Communicating under medical patriarchy: gendered doctor-patient communication between female patients with overactive bladder and male urologists in Hong Kong

Research participants

All 30 participants were Hong Kong Chinese women, and were aged between 28 and 55
y at the time of study. Most participants were in the age group of 30s to 50s. The
sampled women comprised 24 full-time working professionals and 6 homemakers. The 24
working participants were employed in various sectors, including civil service, education,
social welfare, commerce and finance, sales and retailing, information technology,
and administrative and clerical sectors. Four of the homemakers had a part-time job,
working for no more than 30 h per week.

The length of time since diagnosis was 1–6 y at the time of this study, although participants
had symptoms of urinary frequency, urgency, and incontinence for 5–11 y. None of the
participants received diagnosis of OAB immediately after symptoms presented. They
had suffered from the symptoms for at least 2 y before their diagnosis of OAB, and
some of the participants had suffered for 5 y before obtaining a diagnosis. Prior
to OAB diagnosis, the participants mostly attended primary care general practitioners
for treatment, and bladder infection was a common diagnosis. They received a diagnosis
of OAB only on referral to a urologist for further assessment.

All participants continued receiving regular follow-up treatment from male urologists,
and were under the clinical care of them for at least 2 y at the time of this study.
Most participants received follow-up treatment in urology clinics at public hospitals.
Participants who underwent followed-up treatment at public hospitals were not allowed
to choose their doctor; instead, they were assigned to see male urologists for most
of the follow-up sessions. Although a few participants received follow-up treatment
from private practice urologists and were able to choose the doctors they preferred,
they commented difficulty in choosing a female urologist. During follow-up treatment,
the participants were required to undergo urinalysis, receive a physical examination,
have their bladder scanned, undergo urodynamic study, receive bladder training, and
adjust their oral medication. They were required to maintain a voiding diary under
supervision. For some patients, bladder instillation therapy was also performed during
follow-up.

Themes

Because of the gender difference, the participants regarded their communication with
their urologists in the treatment as unpleasant. During their communication, embarrassment,
feelings of not being treated seriously, not being understood, and not being given
autonomy to select treatment approaches prevailed among the participants. Furthermore,
the participants commonly perceived their urologists to lack empathy towards their
suffering. Although a few unpleasant experiences were more due to the structural interaction
between doctors and patients, gender differences between the participants and their
urologists remained the most prominent explanation for the participants’ unpleasant
experiences in communicating with their urologists.

Embarrassment

The symptoms of OAB are embarrassing for affected patients, and this was particularly
the case for the participants. Because of the gender difference, all of the participants
felt embarrassed when communicating about the symptoms to their urologists, who were
men, as indicated by the following participant’s comment:

I wish I could choose to see a female doctor. Seeing a female doctor is much less
embarrassing; but you know, I cannot choose doctors in public hospitals. Even for
a common cold or flu, I would see a female doctor; so it is really embarrassing for
me to see a male doctor for my bladder; you know the location of bladder… [the participant’s
face turned red]. It is even more uncomfortable and embarrassing for me to talk about
my symptoms to a male doctor. [P2]

In many cases, the participants felt embarrassed during diagnostic procedures, physical
examinations, and tests related to their bladder condition. The participants felt
even more embarrassed because the urologists whom they were consulting were men, as
indicated by the following participant’s recollection of her experience:

I feel embarrassed when male doctors perform a physical examination on me. I could
still remember how embarrassing it was when the doctor did a bladder endoscopy [cystoscopy]
on me, because the doctor was a man. It was just like a gynaecological check-up conducted
by a male doctor. The voiding test [urodynamic study] was embarrassing, too. Going
to the toilet is a very private matter for a woman; but in the test, it just made
me feel that such a private matter was under surveillance by a man and made public.
[P7]

The perception of bladder problems among the participants also contributed to their
embarrassment. A few participants related their bladder conditions to sexual and reproductive
organs. Such perceptions made the participants feel even more embarrassed when communicating
with their urologists, particularly when the communication involved the participants’
sex life, as the following participant indicated:

The two organs [urinary organs and reproductive organs] are very close to each other.
When a doctor examines the urinary part, he unavoidably sees the genital area. This
is really embarrassing for me. Also, some doctors ask me about my sex life. I do not
know whether my bladder problem is related to my sex life, but I felt very embarrassed
because I was not prepared for the doctors to ask me about such a private thing. [P19]

In many cases, the feelings of embarrassment among the participants hindered them
from communicating honestly and effectively with their urologists. One of the participants
described how her feelings of embarrassment made it difficult for her urologist to
understand her situation:

I find it very embarrassing for me to tell doctors about my bladder problems, because
they are men, especially because they often talk about sensitive issues during the
follow-up. When the doctor asked me some sensitive questions, I was so embarrassed
that I could only sit in front of him without saying a word. I would avoid telling
the doctor about the severity of my incontinence, because I think this should not
affect his diagnosis and the drugs he would prescribe. I would just tell him that
I need to go to the toilet often and urgently; this symptom sounds less embarrassing.
Telling a male doctor about wetting trousers is very embarrassing for a woman. [P5]

Feelings of not being treated seriously

Most of the participants felt that their urologists tended to simplify their chronic
bladder conditions and suffering given the fact that they were middle-aged women,
although the participants perceived their suffering and symptoms to be bothersome
and disruptive to their physical and emotional conditions. In many cases, the urologists’
responses made them feel that their condition and suffering were not being treated
seriously. One of the participants shared her follow-up experience:

Doctors in public hospitals tend to simplify your problems, “from a big matter to
a small matter, and from a small matter to a negligible matter” [a colloquial expression
in Cantonese]. This is how I have experienced these years of treatment. Every time
I mention my condition to doctors, they just say “There is nothing serious. It is
not uncommon for a middle-aged woman like you.” Then I am asked to leave. Maybe they
have seen such cases so many times in a day that they think that my problem is not
a big deal at all. However, the suffering bothers me. I hope they can help me, but
I do not feel that they are serious about my treatment. [P25]

The brevity of the consultations frequently left the participants feeling that they
did not have sufficient time to communicate with their urologists during follow-up.
Failing to have time to receive updates and clarification about their bladder condition
was a common experience for the participants, making them feel that they were not
treated seriously, as the following participant shared:

I can just see the doctor for around two to three minutes at most in each follow-up
session. There is not much I can say in this amount of time. I can only talk very
briefly about the updates of my symptoms, and the doctor just keeps on typing my history.
I suspect the doctor does not know what I look like, because he just keeps looking
at the computer screen. Then I am asked to leave the [consultation] room and get the
medicine. I just feel like a product in the production line of this medical factory.
The doctors are only concerned about finishing their tasks in a short time, and I
will be passed to the next step in this production line. I do not feel I am respected
as a human in the follow-up, and they never pay much attention to what I say. [P14]

Feelings of not being understood

Often, the gender difference between the participants and their urologists made the
participants feel that their urologists did not understand the extent of their suffering.
More than half of the participants indicated that their urologists often adopted a
male’s viewpoint when the participants expressed suffering. This made the participants’
communication experiences unpleasant. One of the participants recalled:

Many doctors cannot understand my difficulties. They just cannot understand how the
disease has changed my life. They cannot make sense about how my frequency of going
to the toilet can seriously affect my office work and home duties. Some doctors have
even suggested that I consider focussing on home duties only because it is not a big
deal for a married woman. They also commented that I should consider staying at home
so that I can avoid being bothered by the symptoms. It is the 21st century now, but
the doctors still believe a woman should stay at home and depend on her husband. I
find it difficult to communicate with these doctors; they cannot understand the needs
of female patients. [P21]

In some cases, the treatments suggested by the urologists contradicted the concerns
and gender-related roles and responsibilities of the participants as women. The participants
indicated that their urologists frequently failed to understand their social roles
as women, as indicated by the following comment shared by one of the participants:

The doctors have constantly suggested that I try bladder instillation therapy. However,
apart from the expensive treatment fees, I have to spend a whole day in the hospital
for a series of treatments. This is really difficult for me as a working mother: I
have a four-year-old daughter to care for. Also, I work a part-time job to help cover
family expenses. However, the doctors cannot understand my position even though I
have mentioned my concerns. They cannot understand why I have so many considerations
even though there is a better treatment. Women have more family considerations before
accepting treatment; they are men, so they may not be able to understand my concerns.
[P18]

Perceived lack of empathy

The gender difference between the participants and their urologists led them to have
contrasting views regarding the participants’ suffering. As women, the participants
encountered many gender-related difficulties while undergoing treatment. However,
these difficulties were not understood by their urologists. More than half of the
participants reported that their urologists’ responses indicated a lack of empathy,
as the following participant expressed:

The doctors do not care much about my bladder problem. They just think that my problems
are normal for a woman of my age. One doctor even told me that it is a normal ageing
process for a woman; he said if I can accept my problems as a normal ageing process,
I will feel much better emotionally. He said because my problem is due to the ageing
process, there is not much treatment he can do. Although I appreciate his honesty,
I feel he is quite “cold-blooded” [a colloquial expression in Cantonese that means
“apathetic”] towards my suffering. [P20]

In some cases, the urologists blamed the participants for their suffering and their
perceived lack of improvement. The participants, because of their female gender roles,
failed to follow the treatment regimen prescribed by their urologists. The participants
were blamed by their urologists. However, the participants perceived the blame from
the urologists to be a lack of empathy towards them, as indicated by the following
recollection by one of the participants:

It is not easy for me to follow strictly the treatment plan, because I have my commitment
to my family, children, and work. I can take the medicine accordingly, because it
does not conflict with my schedule, but I really find it difficult to keep on receiving
instillation and bladder training sessions. I am a working mother; therefore I have
to put my family and my children at the first priority. If the treatment plan interferes
with my responsibilities and my schedule, the only option for me is to give up. I
understand that this will affect the efficacy [of my treatment], so I do not complain
about the poor outcome at all; but the doctors blame me for treatment disobedience.
They blame me for having so many excuses not to accept their treatment plans, and
they blame me for lacking incentive to improve my condition. They just cannot understand
a working mother’s concerns and difficulties. [P26]

Feelings of not being given autonomy to choose treatment approaches

More than half of the participants reported that they were not given autonomy in selecting
a suitable treatment approach for themselves. One of the reasons was due to the perceived
expert power of doctors and the perceived difference in hierarchy between patients
and doctors. One of the participants shared the following perspective, which was common
among the participants:

Different treatments can have different influences on my life, so of course I want
to have some autonomy to choose the treatment that suits me most. However, I am just
a patient, and doctors will think that I know nothing about treatment. It does not
occur to them to allow me to choose the treatment that I prefer most. Sometimes I
feel that doctors are afraid of patients who have a high level of education. They
may feel that these patients are more troublesome and have more queries and requests
to challenge them. In their mind, patients with a low level of education are good
patients because they rarely ask questions and are more obedient. Therefore, I never
let my doctors know about my education level. I do not want them to label me as a
troublesome patient. [P23]

Another reason was due to the perceived gender difference between the participants
and their urologists. Under the influence of the traditional patriarchal values, the
participants, as women, did not feel comfortable with expressing their thoughts to
male urologists. They tended to accept what their urologists had selected for them,
because many of them were not accustomed to resisting decisions made by men, as indicated
by the following comment by one of the participants:

Usually the doctors determine my treatment—I do not have a say—and I think the doctors
do not expect that I would want to choose treatment approaches for myself, too. Also,
I am a woman, and my doctors are men, so I think it is quite normal for a woman to
listen to a man’s advice, just like I listen to my husband’s advice at home. I tend
not to bargain too much with men. Therefore, I mostly accept what the doctors have
assigned to me, although I am not happy with their suggestions and attitudes sometimes;
after all, they are doctors, and they are men, so they will not listen to what a woman
says. [P8]