears to be more important than gender in increasing comfort. "Human interaction skills are probably far more important to the patient than gender,"
In many of my past posts, I've agreed how important communication is. I still do. But I'm not sure at all I know what "professionalism" means in this context anymore. The word has begun to lose its mening. Also note the use of the word "appears." Why not try to quantify this statement with studies? Again, what "appears" to be true from the caregiver point of view, is considered "true."

"Parsons notes that the few men who need a mammogram may find themselves more comfortable with a male technologist, especially since there is a perception that everyone in the mammography office — patients and technologists — will be female."
Note how here we go into the rare, very rare case of a man needing a mammogram -- rather than considering the more frequent cases of males needing testicular ultrasounds, other types of intimate xrays, or the most intimate kind of prostate procedures.
I also find it interesting to see the frequent double standard -- the male tech mentions his changing his schedule so he would't have to deal with doing an intimate procedure on a teenage girl. Do we ever read about a female tech having the same consideration in dealing with a teenage girl? Rarely. I'm not saying it's never done. But it seems to be pretty much of a standard operating procedure for males. They'd better make the offer, it seems, rather than taking the chance of being considered insensitive, or worse, a pervert.
Interesting articles.
Doug/MER

Joel Sherman MD said...

I agree with your comments Doug. Particularly striking is the example of a man needing a mammogram. A man might be embarrassed, but not likely because he had to take his shirt off with a female tech. The embarrassment is more to do with having a uniquely female disease and sitting in a waiting room where you are likely the only male. About as embarrassing as a man waiting to see a gynecologist.
And it always surprises me that no accommodation is made for men who need a testicular ultrasound. Providing a male tech is never even considered. This despite the fact that if they get regular referrals from urologists, they do the test regularly. You can be sure that if the urologists insisted, they would find a male tech quickly. They are not rare.

Joel Sherman MD said...

Here's a link from KevinMD blog from a woman who picked her physicians solely on the basis of gender, using all female physicians. She now regrets it.
I think any physician would agree with this. We all realize that gender is a significant factor for many patients in terms of comfort but caring and competence out weigh it for most people.

Joel Sherman MD said...

Today's Annie's Mailbox (what used to be Ann Landers) had a question right on topic. A 22 year old woman complained that a male nurse was assigned to remove her urinary catheter. She refused him. The hospital is in a small town, where she kind of knew the nurse. Annie defended the nurse's behavior, but said the patient had a right to express her preference for a female nurse. So far the comments have all been antagonistic to the patient.
Columns like this do tend to reflect common thinking on current morals and ethics.

Doug Capra said...

"So far the comments have all been antagonistic to the patient."

I would bet that a significant number of these comments are from people who have never been in a similar position. When it comes to this issue, these people exist on the level of theory -- they have set ideas of gender neutrality as a theory yet have never had to apply it in situations in their personal lives.
This is what I mean when I say this issue is basically contextual. It's deceptive for people who have never experienced this to say how they "would" feel under similar situations. They need to actually enter into the experience to see how they feel. It's the difference between theory and practice.
A good number of people interpet patient gender
choice as pure discrimination, bias, prejudice. Nonsense. But that's what they see.
Doug/MER

Anonymous said...

I agree with Doug/MER and this is a very important issue:
"I would bet that a significant number of these comments are from people who have never been in a similar position."
After reading hundreds of comments on articles, (away from our standard trusted blogs) and personal e-mails as well, I have started to use the phrase "Frat Boy" comments. These are the kinds of comments where men (boys?) degrade and belittle each other’s masculinity for not wanting female intimate care. It is clear to me that these guys have not been in that situation, because comments from men I have interviewed change drastically after being in that somewhat 'humiliating' circumstance. "Frat Boy" comments will often include the desire to have females do intimate procedures as if it is a pleasurable experience. But remove the fantasies and replace a real scenario such as:
you are getting help with intimate things that you cannot do for yourself, you are bedridden and somewhat helpless, and/or an accident happened and you are being cleaned rather that 'attended to' and the responses usually change.
How many men comment that it was great having the female caregiver insert that catheter? Or change linens when they were too immobile to get out of bed? Or...well, you get the picture.
My point is that when reality sets in, when it is helplessness over 'favors', the comments usually change.
While most of us here see the 'Frat" comments for what they are, it still creates damage for the male modesty issues. There are men out there who believe that their masculinity will be in question (by fellow men) if they prefer not to have females do this type of work on them. It may cause them not to speak up, "suck it up", of face ridicule by their friends and family.
It sometimes seems that men are almost as harsh on their own gender regarding this issue as some female caregivers are judgmental about it.

Suzy/swf

Joel Sherman MD said...

I agree fully Suzy. Most of the comments from men who look forward to having female providers tickle their genitalia are from young guys who have never been seriously sick and who look forward to a physical exam for its titillating value to them. There are exceptions of course from guys who are homophobic. But most of these guys don't need any medical care and most women providers would rather not see them. Most people, both men and women, who need care are embarrassed with opposite gender providers in intimate situations, at least in the beginning, and have all they can do to get thru it with their dignity and self esteem intact.

Joel Sherman MD said...

Here's an article relating a study from the Healthcare for Women International which found that one of the factors that enabled women to obtain more cancer screening was same gender care.
This is hardly a surprise although medicine has barely recognized this as a factor. Apparently the trend was particularly pronounced for African American women which is a surprise to me personally.

Doug Capra said...

Excellent find, Joel. It shows that the medical community is aware of gender influences on medical care -- but what we seems to see is studies led by women about women. Maybe there are studies about men but we haven't found them yet. But I don't think so. I think it's assumed, as we see from the recent account by stressed student, that male patients are either homophobic and/or just prefer female caregivers.
Doug

Joel Sherman MD said...

This was posted on the chaperone part 2 thread. Will repost it here.

Anonymous said...

I had an ultrasound biopsy of my prostate a while back.

They toldme there was no option but to have it undertaken by a female specialist nurse, supported by another female nurse.

I refused absolutely.

Amazingly, it was possible to have it done by 2 males after all, they just "didnt think it was that important".

I am sure they thought i was very strange for standing my ground, i just felt so much more relaxed about the (VERY painful) procedure.

Just as well they relented really, my biopsy was positive, I have since had brachytherapy for the cancer, again by an all male team. Amazing what they can do if pushed.
November 4, 2011 1:05 PM

Doug Capra said...

"I refused absolutely.
Amazingly, it was possible to have it done by 2 males after all, they just "didnt think it was that important"."

This is the key to much of what we're discussing on these modesty blogs. In my opinion, a "No" answer to gender accommodation is mostly a strategy, not an answer. Stand firm and watch how quickly most caregivers will back down. It may take a few refusals. It may take the canceling of a procedure. It make take the patient walking out. But most of the time, they will accommodate, because they know absolutely that under their patient rights guidelines and under their core values, patients have this right. They know it. They may not schedule with this in mind, because they know most patients will suffer silently. But when patients refuse to suffer silently, most of the time they'll quickly revise the schedule.

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