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Transgender men's preferences when choosing obstetricians and gynecologists

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Background: Transgender men are a marginalized population with unique health care needs. However, their usage of health services is low because of considerable discrimination. A major factor in their avoidance is patient-provider interactions. Methods: This cross-sectional study included 102 transgender men who anonymously completed a 55-item questionnaire in clinic, between 10/2017 and 01/2019. In addition, 92 transgender women filled out the part about family physician's preferences. We examined which characteristics transgender men prefer in their obstetricians/gynecologists in order to promote their usage of healthcare services. Results: A small majority of the transgender men (54.1%) had no gender preference for their obstetrician/gynecologist, while 42.9% preferred a female obstetrician/gynecologist and 3.1% preferred a male obstetrician/gynecologist. Most transgender men with a same-gender preference preferred female obstetricians/gynecologists for both invasive procedures (e.g., pelvic examination, 97.4%) and non-invasive procedures (e.g., cesarean section, 60%). The reasons for preferences regarding invasive procedures were feeling comfortable, embarrassment and feeling that female obstetricians/gynecologists are gentler. Transgender men who preferred female obstetricians/gynecologists ranked ability (90.5%), sexual tolerance (92.9%) and gender identity tolerance (90.5%) as the top three desirable qualities of obstetricians/gynecologists, while the responders who did not prefer female ranked ability (94.6%), experience (92.9%) and knowledge (92.9%) as the top three qualities. Transgender men with female preferences considered female obstetricians/gynecologists to be more accepting of gender identity compared to the responders that did not prefer females (47.5% vs. 9.1%, P < .001).. Conclusion: A small majority of the transgender men exhibited no gender preference when choosing an obstetrician/gynecologist, although 42.9% preferred females. The latter choice was associated with the assumption that female obstetricians/gynecologists are more tolerant towards their transgender men patients. Educating the medical staff about their special needs and establishing dedicated SGM centers staffed with high percentages of female healthcare providers are highly recommended.
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Lifshitzetal.
Israel Journal of Health Policy Research (2022) 11:12
https://doi.org/10.1186/s13584-022-00522-z
ORIGINAL RESEARCH ARTICLE
Transgender mens preferences
whenchoosing obstetricians andgynecologists
Dror Lifshitz1,5* , Iris Yaish2, Gal Wagner‑Kolasko3, Yona Greenman2, Yael Sofer2, Sharon Alpern4, Asnat Groutz4,
Foad Azem4 and Hadar Amir4
Abstract
Background: Transgender men are a marginalized population with unique health care needs. However, their usage
of health services is low because of considerable discrimination. A major factor in their avoidance is patient‑provider
interactions.
Methods: This cross‑sectional study included 102 transgender men who anonymously completed a 55‑item ques‑
tionnaire in clinic, between 10/2017 and 01/2019. In addition, 92 transgender women filled out the part about family
physician’s preferences. We examined which characteristics transgender men prefer in their obstetricians/gynecolo‑
gists in order to promote their usage of healthcare services.
Results: A small majority of the transgender men (54.1%) had no gender preference for their obstetrician/gynecolo‑
gist, while 42.9% preferred a female obstetrician/gynecologist and 3.1% preferred a male obstetrician/gynecologist.
Most transgender men with a same‑gender preference preferred female obstetricians/gynecologists for both invasive
procedures (e.g., pelvic examination, 97.4%) and non‑invasive procedures (e.g., cesarean section, 60%). The reasons for
preferences regarding invasive procedures were feeling comfortable, embarrassment and feeling that female obstetri‑
cians/gynecologists are gentler. Transgender men who preferred female obstetricians/gynecologists ranked ability
(90.5%), sexual tolerance (92.9%) and gender identity tolerance (90.5%) as the top three desirable qualities of obstetri‑
cians/gynecologists, while the responders who did not prefer female ranked ability (94.6%), experience (92.9%) and
knowledge (92.9%) as the top three qualities. Transgender men with female preferences considered female obstetri‑
cians/gynecologists to be more accepting of gender identity compared to the responders that did not prefer females
(47.5% vs. 9.1%, P < .001)..
Conclusion: A small majority of the transgender men exhibited no gender preference when choosing an obstetri‑
cian/gynecologist, although 42.9% preferred females. The latter choice was associated with the assumption that
female obstetricians/gynecologists are more tolerant towards their transgender men patients. Educating the medi‑
cal staff about their special needs and establishing dedicated SGM centers staffed with high percentages of female
healthcare providers are highly recommended.
Keywords: Transgender men, Obstetricians/gynecologists, Gender, Tolerant, Sexual and gender minorities
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Background
Transgender individuals are defined as those with a
discrepancy between their sex assigned at birth and
their personal gender identity (cis-centric) [1], a situa-
tion which often leads to severe mental distress (gen-
der dysphoria). ey are estimated to comprise around
0.5–0.6%of the population in the U.S. [2] with youth
Open Access
*Correspondence: dror_lifshitz@hotmail.com
5 Department of Obstetrics and Gynecology, Chaim Sheba Medical
Center (Tel Hashomer), Ramat Gan, Israel
Full list of author information is available at the end of the article
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Lifshitzetal. Israel Journal of Health Policy Research (2022) 11:12
population approximately 2% [3], and reportedly range as
high as 1.2% in other countries worldwide [4]. Transgen-
der people have unique health issues compared to indi-
viduals whose gender identity matches the sex they were
assigned at birth (cisgender) [1, 4], including a higher
prevalence of risky health behaviors (smoking, alcohol
and drug use) [5], mental health problems (depression,
anxiety, and suicidality), and HIV and other sexually
transmitted infections [6]. e poor health outcomes
in this marginalized population have been explained by
structural (e.g., laws and policies), interpersonal (e.g.,
provider discrimination) and individual (e.g., provider
education and knowledge) barriers to healthcare [7].
Public awareness about transgender people has recently
grown considerably, and the field of transgender health
is experiencing a corresponding surge in interest on the
part of policymakers and health providers. e World
Health Organization has identified transgender people as
comprising a population with high vulnerability and spe-
cific health needs that need to be addressed [8]. In 2016,
the Obama administration expanded Sect. 1577, which
prohibits discrimination by any federal health program
on activity on the grounds of race, color, national origin,
sex, age, or disability, to include prohibition of discrimi-
nation based on gender [9].
Providing transgender individuals adequate medi-
cal care is even more complex when it comes to proce-
dures that are perceived by transgender patients as being
invasive and cause them discomfort and distress [10].
Transgender men (individuals who were labelled as being
females at birth but have a male gender identity) whose
reproductive organs have not been removed require
gynecological surveillance, including screening exami-
nations, in order to prevent life-threatening medical
conditions. Additionally, transgender men who choose
to conceive, be pregnant and give birth are subject to
the routine gynecological examinations. e Ameri-
can College of Obstetricians and Gynecologists called
on obstetricians/gynecologists to help eliminate barri-
ers for transgender men by creating nondiscriminatory
practices, assisting with gender transition, and providing
transgender-appropriate and comprehensive healthcare
[11]. However, the obstetricians/gynecologic needs of
transgender men are not taken care of and they use less
the obstetric/gynecologic services, such as fertility pres-
ervation [1012].
A key approach in today’s healthcare is patient-cen-
tered care which acknowledges the patient’s needs and
preferences. is is especially important for populations
with unique health needs and for areas of medicine that
require a pelvic examination. e factors that affect the
patient’s choice of an obstetrician/gynecologist have
recently been under investigation. Several papers that
examined the influence of the physician’s gender in those
choices among non-sexual and gender minorities (SGM)
reported conflicting findings: some reported a clear pref-
erence for female physicians in the cisgender population
[13], while others stated that the gender of their physi-
cian was not an important consideration when choosing
an obstetrician/gynecologist [14]. Moreover, the choice
of a female obstetrician/gynecologist was consistently
more common among religious and ethnic minorities,
primarily due to a sense of embarrassment during a pel-
vic examination [15]. Similarly, lesbians were found to
prefer a female obstetrician/gynecologist because they
felt more comfortable and described them as being gen-
tler, kind, understanding, open and tolerant compared to
male obstetricians/gynecologists [16, 17].
It is incumbent among medical providers to enable
and encourage transgender men to obtain the medical
care that they require. e aim of the current study was
to explore transgender men’ preferences, including gen-
der, when choosing their obstetricians/gynecologists,
and to identify the factors that need to be modified in
the healthcare system in order to promote greater acces-
sibility and use of appropriate medical care of these
individuals.
Methods
Ethical approval
is study was approved by the institutional review
board of the Tel Aviv Sourasky Medical Center (TASMC)
(#0455-17-TLV).
Study population andparticipant recruitment
In light of the anticipated difficulty in recruiting
transgender people [18], we chose to perform the study in
two clinics that provide services mainly to SGM patients.
All the consecutive eligible patients aged 18 years and
above were asked to fill out the anonymous questionnaire
before entering a meeting with the physician. After col-
lecting a total of 200 questionnaires, a similar number of
questionnaires were analyzed in previous studies that we
conducted among minority populations, the recruitment
process was stopped.
Of 113 transgender men and 101 transgender women
(individuals who were labelled male at birth but have
a female gender identity) 102 transgender men (90%
response rate) and 92 transgender women (91% response
rate) were prospectively enrolled and included in our
analyses. Four transgender men completed solely the first
part of the questionnaire and therefore were included
in this part of the survey only. e participants were
referred to the Gender Clinic, Institute of Endocrinol-
ogy, Metabolism and Hypertension of TASMC, a tertiary
university-affiliated medical center, and to the Gender
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Lifshitzetal. Israel Journal of Health Policy Research (2022) 11:12
Clinic, Gan Meir Community Health Care Center, Clalit
Health Services, Tel Aviv, Israel between October 2017
and January 2019.
e patients met with endocrinologists in the first
clinic visit and with a family physician in the second visit.
Patients who were referred to both clinics were asked
to fill out the anonymous questionnaire before entering
a meeting with the physician. Transgender men com-
pleted an anonymous questionnaire designed to assess
gender preferences in choosing their healthcare provid-
ers, including obstetricians/gynecologists. Transgender
women were asked to fill out the part about their family
physician’s preferences. All patients received an explana-
tion of the questionnaire from the nurse, filled out the
questionnaire independently in the waiting room, and
then put it through a slot in a closed box. e researchers
emptied the box daily and transferred the data provided
in the forms to a computerized database.
Questionnaire forthetransgender men
e researchers designed the study questionnaire of 55
items based on previous studies [13, 14]. e first part of
the questionnaire included basic sociodemographic and
clinical information, and those items were answered by
circling the selected choice. e second part included
questions about gender preferences of provider, gender
preferences for different medical situations, such as pel-
vic examinations, pregnancy follow-up visits, gyneco-
logic surgeries, in vitro fertilization treatment or any
other consultation for obstetric or gynecologic issues.
e transgender men were further asked to identify
specific characteristics of the obstetrician/gynecologist
related to their gender preference by circling the word
“male”, “female” or “none”. Lastly, each participant was
also asked to circle characteristics he considered to be
the most important in choosing his obstetrician/gynecol-
ogist from a list of 16.
Statistical analysis
Descriptive statistics were computed as mean and stand-
ard deviation (SD) for continuous variables and as fre-
quencies for categorical variables. Significance was
tested with the t-test, Mann–Whitney U test, χ2 and
Fisher’s exact test as needed. e data are summarized
as mean ± SD, or number of responders (percentage)
according to the variables. P < 0.05 was considered statis-
tically significant. All statistical analyses were performed
with IBM SPSS Statistics version 25.
Results
e study population was comprised of 102 transgender
men (mean age 27 ± 8.16, range 18–62years). In addi-
tion, 92 transgender women (mean age 28 ± 8.2, range
18–57 years) filled out the part about family physi-
cian’s preferences. No significant socio-demographic or
clinical differences were found between the two groups
except for upper body surgery (Table 1). A signifi-
cantly higher rate of upper body surgery was performed
among transgender men compared to transgender
women (48% vs. 20.7%, respectively, P < 0.001).
As shown in Table2, about one-half of each group of
transgender women and men were routinely managed
by male family physicians (47.3% and 42.4%, respec-
tively, P = 0.194) and the other half by female family
physicians (39.6% and 50.5%, respectively, P = 0.194).
Most of the study participants had no gender prefer-
ence for their family physician (59.6% of transgender
women and 64.6% of transgender men, P = 0.242).
We next explored the physician preferences of
transgender men when choosing an obstetrician/
gynecologist. Fifty-three (54.1%) had no gender pref-
erence and 42 (42.9%) preferred a female obstetrician/
gynecologist, a higher figure than the 29.3% of them
who preferred a female family physician. Only three
(3.1%) replied that they preferred a male obstetrician/
gynecologist (Fig.1). e preference for a female obste-
trician/gynecologist was more common among less-
educated patients compared to a male obstetrician/
gynecologist or no gender preference (Table 3). Pri-
mary school- and high school-educated students indi-
cated a female preference (11.9% vs. 1.8% and 64.3% vs.
55.4%, respectively, P = 0.04), while college/university
graduates did not (23.8% vs. 42.9%, P = 0.04). Preferring
a female obstetrician/gynecologist was also more com-
mon among the same transgender men who preferred a
female family physician compared to a male or no gen-
der preference of family physician (38.3% versus 7.3%,
respectively; P < 0.001).
Table4 and Fig.2 displays gender preferences for inva-
sive versus non-invasive aspects of gynecological care.
Transgender men who preferred a female obstetrician/
gynecologist chose a female obstetrician/gynecologist for
both invasive and non-invasive procedures compared to
transgender men who did not (P < 0.001). Almost all of
the transgender men who preferred female obstetricians/
gynecologists preferred them for pelvic examinations
(97.4%) and most (82.5%) preferred them for pregnancy
follow-up procedures that are considered invasive. How-
ever, the preference for a female obstetrician/gynecolo-
gist was less pronounced when it came to non- invasive
procedures, such as a caesarian Sect.(60%). Interestingly,
the percentage of transgender men who preferred female
obstetricians/gynecologists for surgical procedures such
as gynecological surgery (52.5%) was lower than for
non-surgical procedures, such as pregnancy follow-up
(82.5%).
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Lifshitzetal. Israel Journal of Health Policy Research (2022) 11:12
e reasons for preferring a female obstetrician/
gynecologist were then queried (Table5). e major rea-
son given by the transgender men who preferred a female
over a male obstetrician/gynecologist was their feel-
ings during a pelvic examination. ey described feeling
more comfortable with female obstetrician/gynecologist
(100% vs. 13%, respectively, P < 0.001) and more embar-
rassed with male obstetrician/gynecologist (36.8% vs. 0%,
P < 0.001), and judged the pelvic examination as being
more gentle (69.2% vs. 5.4%, P < 0.001). ey also consid-
ered female obstetricians/gynecologists as being more
sympathetic than their male counterparts (57.9% vs.
9.3%, P < 0.001).
Among the top three factors that influenced transgen-
der men regarding their preference in choosing an obste-
trician/gynecologist, only one, “ability”, was chosen by the
vast majority of both groups (90.5% and 94.6%) (Table6;
Fig.3). e other two parameters differed according to
the subject’s gender preference of physician: transgender
men who preferred female obstetricians/gynecologists
highly ranked “sexually tolerant” (92.9%) and “gender
Table 1 Demographic and clinical characteristics of the 194
transgender responders to the study survey
Bold represents P-value under 0.05 was considered to be signicant
Characteristic Transgender
women (n = 92)
n, (%)
Transgender
men (n = 102)
n, (%)
P value
Age, mean (SD)
(range) 28 (8.2) (18–57) 27 (8.16) (18–62) NS
Origin
Israel 69 (82.1) 85 (84.2)
Other 15 (17.9) 16 (15.8) NS
Religion
Jewish 76 (82.6) 89 (87.3)
Other 16 (17.4) 13 (12.7) NS
Religious status
Secular 72 (79.1) 81 (82.7)
Religious 19 (20.9) 17 (17.3) NS
Marital status
Married or with a
partner 19 (20.7) 35 (35.4)
Single or divorced 73 (79.3) 64 (64.6) NS
Children
Yes 7 (7.6) 8 (8.1)
No 85 (92.4) 91 (91.9) NS
Education
Primary school 10 (11.5) 6 (5.9)
High school 50 (57.5) 61 (59.8)
College degree or
higher 27 (31) 35 (34.3) NS
Employment
Yes 61 (66.3) 64 (64.6)
No 31 (33.7) 35 (35.4) NS
Sexual orientation
Heterosexual 54 (60.7) 43 (43.9)
Homosexual 20 (22.5) 15 (15.3)
Bisexual 12 (13.5) 33 (33.7)
Asexual 3 (3.4) 7 (7.1) NS
Psychiatric medication
Yes 32 (35.6) 28 (28)
No 58 (64.4) 72 (72) NS
Gender‑affirming hormone therapy
None 15 (17.6) 22 (22.9)
Less than one year 26 (30.6) 25 (26)
1–5 years 39 (45.9) 39 (40.6)
More than 5 years 5 (5.9) 10 (10.4) NS
Upper body surgery
Yes 19 (20.7) 49 (48)
No 73 (79.3) 53 (52) < 0.001
Lower body surgery
Yes 7 (7.8) 4 (4)
No 83 (92.2) 96 (96) NS
Table 2 Gender preference for family physician of 194
transgender responders to the study survey
Characteristic Transgender
women (n = 92)
n, (%)
Transgender men
(n = 102) n, (%)
P Value
Family physician’s gender (last 3 years)
Male 43 (47.3) 42 (42.4)
Female 36 (39.6) 50 (50.5)
None 12 (13.2) 7 (7.1) NS
Preferred gender for family physician
Male 2 (2.2) 6 (6.1)
Female 34 (38.2) 29 (29.3)
None 53 (59.6) 64 (64.6) NS
Fig. 1 Gender preference for a male or female obstetrician/
gynecologist (Ob/Gyn) among transgender men
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Lifshitzetal. Israel Journal of Health Policy Research (2022) 11:12
Table 3 Demographic and clinical characteristics of 98 transgender men classified by their preference for a male or female
obstetrician/gynecologist (Ob/Gyn)
Bold represents P-value under 0.05 was considered to be signicant
*The values in the parentheses are percentages unless indicated otherwise
Characteristic Prefer female Ob/Gyn (n = 42) Prefer male Ob/Gyn or no gender preference for
Ob/Gyn (n = 56)
P Value
Age, mean (SD) (range) 26.7 (7.42) (18–50) 27.3 (8.52) (18–62) NS
Origin
Israel 37 (88.1) 45 (80.4)
Other 5 (11.9) 11 (19.6) NS
Religious status
Secular 33 (80.5) 9 (16.1)
Religious 8 (19.5) 47 (83.9) NS
Marital status
Married or with a partner 10 (25) 23 (41.8)
Single or divorced 30 (75) 32 (58.2) NS
Children
Yes 5 (12.5) 3 (5.5)
No 35 (87.5) 52 (94.5) NS
Education
Primary school 5 (11.9) 1 (1.8)
High school 27 (64.3) 31 (55.4)
College degree or higher 10 (23.8) 24 (42.9) 0.04
Employment
Yes 26 (65) 36 (64.5)
No 14 (35) 19 (34.5) NS
Sexual orientation
Mainly attracted to women 16 (40) 26 (48.1)
Mainly attracted to men 4 (10) 9 (16.7)
Bisexual 15 (37.5) 17 (31.5)
Asexual 5 (12.5) 2 (3.7) NS
Psychiatric medications
Yes 14 (33.3) 14 (25) NS
No 28 (66.7) 42 (75)
Gender‑affirming hormone therapy
None 8 (20.5) 13 (23.6)
Less than one year 15 (38.5) 9 (16.4)
1–5 years 12 (30.8) 27 (49.1)
More than 5 years 4 (10.3) 6 (10.9) NS
Upper body surgery
Yes 17 (40.5) 29 (51.8)
No 25 (59.5) 27 (48.2) NS
Lower body surgery
Yes 0 (0) 4 (7.1)
No 41 (100) 52 (92.9) NS
Preferred gender for family physician
Male 2 (3.3) 4 (7.3)
Female 23 (38.3) 4 (7.3)
None 35 (58.3) 47 (85.7) < 0.001
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Lifshitzetal. Israel Journal of Health Policy Research (2022) 11:12
tolerant” (90.5%), while transgender men who did not
prefer female obstetricians/gynecologists ranked “experi-
ence” and “knowledge” (92.9% for both) as the other two
most important characteristics. e gender of the obste-
trician/gynecologist was the only parameter that was
significantly different between the two groups (33.3% vs.
3.6%, respectively, P < 0.001).
Discussion
Many studies on SGM and health system issues have
been published, but they did not identify the parame-
ters most important to transgender men in their choice
between female and male obstetricians/gynecologists.
is study was designed to fill that gap. Transgender
patients are a gender minority that confronts serious dis-
crimination when approaching health services. In 2011,
e National Discrimination Survey revealed that a high
percentage of transgender responders experienced dis-
crimination in various sectors of health services, such as
a 24% discrimination rate at the physician’s office [19].
Recent studies confirmed the negative attitude of the
health system towards them that lead to their health-
care needs being unmet [911, 19]. e biggest obstacle
involved in transgender avoidance of healthcare systems
was reported as being patient-provider interactions [20].
Healthcare providers have been implicated in low utility
of healthcare services by other minorities as well [21].
Many studies examined which feature minorities prefer
in their physician and identified same-gender prefer-
ence as being a major one [15, 16]. In addition to routine
care, the healthcare needs of transgender people include
unique treatments, such as gender-affirming hormone
therapy, body-altering surgeries, psychological support,
and others [22]. Family physician are the first line health-
care providers that encounter the transgender patient,
manage their healthcare needs and connect them with
other specialists as required [22]. ere are enormous
barriers when transgender people confront discrimina-
tive behavior and lack of knowledge on the part of the
primary physician [19, 20], and those barriers inter-
fere with the reception of appropriate quality care [23].
Similar to studies conducted among diverse minorities
[15, 16, 24], we did not find a major bias against male or
female family physicians among both transgender men
and women. Same-gender preference for family physician
is not crucial among SGM, presumably because other
parameters are more relevant to them [16, 24, 25].
e obstetrician/gynecologist has a significant role in
transgender men’s health. e needs of the transgender
individuals are unique, such as the management of the
gender-affirming hormone therapy, fertility consultation,
gynecologic follow-up, etc. [19, 26, 27]. Many transgen-
der people reportedly experience discrimination on the
Table 4 Preference for a male or female obstetrician/
gynecologist (Ob/Gyn) for invasive versus non‑invasive Ob/Gyn
procedures among transgender men
Bold represents P-value under 0.05 was considered to be signicant
*The values in the parentheses are percentages unless indicated otherwise
Characteristic Prefer female
Ob/Gyn
(n = 42)
Prefer male Ob/Gyn
or no Ob/Gyn gender
preference (n = 56)
P Value
Invasive procedure
Gender preference for pelvic examination
Male 0 (0) 4 (7.5)
Female 37 (97.4) 7 (13.2)
None 1 (2.6) 42 (79.2) < 0.001
Gender preference for gyn consultation
Male 0 (0) 2 (3.7)
Female 31 (77.5) 3 (5.6)
None 9 (22.5) 49 (90.7) < 0.001
Gender preference for pregnancy follow‑up
Male 0 (0) 1 (1.9)
Female 33 (82.5) 3 (5.8)
None 7 (17.5) 48 (92.3) < 0.001
Gender preference for fertility preservation treatments
Male 0 (0) 2 (3.7)
Female 24 (60) 1 (1.9)
None 16 (40) 51 (94.4) < 0.001
Non-invasive procedure
Gender preference for caesarean section
Male 0 (0) 0 (0)
Female 24 (60) 1 (1.9)
None 16 (40) 51 (98.1) < 0.001
Gender preference for gyn surgery
Male 1 (2.5) 1 (1.9)
Female 21 (52.5) 4 (7.4)
None 18 (45) 49 (90.7) < 0.001
Gender preference if no pelvic examination needed
Male 2 (5.1) 2 (3.6)
Female 22 (56.4) 2 (3.6)
None 15 (38.5) 51 (92.7) < 0.001
Fig. 2 Preference for a male or female Ob/Gyn for invasive (pelvic
examination) versus non‑invasive (no pelvic examination) procedures
among transgender men
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Lifshitzetal. Israel Journal of Health Policy Research (2022) 11:12
Table 5 Reasons for preference for a male or female obstetrician/gynecologist (Ob/Gyn) for specific Ob/Gyn procedures among
transgender men
Characteristic Prefer female Ob/Gyn (n = 42) Prefer male Ob/Gyn or no Ob/Gyn gender preference
(n = 56)
P Value
Pelvic examination
More embarrassment
Male 14 (36.8) 0 (0)
Female 0 (0) 2 (3.7)
No preference 24 (63.2) 52 (96.3) < 0.001
More comfortable
Male 0 (0) 5 (9.3)
Female 38 (100) 7 (13)
No preference 0 (0) 42 (77.8) < 0.001
More gentle
Male 0 (0) 6 (10.7)
Female 27 (69.2) 3 (5.4)
No preference 12 (30.8) 47 (83.9) < 0.001
Physician’s characteristics
More sympathetic
Male 0 (0) 5 (9.3)
Female 22 (57.9) 5 (9.3)
No preference 16 (42.1) 44 (81.5) < 0.001
More patient
Male 0 (0) 3 (5.4)
Female 20 (50) 3 (5.4)
No preference 20 (50) 50 (89.3) < 0.001
Spends more time with patient
Male 0 (0) 3 (5.5)
Female 5 (12.8) 0 (0)
No preference 34 (87.2) 52 (94.5) 0.01
Physician’s professionalism
More understanding of transgender health
Male 0 (0) 2 (3.6)
Female 15 (38.5) 3 (5.4)
No preference 24 (61.5) 51 (91.1) < 0.001
More knowledgeable in transgender health
Male 0 (0) 1 (1.8)
Female 12 (30.8) 2 (3.6)
No preference 27 (69.2) 53 (94.6) < 0.001
Better physician in general
Male 0 (0) 1 (1.8)
Female 11 (28.2) 2 (3.6)
No preference 28 (71.8) 53 (94.6) < 0.001
More accepting of sexual preference
Male 0 (0) 1 (1.8)
Female 16 (40) 6 (10.7)
No preference 24 (60) 49 (87.5) < 0.001
More accepting of gender identity
Male 1 (2.5) 1 (1.8)
Female 19 (47.5) 5 (9.1)
No preference 20 (50) 49 (89.1) < 0.001
Bold represents P-value under 0.05 was considered to be signicant
*The values in the parentheses are percentages unless indicated otherwise
Page 8 of 13
Lifshitzetal. Israel Journal of Health Policy Research (2022) 11:12
part of their obstetricians/gynecologists, and many find
that experience a trigger of dysphoria [19, 2628]. e
outcome is their avoidance of treatment despite their
special needs and risk factors [19, 2628]. e discrep-
ancy between the high needs and low usage of obstetric/
gynecologic services among minorities has previously
been linked with the gender of their provider [1517].
For example, Israeli Druze women responders described
bias based on their traditional and religious beliefs [15].
Contemporary pro-active women’s groups designated
same-gender preference as part of their feminist dogma
[13], and sexual minorities due to greater tolerance of the
same-gender providers to their sexual orientation [16,
17].
Our working hypothesis that the invasive nature of
the obstetric/gynecologic procedures would motivate
transgender men to prefer a female obstetrician/gynecol-
ogist did not materialize and a small majority of the
responders had no preference for obstetrician/gynecolo-
gist. Still, it should be noted that a much higher percent-
age of the transgender men (42.9%) did prefer a female
obstetrician/gynecologist compared with those who pre-
ferred a male (3.1%). Moreover, excluding the respond-
ers with no preference and exploring only the responders
that have preference results in 93.3% of transgender
men that prefer a female obstetrician/gynecologist while
only 6.7% preferred a male obstetrician/gynecologist. It
should be noted that our study population is not homo-
geneous since it is composed of responders in different
stages of their transition process. Some transgender men
might be similar to cisgender men who preferred a male
physician for urological care [29]. In agreement with
our results, Ettner etal. did not find clear preference for
same-gender surgeons by transgender people undergoing
Table 6 Characteristics and percentages of the 16 factors ranked by transgender men as affecting their choice for a female or male
obstetrician/gynecologist (Ob/Gyn)
Bold represents P-value under 0.05 was considered to be signicant
*The values in the parentheses are percentages unless indicated otherwise
Characteristic Prefer female Ob/Gyn (n = 42) Prefer male Ob/Gyn or no Ob/Gyn gender
preference (n = 56)
P Value
Demographics
Age 4 (9.5) 3 (5.4) NS
Sex 4 (33.3) 2 (3.6) < 0.001
Religion 5 (11.9) 1 (1.8) NS
Marital status 0 0
Parental status 0 1 (1.8) NS
Professional skills
Ability (professional) 38 (90.5) 53 (94.6) NS
Experience 36 (85.7) 52 (92.9) NS
Knowledge 34 (80.9) 52 (92.9) NS
Reputation 15 (35.7) 18 (32.1) NS
Qualifications
Board certification 15 (35.7) 27 (48.2) NS
Hospital affiliation 2 (4.8) 4 (7.1) NS
University affiliation 1 (2.4) 2 (3.6) NS
Other qualities
Personality 31 (73.8) 40 (71.4) NS
Availability 19 (45.2) 27 (48.2) NS
Sexually tolerant 39 (92.9) 45 (80.4) NS
Gender tolerant 38 (90.5) 48 (85.7) NS
Fig. 3 Comparison between transgender men who preferred female
Ob/Gyn versus male Ob/Gyn for the top 3 factors affecting their
choice
Page 9 of 13
Lifshitzetal. Israel Journal of Health Policy Research (2022) 11:12
gender-affirming surgery despite the invasive nature of
that surgery [30].
One of the main reasons for same-gender preference of
other minorities was based on how they felt during pel-
vic examinations, e.g., more comfortable and less embar-
rassed [15, 16]. As a result, their preference for a female
obstetrician/gynecologist was restricted to invasive pro-
cedures [15, 16]. e reason our responders gave for their
same-gender preference during invasive procedures was
similar to that other minorities, including feeling more
comfortable, less embarrassed and feeling that a female
obstetrician/gynecologist is gentler. However, their bias
was not limited to invasive procedures but applied to
non-invasive ones as well. Previous studies have demon-
strated that transgender people’s visit to an obstetrician/
gynecologist is associated with anxiety resulting from
factors other than feeling during invasive procedures.
In a survey of transgender men, 92% reported anxiety
regarding receiving gynecological care due to the follow-
ing reasons: encountering gendered forms (50%), sitting
in a waiting room with cisgender women (54%), being
misgendered (59%), having to educate the provider about
transgender issues (70%) and undergoing the gynecologic
exam itself (86%) [28]. Dutton etal. found that all of their
transgender men study participants did not like receiv-
ing gynecological care not only because of the exposure
of personal body part, but also because the visit itself was
accompanied by an extreme emotional conflict between
self-perceptions and physical anatomy [26]. e rea-
son of our responders for their same-gender preference
during non-invasive procedures presumably result from
the emotional issues that emerge during the visit at the
obstetrician/gynecologist.
Our transgender men responders that prefer female
significantly preferred gender tolerant and sexually toler-
ant providers above all other factors with the exception of
professional ability. Unlike our responders, religious and
ethnic minorities added professional skills as interpreted
by the parameters of experience and knowledge to that
of ability [15], although the priorities of other SGM were
influenced by their sexual orientation and gender identity
[16, 17, 25, 31]. Bisexual, queer or lesbian women were
reported to prefer providers who were open-minded and
friendly toward people of different sexual orientations
[32]. SGM youth responders ranked provider qualities
and interpersonal skills, such as being respectful, non-
judgmental and treating SGM equally, higher than pro-
vider knowledge and experience [24]. Frecker etal. found
that the transgender men responders avoided undergoing
gynecological treatment due to transgender-non-friendly
and non-transgender-knowledgeable healthcare provid-
ers [28]. Having a tolerant physician apparently pales
other characteristics and emphasizes the importance
of such qualities to transgender men that prefer female.
e association between the healthcare provider’s gender
and level of tolerance has already been established. SGM
responders demonstrated preference for female family
physicians due to their kinder, more accepting and more
open character [23]. Abdessamad et al. demonstrated
higher Homosexuality Attitude Scale scores among
women [33]. In our study, the transgender men that pre-
fer female considered female obstetricians/gynecologists
as being far more accepting of gender identity (47.5%)
compared to male obstetricians/gynecologists (2.5%).
eir preference was significantly higher than respond-
ers who did not prefer female obstetricians/gynecolo-
gists. Same-gender preference of our responders might
be ascribed to their conception that female obstetricians/
gynecologists are more tolerant than male obstetricians/
gynecologists.
To the best of our knowledge, this is the first study that
addresses transgender men preferences when choosing
an obstetrician/gynecologist. However, it is not without
its’ limitation: (1) No published data about the sociode-
mographic and clinical profiles of transgender persons
in Israel are available, which consequently limits the pos-
sibility to examine whether our study group represents
the transgender population inside and outside Israel.
However, based on previous studies we can conclude that
some of the characteristics including religious status [34],
education [35], employment [36, 37], sexual orientation
[34], mental disorders [35, 36], and gender-affirming sur-
geries [38, 39], are representative. Furthermore, most of
the transgender adolescents and adults nationwide are
referred to our hospital because it is part of a national
center for transgender health medicine. is enables the
adequate representation of all strata of the transgender
population. In addition, the study was conducted in two
clinics, in and out of the hospital, to increase the popula-
tion’s representation. Still, we are aware of this weakness
thus calling for further studies on larger populations. (2)
e study was conducted in only two centers, therefore,
interpersonal relationships with physicians might influ-
ence patient preference. However, both clinics are large
and enable exposure to a variety of physicians. (3) Both
centers are located in the center of Tel Aviv, the most
liberal area in Israel. Nonetheless, as our study is rela-
tively large, and was performed, as already mentioned,
in a multi-disciplinary clinic that serves as the national
referral center for gender dysphoric patients from across
Israel it very likely reflects the preferences of this unique
population. (4) Most of the patients were exposed to
female physicians in the study clinics (75% female physi-
cians). It is possible that if the exposure rate to male phy-
sicians was higher, the results would have changed. (5)
Respondents were not asked if they prefer transgender
Page 10 of 13
Lifshitzetal. Israel Journal of Health Policy Research (2022) 11:12
clinician. is knowledge is significant and might influ-
ence the results. Further studies that include this infor-
mation are desirable.
We found that small majority of the transgender men
do not exhibit preference for obstetricians/gynecolo-
gists’ gender, though their tendency was to prefer female
obstetrician/gynecologist. Transgender men tendency
was associated with the preference for tolerant obstetri-
cian/gynecologist and the assumption that female obste-
tricians/gynecologists are more accepting and tolerant
for gender and sexual minority patients.
eir unique health requirements and the discrimina-
tory environment they encounter in healthcare facilities
drive transgender men to seek an open-minded and tol-
erant obstetrician/gynecologist that accepts their gender
identity. Educating the medical staff about their special
needs and establishing dedicated SGM centers staffed
with high percentages of female healthcare providers are
highly recommended.
Policy implications
Despite the increased understanding of the value of treat-
ing transgender patients in a knowledgeable, mindful and
supportive manner, transgender health policies and their
healthcare delivery issues are still lacking. ere is neg-
ligible public and governmental awareness of the crucial
needs of the transgender population in general, and spe-
cifically of their unique healthcare needs that are differ-
ent from traditional ones [911, 19, 2628]. Transgender
issues are either not included or have not been updated
in medical studies [19, 40]. ere is a dearth of education
on the issues that concern transgender people’s health,
and even more so with regard to issues of gynecology and
reproduction [41, 42]. Medical providers, such as obste-
tricians/gynecologists, acquire their knowledge from
several limited resources (World Professional Associa-
tion for Transgender Health-Standards of Care and Diag-
nostic and Statistical Manual of Mental Disorders), and
are usually not aware of the unique physical and mental
needs of their transgender patients [28, 40, 43, 44]. Hos-
pitals and healthcare centers lack policies and funda-
mental knowledge about the transgender population’s
healthcare issues [911, 19, 2628], often preferring to
avoid them altogether.
e transgender healthcare field of care is still in its
infancy, but there are considerable efforts to promote the
rights of transgender people to receive equal and com-
petent healthcare services. Formal recommendations
for specific education objectives regarding transgender
healthcare were published by the Council of Resident
Education in Obstetrics and Gynecology in the USA [45].
e American College of Obstetricians and Gynecolo-
gists has produced recommendations on care, support,
education and awareness for obstetrician and gynecolo-
gist specialists regarding their transgender patients
[46]. Additionally, there are universities in the USA and
Canada that include updated and expanded curriculum
on the care of transgender populations in their under-
graduate and graduate medicine programs [45, 4750].
In the UK, University College London and Bristol Medi-
cal School have implemented sessions to raise aware-
ness of SGM health inequalities [51]. In Israel, the Tel
Aviv University includes transgender care in its obstetri-
cians/gynecologists continuing medical education train-
ing [52]. ere are updated sources of information about
transgender care, including medical books, e.g., dedi-
cated chapters are included in the new edition of Sper-
off’s Clinical Gynecologic Endocrinology and Infertility
[53]. New web-based resources include SGM educational
materials and workshops online that provide updated
knowledge and education about the transgender popula-
tion’s healthcare [44, 54, 55]. Several new dedicated SGM
interdisciplinary healthcare centers that are composed of
transgender-friendly interdisciplinary healthcare provid-
ers have also been established [56, 57]. e Tel Aviv Med-
ical Center (Tel Aviv, Israel) recently founded a national
center for transgender health medicine which includes
transgender-friendly endocrinologists, plastic surgeons,
skin specialists, psychologists and obstetrician/gynecolo-
gist specialists [58].
We contend that certain policy changes are warranted
in order to encourage greater accessibility by transgen-
der people to the healthcare system. We urge increasing
public awareness and establishing governmental policies
to encourage additional changes in approaches to health-
care issues, such as campaigning to educate providers,
establishing enlightened hospital policies, creating dedi-
cated centers, etc. We suggest creating more dedicated
SGM-friendly clinics and centers that will staff tolerant
and trans-experienced experts, including obstetricians/
gynecologists with high percentages of female healthcare
providers. We strongly recommend establishing formal
protocols and guidelines regarding transgender people’s
healthcare that will be an integral part of the under-
graduate and graduate medical students’ curriculum, in
addition to periodical mandatory training programs and
workshops for physicians and experts in transgender
medicine. e overall aim is to achieve basic knowledge
among the entire population of healthcare providers that
will enable them to provide basic mindful and tolerant
treatment to transgender patients. Such interventions
have already proven to be successful and shown to have
improved providers’ attitudes and professional skills in
the USA and UK [55, 59]. We urge the promotion and
financial support of these efforts through fellowships and
the inclusion of sub-specialties in SGM health programs
Page 11 of 13
Lifshitzetal. Israel Journal of Health Policy Research (2022) 11:12
that will allow young physicians to become experts in
SGM medicine. For example, obstetrician/gynecologist
experts in fertility will be able to gain advanced knowl-
edge and expertise in SGM medicine and apply these
skills to provide suitable treatments to transgender
individuals (e.g., fertility preservation or pregnancy fol-
low-ups for transgender men) [60]. We believe that the
combination of mandatory basic training to all general
healthcare providers together with elective fellowship/
sub-specialization training to healthcare experts will ena-
ble transgender patients to receive compassionate, com-
petent, and appropriate healthcare.
Conclusions
Transgender men comprise a marginalized minority that
their usage of healthcare services is low despite their high
levels of medical needs. A major factor in their avoidance
to seek such services is patient-provider interactions. Most
transgender men that reported gender preference when
choosing an obstetrician/gynecologist preferred female
physicians. eir choice was associated with the assump-
tion that female obstetricians/gynecologists are more tol-
erant towards their transgender male patients. In order to
overcome such avoidance and encourage greater accessi-
bility to the healthcare system, there is a need to increase
the awareness of the population, specifically, that of health-
care providers, to the unique physical and mental health-
care needs of transgender patients. Educating and training
the medical staff about those unique needs are mandatory
in order to overcome the paucity of education on these
issues, and to turn around the discriminatory environment
confronted by the transgender population. Establishing
dedicated SGM interdisciplinary healthcare centers staffed
with tolerant and trans-experienced experts, includ-
ing obstetricians/gynecologists with high percentages of
female healthcare providers, is highly recommended.
Abbreviations
LGBTQ: Lesbian, gay, bisexual, transgender and queer; OB\GYN: Obstetrician/
gynecologist; SD: Standard deviation; SGM: Sexual and gender minorities.
Acknowledgements
We are grateful to the people who participated in this study and agreed to
share their preferences with us.
Authors’ contributions
D.P.L., and H.A. were involved in the project development, study design,
data management, data analysis, and manuscript writing. I.Y., G.W.K., Y.G., Y.S.,
and S.A. data collection and manuscript editing. A.G., and F.A. data analysis
and manuscript editing. All contributors reviewed the manuscript and gave
their approval of the final version. All authors read and approved the final
manuscript.
Funding
No external funding was either sought or obtained for this study.
Availability of data and materials
Data are available upon request.
Declarations
Ethics approval and consent to participate
This study was approved by the institutional review board (Helsinki) of the Tel
Aviv Medical Center (#0455‑17‑TLV).
Consent to participate
Anonymous questionnaire—no consent form is required. Approved by the
institutional review board (Helsinki) of the Tel Aviv Medical Center.
Consent for publication
Not applicable.
Competing interests
The authors declare that they have no conflict of interest.
Author details
1 Depar tment of Obstetrics and Gynecology, Sheba Medical Center, Tel
Hashomer, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University,
Tel Aviv, Israel. 2 Institute of Endocrinology, Metabolism and Hypertension, Tel
Aviv Sourasky Medical Center, Affiliated to the Sackler Faculty of Medicine,
Tel Aviv University, Tel Aviv, Israel. 3 Department of Family Medicine, Clalit
Gan‑Meir LGBT Clinic, Tel Aviv District, Israel. 4 Sara Racine IVF Unit, Department
of Obstetrics and Gynecology, Lis Maternity Hospital, Tel Aviv Sourasky Medical
Center, Affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel
Aviv, Israel. 5 Department of Obstetrics and Gynecology, Chaim Sheba Medical
Center (Tel Hashomer), Ramat Gan, Israel.
Received: 5 May 2021 Accepted: 4 February 2022
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Article
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