Perception of sexual ramification among women toward male doctors in today’s Indian society

Perception of sexual ramification among women toward male doctors in today’s Indian society Abstract The objective of the study was to assess the perception of women patients toward attitude of health professionals who have undergone physical examination. A descriptive cross-sectional study was conducted among 1,257 women. A self-administered structured questionnaire comprising of 16 questions was designed to assess perception of patients toward attitude of health professionals. Mean perception scores of the study population were 19.79 ± 1.78. Women in the age group of 29–38 years had a greater perception (20.34 ± 1.54) that they had been a subject or could be a subject to sexual exploitation by a doctor. Graduate and above group participants had a greater perception (19.54 ± 1.86) when compared to primary and secondary education level (19.52 ± 1.85, 18.35 ± 1.5). Data were analyzed using ANOVA. Women had mixed perception of sexual gratification toward male doctors. It is necessary to educate the doctors regarding the respect, dignity, and values for female patients, which could reduce occupational defamation. Implications Practice: A patients’ psychological state of mind influences all of their medical decisions including gender preference which in turn could influence the treatment outcome. Policy: Knowledge and insight of patient’s preferences are essential for improving the quality of dental care. Research: It adds to that current relationship between doctor and patient appears to be shaped by gender, as per the patient’s comfort level. INTRODUCTION The most precious form of personal information that we possess is our body. It is our own flesh and blood, which holds and sustains our being. Our body is our instrument for living. It is so personal and intimate that we hide it, as its public display would be a source of shame [1]. Gender is today a major determinant of access to all forms of human endeavor including health care [2]. In an ideal situation, health care providers should treat male and female patients equally, even when they have different needs. On the other hand, patients should have equal preference for trained and competent male and female physicians. However, preference for gender in terms of health provider–patient relationship is by no means a new issue [2]. The ultimate objective of any doctor–patient communication is to improve the patient’s health. In the past, descriptive and experimental research has tried to shed light on the communication process during medical consultations. Each relationship between a doctor and patient is like a snow flake, a routine office visit can turn into discovery of a life-threatening illness, thus changing the relationship profusely. To be consistently effective in a relationship, a health professional must know how and when to lead and to follow. Patients’ gender preferences for medical care are a factor that we all know exists yet most physicians prefer to ignore it in daily practice hoping that modern medicine is gender neutral [3]. Effective doctor–patient communication is determined by the doctor’s bedside manner which patients judge as a major indicator of their doctor’s general competence [4]. Doctor–patient communication skills are based upon verbal and nonverbal communication. Affective behavior, however, cannot always be verbally perceived. Only 7% of the emotional communication is conveyed verbally; 22% is transferred by voice tone; but 55% is transferred by visual cues, like eye contact, body positioning, and so forth [5]. Nonverbal behavior has been operationalized in different ways. Tone of voice, gaze, posture, laughter, facial expressions, touch, and physical distance are thought to convey the emotional tone of interpersonal interaction [6, 7]. Sex preferences have numerous foundations—for example, culture, religion, past experiences with a man or woman that can affect a person’s comfort level when he or she must be naked in front of a doctor and can lead to judgments about a physician’s caring or competence [8]. For patients with certain cultural or religious beliefs, any examination requiring the shedding of clothing may be abhorrent and when dealing with such patients the health professionals need to approach the subject with particular sensitivity. Examinations by a member of the opposite sex are effectively considered to be a taboo in some religions. The relationship between a patient and their doctor is based on trust. Physical examinations can be embarrassing or distressing for patients with certain narrow beliefs and a health professional should be sensitive to what the patient may think of as intimate physical examination. A health professional may have no doubts about a patient they have known for a long time, and feel that it is, therefore, not necessary to offer a chaperone when an intimate examination of the patient is required. However, health professionals need to be aware that a patient’s behavior may change and therefore need to be prepared to offer a chaperone to these patients as well. A health professional should be aware that simply touching a patient without their consent is tantamount minor assault and, before proceeding to examine a patient for the purpose of any kind of treatment, they should seek to obtain some explicit indication by a word or gesture that the patient both understands that the doctor proposes for a genuine examination, and that they have consented for the examination. As of more of literature reporting, growing distrust between the patient and doctor relationship we undertook a study where we could examine a general opinion about the patient’s thoughts toward the health professionals physical examination. Hence, the objective of the study was to assess the perception of patients toward attitude of health professionals who have undergone physical examination. MATERIALS AND METHODS Study design and population A cross-sectional descriptive study was conducted among Udaipur women in the month of August 2014. All the subjects who had visited a health professional (minimum four visits) were included and assessed at public places (bus stops, railway stations, libraries, malls). Ethical approval, official permission, and informed consent The study protocol was reviewed by the Ethical Committee and was granted ethical clearance. After examining the purpose and details of the study, a verbal and written informed consent was also taken from the participants. Pretesting of questionnaire A self-administered structured questionnaire was developed and tested among a convenient sample of 50 participants, who were interviewed to gain feedback on the overall acceptability of the questionnaire in terms of length and language clarity. Based on their feedback, the questionnaire was standardized. Cronbach’s coefficient was found to be 0.80, which showed an internal reliability of the questionnaire. Mean content validity ratio (CVR) was calculated as 0.87 based on the opinions expressed by a panel of five academicians. Face validity was also assessed and it was observed that 92% of the participants found the questionnaire to be easy. Questionnaire A self-administered structured questionnaire comprising of 16 questions was designed to assess perception of patients toward attitude of health professionals. The participant’s responses were ranked according to how much they agreed with each statement that was based on the 3-point Likert scale with alternatives: yes, can’t say, and no. Information regarding their age, qualification, and socioeconomic status was also gathered. Methodology The study was conducted for a period of 3 months among a convenient sample of 1,257 females. Investigator visited the predetermined places for getting the questionnaires filled. The purpose of study was informed and explained to participants. All the participants were personally given the questionnaire. Female examiners were appointed to avoid any kind of nonresponse bias or information bias from the participants. Those willing to participate in the survey were requested to fill in the consent form and complete the questionnaire. The examiners were present in order to clarify any difficulties encountered during filling of questionnaire. All the participants were asked to rate each item of the questionnaire choosing the most appropriate option. The samples included in the pilot study were not taken into consideration in main study. Confidentiality and anonymity of the respondents were assured during the entire study. Data analysis Completed questionnaires were coded and spreadsheets were created for data entry. The data were analyzed using SPSS 17 (SPSS Inc., Chicago, IL) Windows software program. Each item of the questionnaire was coded from 1 to 3 (yes, can’t say, and no). Few of the questions were re-coded to ensure that a high score indicated a positive knowledge and attitude, and a low score indicated a negative knowledge and attitude. Mean knowledge and attitude scores and standard deviation were calculated. Descriptive statistics were used to summarize the demographic information and the survey data were analyzed using the one-way ANOVA with post hoc Bonferroni test. Confidence level and level of significance were fixed at 95% and 5%, respectively. RESULTS Table 1 shows the sociodemographic detail of 1,257 study subjects. Majority of the participants 459 (36.6%) were in the age group of 21–30 years followed by 377 (29.9%) participants of 18–28 years old. Most of the participants had secondary education 620 (49.3%) and 477 (33.4%) were graduates and above. Considering the socioeconomic status 776 (61.7%) belonged to middle class. Table 1 Sociodemographic Characteristics of Participants Variables Frequency (%) Age (in years)  18–28 377 (29.9)  29–38 459 (36.6)  >38 421 (33.5) Education  Up to primary 160 (12.8)  Secondary 620 (49.3)  Graduates and above 477 (37.9) Socioeconomic status  Lower 165 (13.1)  Middle 776 (61.7)  Upper 316 (25.2) Total 1,257 (100) Variables Frequency (%) Age (in years)  18–28 377 (29.9)  29–38 459 (36.6)  >38 421 (33.5) Education  Up to primary 160 (12.8)  Secondary 620 (49.3)  Graduates and above 477 (37.9) Socioeconomic status  Lower 165 (13.1)  Middle 776 (61.7)  Upper 316 (25.2) Total 1,257 (100) View Large Table 1 Sociodemographic Characteristics of Participants Variables Frequency (%) Age (in years)  18–28 377 (29.9)  29–38 459 (36.6)  >38 421 (33.5) Education  Up to primary 160 (12.8)  Secondary 620 (49.3)  Graduates and above 477 (37.9) Socioeconomic status  Lower 165 (13.1)  Middle 776 (61.7)  Upper 316 (25.2) Total 1,257 (100) Variables Frequency (%) Age (in years)  18–28 377 (29.9)  29–38 459 (36.6)  >38 421 (33.5) Education  Up to primary 160 (12.8)  Secondary 620 (49.3)  Graduates and above 477 (37.9) Socioeconomic status  Lower 165 (13.1)  Middle 776 (61.7)  Upper 316 (25.2) Total 1,257 (100) View Large The mean perception scores of the study population were evident as 19.79 ± 1.78. Women in the age group 29–38 years felt that they had a greater perception (20.34 ± 1.54) that they had been a subject or could be a subject to sexual exploitation by a doctor. There was statistically significant difference in the age groups (p = .03). When post hoc Bonferroni test was applied, mean perception score was found to be higher for age group 29–38 years compared to other group. Graduate and above group participants had a greater perception (19.54 ± 1.86) when compared to primary and secondary education level respondents (19.52 ± 1.85, 18.35 ± 1.5). A statistically significant difference was seen when level of education was compared with each other (p = .02) using post hoc test. There was no significant difference found when socioeconomic status of different groups was compared (Table 2). Table 2 Association of Mean Perception with Independent Variables Variables Perception Mean ± SD p Value Age (in years)  18–28 19.75 ± 1.78a 0.03*  29–38 20.34 ± 1.54b  >38 19.28 ± 1.62a Education  Up to primary 18.35 ± 1.53a 0.02*  Secondary 19.52 ± 1.85b  Graduates and above 19.54 ± 1.86b Socioeconomic status  Lower 20.05 ± 1.73 0.48  Middle 19.28 ± 1.96  Upper 20.01 ± 1.65 Total 19.33 ± 1.78 Variables Perception Mean ± SD p Value Age (in years)  18–28 19.75 ± 1.78a 0.03*  29–38 20.34 ± 1.54b  >38 19.28 ± 1.62a Education  Up to primary 18.35 ± 1.53a 0.02*  Secondary 19.52 ± 1.85b  Graduates and above 19.54 ± 1.86b Socioeconomic status  Lower 20.05 ± 1.73 0.48  Middle 19.28 ± 1.96  Upper 20.01 ± 1.65 Total 19.33 ± 1.78 Statistical tests applied: one-way ANOVA. Post hoc Bonferroni test: groups with different letters superscripted show statistically significant difference. *Indicates statistically significant difference at p ≤ .05. View Large Table 2 Association of Mean Perception with Independent Variables Variables Perception Mean ± SD p Value Age (in years)  18–28 19.75 ± 1.78a 0.03*  29–38 20.34 ± 1.54b  >38 19.28 ± 1.62a Education  Up to primary 18.35 ± 1.53a 0.02*  Secondary 19.52 ± 1.85b  Graduates and above 19.54 ± 1.86b Socioeconomic status  Lower 20.05 ± 1.73 0.48  Middle 19.28 ± 1.96  Upper 20.01 ± 1.65 Total 19.33 ± 1.78 Variables Perception Mean ± SD p Value Age (in years)  18–28 19.75 ± 1.78a 0.03*  29–38 20.34 ± 1.54b  >38 19.28 ± 1.62a Education  Up to primary 18.35 ± 1.53a 0.02*  Secondary 19.52 ± 1.85b  Graduates and above 19.54 ± 1.86b Socioeconomic status  Lower 20.05 ± 1.73 0.48  Middle 19.28 ± 1.96  Upper 20.01 ± 1.65 Total 19.33 ± 1.78 Statistical tests applied: one-way ANOVA. Post hoc Bonferroni test: groups with different letters superscripted show statistically significant difference. *Indicates statistically significant difference at p ≤ .05. View Large Table 3 depicted that 85% of the women preferred being treated by a doctor of her gender. Sixty-five percent were satisfied with the medical care they received and similar percentage of the study participants felt that the doctor showed unnecessary interest in them. Most of the participants (84%) felt that the doctor gave them respect. Only 20% of the participants felt that the doctor could easily take advantage of them. Forty percent of the participants felt that their doctor treats them in a friendly manner. Sixteen of the women wished for a relationship with their doctor. Almost half (54%) of the participants in this study had experienced eve-teasing, staring, or had been touched in an unacceptable way that made them feel uncomfortable. Only 19% of the women felt comfortable in the clinic in absence of their family members or a female medical attendant. Table 3 Frequency of Responses Regarding Perception Items Yes Can’t say No I would always prefer being treated by a doctor of my gender 1,069 (85) 125 (9.9) 63 (5.1) I am satisfied with the medical care I receive 818 (65.2) 314 (24.9) 125 (9.9) Doctors are good about explaining the reasons for physical/medical tests that they perform on me 628 (49.9) 0 (0) 629 (50.1) Have you felt a doctor showing unnecessary interest in you? 818 (65.2) 251 (19.9) 188 (14.9) Did you experience your doctor advising you more tests than required? 377 (29.9) 503 (40.2) 377 (29.9) Does your doctor give you respect? 1,068 (84.9) 64 (5.2) 125 (9.9) Doctors act too business like/impersonal towards me 566 (45) 189 (15) 502 (39.9) I feel my doctor takes advantage of me 252 (20.2) 314 (24.9) 691 (54.9) My doctors would never expose me to unnecessary risk 906 (72.2) 226 (17.9) 125 (9.9) My doctors treat me in a very friendly and courteous manner 503 (40) 314 (24.9) 440 (35) Did you experience exposure of your privacy by the doctor? 126 (10) 377 (29.9) 754 (59.9) Did you ever had interest or wish to have relationship with your doctor other than a patient? 213 (16.9) 37 (2.9) 1,007 (80.1) Have you ever experienced staring and touch in an unacceptable way which makes you feel uncomfortable? 691 (54.9) 314 (24.1) 252 (20) Have you ever experienced unnecessary delay in the treatment, taking advantage of you? 251 (19.9) 692 (55) 314 (24.9) Do you feel safe with your doctor in absence of your family members or a male/female medical attendant? 251 (19.9) 693 (55.1) 313 (24.9) If you experience any starring, unacceptable touch would you raise an alarm 1,068 (84.9) 127 (10.1) 62 (4.9) Items Yes Can’t say No I would always prefer being treated by a doctor of my gender 1,069 (85) 125 (9.9) 63 (5.1) I am satisfied with the medical care I receive 818 (65.2) 314 (24.9) 125 (9.9) Doctors are good about explaining the reasons for physical/medical tests that they perform on me 628 (49.9) 0 (0) 629 (50.1) Have you felt a doctor showing unnecessary interest in you? 818 (65.2) 251 (19.9) 188 (14.9) Did you experience your doctor advising you more tests than required? 377 (29.9) 503 (40.2) 377 (29.9) Does your doctor give you respect? 1,068 (84.9) 64 (5.2) 125 (9.9) Doctors act too business like/impersonal towards me 566 (45) 189 (15) 502 (39.9) I feel my doctor takes advantage of me 252 (20.2) 314 (24.9) 691 (54.9) My doctors would never expose me to unnecessary risk 906 (72.2) 226 (17.9) 125 (9.9) My doctors treat me in a very friendly and courteous manner 503 (40) 314 (24.9) 440 (35) Did you experience exposure of your privacy by the doctor? 126 (10) 377 (29.9) 754 (59.9) Did you ever had interest or wish to have relationship with your doctor other than a patient? 213 (16.9) 37 (2.9) 1,007 (80.1) Have you ever experienced staring and touch in an unacceptable way which makes you feel uncomfortable? 691 (54.9) 314 (24.1) 252 (20) Have you ever experienced unnecessary delay in the treatment, taking advantage of you? 251 (19.9) 692 (55) 314 (24.9) Do you feel safe with your doctor in absence of your family members or a male/female medical attendant? 251 (19.9) 693 (55.1) 313 (24.9) If you experience any starring, unacceptable touch would you raise an alarm 1,068 (84.9) 127 (10.1) 62 (4.9) View Large Table 3 Frequency of Responses Regarding Perception Items Yes Can’t say No I would always prefer being treated by a doctor of my gender 1,069 (85) 125 (9.9) 63 (5.1) I am satisfied with the medical care I receive 818 (65.2) 314 (24.9) 125 (9.9) Doctors are good about explaining the reasons for physical/medical tests that they perform on me 628 (49.9) 0 (0) 629 (50.1) Have you felt a doctor showing unnecessary interest in you? 818 (65.2) 251 (19.9) 188 (14.9) Did you experience your doctor advising you more tests than required? 377 (29.9) 503 (40.2) 377 (29.9) Does your doctor give you respect? 1,068 (84.9) 64 (5.2) 125 (9.9) Doctors act too business like/impersonal towards me 566 (45) 189 (15) 502 (39.9) I feel my doctor takes advantage of me 252 (20.2) 314 (24.9) 691 (54.9) My doctors would never expose me to unnecessary risk 906 (72.2) 226 (17.9) 125 (9.9) My doctors treat me in a very friendly and courteous manner 503 (40) 314 (24.9) 440 (35) Did you experience exposure of your privacy by the doctor? 126 (10) 377 (29.9) 754 (59.9) Did you ever had interest or wish to have relationship with your doctor other than a patient? 213 (16.9) 37 (2.9) 1,007 (80.1) Have you ever experienced staring and touch in an unacceptable way which makes you feel uncomfortable? 691 (54.9) 314 (24.1) 252 (20) Have you ever experienced unnecessary delay in the treatment, taking advantage of you? 251 (19.9) 692 (55) 314 (24.9) Do you feel safe with your doctor in absence of your family members or a male/female medical attendant? 251 (19.9) 693 (55.1) 313 (24.9) If you experience any starring, unacceptable touch would you raise an alarm 1,068 (84.9) 127 (10.1) 62 (4.9) Items Yes Can’t say No I would always prefer being treated by a doctor of my gender 1,069 (85) 125 (9.9) 63 (5.1) I am satisfied with the medical care I receive 818 (65.2) 314 (24.9) 125 (9.9) Doctors are good about explaining the reasons for physical/medical tests that they perform on me 628 (49.9) 0 (0) 629 (50.1) Have you felt a doctor showing unnecessary interest in you? 818 (65.2) 251 (19.9) 188 (14.9) Did you experience your doctor advising you more tests than required? 377 (29.9) 503 (40.2) 377 (29.9) Does your doctor give you respect? 1,068 (84.9) 64 (5.2) 125 (9.9) Doctors act too business like/impersonal towards me 566 (45) 189 (15) 502 (39.9) I feel my doctor takes advantage of me 252 (20.2) 314 (24.9) 691 (54.9) My doctors would never expose me to unnecessary risk 906 (72.2) 226 (17.9) 125 (9.9) My doctors treat me in a very friendly and courteous manner 503 (40) 314 (24.9) 440 (35) Did you experience exposure of your privacy by the doctor? 126 (10) 377 (29.9) 754 (59.9) Did you ever had interest or wish to have relationship with your doctor other than a patient? 213 (16.9) 37 (2.9) 1,007 (80.1) Have you ever experienced staring and touch in an unacceptable way which makes you feel uncomfortable? 691 (54.9) 314 (24.1) 252 (20) Have you ever experienced unnecessary delay in the treatment, taking advantage of you? 251 (19.9) 692 (55) 314 (24.9) Do you feel safe with your doctor in absence of your family members or a male/female medical attendant? 251 (19.9) 693 (55.1) 313 (24.9) If you experience any starring, unacceptable touch would you raise an alarm 1,068 (84.9) 127 (10.1) 62 (4.9) View Large DISCUSSION Relationship between doctors and patient is attracting an increasing amount of attention. Despite increased attention in this area, there are not many studies that have used a systematic approach in targeting perception of sexual gratification among women toward male doctors. Many factors contribute to lack of trust in doctors and dissatisfaction with their care. In our study, 85% of the participants preferred being treated by female doctors and this was in accordance with a study conducted by Zaghloul et al. [9]. In a similar survey conducted by Amer-Alshiek et al. [10], women patients were more comfortable and less embarrassed with female doctors than compared to male doctors. Only 9.9% of the participants felt unsatisfied with the medical care they received. According to Pascoe [11], satisfaction can be defined as the extent of an individual’s experience compared with his or her expectations. Evaluating to what extent patients are satisfied with health services is clinically relevant, as satisfied patients are more likely to comply with treatment [12], take an active role in their own care [13], and continue using medical care services. Roter et al. [14] found that doctors’ instrumental behaviors were significantly related to patient satisfaction. Smith et al. [15] also found that higher levels of information given by the doctor, time spent in discussion of preventive care by the doctor, and greater interview lengths were positively associated with patient satisfaction. In our study, 65% of the participants felt that doctor showed unnecessary interest in them. According to Scheflen [16], it could all depend upon eye contact; for instance, it could reflect attentiveness, seduction, or a challenge for dominance, depending upon the situation and the subjects. Nonverbal communications like these can support, modify, or even contradict verbal messages [17]. Doctors who have had a great deal of experience in interacting successfully with patients in settings and are not judged to be harsh are considered better in interaction and relationships with patients [18]. Similarly, in our study, 40% of the participants felt that the doctor did treat them in a very friendly and courteous manner. Onyemocho et al. [2] concluded that 79% of the women preferred female doctors because they had better communication skills. When the respondents were asked about their privacy exposure, 59.9% felt their privacy was not exposed. Sustained eye contact, for example, may be perceived by the patient as too intimate for the relationship, thus violating norms in the medical context leading to exploitation of privacy for the patient. Friedman [19] has identified reasons regarding patients’ sensitiveness and observance of nonverbal communications conveyed by their doctors. Illness usually involves emotions such as fear, anxiety, and emotional uncertainty; most patients are active in searching for information about different aspects of their disease. Nonverbal communication like touch “leaks” messages that are not meant to be transmitted [20]. Patients are very sensitive to these messages, and such inconsistencies between physicians’ verbal and nonverbal communication can portray lack of genuineness. Some doctors’ behaviors have been identified by patients as violations of physical privacy. Similar results were found in our study when the participants were asked whether they had experienced touch or staring in an unacceptable way—54.9% said yes. During medical examinations it is certain that patients have very limited physical privacy; intimate touch is unavoidable but could be necessary. This negative attitude of the patient toward the doctors can be reduced by avoiding watching a patient while getting ready for an examination, touching the patient unexpectedly, overhearing intimate conversation or activities, or by taking personal interests [21]. In our study, only 19.9% of the participants felt safe in the absence of their family member or a chaperone. Doctors are particularly vulnerable to false accusations and the results can be devastating. Due to the increasing incidence of allegations of assault by patients against doctors, Speelman et al. [22] strongly recommended the use of chaperones for young person’s wherever possible. The presence of a chaperone is helpful not only in reassuring the patient but also in minimizing the risk of the doctor’s actions being misinterpreted by the patient. Due to frequent accusations on doctors, medical students and postgraduates are increasingly given instructions on technique for listening, explaining, questioning, counseling, and motivating of the patients who could help them develop a better patient–physician communication skill. The degree of truthfulness and how thoughtfully the respondents have answered the questionnaire, and the level of subjectivity are not acknowledged in the current study which may be a limitation. Considering the fact that this study was done on a small scale with small sample size, we cannot generalize these results. Therefore, similar studies covering a larger population must be undertaken. This study opens new vistas for future research to understand perception of women toward male doctors in today’s society. CONCLUSION The present study concluded that the women had mixed perception toward sexual ramification from male doctors. Women should report the incidence to concerned authorities so that this type of violation could be reduced in the form of occupational fear. It is also necessary for female patients to recognize the differences between an assault and a touch for help. It has become necessary to train doctors to avoid accusations made against them by counseling the patients and informing them about the procedures before proceeding for any physical examination. Acknowledgements The authors would like to thank the study participants for their participation and kind cooperation throughout the study. All the findings reported have not been previously published and that the manuscript is not being simultaneously submitted elsewhere. Further the authors have full control of all primary data and we agree to allow the journal to review our data. The welfare of the animals does not get affected. Compliance with Ethical Standards Conflict of Interest: None declared. Authors’ Contributions: RN contributed with the concept of study, acquisition, analysis and interpretation of data and took part in drafting of the manuscript. SB contributed with the design, analysis and interpretation of data and took part in drafting of the manuscript. KA, HD, VVG, PC and HJ contributed with drafting of the manuscript, analysis and interpretation of data and revised it critically. Ethical Approval: The study protocol was reviewed by the Institutional Ethical Committee of Pacific Dental College and Hospital, Udaipur and was granted ethical clearance. Informed Consent: Our research was conducted in full accordance with the World Medical Association Declaration of Helsinki. Subjects who agreed to participate signed a written informed consent form. References 1. Balayla J . Male physicians treating female patients: issues, controversies and gynecology . Mcgill J Med . 2011 ; 13 ( 1 ): 72 . Google Scholar PubMed 2. Onyemocho A , Johnbull O , Abdullahi U , et al. 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BMJ . 1993 ; 307 ( 6910 ): 986 – 987 . Google Scholar Crossref Search ADS PubMed © Society of Behavioral Medicine 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Translational Behavioral Medicine Oxford University Press

Perception of sexual ramification among women toward male doctors in today’s Indian society

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Abstract The objective of the study was to assess the perception of women patients toward attitude of health professionals who have undergone physical examination. A descriptive cross-sectional study was conducted among 1,257 women. A self-administered structured questionnaire comprising of 16 questions was designed to assess perception of patients toward attitude of health professionals. Mean perception scores of the study population were 19.79 ± 1.78. Women in the age group of 29–38 years had a greater perception (20.34 ± 1.54) that they had been a subject or could be a subject to sexual exploitation by a doctor. Graduate and above group participants had a greater perception (19.54 ± 1.86) when compared to primary and secondary education level (19.52 ± 1.85, 18.35 ± 1.5). Data were analyzed using ANOVA. Women had mixed perception of sexual gratification toward male doctors. It is necessary to educate the doctors regarding the respect, dignity, and values for female patients, which could reduce occupational defamation. Implications Practice: A patients’ psychological state of mind influences all of their medical decisions including gender preference which in turn could influence the treatment outcome. Policy: Knowledge and insight of patient’s preferences are essential for improving the quality of dental care. Research: It adds to that current relationship between doctor and patient appears to be shaped by gender, as per the patient’s comfort level. INTRODUCTION The most precious form of personal information that we possess is our body. It is our own flesh and blood, which holds and sustains our being. Our body is our instrument for living. It is so personal and intimate that we hide it, as its public display would be a source of shame [1]. Gender is today a major determinant of access to all forms of human endeavor including health care [2]. In an ideal situation, health care providers should treat male and female patients equally, even when they have different needs. On the other hand, patients should have equal preference for trained and competent male and female physicians. However, preference for gender in terms of health provider–patient relationship is by no means a new issue [2]. The ultimate objective of any doctor–patient communication is to improve the patient’s health. In the past, descriptive and experimental research has tried to shed light on the communication process during medical consultations. Each relationship between a doctor and patient is like a snow flake, a routine office visit can turn into discovery of a life-threatening illness, thus changing the relationship profusely. To be consistently effective in a relationship, a health professional must know how and when to lead and to follow. Patients’ gender preferences for medical care are a factor that we all know exists yet most physicians prefer to ignore it in daily practice hoping that modern medicine is gender neutral [3]. Effective doctor–patient communication is determined by the doctor’s bedside manner which patients judge as a major indicator of their doctor’s general competence [4]. Doctor–patient communication skills are based upon verbal and nonverbal communication. Affective behavior, however, cannot always be verbally perceived. Only 7% of the emotional communication is conveyed verbally; 22% is transferred by voice tone; but 55% is transferred by visual cues, like eye contact, body positioning, and so forth [5]. Nonverbal behavior has been operationalized in different ways. Tone of voice, gaze, posture, laughter, facial expressions, touch, and physical distance are thought to convey the emotional tone of interpersonal interaction [6, 7]. Sex preferences have numerous foundations—for example, culture, religion, past experiences with a man or woman that can affect a person’s comfort level when he or she must be naked in front of a doctor and can lead to judgments about a physician’s caring or competence [8]. For patients with certain cultural or religious beliefs, any examination requiring the shedding of clothing may be abhorrent and when dealing with such patients the health professionals need to approach the subject with particular sensitivity. Examinations by a member of the opposite sex are effectively considered to be a taboo in some religions. The relationship between a patient and their doctor is based on trust. Physical examinations can be embarrassing or distressing for patients with certain narrow beliefs and a health professional should be sensitive to what the patient may think of as intimate physical examination. A health professional may have no doubts about a patient they have known for a long time, and feel that it is, therefore, not necessary to offer a chaperone when an intimate examination of the patient is required. However, health professionals need to be aware that a patient’s behavior may change and therefore need to be prepared to offer a chaperone to these patients as well. A health professional should be aware that simply touching a patient without their consent is tantamount minor assault and, before proceeding to examine a patient for the purpose of any kind of treatment, they should seek to obtain some explicit indication by a word or gesture that the patient both understands that the doctor proposes for a genuine examination, and that they have consented for the examination. As of more of literature reporting, growing distrust between the patient and doctor relationship we undertook a study where we could examine a general opinion about the patient’s thoughts toward the health professionals physical examination. Hence, the objective of the study was to assess the perception of patients toward attitude of health professionals who have undergone physical examination. MATERIALS AND METHODS Study design and population A cross-sectional descriptive study was conducted among Udaipur women in the month of August 2014. All the subjects who had visited a health professional (minimum four visits) were included and assessed at public places (bus stops, railway stations, libraries, malls). Ethical approval, official permission, and informed consent The study protocol was reviewed by the Ethical Committee and was granted ethical clearance. After examining the purpose and details of the study, a verbal and written informed consent was also taken from the participants. Pretesting of questionnaire A self-administered structured questionnaire was developed and tested among a convenient sample of 50 participants, who were interviewed to gain feedback on the overall acceptability of the questionnaire in terms of length and language clarity. Based on their feedback, the questionnaire was standardized. Cronbach’s coefficient was found to be 0.80, which showed an internal reliability of the questionnaire. Mean content validity ratio (CVR) was calculated as 0.87 based on the opinions expressed by a panel of five academicians. Face validity was also assessed and it was observed that 92% of the participants found the questionnaire to be easy. Questionnaire A self-administered structured questionnaire comprising of 16 questions was designed to assess perception of patients toward attitude of health professionals. The participant’s responses were ranked according to how much they agreed with each statement that was based on the 3-point Likert scale with alternatives: yes, can’t say, and no. Information regarding their age, qualification, and socioeconomic status was also gathered. Methodology The study was conducted for a period of 3 months among a convenient sample of 1,257 females. Investigator visited the predetermined places for getting the questionnaires filled. The purpose of study was informed and explained to participants. All the participants were personally given the questionnaire. Female examiners were appointed to avoid any kind of nonresponse bias or information bias from the participants. Those willing to participate in the survey were requested to fill in the consent form and complete the questionnaire. The examiners were present in order to clarify any difficulties encountered during filling of questionnaire. All the participants were asked to rate each item of the questionnaire choosing the most appropriate option. The samples included in the pilot study were not taken into consideration in main study. Confidentiality and anonymity of the respondents were assured during the entire study. Data analysis Completed questionnaires were coded and spreadsheets were created for data entry. The data were analyzed using SPSS 17 (SPSS Inc., Chicago, IL) Windows software program. Each item of the questionnaire was coded from 1 to 3 (yes, can’t say, and no). Few of the questions were re-coded to ensure that a high score indicated a positive knowledge and attitude, and a low score indicated a negative knowledge and attitude. Mean knowledge and attitude scores and standard deviation were calculated. Descriptive statistics were used to summarize the demographic information and the survey data were analyzed using the one-way ANOVA with post hoc Bonferroni test. Confidence level and level of significance were fixed at 95% and 5%, respectively. RESULTS Table 1 shows the sociodemographic detail of 1,257 study subjects. Majority of the participants 459 (36.6%) were in the age group of 21–30 years followed by 377 (29.9%) participants of 18–28 years old. Most of the participants had secondary education 620 (49.3%) and 477 (33.4%) were graduates and above. Considering the socioeconomic status 776 (61.7%) belonged to middle class. Table 1 Sociodemographic Characteristics of Participants Variables Frequency (%) Age (in years)  18–28 377 (29.9)  29–38 459 (36.6)  >38 421 (33.5) Education  Up to primary 160 (12.8)  Secondary 620 (49.3)  Graduates and above 477 (37.9) Socioeconomic status  Lower 165 (13.1)  Middle 776 (61.7)  Upper 316 (25.2) Total 1,257 (100) Variables Frequency (%) Age (in years)  18–28 377 (29.9)  29–38 459 (36.6)  >38 421 (33.5) Education  Up to primary 160 (12.8)  Secondary 620 (49.3)  Graduates and above 477 (37.9) Socioeconomic status  Lower 165 (13.1)  Middle 776 (61.7)  Upper 316 (25.2) Total 1,257 (100) View Large Table 1 Sociodemographic Characteristics of Participants Variables Frequency (%) Age (in years)  18–28 377 (29.9)  29–38 459 (36.6)  >38 421 (33.5) Education  Up to primary 160 (12.8)  Secondary 620 (49.3)  Graduates and above 477 (37.9) Socioeconomic status  Lower 165 (13.1)  Middle 776 (61.7)  Upper 316 (25.2) Total 1,257 (100) Variables Frequency (%) Age (in years)  18–28 377 (29.9)  29–38 459 (36.6)  >38 421 (33.5) Education  Up to primary 160 (12.8)  Secondary 620 (49.3)  Graduates and above 477 (37.9) Socioeconomic status  Lower 165 (13.1)  Middle 776 (61.7)  Upper 316 (25.2) Total 1,257 (100) View Large The mean perception scores of the study population were evident as 19.79 ± 1.78. Women in the age group 29–38 years felt that they had a greater perception (20.34 ± 1.54) that they had been a subject or could be a subject to sexual exploitation by a doctor. There was statistically significant difference in the age groups (p = .03). When post hoc Bonferroni test was applied, mean perception score was found to be higher for age group 29–38 years compared to other group. Graduate and above group participants had a greater perception (19.54 ± 1.86) when compared to primary and secondary education level respondents (19.52 ± 1.85, 18.35 ± 1.5). A statistically significant difference was seen when level of education was compared with each other (p = .02) using post hoc test. There was no significant difference found when socioeconomic status of different groups was compared (Table 2). Table 2 Association of Mean Perception with Independent Variables Variables Perception Mean ± SD p Value Age (in years)  18–28 19.75 ± 1.78a 0.03*  29–38 20.34 ± 1.54b  >38 19.28 ± 1.62a Education  Up to primary 18.35 ± 1.53a 0.02*  Secondary 19.52 ± 1.85b  Graduates and above 19.54 ± 1.86b Socioeconomic status  Lower 20.05 ± 1.73 0.48  Middle 19.28 ± 1.96  Upper 20.01 ± 1.65 Total 19.33 ± 1.78 Variables Perception Mean ± SD p Value Age (in years)  18–28 19.75 ± 1.78a 0.03*  29–38 20.34 ± 1.54b  >38 19.28 ± 1.62a Education  Up to primary 18.35 ± 1.53a 0.02*  Secondary 19.52 ± 1.85b  Graduates and above 19.54 ± 1.86b Socioeconomic status  Lower 20.05 ± 1.73 0.48  Middle 19.28 ± 1.96  Upper 20.01 ± 1.65 Total 19.33 ± 1.78 Statistical tests applied: one-way ANOVA. Post hoc Bonferroni test: groups with different letters superscripted show statistically significant difference. *Indicates statistically significant difference at p ≤ .05. View Large Table 2 Association of Mean Perception with Independent Variables Variables Perception Mean ± SD p Value Age (in years)  18–28 19.75 ± 1.78a 0.03*  29–38 20.34 ± 1.54b  >38 19.28 ± 1.62a Education  Up to primary 18.35 ± 1.53a 0.02*  Secondary 19.52 ± 1.85b  Graduates and above 19.54 ± 1.86b Socioeconomic status  Lower 20.05 ± 1.73 0.48  Middle 19.28 ± 1.96  Upper 20.01 ± 1.65 Total 19.33 ± 1.78 Variables Perception Mean ± SD p Value Age (in years)  18–28 19.75 ± 1.78a 0.03*  29–38 20.34 ± 1.54b  >38 19.28 ± 1.62a Education  Up to primary 18.35 ± 1.53a 0.02*  Secondary 19.52 ± 1.85b  Graduates and above 19.54 ± 1.86b Socioeconomic status  Lower 20.05 ± 1.73 0.48  Middle 19.28 ± 1.96  Upper 20.01 ± 1.65 Total 19.33 ± 1.78 Statistical tests applied: one-way ANOVA. Post hoc Bonferroni test: groups with different letters superscripted show statistically significant difference. *Indicates statistically significant difference at p ≤ .05. View Large Table 3 depicted that 85% of the women preferred being treated by a doctor of her gender. Sixty-five percent were satisfied with the medical care they received and similar percentage of the study participants felt that the doctor showed unnecessary interest in them. Most of the participants (84%) felt that the doctor gave them respect. Only 20% of the participants felt that the doctor could easily take advantage of them. Forty percent of the participants felt that their doctor treats them in a friendly manner. Sixteen of the women wished for a relationship with their doctor. Almost half (54%) of the participants in this study had experienced eve-teasing, staring, or had been touched in an unacceptable way that made them feel uncomfortable. Only 19% of the women felt comfortable in the clinic in absence of their family members or a female medical attendant. Table 3 Frequency of Responses Regarding Perception Items Yes Can’t say No I would always prefer being treated by a doctor of my gender 1,069 (85) 125 (9.9) 63 (5.1) I am satisfied with the medical care I receive 818 (65.2) 314 (24.9) 125 (9.9) Doctors are good about explaining the reasons for physical/medical tests that they perform on me 628 (49.9) 0 (0) 629 (50.1) Have you felt a doctor showing unnecessary interest in you? 818 (65.2) 251 (19.9) 188 (14.9) Did you experience your doctor advising you more tests than required? 377 (29.9) 503 (40.2) 377 (29.9) Does your doctor give you respect? 1,068 (84.9) 64 (5.2) 125 (9.9) Doctors act too business like/impersonal towards me 566 (45) 189 (15) 502 (39.9) I feel my doctor takes advantage of me 252 (20.2) 314 (24.9) 691 (54.9) My doctors would never expose me to unnecessary risk 906 (72.2) 226 (17.9) 125 (9.9) My doctors treat me in a very friendly and courteous manner 503 (40) 314 (24.9) 440 (35) Did you experience exposure of your privacy by the doctor? 126 (10) 377 (29.9) 754 (59.9) Did you ever had interest or wish to have relationship with your doctor other than a patient? 213 (16.9) 37 (2.9) 1,007 (80.1) Have you ever experienced staring and touch in an unacceptable way which makes you feel uncomfortable? 691 (54.9) 314 (24.1) 252 (20) Have you ever experienced unnecessary delay in the treatment, taking advantage of you? 251 (19.9) 692 (55) 314 (24.9) Do you feel safe with your doctor in absence of your family members or a male/female medical attendant? 251 (19.9) 693 (55.1) 313 (24.9) If you experience any starring, unacceptable touch would you raise an alarm 1,068 (84.9) 127 (10.1) 62 (4.9) Items Yes Can’t say No I would always prefer being treated by a doctor of my gender 1,069 (85) 125 (9.9) 63 (5.1) I am satisfied with the medical care I receive 818 (65.2) 314 (24.9) 125 (9.9) Doctors are good about explaining the reasons for physical/medical tests that they perform on me 628 (49.9) 0 (0) 629 (50.1) Have you felt a doctor showing unnecessary interest in you? 818 (65.2) 251 (19.9) 188 (14.9) Did you experience your doctor advising you more tests than required? 377 (29.9) 503 (40.2) 377 (29.9) Does your doctor give you respect? 1,068 (84.9) 64 (5.2) 125 (9.9) Doctors act too business like/impersonal towards me 566 (45) 189 (15) 502 (39.9) I feel my doctor takes advantage of me 252 (20.2) 314 (24.9) 691 (54.9) My doctors would never expose me to unnecessary risk 906 (72.2) 226 (17.9) 125 (9.9) My doctors treat me in a very friendly and courteous manner 503 (40) 314 (24.9) 440 (35) Did you experience exposure of your privacy by the doctor? 126 (10) 377 (29.9) 754 (59.9) Did you ever had interest or wish to have relationship with your doctor other than a patient? 213 (16.9) 37 (2.9) 1,007 (80.1) Have you ever experienced staring and touch in an unacceptable way which makes you feel uncomfortable? 691 (54.9) 314 (24.1) 252 (20) Have you ever experienced unnecessary delay in the treatment, taking advantage of you? 251 (19.9) 692 (55) 314 (24.9) Do you feel safe with your doctor in absence of your family members or a male/female medical attendant? 251 (19.9) 693 (55.1) 313 (24.9) If you experience any starring, unacceptable touch would you raise an alarm 1,068 (84.9) 127 (10.1) 62 (4.9) View Large Table 3 Frequency of Responses Regarding Perception Items Yes Can’t say No I would always prefer being treated by a doctor of my gender 1,069 (85) 125 (9.9) 63 (5.1) I am satisfied with the medical care I receive 818 (65.2) 314 (24.9) 125 (9.9) Doctors are good about explaining the reasons for physical/medical tests that they perform on me 628 (49.9) 0 (0) 629 (50.1) Have you felt a doctor showing unnecessary interest in you? 818 (65.2) 251 (19.9) 188 (14.9) Did you experience your doctor advising you more tests than required? 377 (29.9) 503 (40.2) 377 (29.9) Does your doctor give you respect? 1,068 (84.9) 64 (5.2) 125 (9.9) Doctors act too business like/impersonal towards me 566 (45) 189 (15) 502 (39.9) I feel my doctor takes advantage of me 252 (20.2) 314 (24.9) 691 (54.9) My doctors would never expose me to unnecessary risk 906 (72.2) 226 (17.9) 125 (9.9) My doctors treat me in a very friendly and courteous manner 503 (40) 314 (24.9) 440 (35) Did you experience exposure of your privacy by the doctor? 126 (10) 377 (29.9) 754 (59.9) Did you ever had interest or wish to have relationship with your doctor other than a patient? 213 (16.9) 37 (2.9) 1,007 (80.1) Have you ever experienced staring and touch in an unacceptable way which makes you feel uncomfortable? 691 (54.9) 314 (24.1) 252 (20) Have you ever experienced unnecessary delay in the treatment, taking advantage of you? 251 (19.9) 692 (55) 314 (24.9) Do you feel safe with your doctor in absence of your family members or a male/female medical attendant? 251 (19.9) 693 (55.1) 313 (24.9) If you experience any starring, unacceptable touch would you raise an alarm 1,068 (84.9) 127 (10.1) 62 (4.9) Items Yes Can’t say No I would always prefer being treated by a doctor of my gender 1,069 (85) 125 (9.9) 63 (5.1) I am satisfied with the medical care I receive 818 (65.2) 314 (24.9) 125 (9.9) Doctors are good about explaining the reasons for physical/medical tests that they perform on me 628 (49.9) 0 (0) 629 (50.1) Have you felt a doctor showing unnecessary interest in you? 818 (65.2) 251 (19.9) 188 (14.9) Did you experience your doctor advising you more tests than required? 377 (29.9) 503 (40.2) 377 (29.9) Does your doctor give you respect? 1,068 (84.9) 64 (5.2) 125 (9.9) Doctors act too business like/impersonal towards me 566 (45) 189 (15) 502 (39.9) I feel my doctor takes advantage of me 252 (20.2) 314 (24.9) 691 (54.9) My doctors would never expose me to unnecessary risk 906 (72.2) 226 (17.9) 125 (9.9) My doctors treat me in a very friendly and courteous manner 503 (40) 314 (24.9) 440 (35) Did you experience exposure of your privacy by the doctor? 126 (10) 377 (29.9) 754 (59.9) Did you ever had interest or wish to have relationship with your doctor other than a patient? 213 (16.9) 37 (2.9) 1,007 (80.1) Have you ever experienced staring and touch in an unacceptable way which makes you feel uncomfortable? 691 (54.9) 314 (24.1) 252 (20) Have you ever experienced unnecessary delay in the treatment, taking advantage of you? 251 (19.9) 692 (55) 314 (24.9) Do you feel safe with your doctor in absence of your family members or a male/female medical attendant? 251 (19.9) 693 (55.1) 313 (24.9) If you experience any starring, unacceptable touch would you raise an alarm 1,068 (84.9) 127 (10.1) 62 (4.9) View Large DISCUSSION Relationship between doctors and patient is attracting an increasing amount of attention. Despite increased attention in this area, there are not many studies that have used a systematic approach in targeting perception of sexual gratification among women toward male doctors. Many factors contribute to lack of trust in doctors and dissatisfaction with their care. In our study, 85% of the participants preferred being treated by female doctors and this was in accordance with a study conducted by Zaghloul et al. [9]. In a similar survey conducted by Amer-Alshiek et al. [10], women patients were more comfortable and less embarrassed with female doctors than compared to male doctors. Only 9.9% of the participants felt unsatisfied with the medical care they received. According to Pascoe [11], satisfaction can be defined as the extent of an individual’s experience compared with his or her expectations. Evaluating to what extent patients are satisfied with health services is clinically relevant, as satisfied patients are more likely to comply with treatment [12], take an active role in their own care [13], and continue using medical care services. Roter et al. [14] found that doctors’ instrumental behaviors were significantly related to patient satisfaction. Smith et al. [15] also found that higher levels of information given by the doctor, time spent in discussion of preventive care by the doctor, and greater interview lengths were positively associated with patient satisfaction. In our study, 65% of the participants felt that doctor showed unnecessary interest in them. According to Scheflen [16], it could all depend upon eye contact; for instance, it could reflect attentiveness, seduction, or a challenge for dominance, depending upon the situation and the subjects. Nonverbal communications like these can support, modify, or even contradict verbal messages [17]. Doctors who have had a great deal of experience in interacting successfully with patients in settings and are not judged to be harsh are considered better in interaction and relationships with patients [18]. Similarly, in our study, 40% of the participants felt that the doctor did treat them in a very friendly and courteous manner. Onyemocho et al. [2] concluded that 79% of the women preferred female doctors because they had better communication skills. When the respondents were asked about their privacy exposure, 59.9% felt their privacy was not exposed. Sustained eye contact, for example, may be perceived by the patient as too intimate for the relationship, thus violating norms in the medical context leading to exploitation of privacy for the patient. Friedman [19] has identified reasons regarding patients’ sensitiveness and observance of nonverbal communications conveyed by their doctors. Illness usually involves emotions such as fear, anxiety, and emotional uncertainty; most patients are active in searching for information about different aspects of their disease. Nonverbal communication like touch “leaks” messages that are not meant to be transmitted [20]. Patients are very sensitive to these messages, and such inconsistencies between physicians’ verbal and nonverbal communication can portray lack of genuineness. Some doctors’ behaviors have been identified by patients as violations of physical privacy. Similar results were found in our study when the participants were asked whether they had experienced touch or staring in an unacceptable way—54.9% said yes. During medical examinations it is certain that patients have very limited physical privacy; intimate touch is unavoidable but could be necessary. This negative attitude of the patient toward the doctors can be reduced by avoiding watching a patient while getting ready for an examination, touching the patient unexpectedly, overhearing intimate conversation or activities, or by taking personal interests [21]. In our study, only 19.9% of the participants felt safe in the absence of their family member or a chaperone. Doctors are particularly vulnerable to false accusations and the results can be devastating. Due to the increasing incidence of allegations of assault by patients against doctors, Speelman et al. [22] strongly recommended the use of chaperones for young person’s wherever possible. The presence of a chaperone is helpful not only in reassuring the patient but also in minimizing the risk of the doctor’s actions being misinterpreted by the patient. Due to frequent accusations on doctors, medical students and postgraduates are increasingly given instructions on technique for listening, explaining, questioning, counseling, and motivating of the patients who could help them develop a better patient–physician communication skill. The degree of truthfulness and how thoughtfully the respondents have answered the questionnaire, and the level of subjectivity are not acknowledged in the current study which may be a limitation. Considering the fact that this study was done on a small scale with small sample size, we cannot generalize these results. Therefore, similar studies covering a larger population must be undertaken. This study opens new vistas for future research to understand perception of women toward male doctors in today’s society. CONCLUSION The present study concluded that the women had mixed perception toward sexual ramification from male doctors. Women should report the incidence to concerned authorities so that this type of violation could be reduced in the form of occupational fear. It is also necessary for female patients to recognize the differences between an assault and a touch for help. It has become necessary to train doctors to avoid accusations made against them by counseling the patients and informing them about the procedures before proceeding for any physical examination. Acknowledgements The authors would like to thank the study participants for their participation and kind cooperation throughout the study. All the findings reported have not been previously published and that the manuscript is not being simultaneously submitted elsewhere. Further the authors have full control of all primary data and we agree to allow the journal to review our data. The welfare of the animals does not get affected. Compliance with Ethical Standards Conflict of Interest: None declared. Authors’ Contributions: RN contributed with the concept of study, acquisition, analysis and interpretation of data and took part in drafting of the manuscript. SB contributed with the design, analysis and interpretation of data and took part in drafting of the manuscript. KA, HD, VVG, PC and HJ contributed with drafting of the manuscript, analysis and interpretation of data and revised it critically. Ethical Approval: The study protocol was reviewed by the Institutional Ethical Committee of Pacific Dental College and Hospital, Udaipur and was granted ethical clearance. Informed Consent: Our research was conducted in full accordance with the World Medical Association Declaration of Helsinki. Subjects who agreed to participate signed a written informed consent form. References 1. Balayla J . Male physicians treating female patients: issues, controversies and gynecology . Mcgill J Med . 2011 ; 13 ( 1 ): 72 . Google Scholar PubMed 2. Onyemocho A , Johnbull O , Abdullahi U , et al. Preference for health provider’s gender amongst women attending obstetrics/gynecology clinic, ABUTH, Zaria, Northwestern Nigeria . Am J Public Health Res . 2014 ; 2 ( 1 ): 21 – 26 . 3. Sherman J . Patient gender preferences for medical care . Available at http://www.kevinmd.com/blog/2010/11/patient-gender-preferences-medical-care.html. Accessibility verified July 24, 2016 . 4. Hall JA , Roter DL , Rand CS . Communication of affect between patient and physician . J Health Soc Behav . 1981 ; 22 ( 1 ): 18 – 30 . Google Scholar Crossref Search ADS PubMed 5. van den Brink-Muinen A , Verhaak PF , Bensing JM , et al. Communication in general practice: differences between European countries . Fam Pract . 2003 ; 20 ( 4 ): 478 – 485 . Google Scholar Crossref Search ADS PubMed 6. Smith CK , Polis E , Hadac RR . Characteristics of the initial medical interview associated with patient satisfaction and understanding . J Fam Pract . 1981 ; 12 ( 2 ): 283 – 288 . Google Scholar PubMed 7. Larsen KM , Smith CK . Assessment of nonverbal communication in the patient-physician interview . J Fam Pract . 1981 ; 12 ( 3 ): 481 – 488 . Google Scholar PubMed 8. Waseem M , Miller AJ . Patient requests for a male or female physician . Virtual Mentor . 2008 ; 10 ( 7 ): 429 – 433 . Google Scholar Crossref Search ADS PubMed 9. Zaghloul AA , Youssef AA , El-Einein NY . Patient preference for providers’ gender at a primary health care setting in Alexandria, Egypt . Saudi Med J . 2005 ; 26 ( 1 ): 90 – 95 . Google Scholar PubMed 10. Amer-Alshiek J , Alshiek T , Amir Levy Y , Azem F , Amit A , Amir H . Israeli Druze women’s sex preferences when choosing obstetricians and gynecologists . Isr J Health Policy Res . 2015 ; 4 : 13 . Google Scholar Crossref Search ADS PubMed 11. Pascoe GC . Patient satisfaction in primary health care: a literature review and analysis . Eval Program Plann . 1983 ; 6 ( 3–4 ): 185 – 210 . Google Scholar Crossref Search ADS PubMed 12. Guldvog B . Can patient satisfaction improve health among patients with angina pectoris ? Int J Qual Health Care . 1999 ; 11 ( 3 ): 233 – 240 . Google Scholar Crossref Search ADS PubMed 13. Donabedian A . The quality of care. how can it be assessed ? JAMA . 1988 ; 260 ( 12 ): 1743 – 1748 . Google Scholar Crossref Search ADS PubMed 14. Roter DL , Hall JA , Katz NR . Relations between physicians’ behaviors and analogue patients’ satisfaction, recall, and impressions . Med Care . 1987 ; 25 ( 5 ): 437 – 451 . Google Scholar Crossref Search ADS PubMed 15. Smith CK , Polis E , Hadac RR . Characteristics of the initial medical interview associated with patient satisfaction and understanding . J Fam Pract . 1981 ; 12 ( 2 ): 283 – 288 . Google Scholar PubMed 16. Scheflen AE . The significance of posture in communication systems . Psychiatry . 1964 ; 27 : 316 – 331 . Google Scholar Crossref Search ADS PubMed 17. Watzlawick P , Beavin JH , Jackson DD . Some tentative axioms of communication . In: Pragmatics of human communication . New York, NY: W.W. Norton & Company. 1967 : 275 – 288 . 18. Garrett MT . Understanding the medicine of native American traditional values: an integrative review . Couns Value . 1999 ; 43 ( 2 ): 84 – 98 . Google Scholar Crossref Search ADS 19. Friedman HS . Non-verbal communication between patients and medical practitioners . J Soc Issues . 1979 ; 35 ( 1 ): 82 – 99 . Google Scholar Crossref Search ADS 20. DiMatteo MR , Taranta A , Friedman HS , Prince LM . Predicting patient satisfaction from physicians’ nonverbal communication skills . Med Care . 1980 ; 18 ( 4 ): 376 – 387 . Google Scholar Crossref Search ADS PubMed 21. Parrott R , Burgoon JK , Burgoon M , LePoire BA . Privacy between physicians and patients: more than a matter of confidentiality . Soc Sci Med . 1989 ; 29 ( 12 ): 1381 – 1385 . Google Scholar Crossref Search ADS PubMed 22. Speelman A , Savage J , Verburgh M . Use of chaperones by general practitioners . BMJ . 1993 ; 307 ( 6910 ): 986 – 987 . Google Scholar Crossref Search ADS PubMed © Society of Behavioral Medicine 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com. This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Journal

Translational Behavioral MedicineOxford University Press

Published: Sep 8, 2018

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