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Muslim Women's Physician Preference: Beyond Obstetrics and Gynecology a
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Michelle McLean , Fatima Al Yahyaei , Muneera Al Mansoori , b
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Mouza Al Ameri , Salma Al Ahbabi & Roos Bernsen
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Department of Medical Education, United Arab Emirates University, Al Ain, United Arab Emirates b
United Arab Emirates University, Al Ain, United Arab Emirates
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Department of Community Medicine, United Arab Emirates University, Al Ain, United Arab Emirates Accepted author version posted online: 21 Feb 2012.Version of record first published: 14 Aug 2012.
To cite this article: Michelle McLean, Fatima Al Yahyaei, Muneera Al Mansoori, Mouza Al Ameri, Salma Al Ahbabi & Roos Bernsen (2012): Muslim Women's Physician Preference: Beyond Obstetrics and Gynecology, Health Care for Women International, 33:9, 849-876 To link to this article: http://dx.doi.org/10.1080/07399332.2011.645963
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Health Care for Women International, 33:849–876, 2012 Copyright © Taylor & Francis Group, LLC ISSN: 0739-9332 print / 1096-4665 online DOI: 10.1080/07399332.2011.645963
Muslim Women’s Physician Preference: Beyond Obstetrics and Gynecology MICHELLE MCLEAN
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Department of Medical Education, United Arab Emirates University, Al Ain, United Arab Emirates
FATIMA AL YAHYAEI, MUNEERA AL MANSOORI, MOUZA AL AMERI, and SALMA AL AHBABI United Arab Emirates University, Al Ain, United Arab Emirates
ROOS BERNSEN Department of Community Medicine, United Arab Emirates University, Al Ain, United Arab Emirates
When Emirati (Muslim) women (n = 218) were asked about their preferred physician (in terms of gender, religion, and nationality) for three personal clinical scenarios, a female was almost exclusively preferred for the gynecological (96.8%) and “stomach” (94.5%) scenarios, while ±46% of the women also preferred a female physician for the facial allergy scenario. Only 17% considered physician gender important for the prepubertal child scenario. Just over half of the women preferred a Muslim physician for personal examinations (vs. 37.6% for the child). Being less educated and having a lower literacy level were significant predictors of preferred physician religion for some personal scenarios, whereas a higher education level was a significant predictor for physician gender not mattering for the facial allergy scenario. Muslim women’s preference for same gender physicians, and to a lesser extent religion, has implications for health care services beyond obstetrics and gynecology.
Received 10 December 2010; accepted 5 October 2011. Michelle McLean is now affiliated with Bond University. Address correspondence to Michelle McLean, Faculty of Health Sciences and Medicine, Bond University, Gold Coast, 4226 Queensland, Australia. E-mail:
[email protected] 849
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This study is an extension of a research project we designed to ascertain what Emirati women would allow male and female students to undertake during the clinical encounter (McLean et al., 2010). The original study was initiated in response to difficulties Emirati medical students experienced during cross-gender consultations at the public hospitals in the city of Al Ain, United Arab Emirates (UAE). With medical training in the United Arab Emirates beginning in the late 1980s only, physicians are recruited from across the globe to service the health care needs of the local indigenous population of ±1.0 million (±15% of the UAE census; http://www.uaeinteract.com) and the large transient expatriate community. While many physicians are of Middle Eastern origin (e.g., Jordanian, Syrian, Egyptian), often with North American postgraduate qualifications, Western doctors also practice in the UAE public health care sector. In view of the fact that health care in the UAE is thus provided by a multinational (including Emirati Nationals) community of doctors, we designed a study to ascertain Emirati women’s physician preference for four hypothetical clinical scenarios.
Women’s Physician Preference Much of the research investigating female patients’ choice of physician relates to obstetrics and gynecology (O&G), where a global increasing preference amongst women for same-gender obstetricians and gynecologists has been reported (Adams 2003; Chandler, Chandler, & Dabbs, 2000; Lafta, 2006; Rizk, El-Zubeir, Al-Dhaheri, Al-Mansouri, & Al-Jenaib, 2005; Schnatz, Murphy, O’Sullivan, & Sorosky, 2007; Uskul & Ahmad, 2003; Zuckerman, Navizedeh, Feldman, McCalla, & Minkoff, 2002). Board certification, communication skills, professional attitude and behavior, a long-standing history with an obstetrician or gynecologist, and religion and culture are some of the many factors influencing patients’ preference (Christen, Alder, & Bitzer, 2008; Piper, Shvarts, & Lurie, 2008; Rizk et al., 2005; Schnatz et al., 2007; Uskul & Ahmad, 2003; Zuckerman et al., 2002). Schnatz and colleagues (2007) have suggested, however, that gender stereotyping may play a role in physician preference amongst female gynecological patients, as same-gender preference disappeared when the male gynecologist’s technical competence or humanistic qualities was advertised. Preference for female doctors in general practice is reported to be related to patients’ perceptions of female physicians being more empathetic and responsive (Bertakis, Franks, & Azari, 2003; Cooper-Patrick et al., 1999). Much less has been documented specifically on Muslim women’s health care preferences and requirements (if so, then usually O&G) in Western settings (Ahmad, Kernohan, & Baker, 1989; Hammoud, White, & Fetters, 2005; Matin & LeBaron, 2004; Rajaram & Rashid, 1999, 2003; Underwood, Shaikha, & Bakr, 1999; Zuckerman et al,. 2002) or in Islamic countries (Lafta, 2006;
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Rizk et al. 2005; Rizk & El-Safty, 2006; Rizk, Nasser, Thomas, & Ezimokhai, 2001; Rizk, Shaheen, Thomas, Dunn, & Hassan, 1999; Uskul & Ahmad, 2003; Winslow & Honein, 2007). Thus, in contexts and communities where culture and religion are deep rooted, a same-gender practitioner is likely to be important for women, particularly for intimate examinations such as breast, obstetric, gynecological, and urogenital examinations (Aldeen, 2007; Matin & LeBaron, 2004; Rajaram & Rashidi, 1999, 2003; Rizk & El-Safty, 2006; Rizk et al., 2001, 2005; Underwood et al., 1999; Zuckerman et al., 2002). Since failure to take cognizance of patients’ cultural and religious perspective may compromise their health (Aldeen, 2007; Rizk & El-Safty, 2006; Underwood et al., 1999; Winslow & Honein, 2007), medical regulatory bodies expect clinicians to be culturally competent, respecting patient autonomy and religious and cultural values (Laird, de Marrais, & Barnes, 2007). If “culture embodies those values, religious, and otherwise, that constitute the background to individuals’ health attitudes and behaviors” (Rizk & ElSafty, 2006, p. 436), then the reported resistance of African American and American Muslim immigrant women to breast and cervical cancer screening because these women believed procedures were not consistent with Islamic customs or their beliefs is testimony of the influence of religious and cultural values on health-seeking behavior and ultimately health outcomes (Matin & LeBaron, 2004; Rajaram & Rashidi, 1999, 2003; Underwood et al., 1999).
Understanding Muslim Women’s Health Care Needs To understand the implications of a cross-gender clinical consultation in an Islamic context requires knowledge of some of the religious requirements and recommendations for Muslims, women in particular. In the first instance, Islam requires men and women to be modest on reaching the onset of maturity (bulugh; Hedayat & Pirzadeh, 2001). For traditional or conservative Muslim women (or their husbands), this means being clothed from head to ankle, usually with an abeya (full length black cloak) so as not to show their awrah, parts of the body that should not be publically exposed (Aldeen, 2007; Hathout, 1986). Women should also not display their zeenah (charms, beauty, ornaments, i.e., hips, legs, chest, hair) to anyone other than their husband, father, and sons (Sechzer, 2004). In the United Arab Emirates, a woman’s head is covered by a chiffon scarf, a sheyla, which elsewhere may be referred to as hijab. Hijab, which also describes the principle of modesty, literally means “curtain” and historically refers to the screen behind which Muslims were to address Prophet Muhammad’s wives. In public, this became a veil worn by women (Sechzer, 2004). Although Islam prohibits touching or physical contact by the opposite gender, unless appropriate (e.g., by a spouse), contrary to the belief of many Muslims, the religion does not preclude examination by a doctor
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of the opposite gender. In Islam, necessity allows the forbidden (Aldeen, 2007), and so the cross-gender physical contact restriction has long been waived for medical purposes, provided it is essential. Such would be the case when a same-gender physician is not available or in life and death situations (Aldeen, 2007; Hammoud et al., 2005; Hathout, 1986; Hedayat & Pirzadeh, 2001; Lafta, 2006; Rizk et al., 2005). Islam thus recommends (but does not prescribe) first a same-gender Muslim physician, followed by a same-gender non-Muslim and, failing their availability, a Muslim of opposite gender, and, last, an opposite-gender non-Muslim doctor (Aldeen, 2007; Hedayat & Pirzadeh, 2001). In cross-gender consultations, however, Muslim women generally need to be accompanied by a same-gender third party (Aldeen, 2007; Hammoud et al., 2005; Hathout, 1986). Muslim patients’ present-day insistence on same-gender physicians is worthy of discussion in view of the Islamic history of medicine during Prophet Muhammad’s life. The medical corps at that time comprised “lady healers,” or asiyaat, who were responsible for treating wounded soldiers, irrespective of the type or location of their injuries. Cross-gender medical care was established during the battles of Badr and Uhud, and so, according to the tradition of the Prophet, the rule governing covering of areas of the body was waived in the interest of medical treatment (Aldeen, 2007; Hathout, 1986). The ancient literature on medical care attests to the possibility of and necessity for cross-gender examinations. In the eighth century, Ibn Quaddama wrote that it was permissible for a male doctor to inspect whatever parts of the woman’s body warranted during the medical examination. Similarly, Ibn-Muflih stated the following: A man doctor may inspect the awra of a women’s body as far as the medical examination warrants if only a male doctor is available to treat her, even if he has to look at her private parts. The same would be true if a man is ill and there is but the woman doctor to treat him. She may inspect his body even his private parts. (Hathout, 1986, p. 3)
Over 600 years ago, Ibn Qayyim Al Jawziyya wrote in The Prophetic Medicine that Muslims should seek the best authority in each matter and field because such expertise will ensure that the task is done with excellence (El-Qadar, 2007). Implicit in this hadith (narrative originating from the words or deeds of Prophet Muhammad) would be the need to consult an opposite-gender physician if he or she was the most qualified.
The United Arab Emirates (UAE) Context Following the discovery of oil in 1958, the United Arab Emirates, a federation of seven emirates formed in 1971, has undergone dramatic modernization, impacting on the country’s political and economic systems and its social
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fabric (Al Seyegh, 2004; Schvaneveldt, Kerpelman, & Schvaneveldt, 2005). In a mere 40 years, the Emirati population, a nation of Bedouins, pearl-divers, and traders, has been catapulted into a world of mechanization, technology, and development. While UAE leaders strove to ensure a healthy, modern, and educated society, they have also tried to preserve its cultural traditionalism and religious conservatism, placing considerable emphasis on religion to protect the country’s tribal inheritance. Despite considerable social and political changes over the past 4 decades, which have culminated in, for example, Emirati women accounting for 70% of university enrolment (Ridge, 2009) and competing successfully in the labor market (Nelson, 2004), the country’s patriarchal ideology persists (Al Seyegh, 2004; Schvaneveldt et al., 2005; Winslow & Honein, 2007). In line with the traditional religious, social, and cultural norms of most Islamic societies (Badawi, 1971), girls have been socialized into the nurturing roles of wife and mother, while males are regarded as breadwinners and may head extended polygamous families (Schvaneveldt et al., 2005; Winslow & Honein, 2007). In the gendersegregated UAE society, as in other patriarchal societies, men are perceived as the protectors of women who, until recently, had little opportunity to interact outside the family. Even today, some Emirati women are not permitted to drive or may not travel without their husband or a member of their mahram (nonmarriageable male relatives).
The Present Study It is estimated that some 1,200 Emirati Nationals have been trained as doctors, both locally and abroad. In view of the fact that health care in the United Arab Emirates is provided by a multinational community of doctors, including an increasing cadre of Emirati doctors, we designed a study to ascertain Emirati women’s physician preference in terms of gender, religion, age, region/country of certification, marital status, and nationality for four three-personal and one-child clinical scenarios. The three personal presentations were selected based on what we considered to be increasing intimacy for the personal examinations, with Scenarios 2 and 3 involving the awrah: • Personal scenario 1: An allergy with red, itchy eyes and a runny nose, which would involve an eye examination; • Personal scenario 2: A sore “stomach” that would require an abdominal and possibly a chest examination; • Personal scenario 3: A gynecological problem (e.g., vaginal discharge) that would require an internal examination; and • Scenario 4: An 8-year-old child (no gender specified; prepubertal; no particular illness described).
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Based on the literature regarding Muslim women’s reproductive health preferences, informed by local anecdotal accounts of students and practitioners, taking cognizance of the gender-segregated UAE society with considerable restrictions placed on unmarried females and being aware of some Islamic religious and local cultural practices, we generated the following hypotheses:
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Hypothesis 1: Physician gender (i.e., being female), followed by religion (i.e., being Muslim) would be the most important considerations influencing female Emirati women’s preference for the three personal scenarios. The more intimate and personal the examination (e.g., gynecological > “stomach” > facial allergy scenario), the more selective would women be in terms of physician gender and religion. There would be no particular physician preference for the 8-year-old, prepubertal child. Hypothesis 2: With regard to physician nationality and certification, preference would generally be for an Emirati or other Arab doctor trained in the West (North America or Europe). Hypothesis 3: Of the women’s biographical data, marital status (i.e., being unmarried) and age (i.e., being younger) would be the most important considerations impacting on physician preference, in particular, physician gender.
Conceptual Frameworks To gain insight into the health care needs (in this case, physician preference) of Emirati women living in a patriarchal, gender-segregated Islamic society undergoing rapid modernization, this study was informed by several conceptual frameworks. Within an overarching framework embodying the concept of gender sensitivity in health care (Annandale & Hunt, 2000; Hammarstr¨om, 2007; Saulnier et al., 1999), women’s health-seeking behavior and health are considered in terms of the inter-relationship and intersection of culture, religion, and gender (Moss, 2002; Raday, 2003). Models such as Estes and Zitzow’s Model of Heritage Consistency, originally conceptualized to understand the influence of culture, ethnicity, and religion on the manner in which an individual interacts with society, can be used to explain a person’s behavior and lifestyle as a reflection of their religion, culture, and ethnicity (Spector, 2004). Also informing this study is the concept of patientcentered care, a holistic approach to health care that takes into account all aspects of a patient’s illness and life (Balint, 1969; Bensing, 2000; Engel, 1977; Mead & Bower, 2000). Viewing health care through different lenses enables researchers and medical professionals to recognize and acknowledge the myriad of social, cultural, demographic, and religious factors influencing the
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health-seeking behavior and, ultimately, the health outcomes of men and women. Gender sensitivity in health care. Parallel with the feminist movement (Im & Meleis, 2001), gender issues in health care have gained prominence as researchers and physicians have come to realize that men and women have different physiological and social needs. Recognizing the historic gender bias in research (Ruiz-Cantero et al., 2007), the literature now reflects terms such as “gender equity,” “gender-sensitive” research and theories, and “gender mainstreaming” (Annandale & Hunt, 2000; Hammarstr¨om, 2007; Im & Meleis, 2001; Saulnier et al., 1999). While the traditional hypotheticodeductive biomedical research model has advanced medical knowledge, this paradigm has generally ignored the “soft” issues that impact on health outcomes and that may be different for males and females (Im & Meleis, 2001; Risberg, Hamberg, & Johansson, 2006). Im and Meleis (2001) reviewed the value of three gender-sensitive theories (feminism, social critical theory, postmodernism) in developing a theoretical framework to guide and interpret women’s health research and to understand the events that shape their well-being, while Risberg and colleagues (2006) have provided an overview of other scientific research approaches in the broader field of medical research that take cognizance of sometimes-neglected psychosocial factors. For example, medical philosophy research might encompass medical ethics, medical sociology, anthropological research, or gender-theory studies, while “empowering” research provides a voice to the subordinated and oppressed groups or individuals to ensure better health by recognizing their position in society, living conditions, and their life experiences of health and disease (Risberg et al., 2006). Importantly, gender sensitive theories acknowledge gender equity and are based on the premise that women need to be affirmed as having control over their own bodies and health. By incorporating women’s experiences, in which their diversities and complexities in social, cultural, and political contexts are acknowledged, such theories and frameworks provide a basis to empower women in terms of their health (Dudgeon & Inhorn, 2004; Saulnier et al., 1999). Gender “mainstreaming” research strategies should then collect and analyze information about the different needs and concerns of women (and men) and address barriers that disadvantage them (Saulnier et al., 1999). Culture, religion, and gender: Issues in health care. Some of the bestknown work describing the impact of culture on health care is that of Madeleine Leininger, who coined the phrase “culturally congruent care.” Leininger went on to formalize her theory of culture care, diversity and universality, which takes cognizance of a patient’s worldview and social and political circumstances, amongst many other factors, in order to deliver culturally competent nursing care (Leininger, 2002; Leininger & McFarland, 2006). Culture would include physical and social environments and the interaction of factors such as race, geography, ability, age, socioeconomic status,
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religion, sexuality, and family type (Annandale & Hunt, 2000; Moss, 2002; Raday, 2003; Spector, 2004). For many women, complexities within their culture are as important as their gender and may be more critical than their sex as determinants of their health. Gender identity is thus a social construct, emerging from the “norms” of behavior imposed on women and men by culture and religion. In El-Safty’s (2004) view, “Women’s issues, Islamic or otherwise, and gender concerns are endemic of society’s broader dynamics. For this reason, a woman’s circumstances cannot be understood apart from her context.” (p. 273) While Reis`ebrodt (1998) sees the global resurgence of religious “fundamentalism” as a patriarchal reaction to feminism, the emancipation of women and the threat of gender equality, Raday (2003) takes a more radical stance, stating that “the story of ‘gender’ in traditionalist cultures and religions is that of the systematic domination of women by men, of women’s exclusion from public power, and of their subjection to patriarchal power within the family” (p. 669). Saulnier and colleagues (1999) contend that to understand gender as a determinant of health requires acknowledging issues in the system that are beyond an individual’s control, with women being affected by their social environment, their social roles, and the fact that they generally have less power and influence than men in society. Patient-centered care. In recognizing patients as integral family and community members, Edith Balint (1969) led the paradigm shift from doctorcentered to patient-centered care, placing the patient who has an illness (rather than a disease) at the center of the clinical encounter in which psychological, social, and biomedical elements are valued equally, with patient participation an important part of decision making (Bensing, 2000; Mead & Bower, 2000). A few years later, George Engel (1977) challenged the biomedical disease model of Western medicine, calling for the profession to broaden its approach. He advocated a biopsychosocial approach, highlighting that the “fuzzy” boundaries between health and disease are infused with cultural, social, and psychological considerations. A patient-centered approach would certainly be consistent with Islamic bioethics, which advocate treating a patient with respect and compassion, with consideration of their physical, mental, and spiritual well-being (Daar & Al Khitamy, 2001). An important tenet of a patient-centered approach is the doctor–patient relationship, which would necessitate good communication (Mead & Bower, 2000; Hammoud et al., 2005; Christen et al., 2008). For Muslim patients, doctor–patient communication would be particularly important, considering the value ascribed to personal relationships (Hedayat & Pirzadeh, 2001; Hammoud et al., 2005). As privacy is a requisite for Muslim patients, trust in the health care provider often needs to be established before personal information is divulged. For the physician, this may necessitate forsaking a professional fac¸ade for an approach that combines expertise and authority with warmth and personal interest. Muslim patients may also be more
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comfortable with a health care professional about whom they know something personal, so small talk is often required before the reason for the visit can be broached or discussed. For Taylor (2005), failure of a physician to understand such a cultural context, perhaps compounded by a language difference, may culminate in misdiagnosis, poor health outcomes, and ultimately patient dissatisfaction. In describing Muslim patients in the United States, Lipson and Meleis (1983) and Aboul-Enein and Aboul-Enein (2010) reiterate the importance of language in the medical encounter, pointing out that a Muslim patient may offer information simply to please the non-Arabicspeaking physician or perhaps to save face.
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METHODS Study Setting We conducted the study in Al Ain (Abu Dhabi emirate), the fourth largest city in the United Arab Emirates located some 160 km northeast of Abu Dhabi and 120 km southeast of Dubai, with a population of 375,000–400,000 local and expatriate residents. The Garden City, home to the greatest number of UAE Nationals and a center of Emirati culture, is the birthplace of the late Sheikh Zayed bin Sultan Al Nahyan, the first UAE president. The study site was the female outpatient polyclinics at the public hospital adjacent to the medical school, frequented by Emirati Nationals and where clinical students receive some of their training. The gender-segregated polyclinics service most clinical disciplines, including but not limited to O&G, Pediatrics, Endocrinology, Diabetes, Dermatology, and Rheumatology. While O&G is almost exclusively serviced by female physicians, female patients may encounter male specialists in most other disciplines.
Participants (Patients and Their Female Companions) As Emirati women rarely travel alone, participants (n = 218) were female Emirati Nationals or their accompanying female companions (often relatives) attending the specialist outpatient clinics described above.
Procedures Survey instrument. We chose an interview–based instrument over a self-administrated questionnaire to increase the response rate and to ensure completion of survey items. We designed the questionnaire such that students could simultaneously interview and circle the women’s responses for the various questionnaire items. Our choice of data collection method was also influenced by the anticipated varied education and literacy levels of our participants. The questionnaire was designed in English, translated into
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Arabic by the students, after which it was translated back into English by a professional translator and then checked by the students (Appendix 1). Students piloted the final questionnaire under supervision with four Faculty of Medicine and Health Sciences support staff members (two in English; two in Arabic) to ensure understanding by participants with little or no medical background. Biographical variables: Emirati women. In view of the gendersegregated social context and restrictions placed on unmarried females, we considered the following demographic independent variables important in understanding Emirati women’s preference of physician: age, marital status, parity, income, education status, and level of literacy. For the purpose of this study, “literate” was defined as a woman who was able to speak, read, and write English and Arabic, while one who could speak Arabic only was considered to have a “basic literacy.” A woman with a literacy level falling between these extremes was considered as “moderately literate.” Physician characteristics. The following characteristics were included as dependent variables in terms of Emirati women’s physician preference: sex, religion, age, nationality, region or country of specialization, and marital status. Data collection: Questionnaires. After receiving ethical approval from the university and the hospital to undertake the study, four female Emirati medical students who had just finished their first year of studies (July 2008) conducted face-to-face interviews with Emirati women at the clinics. After explaining the study to a patient or her accompanying chaperone and providing an information sheet in Arabic, verbal consent was obtained to interview. For minors, consent was obtained from the accompanying adult. Initially, a pair of students collected data, with one student asking the questions and the other documenting the responses on the survey sheet. Once comfortable with simultaneously collecting and documenting responses, individual students interviewed the participants. Participants were presented with the four hypothetical clinical scenarios (3 personal; 1 child) and asked for their preference of physician in terms of the characteristics described above (Appendix 1).
Data Collection, Capture, and Statistical Analysis Prenumbered questionnaires were completed anonymously as each interview proceeded. Information was then transferred to English questionnaire sheets, and each data sheet was checked. Data for each item were coded, entered into an Excel spreadsheet, and checked again with the English transcript before being imported into SPSS (SPSS Inc., Chicago, IL, Version 17.0). Participant characteristics are presented as median (range) and mean (±SD) for age (i.e., continuous variable) and as percentages for categorical variables such as marital status, level of education, and literacy. McNemar’s test
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(paired comparison) was used to compare preference for physician characteristics between different scenarios (e.g., allergy vs. “stomach”). Associations between the women’s preference for physician characteristics (dependent variables: gender, religion, nationality, region of certification, marital status, age) and participant demographics (independent variables: age, level of education, marital status, income, parity, literacy status) were tested by means of a logistical regression using a stepwise method (Backward Wald) to include significant variables. The results are depicted as odds ratios (OR), that is, the women having the opinion that a certain physician characteristic matters or does not matter (ratios of different categories for significant variables). An OR > 1 indicates that the women’s biographical variable (e.g., parity or education level) was a predictor for preference of a physician characteristic (e.g., age or nationality) to be important or to matter. An OR < 1 would therefore suggest that the women’s parity or education level) was not a predictor for her physician preference. All test outcomes were considered significant at p < .05.
RESULTS Participant Profile The women ranged in age from 12 to 70 years, with a mean (± SD) of 30 (± 11) years (median: 28 years). Only two females were younger than 15 years (i.e., 12 and 13). The majority of women (68%) were married, with one-third having more than four children (Table 1). Literacy ranged from 69% of the women who were fluent in both English and Arabic to 8% who could speak Arabic only (i.e., basic literacy). In terms of education, 41% of the women had completed high school, while 15% had completed tertiary education (Table 1).
Hypotheses Tested Hypothesis 1. While a female, and to a lesser extent, Muslim physician would be important for personal examinations (gynecological > stomach > allergy involving the eyes), the women would have no preference for the gender and religion of the doctor attending to their prepubertal child. As anticipated, physician gender (i.e., being female) was the most important consideration for the personal scenarios, with 94.5% and 96.8% of women preferring a female doctor for the abdominal and gynecological scenarios, respectively (Table 2). Unanticipated, however, was that 45.9% of the women preferred a female physician if they presented with a runny nose and red eyes (allergy scenario). As hypothesized, only 17.5% of the women stated that physician gender was important for the child
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scenario, with 13.8% preferring a male doctor (vs. ± 4% preferring a female; Table 2). Although more women (54.6%) preferred a Muslim doctor for the facial allergy scenario than for the abdominal and gynecological scenarios, this was not significant (Table 2). While the physician being Muslim was the most important consideration for the child scenario, this percentage (37.6% of women) was significantly lower than for the personal scenarios. Hypothesis 2. Preference would generally be for an Emirati or other Arab doctor who had specialized in the West. For more than 62% of the women, physician specialist certification and nationality was of no consequence. For those for whom these considerations did matter, statistical differences were recorded in terms of the personal scenarios, in particular, the facial allergy scenario (Table 2). Preference was for European or North American-trained physicians (25.7% allergy > 18.4% abdomen > 16.1% gynecology > 12.2% child), who were Emirati or Arabic (23.8% allergy > 19.7% abdomen > 17.9% gynecology > 10.5% child). Hypothesis 3. Women’s marital status (i.e., unmarried) and age (i.e., younger) would be the most important considerations impacting on physician preference, particularly in terms of gender. Contrary to expectation, age and marital status were not predictors of preferred physician characteristics. Having a tertiary education was, however, a significant predictor for physician religion “not to matter” for the three personal scenarios and for physician gender not to be important for the facial allergy scenario. In contrast, moderately literate and women with basic TABLE 1 Demographics of Emirati Women Interviewed (n = 218) Participant demographics Marital status Married Single Divorced Widowed Parity 0 (including 52 single females) 1 2 3 4+ Level of education completed University High school Elementary school or less Literacy Literate (speak, read, write English + Arabic) Moderate literacy Basic literacy (speak Arabic only)
% of women 68 24 4 4 35 11 11 9 34 15 41 44 69 23 8
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95.0a,d 94.5 0.5 50.9j 30.7l,o Europe: 13.8 UAE: 5.0 North America: 4.6 28.0q,t Emirati: 10.1 Arab: 9.6 Western: 6.9 16.5v 15.1 5.5 4.6
54.1a,b,c 45.9 8.2 54.6i 38.1l,m,n Europe: 17.9 North America: 7.8 UAE: 6.0 34.9q,r,s Emirati: 12.8 Arab: 11.0 Western: 9.2 22.0v,w 20.6 7.8 7.3
Gender Female Male Religion (Muslim) Specialist certification (country/region)
96.8b,e 96.8 0.0 52.8k 28.0m Europe: 12.4 UAE: 5.5 North America: 3.7 26.6r,u Emirati: 9.2 Arab: 8.7 Western: 5.5 17.4 16.1 5.5 5.5
Gynecology
17.4c,d,e 3.6 13.8 37.6i,j,k 24.8n,o Europe: 10.1 UAE: 4.6 North America: 4.1 17.0s,t,u Emirati: 6.4 Western: 5.0 Arab: 4.1 15.1w 12.8 5.5 5.0
Child
NSD
v: .029; w: .020
q: .028; r: .006; s–u: < .0005
i–k: < .0005 l: .009; o: .015; m,n: < .0005
a–e: < .0005
p values
McNemar’s test (paired comparison): xa,b - values with the same superscripted letter are significantly different (e.g., 54.1% and 95% of women for whom physician gender matters for the facial allergy is statistically significant, p < .005); NSD = no significant differences.
Age (>35 yrs) Marital status (married)
Nationality
Abdomen
Face
Physician characteristic
Clinical scenario
TABLE 2 Emirati Women (%) Who Indicated That Physician Gender, Marital Status, Religion, Age, Region of Certification, and Nationality “Mattered.” The % of Women Indicating Their Preference for Particular Physician Characteristics Reflects a Calculation Based on the Total Sample of 218 Women. Only the Most Frequently Identified Preferences Regarding Physician Characteristics Have Been Included
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literacy were more likely to prefer a Muslim physician to examine their face or abdomen. Relative to ‘literate’ women, those with lower literacy levels were also less likely to be concerned about physician age (Table 3), while having completed high school was a significant predictor for the physician to be married for the gynecological scenario.
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DISCUSSION We found that the Muslim women in our study, irrespective of their age, marital status, income, and literacy status, almost exclusively requested a female physician for medical conditions involving the awrah, areas of the body required by Islam to be covered, and which Muslim women generally find embarrassing to expose to the opposite gender (Underwood et al., 1999; Winslow & Honein, 2007; Yosef, 2008). Our findings confirm reports of Muslim women’s request for same-gender physicians in O&G (Aldeen, 2007; Hammoud et al., 2005; Lafta, 2006; Rizk et al., 2005; Rizk & El-Safty, 2006; Uskul & Ahmad, 2003). That almost half of the Emirati women preferred a female physician to examine their eyes was, however, unexpected, as we considered this scenario not to be sensitive. Two explanations are possible, one taking cognizance of the local cultural context and the other a religious perspective. Although Islam does not require females to cover their face, devout Muslims, particularly in gender-segregated, traditional societies such as the United Arab Emirates and Saudi Arabia, may still be influenced by a perceived “requirement” to veil and be secluded, that is, that of enforced veiling and seclusion (purdah) of women by Prophet Muhammad’s successor, Umar (Sechzer, 2004). Concealing one’s face in public is common amongst Emirati women, with older females wearing a burqa, a covering of the mouth and nose, although more globally this term may refer to the complete attire used by women to cover, including the face or a niqab, a cloth face covering leaving only the eyes exposed. Younger Emirati women tend to wear a gashwa, a black veil draped over the head that completely covers the face or a niqab. In terms of a religious explanation for a preference for a female physician to examine their eyes, the Qur’an Sura Nur (24: 31–32) states that both men and women should lower their gaze and guard their modesty as eye contact may generate a sexual desire, which could lead to lustful thoughts and possible unlawful activity (Al-Sheha, 2002). Muslims therefore generally do not make eye contact with the opposite gender (Hammoud et al., 2005). Thus, although a stronger religious underpinning may exist to explain avoidance of eye contact than for exposing one’s awrah to a male doctor, with Islam condoning and recommending the latter if the doctor is the best qualified physician (Aldeen, 2007; El-Qadar, 2007; Hathout, 1986), for Muslim women, particularly the more traditional and religiously
863
NSP
Marital status
University degree OR = 0.34, p = .02 Literacy Literate: Reference Semi-literate: OR = 1.59, p = .17 Illiterate: OR = 5.20, p = .01 NSP NSP Literacy Literate: Reference Semi-literate: OR = 0.26, p = .03 Illiterate: OR = 0.80, p = .74 NSP
NSP
Abdomen
High school completed OR = 9.32, p = .03
NSP NSP NSP
University degree OR = 0.30, p = .004
NSP
Gynecology
Clinical scenario involving
High school completed OR = 0.53, p = .04 Monthly income (AED) 50K: OR = 1.48, p = 0.63 NSP NSP Literacy Literate: Reference Semi-literate: OR = 0.27, p = .04 Illiterate: OR = 0.25, p = .18 Marital status (married/single) OR = 0.14, p = .004
NSP
8-year old child
Logistical regression: Odds ratios (OR) of having the opinion that a certain physician characteristic matters (ratios of different categories for significant variables) with p values. An OR < 1 indicates that it “does not matter” about the physician characteristic. p = significant. NSP = no significant predictor.
Religion
Certification Nationality Age
Face
University degree OR = 0.44, p = .048 University degree OR = 0.44, p = .05 Literacy Literate: Reference Semi-literate: OR = 2.38, p = .02 Illiterate: OR = 5.00, p = .02 NSP NSP NSP
Gender
Physician characteristic
TABLE 3 Logistical Regression of Emirati Women’s Biographical Variables as Significant Predictors of Preference for Physician Characteristics
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conservative, having a male doctor examine their face (with unavoidable eye contact) would be uncomfortable as it may contravene their religious beliefs. We found that women with a university education were less concerned about a female physician for the facial allergy scenario, which may reflect greater acceptance of cross-gender health care for areas of a woman’s body not involving the awrah, perhaps as a result of increased flexibility in terms of understanding Islam and medicine. It is also possible that they would have been exposed to numerous male teachers, largely expatriate, during their higher education studies and so were more comfortable in the presence of the opposite gender. The same did not, however, hold true for the scenarios involving the awrah. All women, irrespective of their educational status, preferred female physician for medical conditions involving these religiously sensitive areas of the body. This is in contrast to Lafta’s (2006) study in which Muslim Iraqi women with a university education were less likely to be concerned about gynecologist or obstetrician gender. The overwhelming preference for a female doctor, while reflecting a modesty stemming from deep-rooted religious beliefs and perhaps perceptions of a religious recommendation (but not requirement) for a same-gender doctor first (Aldeen, 2007; Hathout, 1986; Hedayat & Pirzadeh, 2001), has probably also been reinforced by the prevailing local gender-segregated social and traditional Bedouin cultural context (Winslow & Honein, 2007). This preference for same-gender physicians beyond O&G highlights the need to take cognizance of cultural and religious considerations in the health care encounter. Not providing female health care professionals for examinations involving the awrah may impact on women’s health-seeking behavior as practices or procedures perceived as culturally inappropriate will be avoided, as was reported for some breast and cervical cancer screening programs in the United States (Matin & LeBaron, 2004; Rajaram & Rashidi, 1999, 2003; Underwood et al., 1999). In a UAE study on urinary incontinence, Rizk and colleagues (1999) found that 70.9% of incontinent women and 77.5% of continent women would be too embarrassed to consult a male doctor (vs. 29.1% and 22.5%, respectively, who would not consult a female doctor). These and other findings (e.g., Rizk & El-Safty, 2006) suggest that if female practitioners are not available, preventable diseases and conditions may remain untreated for some Muslim women. For the Emirati women in this study, the physician being Muslim was generally not as important as being attended to by a female doctor. The exception was for the facial allergy scenario, where almost 55% preferred a Muslim. That two-thirds of the women were not particular about physician religion for intimate examinations is interesting, considering that Islam recommends (but does not insist) on a same-gender Muslim physician as a Muslim patient’s first choice (Aldeen, 2007; Hathout, 1986; Hedayat & Pirzadeh, 2001). This finding may also reflect these women’s experiences with the UAE health care system, which is serviced largely by expatriate physicians, many
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of whom are of Middle Eastern origin and so would generally be Muslim. It is also possible that if the women had assumed that they would be attended to by a female physician, then her being non-Muslim would not be an issue (i.e., second preference according to Islam). Education level (higher) and literacy status (less literate), however, impacted on preference for a Muslim physician. To this end, for personal examinations, women with a tertiary education were less likely to request a Muslim doctor, and, conversely, being less literate was a significant predictor for a preference for a Muslim physician. As suggested for physician gender not mattering in terms of the facial allergy scenario for women with a higher education, Emirati females attending college or university would have been exposed to many Western expatriate teachers and lecturers who would generally not be Muslim. A further explanation is that more-educated women may also be able to distinguish Islamic teachings from cultural interpretations of Islam (i.e., that Islam does not insist on a Muslim physician and that the best trained doctor should be consulted). Communication between a doctor and patient is important (Christen et al., 2008; Mead & Bower, 2000), as it may impact on the information divulged, a patient’s behavior, and ultimately a patient’s satisfaction and health outcomes (Aboul-Enein & Aboul-Enein, 2010; Lipson & Meleis, 1983; Taylor, 2005). For gynecology outpatients at Swiss clinics, it was not the gynecologist’s gender that influenced patient satisfaction and compliance but the doctor’s patient-centered communication skills (Christen et al., 2008). In a similar vein, Uskul and Ahmad (2003) reported qualitative differences between male and female gynecologists’ communication skills, with Turkish patients asking more questions and disclosing more about their physical problem with female physicians. For the Arab or Middle Eastern patient, considering the value attached to personal relationships and the religious and cultural issues associated with health, illness, and death (Aboul-Enein & Aboul-Enein, 2010; Lipson & Meleis, 1983), communication in the clinical consultation may be of heightened importance. Not taking cognizance of or not understanding the impact of race, ethnicity, and culture in the clinical consultation may compromise patient–physician communication (CooperPatrick et al., 1999; Hammoud et al., 2005). That between 18% and 24% of the women in the present study had a preference for an Emirati and another Arab doctor for personal examinations may reflect their need for cultural and/or language congruence with the physician. With ±25% of the women unable to communicate in English, being attended to by an Arabic-speaking physician would probably be an important consideration. Winslow and Honein’s (2007) study of Al Ain Emirati women supports this, with the women in their study identifying a lack of culturally sensitive care and language as two of the many barriers to their health. They complained of hospitals and clinics being staffed largely by expatriate health professionals (often males), many of whom did not speak Arabic or did not
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understand the culture. In particular, they mentioned that it was culturally inappropriate for a Muslim woman to be examined or even be seen unveiled by a male doctor, as others have also reported (Underwood et al., 1999; Yosef, 2008). In a United Kingdom study, Ahmed and colleagues (1989) suggested that female Pakistani Muslim patients, the most likely group to prefer same-gender physicians, had consulted mainly Asian male doctors to meet linguistic needs. Ahmed and colleagues (1989) were, however, concerned that there was “evidence from health visitors and health liaison workers . . . that a considerable minority of Asian, particularly Muslim, women are not consulting their general practitioner for gynaecological conditions and are therefore going without proper medical care” (p. 155), highlighting the need for culturally congruent health care if women’s health needs are to be met. In a patient-centered approach, a physician tries to enter the patient’s world, to see illness through the patient’s eyes (McWhinney, 1989). In such an approach, it is difficult to imagine how a male doctor can empathetically comprehend women’s reproductive health experiences. In the same vein, it is probably not possible for a non-Muslim physician to truly understand the religious and cultural innuendos and nuances underlying Islamic patients’ perceptions of or attitude toward illness.
Intimacy of Medical Complaints: Implications for Health Care for Muslim Women Our study has identified that for Muslim women with an innate modesty stemming from their religious upbringing, health care involves more than providing female service providers in O&G. The awrah includes the abdomen, chest, legs, and arms. The facial allergy scenario was deemed “nonsensitive,” based on the fact that although Islam requires a woman’s hair to be covered, her face can be exposed. For some Muslim women in our study, however, in particular those less educated or less literate, having a male doctor examine their eyes appears to be unacceptable, as opposite genders should not make eye contact (Hammoud et al., 2005). A possible explanation that more women preferred an Emirati or another Arab (likely to be Muslim) doctor for their allergy may reflect a common understanding of the religious underpinnings relating to cross-gender eye contact. That more of these women preferred a male physician to attend to their 8-year-old child is interesting but difficult to explain. Had the child scenario been a 12- or 13-year-old adolescent (pubertal, unmarried) female, however, the physician would definitely need to be female (Hedayat & Pirzadeh, 2001). Some of our findings have implications for health care provision not only for Emirati women, but also for Muslim women in general. Irrespective of where “home” might be, based on religious beliefs (whether correctly interpreted or not) and a strong sense of modesty, Muslim women’s preference for most personal medical problems involving the awrah (i.e., beyond O&G)
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would generally be a female physician. That the female doctor was also Muslim would satisfy a religious recommendation (Aldeen, 2007; Hathout, 1986; Hedayat & Pirzadeh, 2001), which conservative Muslims may perceive as a requirement. In the light of these findings, it would certainly be appropriate for clinics and hospitals to provide female (if possible, Muslim) health care professionals to attend to Muslim women not only for O&G and for areas of the body that Islam dictates should be covered. In addition, our results suggest that there are other medical complaints that may be considered sensitive to Muslim patients but are not perceived as such in a Western context. Examining the eyes and perhaps exposing the hair, the latter being part of a woman’s zeenah, would be two such examples. Although Islam advises that physician gender does not matter during emergencies and in situations when the best available specialist is required, some women (or their husbands) would probably still not readily accept being examined by a male doctor (Aldeen, 2007; Hathout, 1986), potentially creating a dilemma for hospital staff and administrators. With a global trend toward religious conservatism within Islamic countries and Muslim communities in Western countries, together with the rapid spread of Islam, this eventuality should be anticipated. In the United States, it is projected that Muslims will soon comprise the second largest religious group (Hasnain, 2006; Underwood et al., 1999). In the United Arab Emirates, and probably also in many other countries, while O&G specialists and consultants are often female, the same cannot be said for other medical disciplines (Winslow & Honein, 2007). If women feel uncomfortable because the health care service is not aligned with their religious or cultural beliefs, this may negatively impact on their health-seeking behavior, as happened with some breast (Rajaram & Rashidi, 1999; Underwood et al., 1999) and cervical cancer (Matin & LeBaron, 2004) screening programs in the United State In Rizk and El-Safty’s (2006) view, the implications of culture, and, in this case, religious views, will impact profoundly on women’s health: “The health status in any one society cannot be understood apart from the cultural factors that determine not only the individual’s attitudes towards health matters but also the behavior of these individuals” (p. 436). Within a gender equity framework, recognizing how religion and culture influence health-seeking behavior would necessitate the availability of appropriate health care providers and programs that encourage rather than discourage women (or men) from attending. Although patient autonomy is paramount, physician and patient education is also important (Adams, 2003). This is particularly so for Muslim patients, some of whom may not recognize or accept the waiving of the religious requirement regarding modesty and cross-gender touching during medical care (Aldeen, 2007; Hathout, 1986; Hedayat & Pirzadeh, 2001). Hathout (1986) is of the opinion that the present day health-seeking behavior of Muslims may, in part, reflect a rekindling of Islamic feelings, lest their activities be scrutinized and be found objectionable to Islam. The
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insistence by most Muslim women (and presumably also many men) to be examined by a same-gender doctor is one such behavior that may arise from differing perceptions or interpretations of a religious recommendation. Since culture, religion, and gender are intricately intertwined (Raday, 2003), it is often difficult to extricate religious teachings and beliefs from cultural or traditional practices. Although religious leaders might point out that Islam does not prohibit cross-gender examinations, the culture and social dynamics of the community, population, or country may serve to reinforce long-established religious or cultural traditions and beliefs. Cultural factors stemming from religious beliefs and practices can thus potentially impact (negatively or positively) on men and women’s health-seeking behavior and ultimately their health. In a patient-centered, biopsychosocial approach (Bensing, 2000; McWhinney, 1989; Mead & Bower, 2000) and in line with Islamic bioethics (Daar & Al Khitamy, 2001), a patient should be treated with respect and compassion and cognizance taken of all aspects of his or her physical, mental, and spiritual well-being. Providing same-gender physicians and not requesting women to unnecessarily expose their awrah or remove their sheylas would undoubtedly contribute to better compliance and health outcomes, particularly amongst more traditional Muslims. Using HausmannMuela and colleagues’ (2003) “four As” model of health care (availability, accessibility, affordability, acceptability), acceptability (e.g., physician gender) would be the most important consideration in the context of providing culturally congruent health care for Emirati women and probably for most Muslim women. For innately modest Muslim women and for women raised in gender-delineated societies such as the UAE and Saudi Arabia, to expose their awrah to the opposite gender would probably be a violation of their religious upbringing and cultural practice (Winslow & Honein, 2007). As it is stressful for Muslim women to expose their bodies to male health care providers or even to discuss sensitive topics related to women’s health with them (Yosef, 2008), medical problems such as urinary incontinence (Rizk et al., 1999) and pelvic floor dysfunction (Rizk & El-Safty, 2006) may be largely untreated. Emerging from our study is the acknowledgment that Muslim women’s health care extends beyond O&G. This is probably true for women’s health in general, as there has been a preoccupation with women’s reproductive health and maternal well-being, sometimes to the exclusion of other important medical problems (Saulnier et al., 1999). Quality health outcomes for Muslim women thus require an approach that acknowledges the religious, social, and cultural factors that impact not only traditionally modest women’s perceptions of their health, but also men’s attitudes and behavior toward women’s health (Dudgeon & Inhorn, 2004; El-Safty, 2004; Rizk & El-Safty, 2006). Although the Qur’an views men and women as equal in human dignity (Badawi, 1971), this is not always reflected in Islamic society as women may not have equal rights, for example, in terms of their choice of marriage partner or divorce (El-Safty, 2004; Sechzer, 2004). Such situations
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have arisen largely due to the (mis)interpretation of Qur’anic verses that refer to men as guardians (qawamum) of women and so may have considerable influence over women’s health-seeking behavior and ultimately their well-being (El-Safty, 2004; Hammoud et al., 2005; Sechzer, 2004).
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CONCLUSIONS Notwithstanding that this study reflects the views of Muslim women in one city in one country, some of the issues raised apply to Muslim women elsewhere. The study has provided insight into these women’s preference for a service provider, not only in terms of intimate O&G problems, but also for health issues involving areas of the body considered less sensitive in the West but that may perhaps be haram (forbidden) for many Muslims and that have generally not been described in the literature. Within a framework of gender sensitivity and gender equity in health care, Saulnier and colleagues (1999) have pointed out that gender biases and the lack of gender analysis have manifest as a preoccupation with women’s reproductive health and maternal well-being, to the exclusion of other pressing health issues. The present study supports the need to look beyond Muslim women’s reproductive health issues and to consider their health requirements and general well-being within the cultural and social context in which the women find themselves. Mainstreaming gender into health-related policies and programs (i.e., by incorporating their views and priorities) requires a health approach in which an individual’s social and physical environment and socioeconomic conditions are considered as important factors influencing their health status (Leininger, 2002; Leininger & McFarland, 2006; Saulnier et al., 1999; Spector, 2004). The findings of this study have been explained within a broad framework of culture and its impact on health and health-seeking behavior. As religion and gender are often intricately embedded within the culture (Raday, 2003), probably more so in Muslim communities, where Islam is not only a religion but a way of life, it is often difficult to tease out which perceptions, beliefs, and behaviors can be attributed to local traditions and which have religious underpinnings. Considering the history of Islamic medicine, with female nurses and with religious leaders condoning cross-gender health care, the present-day request by Muslim women for a same-gender physician, while underpinned to some extent by an Islamic recommendation relating to the order of preference of physician (i.e., same-gender Muslim first, opposite-gender non-Muslim last), has possibly arisen through different interpretations that have become part of a traditional belief system handed down over several generations and that is now entrenched in the day-today lives of many Muslims. The intimate relationship between religion and traditional cultural values and beliefs thus make it difficult for outsiders and Muslims alike to separate Qur’anic teachings from different interpretations
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that have been woven into the social fabric of a population or community. If culturally sensitive and congruent health care is to be offered, understanding these intricacies and nuances, albeit difficult, should be the starting point for health care providers servicing a Muslim community as they have implications in terms of resources, physician training, and patient education. In their paper on men’s influences on women’s reproductive health, Dudgeon and Inhorn (2004) assert that health equality, but particularly health equity, should apply equally to all aspects of men and women’s health. While equality emphasizes egalitarian health outcomes through equal and complementary services, equity emphasizes justice in health outcomes through the provision of appropriate services (Dudgeon & Inhorn, 2004). In terms of women’s health, Moss states the following: A thoughtful consideration of culture moves us beyond the language of the dominant institutions into the understandings that women have about their health-related behaviors, and into a more rounded consideration of the ways in which equity and power are expressed in every day life. (2002, p. 653)
Thus, if equitable health outcomes require same-gender physicians, then such provisions should be made. Until there are interventions from religious leaders highlighting that cross-gender consultations are acceptable and not haram, in the interest of patients’ well-being, patient autonomy should be respected and same-gender physicians provided. Despite 40 years of modernization and development in the UAE, a country in which only ±15% of the population is comprised of indigenous inhabitants, a deep devotion to the theology of Islam has largely ensured the preservation of traditional Emirati culture and values (Schvaneveldt et al., 2005). The present study suggests that while education and literacy may contribute to increasing flexibility in terms of some practices in health care, for example, a physician not needing to be being Muslim, the cultural context of the UAE (i.e., gender segregation) might continue to reinforce the reported “requirement” for a female doctor for medical problems involving areas of the body Islam requires to be covered. Education and increasing female employment may, however, contribute to relaxation of patriarchal attitudes toward traditional gender roles (Damji & Lee, 1995; Schvaneveldt et al., 2005). Although two generations of women in Schvaneveldt and colleagues’ (2005) study (college students and their mothers) perceived Islam and family as foundations that would guide their nation with its rich desert history through the current social revolution, in view of the value attached to education (Ridge, 2009) and the large numbers of Emirati women entering the labor market (Nelson, 2004), the traditional Emirati family and its patriarchal values will soon find themselves at a crossroad.
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Limitations As this study was conducted in Al Ain, the views of Emirati women in one city only have been canvassed. In view of the global trend toward religious conservatism and the increasing conversion to Islam, making it the fastest growing religion, the authors are of the opinion that Muslim women’s preference for same-gender physicians and, to a lesser extent, for a Muslim physician, applies to many followers of Islam, irrespective of where home might be. This study reflects information gathered from a group of traditionally and culturally modest Emirati women who may not have been open about some issues, as Badrinath, Ghazal-Aswad, Parfitt, and Osman (2004) experienced in Saudi Arabia when trying to research issues considered sensitive amongst Muslims (i.e., physical and sexual maturation). The students who undertook the study were also female Emiratis. Besides gaining considerable experience and insight into the future practice of medicine in their own country, students reported that the women were supportive of the research and genuinely interested in contributing as their perceptions regarding their health care requirements were being canvassed. Winslow and colleagues (2002) recommend same-gender and same-culture interviewers for qualitative research in such studies.
REFERENCES Aboul-Enein, B. H., & Aboul-Enein, F. (2010). The cultural gap delivering health care services to Arab American populations in the United States. Journal of Cultural Diversity, 17(1), 20–23. Adams, K. E. (2003). Patient choice of provider gender. Journal of the American Medical Women’s Association, 58(2), 117–119. Ahmad, W. I. U., Kernohan, E. E. M., & Baker, M. R. (1989). Patients’ choice of general practitioner: Influence of patients’ fluency in English and the ethnicity and sex of the doctor. Journal of the Royal College of General Practitioners, April, 153–155. Al Sayegh, F. (2004). Post-9/11 changes in the Gulf: The case of the UAE. Middle East Policy, XI, 107–124. Aldeen, A. Z. (2007). The Muslim ethical tradition and emergent medical care: An uneasy fit. Academic Emergency Medicine, 14, 277–278. Al-Sheha, A. A. (2002). Islamic perspective of sex (M. S. Dabas, Trans.). Retrieved from http://www.islambasics.com/view.php?authID=40 Annandale, E., & Hunt, K. (2000). Gender inequalities in health. In E. Annandale & K. Hunt (Eds.), Gender inequalities in health (pp. 1–35). Philadelphia, PA: Open University Press. Badawi, J. A. (1971). The status of women in Islam. Al-Ittihad, 8(2). Retrieved from http:///www.jannah.org/sisters/badawistatus.pdf Badrinath, P., Ghazal-Aswad, S., Parfitt, D., & Osman, N. (2004). Cultural and ethnic barriers in conducting research. Factors influencing menarche in the United Arab Emirates. Saudi Medical Journal, 25, 1626–1630. Balint, E. (1969). The possibilities of patient-centred medicine. Journal of the Royal College of General Practitioners, 17, 269–276.
Downloaded by [Bond University] at 18:50 27 October 2012
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Bensing, J. (2000). Bridging the gap. The separate worlds of evidence-based medicine and patient-centered medicine. Patient Education & Counseling, 39, 17–25. Bertakis, K. D., Franks, P., & Azari, R. (2003). Effects of physician gender on patient satisfaction. Journal of the American Medical Women’s Association, 58(2), 69–75. Chandler, P. J., Chandler, C., & Dabbs, M. L. (2000). Provider gender preference in obstetrics and gynecology: A military population. Military Medicine, 165, 938–940. Christen, R. N., Alder, J., & Bitzer, J. (2008). Gender differences in physicians’ communicative skills and their influence on patient satisfaction in gynaecological outpatient consultations. Social Science & Medicine, 66, 1474–1483. Cooper-Patrick, L., Gallo, J. J., Gonzales, J. J., Vu, H. T., Powe, N. R., Nelson, C., & Ford, D. E. (1999). Race, gender, and partnership in the patient-physician relationship. Journal of the American Medical Association, 282, 583–589. Daar, A. S., & Al Khitamy, B. (2001). Bioethics for clinicians: 21. Islamic bioethics. Journal of the Canadian Medical Association, 164, 60–63. Damji, T., & Lee, C. M. (1995). Gender role identity and perceptions of Ismaili Muslim men and women. The Journal of Social Psychology, 135, 215–223. Dudgeon, M. R., & Inhorn, M. C. (2004). Man’s influence on women’s reproductive health: Medical anthropological perspectives. Social Science & Medicine, 59, 1379–1395. El-Qadar, A. (Trans.). (2007). Ibn Qay’em El-Jozeyah on The Prophet Medicine. Retrieved from http://www.islamhouse.com/p/51834 El-Safty, M. (2004). Women in Egypt: Islamic rights versus cultural practice. Sex Roles, 51, 273–281. Engel, G. (1977). The need for a new medical model: A challenge for biomedicine. Science, 196, 129–136. Hammarstr¨om, A. (2007). A tool for developing gender research in medicine: Examples from the medical literature on work life. Gender Medicine, 4(Suppl. B), S123–S132. Hammoud, M. M., White, C. B., & Fetters, M. D. (2005). Opening cultural doors: Providing culturally sensitive healthcare to Arab American and American Muslim patients. American Journal of Obstetrics and Gynecology, 193, 1307–13011. Hasnain, M. (2006). Bridging the quality gap for Muslim women. In M. Hasnain (Ed.), Patient-centered health care for Muslim women in the United States. Conference proceedings and postconference evaluation report. Chicago, IL: University of Illinois at Chicago Press. Retrieved from http://uic.edu/depts/mcfp/ Pcc%20for%20Muslim%20Women%20Conference%20Proceedings%20final.pdf Hathout, H. (1986). The male gynaecologist. Medical examination of the other sex. Retrieved from http://www.islamset.org/bioethics/obstet/examin.html Hausmann-Muela, S., Ribera, J. M., & Nyamongo, I. (2003). Health-seeking behavior and the health system response. Disease Control Priorities Project (Working Paper No. 14). Retrieved from http://www.dcp2.org/file/29/wp14.pdf Hedayat, K. M., & Pirzadeh, R. (2001). Issues in Islamic biomedical ethics: A primer for the pediatrician. Pediatrics, 108, 965–971. Im, E.-O., & Meleis, A. I. (2001). An international imperative for gender-sensitive theories in women’s health. Journal of Nursing Scholarship, 33, 309–314.
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Muslim Women’s Physician Preference
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Lafta, R. K. (2006). Practitioner gender preference amongst gynecologic patients in Iraq. Health Care for Women International, 27, 125–130. Laird, L. D., de Marrais, J. J., & Barnes, L. L. (2007). Portraying Islam and Muslims in MEDLINE: A content analysis. Social Science & Medicine, 65, 2425–2439. Leininger, M. (2002). Cultural care theory: A major contribution to advance transcultural nursing knowledge and practices. Journal of Transcultural Nursing, 13, 189–192. Leininger, M., & McFarland, M. (2006). Culture care diversity and universality: A worldwide nursing theory. Sudbury, MA: Jones and Bartlett. Lipson, J. G., & Meleis, A. I. (1983). Issues in health care of Middle Eastern patients. The Western Journal of Medicine, 139, 854–861. Matin, M., & LeBaron, S. (2004). Attitudes toward cervical cancer screening amongst Muslim women: A pilot study. Women and Health, 39, 63–77. McLean, M., Al Ahbabi, S., Al Ameri, M., Al Mansoori, M., Al Yahyaei, F., & Bernsen, R. (2010). Muslim women and medical students in the clinical encounter: A United Arab Emirates study. Medical Education, 44, 306–315. McWhinney, I. (1989). The need for a transformed clinical method. In M. Stewart & D. Roter (Eds.), Communicating with medical patients (pp. 25–42). London, England: Sage. Mead, N., & Bower, P. (2000). Patient-centredness: A conceptual framework and review of the empirical literature. Social Science & Medicine, 51, 1087–1110. Moss, N. E. (2002). Gender equity and socioeconomic inequality: A framework for the patterning of women’s health. Social Science & Medicine, 54, 649–661. Nelson, C. (2004). UAE National women at work in the private sector: Conditions and restraints (Labour Market Study No. 20). Dubai, United Arab Emirates: Centre for Labour Market Research & Information, National Human Resource Development and Employment Agency. Piper, I., Shvarts, S., & Lurie, S. (2008). Women’s preferences for their gynecologist or obstetrician. Patient Education & Counseling, 72(1), 109–114. Raday, F. (2003). Culture, religion, and gender. International Journal of Constitutional Law, 1, 663–715. Rajaram, S. S., & Rashidi, A. (1999). Asian-Islamic and breast cancer screening: A socio-cultural analysis. Women and Health, 28(3), 45–58. Rajaram, S. S., & Rashidi, A. (2003). African-American Muslim women and health care. Women and Health, 37(3), 81–96. Reis`ebrodt, M. (1998). Pious passion: The emergence of modern fundamentalism in the United States and Iran (trans. D. Reneau). Berkley, CA: University of California Press. Ridge, N. (2009, August). The hidden gender gap in education in the UAE. Dubai, UAE: Dubai School of Government Policy Brief No. 12. Risberg, G., Hamberg, K., & Johansson, E. E. (2006). Gender perspective in medicine: A vital part of medical scientific rationality. A useful model for comprehending structure and hierarchies within medical science. BMC Medical Education, 4(20). doi:10.11861/1741–7015/4/20. Retrieved from http://www.biomedicalcentral. com/1741-7015/4/20 Rizk, D. E. E., & El-Safty, M. (2006). Female pelvic floor dysfunction in the Middle East: A tale of three factors—Culture, religion and socialization of health role stereotypes. International Urogynecological Journal, 17, 436–438.
Downloaded by [Bond University] at 18:50 27 October 2012
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M. McLean et al.
Rizk, D. E. E., El-Zubeir, M. A., Al-Dhaheri, A., Al-Mansouri, F. R., & Al-Jenaib, H. S. (2005). Determinants of women’s choice of their obstetrician and gynecologist provider in the UAE. Acta Obstetrics & Gynecology Scandinavia, 84, 48–53. Rizk, D. E. E., Nasser, M., Thomas, L., & Ezimokhai, M. (2001). Women’s perceptions and experiences of childbirth in United Arab Emirates. Journal of Perinatal Medicine, 29, 298–307. Rizk, D. E. E., Shaheen, H., Thomas, L., Dunn, E., & Hassan, M. Y. (1999). The prevalence and determinants of health care-seeking behavior for urinary continence in United Arab Emirates women. International Urogynecological Journal, 10, 160–165. Ruiz-Cantero, M. T., Vives-Cases, C., Artazcoz, L., Delgado, A., Calvente, M. de M. G., Misqueo, C., . . . Valls, C. (2007). A framework to analyse gender bias in epidemiological research. Journal of Epidemiology and Community Health, 61(supp II), ii46–ii53. doi:10.1136/jech.2007.062034 Saulnier, C., Bentley, S., Gregor, F., MacNeil, G., Rathwell, T., & Skinner, E. (1999). Gender mainstreaming: Developing a conceptual framework for en-gendering healthy public policy. Halifax, Nova Scotia, Canada: Maritime Centre of Excellence for Women’s Health, Dalhousie University. Schnatz, P. F., Murphy, J. L., O’Sullivan, D. M., & Sorosky, J. I. (2007). Patient choice: Comparing criteria for selecting an obstetrician-gynecologist based on image, gender, and professional attributes. American Journal of Obstetrics and Gynecology, 197, 548.e1–e7. Schvaneveldt, P. L., Kerpelman, J. L., & Schvaneveldt, J. D. (2005). Generational and cultural changes in family life in the United Arab Emirates: A comparison of mothers and daughters. Journal of Comparative Family Studies, 36, 77–91. Sechzer, J. A. (2004). Islam and woman: Where tradition meets modernity: History and interpretations of Islamic women’s status. Sex Roles, 51(5–6), 263–272. Spector, R. (2004). Cultural diversity in health and illness (6th ed.) Upper Saddle River, NJ: Prentice Hall. Taylor, R. (2005). Addressing barriers to cultural competence. Journal for Nurses in Staff Development, 21, 135–142. Underwood, S. M., Shaikha, L., & Bakr, D. (1999). Veiled yet vulnerable. Cancer Practice, 7, 285–290. Uskul, A. K., & Ahmad, F. (2003). Patient-physician interaction: A gynecology clinic in Turkey. Social Science & Medicine, 57, 205–215. Winslow, W. W., & Honein, G. (2007). Bridges and barriers to health: Her story—Emirati women’s health needs. Health Care for Women International, 28, 285–308. Winslow, W. W., Honein, G., & Elzubeir, M. A. (2002). Seeking Emirati women’s voices. The use of focus groups with an Arab population. Health Care for Women International, 12, 566–575. Yosef, A. R. (2008). Health beliefs, practice, and priorities for health care of Arab Muslims in the United States: Implications for nursing care. Journal of Transcultural Nursing, 19, 284–291. Zuckerman, M., Navizedeh, N., Feldman, J., McCalla, S., & Minkoff, H. (2002). Determinants of women’s choice of obstetrician/gynecologist. Journal of Women’s Health and Gender-Based Medicine, 11, 175–180.
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Appendix 1: English Version of the Questionnaire Used to Solicit Female Emirati’s Physician Preference Patients’ Physician Preference Questionnaire Verbal consent: Yes A1
Patient No :
A2
Study Site: Tawam Clinic:
A3
Age: Date of Birth:
A4
(day/month/year)
Level of education and language skills: a. Highest school year/grade completed: b. University degree: c. Read Arabic: Yes/No
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d. Write Arabic: Yes/No e. Speak English: Yes/No f. Read English: Yes/No A5
What is your occupation? a. Housewife: b. Professional: c. Other:
A6
What is your marital status? a. Single b. Married c. Divorced d. Widowed
A7
What is your husband’s occupation? a. Unemployed: b. Manual worker: c. Professional: d. Other:
A8
What is your family’s monthly income in UAE Dirham? a. Less than 20000 b. Between 20000–50000 c. More than 50000
A9
How many children do you have?
A10
What is your reason for visiting the hospital today?
A11
Why did you choose this hospital?
A12
Describe the type of doctor you would like to see today. (Continued on next page)
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Appendix 1: English Version of the Questionnaire Used to Solicit Female Emirati’s Physician Preference (Continued ) A13
Was he/she recommended to you? Yes/No If YES, by whom?
B1
We will give you 4 scenarios and ask you about your doctor preference in terms of several factors. Then, we will ask you about your views on students training to be doctors.
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Case 1: You have an allergy, itching, red eyes and a runny nose: You prefer that your doctor is:
B2
B3
B4
a. Female
Male
Does not matter
b. Younger than 35
Older than 35
Does not matter
c. Married
Single
Does not matter
d. Emirati
Arab
e. Muslim
Non-Muslim
f. Medical specialization, certification
UAE
Asian
Western
Does not matter
Does not matter Arab countries
North America
Europe
Does not matter
Case 2: You have pains in the stomach that require examination of your abdomen and probably your chest. You prefer your doctor to be: a. Female
Male
Does not matter
b. Younger than 35 years
Older than 35 years
Does not matter
c. Married
Single
d. Emirati
Arab
Does not matter Asian
Western
e. Muslim
Non-Muslim
Does not matter
f. Medical specialization, certification
Arab countries
North America
Does not matter
Europe
Does not matter
Case 3: You have a gynecological problem such as irregular periods or maybe “vaginal inflammation” that requires an intimate internal examination. Do you prefer your doctor to be: a. Female
Male
Does not matter
b. Younger than 35
Older than 35 years
Does not matter
c. Married
Single
d. Emirati
Arab
e. Muslim
Non-Muslim
f. Medical specialization, certification UAE
UAE
Does not matter Asian
Western
Does not matter
Does not matter Arab countries
North America
Europe
Does not matter
Case 4: Your child is 8 years old (male/female) and is sick. Do you prefer your doctor to be: a. Female
Male
Does not matter
b. Younger than 35
Older than 35 years
Does not matter
c. Married
Single
d. Emirati
Arab
e. Muslim
Non-Muslim
f. Medical specialization, certification
UAE
Does not matter Asian
Western
Does not matter
Does not matter Arab countries
North America
Europe
Does not matter
