Muslim women choice for gender of obstetricians and gynecologist in Turkey 1

Objective: It would generally be thought of that the Muslim women especially preferred female obstetricians/gynecologists (ob/gyn). The aim of this study is to investigate the gender preference of Turkish Muslim women regarding ob/gyn, and identify other features that affect their choice. Methods: In this study it has been included 710 women attending to gynecology and antenatal clinics and they have been asked to complete a survey questionnaire containing 16 items and requiring opinion on whether they want to be examined medically by a female or male ob/gyn and have no preference. The questions have also contained the reasons for the stated preference. Results: Of all participants, 230 (32,3%) preferred to have a female ob/gyn, 380(53,5%) declared no preference, and 100(14,2%) preferred to have a male ob/gyn. The reasons for female preference were i) having a very good communication (36%), ii) embarrassment (32%) and iii) feeling comfortable with female ob/gyn (27%). Surprisingly, only 5% women responded that the religious orders are important in their preference. The participants who have larger family, lower level of education, lower income, higher unemployment, parity of 4 and over, and first gynecological examination, have preferred female ob/gyn (p<0,05). One hundred women who preferred to be examined by a male doctor stated that the reasons for their preference were i) surgical skills (45%), ii) even tempered (35%) and iii) understanding problems better (20%). Conclusions: The majority of women have expressed no preference about gender of their ob/gyn, but a significant proportion of the remainder would prefer to be examined by a female doctor when they have been given the choice. However the religious effects on female ob/gyn preference have been found much less than the cultural effects.


INTRODUCTION
Many studies which are related to the choice of women for the obstetricians/gynecologists (ob/gyn) gender, have been carried out in the past.Although there are studies supporting the significance of choosing ob/gyn gender, the contradictory studies are also present in literature.The major differences in these studies originate from various socio, economic, religious, traditional and cultural factors (Plunkett, Kohli, & Milad, 2002 Bashour et al. reported that more than 85% of Syrian preferred their obstetrician to be a female person (Bashour, & Abdulsalam 2005).Lafta et al. found that 74% of Iraqi women patients preferred female gynecologists, 8% preferred male gynecologists and 18% had no gender preference (Lafta 2006).
Islamic teologists have reported that the Muslim women should take medical services from women ob/gyn according to the general principles of Quran unless compulsory.So it is not appropriate for Muslim women to be examined by a male doctor particularly in consultation for necessary examination of the genitalia (Sechzer, 2004).
Turkey is a mostly Muslim-populated, culturally rich, but the only secular country in the region.
Due to this secular pattern, the study about the choice of women for ob/gyn gender in Turkey and the factors affecting the gender preference for ob/gyn is of significant importance to contribute to the literature.

MATERIALS & METHODS
This cross-sectional and descriptive study has been performed in Istanbul.Istanbul is the largest city and has the most nomadic population in Turkey.Because of this, Istanbul has more diversity than the other cities in Turkey.The study was approved by the Institutional Review Board of Medical Faculty.This study has been conducted between the dates of February 2013 and June 2013, among the women who volunteered to participate in the survey and have been appropriate for the criteria.The study has been carried out for patients who applied to antenatal or gynecologic departments.The patients have been selected to reduce a potential practice-setting bias, after having antenatal or gynecologic care.The data have been collected with a questionnaire produced by the researcher.The questionnaire has been filled in waiting room.The participants have been asked why they selected the corresponding gender for their examiner.The women have responded to this question by selecting more than one choice in the questionnaire.
Of the total 745 women, 35 refused enrollment and the remaining (eligible) 710 women gave their oral consent to participate in the study.There were two parts of questionnaire: The first part of the questionnaire had the basic socio-demographic data (such as; age, educational level, marital status, family status, income level, employment status), in the second part, the women were asked about the obstetric/gynecologic histories and their gender preferences and the reasons.
The Statistical Package for Social Sciences (SPSS) was used for the statistical analysis of the data.
The findings were evaluated with a confidence interval of 95%, and p<0.05 was accepted as a significance proportion.

RESULTS
The cross sectional study sample consisted of 710 (95% response rate) out of 745 consecutive patients attending to the antenatal or gynecology outpatient departments.The participants had the ages between 17 and 58 and were all Muslim.The demographic data of all participants are shown in Table 1.In this study the little family means that it has only the mother/father and children while the large family has the mother/father, children, grandfather, and grandmother etc.The income level of participants has been based on their declaration.The income level has been classified into two groups; one of them is low income that means if the expenses are higher than income, otherwise it is classified as a sufficient income.
In order to perform the data analysis, the factors that may have affected ob/gyn gender preference by women, have been summarized in Table 2.
The women who preferred female ob/gyn, stated that they had very good communication with female ob/gyn (36%), much less embarrassment (32%) and much more felt as comfortable (27%).Surprisingly, only 5% of women responded that the religious orders are important for their selection.
In this study the majority of the women preferred male ob/gyn for surgical skills (urogynecology, gynecologic oncology, operative laparoscopy etc) (45%), even tempered (35%) and understanding the problems better (20%), respectively.

DISCUSSION
The awareness of women in Turkey on women's health is getting more improved than before, and thus, this improvement influences the selection of ob/gyn gender.It would be considered that especially the Muslim women preferred female ob/gyn.Contrary to this, in the present study; it has been shown that the half of the patients have given no importance for ob/gyn gender selection when they had obstetric and gynecologic problems.Similar results were found in studies performed in Chicago (Plunkett, Kohli, & Milad, 2002), California (Thompson, & Nussbaum, 2000), ( Muslim women believe that they should be examined for their obstetric and gynecologic problems by the same gender (women) and Muslim ob/gyn (Scheinberg, 2006).The instructions for Kuwaiti doctors are close to the precautions listed so far: during a vaginal examination, the patient should remain covered as for as possible by a sheet; if the patient is being examined by a male doctor, a nurse or other women must be present.During the labor, the pregnant woman may instinctively grip the doctor's hand or arm to obtain a psychological comfort.However, the doctor should not encourage such a behavior but be replaced by a nurse (Atighetchi, 2007).Muslim women, especially in the traditional countries, are reluctant to be examined by a man even in the presence of another woman during the examination.A survey at the gynecological clinics of two major hospitals in Riyadh 500 female patients confirmed this trend (Eiad et al 2004).Among the reasons to justify the preference of women doctors during the examination, the religion was the main reason for 69 % of the Saudi Arabians against 50% of the non Saudi Arabians (Al-Shammari, Jarallah, & Felimban, 1997) .The importance of the religious factor is obvious in a very recent survey on the behavior of 508 patients of the obstetric and gynecologic department in UAE.In this case, 86,4% preferred a women doctor, 12 mentioned no particular preference, whilst 1.6 preferred a male gynecologist (Rizk et al.

2004
).However, in the study done with non-Muslim women by Amir et.al, (2012), the secular, religious and ultra-orthodox women preferred a female gynecologist in the percentage of 52%, 69% with Muslim women, it was shown that the women who had embarrassment during intimate examination (89,1%), religious attitudes (74.3%), cultural objections (45.3%) and were reluctance to discuss sensitive and confidential issues (68,8%), also selected female ob/gyn in a higher rate Our study revealed that the male ob/gyn has been needed for obstetric or gynecological problems of women when the participants were looking for more surgical skills.Interestingly in different cultures similar results were obtained (Lafta , 2006 Most of the women who preferred male ob/gyn thought of that male ob/gyn understands much better than women ob/gyn.Parallel to the results of this study, in Dulmen et al, the male gynecologists used significantly more instruments and male gynecologists asked significantly more medical questions compared with female gynecologists (van Dulmen &Bensing 2000).In addition, in the study of Makam et.al, all women who preferred male ob/gyn, noted that male ob/gyn understood them much better than female ob/gyn Mavis, Vasilenko, Schnuth, Marshall, & Jeffs

2005).
Another factor affecting the preference of male ob/gyn has been the even-tempered behaviors of male ob/gyn.In our opinion the basic probable reason of this factor could be that there is a patriarchal family pattern in Turkey.In patriarchal family pattern, the male ob/gyn can be much even-tempered in risky conditions.
We have also found that the socio-cultural factors play an important role in the gender selection.In this study the participants who had larger family, lower level of education, lower income, higher unemployment and parity of 4 and over, preferred female ob/gyn.In a study performed with 6000 women, a significant correlation was found between the low level of income and the choice of female ob/gyn (Schmittdiel, Selby, Grumbach, & Quesenberry 1999).In another study, the women from families with low income level and preferring female ob/gyn were found not to be much volunteer and shown to be resistant to pelvic examination (Haar, Halitsky, & Stricker 1975).
In a similar way, the women unemployed and from families with low income level, also preferred female ob/gyn more than those in the current study.In addition, a significant correlation was found between the choice of female ob/gyn, and low level of education, high parity, and large family.The findings in this study have been consistent with those in literature (Lafta, 2006 ; Thompson, & Nussbaum, 2000; Makam, Mallappa Saroja, & Edwards, 2010; Mavis, Vasilenko, Schnuth, Marshall, & Jeffs, 2005; Schmittdiel, Selby, Grumbach, & Quesenberry, 1999; Chandler, Chandler, & Dabbs, 2000; Roter, & Hall 2001; Lafta, 2006).In 2005, Rizk et al. carried out a survey on gender preference and the factors effecting on the gynecologist/ obstetrician preference in the United Arab Emirates (UAE) in which the majority of participants (95%) were Muslims.They found that the gender was ranked as one of the most important factors for selection of women, regardless of other relevant factors (Rizk et al. 2005).

(
Rizk, El-Zubeir, Al-Dhaheri, Al-Mansouri, & Al-Jenaibi, 2005).The orthodox Jewish women, who were more comfortable and had less embarrassment attitude, also selected female ob/gyn(Scheinberg, 2006).In the studies performed by Lafta et al. in Iraq and by Rizk et al. in United Arabic Emirates, female ob/gyn were preferred due to better communicative skills and feeling relaxed by women patients, and male ob/gyn due to better surgical skills.The results are compatible with those in our study(Lafta, 2006; Rizk, El-Zubeir, Al-Dhaheri, Al-Mansouri, & Al-Jenaibi, 2005).In a recent study by Janssenet.al. it was found out that the women ob/gyn have been chosen much more since they had patient centered communication (Janssen & Lagro-Janssen 2012).
; Rizk, El-Zubeir, Al-Dhaheri, Al-Mansouri, & Al-Jenaibi 2005).In the present study the fourteen percentages of participants were coming from large families.The source of the reason why women preferred female ob/gyn at a higher rate in large families may be from the pressure coming from the elder people who had low level of education.It has also been obtained that the previous experiences of women had significance effect on the ob/gyn gender selection (Childs, Friedman, Schwartz, Johnson, & Royek, 2005).We have found that the patients, who were examined by a female ob/gyn at their gynecologic examination with a female ob/gyn, were more likely to prefer a female ob/gyn.