ORIGINAL RESEARCH ARTICLE

Hostile Sexist Male Patients and Female Doctors: A ChallengingEncounter

Christina Klockner Cronauer • Marianne Schmid Mast

Published online: 18 September 2013

� Springer International Publishing Switzerland 2013

Abstract

Background Patient characteristics and attitudes can

affect how patients react to the physician’s communication

style, and this reaction can then influence consultation

outcomes.

Objective The goal of the present study was to investigate

whether the attitude of a sexist male patient affects how he

perceives a female physician’s nonverbal communication

and whether this then results in expecting less positive

consultation outcomes.

Study design and setting Participants were analog

patients who viewed four videotaped male and four vid-

eotaped female physicians in a consultation with one of

their patients. Physician videos were preselected to repre-

sent a range of high and low patient-centered physician

nonverbal behavior. Participants filled in questionnaires to

assess how patient-centered they perceived the female and

male physicians’ nonverbal communication to be, and

participants indicated how positive they expected the

consultation outcomes to be. Moreover, we assessed the

participants’ sexist attitudes with a questionnaire measur-

ing hostile and benevolent sexism.

Participants Students (N = 60) from a French-speaking

university in Switzerland were recruited on campus.

Main outcome measure The main outcome measures

were the extent to which analog patients expect the con-

sultation outcomes to be positive (high satisfaction,

increased trust in the physician, intention to adhere to

treatment recommendations, and perceived physician

competence) and the extent to which analog patients per-

ceive physicians as patient-centered (judged from the

physicians’ nonverbal cues).

Results Male analog patients’ hostile sexism was nega-

tively related to perceiving the physicians as patient-cen-

tered, and male analog patients’ hostile sexism was also

negatively related to expected positive consultation out-

comes. For male patients viewing female physicians,

mediation analysis revealed that perceived physician

patient-centeredness mediated the negative relationship

between hostile sexism and expected positive consultation

outcomes.

Conclusion Male hostile sexist patients perceive a female

physician’s nonverbal communication as less patient-cen-

tered and this negatively affects their expectation of posi-

tive outcomes from the consultation.

Key Points for Decision Makers

• Male hostile sexist analog patients expect less positive con-

sultation outcomes from medical consultations with male and

female doctors.

• Male hostile sexist analog patients’ perception of female doc-

tors as less patient-centered decreases their expectation of posi-

tive consultation outcomes.

1 Introduction

The way physicians communicate with their patients

affects patient outcomes [1–3], and there is consensus in

the literature that a patient-centered communication style

is beneficial for the patient [4–6]. Patient-centered

Electronic supplementary material The online version of thisarticle (doi:10.1007/s40271-013-0025-0) contains supplementarymaterial, which is available to authorized users.

C. Klockner Cronauer (&) � M. Schmid Mast

Institute of Work and Organizational Psychology, University of

Neuchatel, Rue Emile-Argand 11, 2009 Neuchatel, Switzerland

e-mail: christina.klockner@unine.ch

Patient (2014) 7:37–45

DOI 10.1007/s40271-013-0025-0

communication is characterized by taking the patient’s

perspective and viewing the patient in his or her psycho-

social context; by establishing shared understanding and

sharing of power and responsibility [7]. Physicians who use

a patient-centered communication style have more satisfied

patients [8, 9] who trust their physicians more [10] and who

adhere more to the treatment recommendations [2, 11].

However, not every patient reacts in the same way to the

physician’s communication. Patient characteristics such as

sex, age, or education [12–14], as well as patient personality

traits, attitudes, and expectations influence how patients

perceive a physician’s communication and how much they

profit from the medical consultation. A physician who takes

more time to explain the rationale of the treatment yields

more satisfaction with assertive than with non-assertive

patients [15]. More agreeable patients have more trust and

are more determined to adhere to the treatment when they

consult with a high affiliative physician [16].

Women and men react differently to physicians [17],

and female and male physicians behave differently towards

their patients [18]. Moreover, the sex composition of the

patient–doctor dyad plays a role in how well the medical

consultation unfolds and for the quality of the consultation

outcomes. Sandhu and colleagues [19] reviewed ten

research articles and concluded that sex congruence affects

the consultation rather positively in a medical consultation

while mixed-sex-dyads are prone to tension due to the

distribution of dominance or to sex stereotype conflicts. For

instance, female physicians seeing a male patient talk with

the least friendly and most tense voice (as opposed to all

other dyads), while male patients seem to be most bored

with female physicians. Also, other research shows that the

female physician–male patient dyad is particularly difficult

[20]. For instance, the more male patients perceive female

doctors as expressing uncertainty, the less satisfied they

were with the female doctor, whereas perceived physician

uncertainty was unrelated to patient satisfaction in all other

dyadic constellations [21]. In the present study, we inves-

tigated whether male patients’ sexism affects how they

perceive female physicians’ communication style and

whether this perception explains why more sexist male

patients are less satisfied with their female physician, trust

her less, are less inclined to follow her treatment recom-

mendations, and perceive her as less competent. We argue

that for male sexist patients when together with female

doctors, the sexist attitudes the patient harbors are partic-

ularly salient because the target of the sexism, the woman

doctor, is right there in the male patient’s face. Moreover,

the male patient is in a relatively low power position

because he seeks advice from the doctor and he might be in

pain or discomfort [22]. This relative power difference

might exacerbate the sexist attitudes. This is why we

expect the sexist attitudes to affect the perception of the

physician and the consultation outcomes more so in the

female doctor–male patient dyad than in all other dyadic

sex combinations. Indeed, research shows that women

doctors are perceived differently from male doctors in

general. For instance, female medical students are seen as

less confident even though they show the same nonverbal

behavior as their male fellow students [23]. Furthermore,

female medical students are not perceived as more com-

petent when applying a patient-centered style, but male

medical students are [24]. Another study finds that patients

are more satisfied with female doctors when they adhere to

a female-typical communication style [4]. Sexist men

might harbor these expectations to an even more pro-

nounced degree.

In the present study, we focus on the nonverbal behavior

of the physician because we want to show that sexist

patients pick up relatively subtle nonverbal cues of their

social interaction partners and perceive them in a certain

way (as less patient-centered when they come from a

female physician) and that this affects the expected con-

sultation outcomes. Moreover, research demonstrates the

strong effects that physician nonverbal behavior can have

on how the patient behaves during the medical consultation

and how the patient experiences the consultation outcomes

[25–28].

Sexism can be described as an individual’s negative

attitude towards the other sex, with women most often

being the targets of sexism [29]. While the effects of

sexism are described as negative, Glick and Fiske [29]

point out that a sexist attitude is characterized by ambiv-

alence. They suggest two forms of sexism: benevolent and

hostile sexism. Benevolent sexism is a rather positive,

protective view on women (women need to be protected

and cherished). Nevertheless, benevolent sexism is nega-

tive because it includes the perspectives that women are

dependent and incompetent. Hostile sexism consists of a

purely negative view of women (women try to gain power

over men, women exaggerate problems at work). Both

types of sexism can be simultaneously held by a single

person, but need not be equally strongly developed. Sexism

in medical care has so far mostly been researched from the

perspective of the physician, e.g. how sex bias in care-

takers affects patient treatment [30]. The current study

looks at male patients’ sexism towards female physicians.

According to Glick and Fiske [31], sexist individuals hold

an especially strong antipathy towards women who violate

the female sex role by intruding on typically male or high-

status domains. It is therefore likely that sexist patients

seeing a female doctor will react negatively to her, because

finding a woman in a high-status job, such as a physician,

contradicts their representations of the female sex role.

Given the distinction introduced by Glick and Fiske

[29], we expect that the patient’s hostile sexist attitude

38 C. K. Cronauer, M. S. Mast

rather than the patient’s benevolent sexism is the one that

will affect the perception of the female doctor. This is

because doctors are in a relative position of power, and

women in powerful positions are exactly what the hostile

sexist individuals are against and devaluate. Benevolent

sexist individuals perceive women in a more differentiated

way, still stereotypically female but with a feeling of

‘goodwill’. According to Glick and Fiske [29], benevolent

sexists are likely to think that women should be helped

because they are needy in general or that women are

especially skilled to cope with self-disclosure from others,

because women tend to have more intimate relationships.

Benevolent sexist patients might have a positive attitude

towards women. Consequently, they might feel less or no

tension between sex and professional stereotypes when

seeing a female doctor.

We predict male patients’ hostile sexism (but not

benevolent sexism) to be related to perceiving female

physicians as less patient-centered. Furthermore, this per-

ception of female physicians not acting in a patient-cen-

tered way will be responsible for hostile sexist male

patients expecting the consultation outcomes to be less

positive. To test this hypothesis, and investigate the extent

to which the predicted relationships are exclusive for the

male patient–female doctor dyad, we included women and

men in the role of patients and we measured their per-

ception of female and male physicians.

2 Method

2.1 Participants

Participants were 60 students (35 female, 25 male) from a

French-speaking Swiss university who acted as so-called

analog patients who put themselves in the shoes of a patient

seeing a doctor [4, 32–34]. Participants were approached in

common places at the university (e.g., cafeteria, library)

and were asked for their participation in the study in late

summer of 2009. For their participation in a testing session

of 45 min, participants were remunerated with 15 Swiss

Francs. When they agreed to participate, they were

accompanied to a quiet place and watched the videotaped

physicians and filled in the questionnaires. Results based

on this study but unrelated to the current one are reported

elsewhere [16].

2.2 Material

2.2.1 Physician Videos

Participants watched short (2 min) excerpts of eight phy-

sicians (four females and four males) videotaped in their

respective medical practices in real consultations with one

of their patients (not visible on the video). For each con-

sultation, we selected the second and the third-to-last

minute of the consultation to show to the participants, with

the sound off. The mean age of the physicians was 47 years

(range from 33 to 56).

The videos were selected from a database with 11 videos

[34]. To ensure a range of physician patient-centeredness to

which the analogue patients could react, we selected two

female and two male physicians who each showed rela-

tively low levels of patient-centered nonverbal behavior

and two female and two male physicians who each showed

relatively high levels of patient-centered nonverbal

behavior. Patient-centered nonverbal behavior of the phy-

sician encompasses smiling, back-channeling (i.e. listener

responses aimed at showing understanding and to encour-

age the patient to continue talking, e.g. ‘uh-huh’ or little

head movements), eye contact, and nodding [28, 35]. We

coded these nonverbal behaviors in each of the eight

stimulus videotapes to ensure that the high and low patient-

centered physicians really differed in this regard. Repeated

measure t tests showed that the four physicians we selected

as highly patient-centered smiled more, t(6) = 2.35, p =

0.05, made more backchannels, t(6) = 2.48, p = 0.048,

established more eye contact, t(6) = 2.61, p = 0.040, and

nodded more, t(6) = 2.66, p = 0.038, than the four phy-

sicians we selected as the low patient-centered.

2.2.2 Perceived Physician Patient-Centeredness

To assess how patient-centered the physicians were per-

ceived based on their nonverbal behavior, participants rated

each physician on five items on a 5-point Likert scale

(1 = ‘completely disagree’, 5 = ‘completely agree’).

Sample items are ‘The physician seemed to involve the

patient actively in the discussion’, ‘The physician seems to

care about the patient’s problems’, or ‘The physician

seemed interested in his patient’ (for the complete ques-

tionnaire, refer to the Electronic Supplementary Material

[online resource 1]). Repeated measure t-tests were applied

to compare means between female and male physicians,

and female and male highly patient-centered physicians,

and female and male low patient-centered physicians.

2.2.3 Expected Positive Consultation Outcomes

We asked participants to rate how satisfied they would

have been with each of the physicians (three items), the

extent to which they would trust each of the physicians

(three items), how competent they perceived each of the

physicians to be (three items), and how much they would

adhere to the treatment recommendations of each of the

physicians (three items) on a 5-point Likert scale

Hostile Sexist Patients and Female Doctors 39

(1 = ‘completely disagree’, 5 = ‘completely agree’) (for

the complete questionnaire, refer to online resource 1).

Cronbach’s alpha served as an indicator of scale reliability.

We combined the four measures to form a composite

positive consultation outcome measure. Scores on the

measures were averaged separately for the four female and

the four male physicians to obtain an expected positive

consultation outcome score for female and for male phy-

sicians separately. We compared the mean expected posi-

tive consultation outcomes for female and male physicians

with a repeated measure t test. Also, we indicated the

intercorrelation between perceived patient-centeredness

and consultation outcomes with Pearson’s r.

2.2.4 Patient Sexism

We used the ambivalent sexism inventory (ASI) [29] to

assess the degree of sexism of the participant. The theory

of ambivalent sexism distinguishes between a negative,

hostile view of women (e.g., women are seen as competi-

tors for power positions) and a positive (in the eyes of the

sexist), benevolent view of women (e.g., women are seen

as worthy of or needing particular protection) [31]. Even

though benevolent sexism is based on a positive attitude

towards women, it is still sexist, such as seeing women in

an inferior role to men. Therefore, we wanted to measure

both types of sexism. The ASI consists of 11 items mea-

suring hostile and 11 items measuring benevolent sexism

(on a scale of 1 = ‘completely disagree’ to 5 = ‘com-

pletely agree’). A sample item for benevolent sexism is:

‘Women should be cherished and protected by men’. A

sample item for hostile sexism is: ‘Women seek to gain

power by getting control over men’ (for the complete

questionnaire, refer to online resource 1).

2.3 Procedure

After filling in the ASI, participants were asked to take

the perspective of a patient in the consultation with the

doctor they watched on the silent video. In this analog

patient role, participants watched each of the eight vid-

eotaped doctors and rated each on perceived patient-

centeredness and on satisfaction, trust, probable adherence

to treatment recommendations, and perceived compe-

tence. The videos were presented without sound because

we were interested in the effect of physician nonverbal

patient-centeredness and its effects depending on patient

sexism.

The order of the videos was the same for all participants.

Physician sex and patient-centeredness were randomly

arranged within the sequence of the eight videos. The

medical contents of the consultations were minor medical

problems comparable in severity, like headaches or

influenza. The medical content could not have influenced

the participants’ perceptions because they watched the

video in silent mode. Participants also indicated their sex,

age, current health status, and the frequency with which

they consulted a physician per year.

The use of analog patients and standardized physicians

is widespread [34, 36–38]. Using standardized physicians

has the advantage of having all participants being con-

fronted with the same physician. Therefore, all the variance

in the data stems from the analog patients (because the

physicians are held constant among the participants).

2.4 Statistical Analysis

To test whether female and male analog patients differed in

how patient-centered they perceived the female and male

doctors to be and how positive they expected the consul-

tation outcome to be with female and male doctors, we

calculated two separate mixed-model analysis of variance

(ANOVAs) with analog patient sex as the independent

variable and physician sex as the repeated measure factor,

controlling for analog patient age, health status, and

experience with medical consultations. Furthermore, we

used Sobel tests to analyze the difference between corre-

lated correlation coefficients such as the correlations

between sexism and consultation outcomes for female and

male physicians.

3 Results

3.1 Participant Characteristics

On average, participants were 23 years old (standard

deviation [SD] 3.20), and most of them indicated they were

in good health (Mean (M) = 4.13, SD = 0.70) on a scale

from 1 (not good at all) to 5 (very good). Furthermore,

most participants indicated they would see a physician

between one and two times a year (M = 2.13; SD = 1.19)

on a scale from 1 (less than once a year) to 5 (more than six

times a year).

3.2 Statistical Description of the Perception of Male

and Female Physicians

3.2.1 Perceived Physician Patient-Centeredness

Scores for perceived physician patient-centeredness were

averaged across items and separately for the four female

and the four male physicians to obtain a perceived patient-

centeredness score for female and for male physicians

(female physicians: Mean (M) = 3.45, SD = 0.41, Cron-

bach’s alpha = 0.85; male physicians: M = 3.28,

40 C. K. Cronauer, M. S. Mast

SD = 0.43, Cronbach’s alpha = 0.87). Although female

physicians were perceived as being more patient-centered

on average than male physicians, t(59) = 2.65, p = 0.01,

the standard deviations for female and male physicians

were comparable.

3.2.2 Expected Positive Consultation Outcomes

All sub-scales showed good scale reliability (satisfaction:

Cronbach’s alpha = 0.89; trust: Cronbach’s alpha = 0.87;

competence: Cronbach’s alpha = 0.73; intention to adhere:

Cronbach’s alpha = 0.84). When combining the subscales

to the expected positive consultation outcomes measure,

participants expected average consultation outcomes of

M = 3.41 (SD = 0.45; Cronbach’s alpha = 0.84) when

watching female physicians and M = 3.43 (SD = 0.40,

Cronbach’s alpha = 0.84) when watching male physicians,

t(59) = 0.41, p = 0.68. Thus, there was no difference in

consultation outcomes when watching female physicians as

compared with watching male physicians. Furthermore, the

standard deviations associated to the expected positive

consultation outcomes of female and male physicians were

comparable.

Perceived physician patient-centeredness and expected

positive consultation outcomes were positively correlated

(r = 0.73, p = 0.001). This is in line with other research

showing that a positive perception of the physician’s

communication style is positively related to patient out-

comes [3, 5, 39].

3.2.3 Patient Sexism

The average score for hostile sexism (Cronbach’s

alpha = 0.87) was M = 2.64 (SD = 0.74). For benevolent

sexism (Cronbach’s alpha = 0.84) it was M = 2.61

(SD = 0.74).

3.3 Perceived Patient-Centeredness, Expected Positive

Consultation Outcomes, and Sexism

We calculated a two (participant sex) by two (physician

sex) mixed-model ANOVA, with physician sex as the

repeated measure factor once for perceived physician

patient-centeredness and once for expected positive con-

sultation outcomes.

Results for perceived physician patient-centeredness

showed neither a significant main effect nor interaction

effect (all Fs \ 0.16, all p-values [0.68). Results for

expected positive consultation outcomes showed no sig-

nificant main effects (both Fs \ 0.09, both p-val-

ues [0.76); however, there was a significant interaction

effect, F(1, 54) = 4.65, p = 0.04. Male analog patients

expected significantly less positive outcomes in

consultations with female physicians (M = 3.33) than in

consultation with male physicians (M = 3.49), t(24) =

-2.01, p = 0.05, whereas for female analogue patients, the

expected outcomes did not differ significantly when

viewing female physicians (M = 3.46) than when viewing

male physicians (M = 3.38), t(34) = 1.24, p = 0.23. Male

analog patients had significantly higher scores on the

benevolent sexism scale (M = 2.89) than the female ana-

log patients (M = 2.42), t(58) = 2.58, p = 0.012, and

male analog patients had marginally significantly higher

scores on the hostile sexism (M = 2.85) scale than the

female analog patients (M = 2.50), t(58) = 1.88,

p = 0.065.

To test whether sexism is related to the perception of

physicians as less patient-centered and therefore to the

expectation of less positive consultation outcomes, we

correlated, separately for female and male analog patients,

benevolent and hostile sexism with perceived physician

patient-centeredness (Table 1) and with expected positive

consultation outcomes (Table 2) when viewing a female

and when viewing a male physician, controlling for analog

patient age, health status, and medical experience. All of

the mentioned results remained essentially the same when

not controlling for the aforementioned variables.

Table 1 shows that the more hostile sexist a male par-

ticipant, the less he perceived the female physician as

patient-centered. This link did not emerge for male par-

ticipants perceiving male physicians. This difference was

statistically significant, Z = 0.74, p = 0.01 [40]. There

was no significant association between hostile sexism and

perceived patient-centeredness for female participants,

whether viewing a female or a male physician. For male

and female participants, perceived physician patient-cen-

teredness was not related to benevolent sexism, whether

viewing a female or a male physician.

Table 2 shows that the more hostile sexist a male par-

ticipant, the less positive he expected the consultation

outcomes to be, and this was true when viewing a female as

well as when viewing a male physician (no significant

difference of the relationships when viewing a female or a

Table 1 Relationship between sexism and perceived physician

patient-centeredness when viewing a female or a male physician

Sexism Perceived physician patient-centeredness

Female physician Male physician

Participants

Female Male Female Male

Hostile -0.12 -0.80* 0.16 -0.42

Benevolent 0.14 -0.25 -0.04 0.17

All entries are partial correlations, controlled for sex, age, health

status, and medical experience. * p \ 0.001

Hostile Sexist Patients and Female Doctors 41

male physician, Z = 0.06, p [ 0.10; comparison of corre-

lated correlation coefficients [40]). For female participants,

hostile sexism was not related to expected consultation

outcomes. For both female and male participants, benevo-

lent sexism was not related to expected outcomes, whether

viewing a female or a male physician.

To investigate whether male hostile sexist patients’ low

expectations about the consultation outcomes were low

because they perceived female physicians as less patient-

centered, when seeing a female doctor, we proceeded to a

mediation analysis. Hostile sexism was negatively related

to expected positive consultation outcomes and negatively

related to perceived physician patient-centeredness only for

male patients viewing female doctors. These are the nec-

essary prerequisites that allow testing for mediation [41].

When controlling the relationship between hostile sexism

and expected positive consultation outcomes for perceived

female physician patient-centeredness (including the

aforementioned control variables), the relationship between

hostile sexism and consultation outcomes drops to partial

correlation (pr) = -0.24. To see whether this drop is a

significant drop from pr = -0.74, we performed a Sobel

test [41]. The Sobel test revealed that the drop was sig-

nificant (Z = 1.98, p = 0.048). This means that, for male

participants, perceived physician patient-centeredness

explains the relationship between hostile sexism and

expected consultation outcomes when viewing a female

physician.

4 Discussion and Conclusion

The goal of this study was to test whether male analog

patients’ negative attitudes towards women (sexism) are

related to perceiving female physicians as less patient-

centered and this being the reason why their negative

attitudes are related to expecting less positive outcomes in

consultations with female doctors. Results confirmed that

the more the male analog patient was overtly sexist (hostile

sexism), the less he perceived the nonverbal behavior of

female physicians as patient-centered and the less positive

he expected the consultation outcomes with a female

physician to be. Moreover, lower levels of perceived

patient-centeredness after having watched a female physi-

cian explained why male analog patients’ hostile sexism

was related to less positive expectations about the consul-

tation outcomes. The results confirmed our predictions.

Our results show that male analog patients harbor more

sexist attitudes than female analog patients. This is in line

with research showing that men’s sex stereotypes and

sexist attitudes are typically more pronounced than those of

women [42]. We also show that the relationship between

(hostile) sexist attitudes and the negative perception of a

social interaction partner (low levels of patient-centered-

ness and low levels of satisfaction, trust, intention to

adhere, etc.) emerged only for men (male analog patients)

and not for women.

Male analog patients’ hostile sexism is related to

expecting less positive consultation outcomes not only

from female doctors but also from male doctors. It seems

as if hostile sexist men have a negative attitude towards

social interactions in general (and not only with women) or

maybe they see the world overall in a more negative light.

This is in line with a study linking hostile sexism to poorer

perception of subjective well-being [43]. Hostile sexist

males might be mostly hostile and this part of the construct

might have driven the effect more than the sexist part. So

hostile sexist men might be similar to what are known as

difficult patients. For instance, difficult patients are more

likely to have unmet expectations after a medical consul-

tation and are less satisfied in general with healthcare [44].

The male patient–female doctor constellation seems

particularly difficult and fragile [19–21]. We find that the

more a male analog patient was hostile sexist, the less he

would perceive the female physician’s nonverbal behavior

as patient-centered and this would negatively affect his

expectation of positive consultation outcomes with a

female physician. This suggests that in the male patient–

female doctor dyad, sex and power or status issues become

particularly salient. Hostile sexist individuals adhere to a

very traditional view of women combined with perceiving

women as trying to gain power over men [29]. Thus hostile

sexist patients might be irritated or might feel threatened

by a woman in a professional context associated with high

status and dominance, such as a doctor. This violation of

the traditional sex role might be responsible for perceiving

female doctors in a less positive light and as less typically

female (i.e., less patient-centered).

While physicians can commonly improve their patient’s

health outcomes by adopting a patient-centered commu-

nication style, our results suggest that this measure is of no

avail when female doctors are consulting with a hostile

sexist male patient. Hostile patients’ negative attitude

Table 2 Relationship between sexism and expected positive con-

sultation outcomes when viewing a female or a male physician

Sexism Expected positive consultation outcomes

Female physician Male physician

Participants

Female Male Female Male

Hostile -0.14 -0.74* -0.09 -0.59*

Benevolent 0.01 -0.04 -0.05 0.08

All entries are partial correlations, controlled for analogue patient sex,

age, health status, and medical experience. * p \0.01; ** p \ 0.001

42 C. K. Cronauer, M. S. Mast

towards women seems to deter their health outcomes. In

reality, when given the chance, hostile sexist patients might

automatically select a male doctor, especially in countries

and situations where free doctor choice is possible. Most

patients have a preference for either a female or a male

doctor and the nature of the health problem affects this sex

preference [45]. Nevertheless, there still exist situations in

which a female physician faces a sexist patient. Which

verbal or nonverbal communication a female doctor should

then adopt to counter the patients’ negative attitude

towards her remains an open question. Maybe a particu-

larly patient-centered or feminine communication approach

would remedy low outcome expectations, because our

results show that low levels of perceived patient-centered

nonverbal behavior were related to less positive outcomes.

Maybe if the hostile patient can be convinced that the

female physician is very patient-centered, the outcome

expectations would be more positive. Another approach

would be to try to level the power difference most likely

experienced by male sexist patients in consultations with

female physicians.

In the present study, we focused on the reactions of male

sexist patients to the female physician’s nonverbal behavior

because we were interested in how sexist patients project

their perceptions and evaluations onto the female targets.

Whether the verbal communication of female doctors is

perceived in the same way by male hostile sexist patients

remains an open question. It is possible that the effects only

pertain to the nonverbal channel. Nonverbal behavior offers

better opportunities to project because the meaning is less

objective and therefore leaves more room for subjective

interpretation than verbal behavior. For instance, a patient

can interpret a physician’s gaze as the physician being

interested or intimidating. In contrast, a physician asking the

patient for his or her opinion clearly signals interest in the

patient’s perspective. This said, maybe female doctors can

counteract the relatively negative perception male hostile

sexist patients have of them by adopting a verbal commu-

nication style that levels power differences by asking—rel-

atively more than she already habitually does—about how he

experiences his illness and what he wants to do about it (e.g.,

partnership-building verbal medical communication).

To actively counteract the negative perception a male

sexist patient has of female doctors, doctors would need to

be able to detect a sexist attitude in the patient. One might

wonder whether a doctor is able to accurately perceive

sexism of his or her patient. Indeed, research shows that

people are able to correctly infer others’ attitudes such as

their racism based on the observation of very short excerpts

of their behavior (20 s) [46]. So there is reason to assume

that, in general, physicians are able to correctly detect

whether or not their patients are sexist and can then take

the necessary actions (e.g., level power).

Putting the focus on the physician’s nonverbal behavior

was motivated by showing that subtle differences in phy-

sician behavior can be interpreted in a different way

depending on physician sex and the attitudes of the patient.

However, it is, at the same time, a limitation of the current

research to not have included the verbal channel, which

future research should do. Another limitation of the current

research concerns the choice of the study participants. We

used students in the role of analog patients and therefore

the sample was relatively homogenous with respect to age

(and with respect to other factors such as educational sta-

tus). When using a student sample, we probably selected

participants who scored relatively low on sexism. Had we

used participants with more pronounced sexist attitudes,

the effects would probably have been even stronger. It

would be interesting to see whether the effects of sexism on

how physicians are perceived and on patient outcomes are

different in older patients, in patients with more serious

health issues, or in patients who see their doctor more often

than our participants did.

We used analog patients as participants and not real

patients. Analog patients are common practice in research

[33, 34, 36–38]. Studies testing real patients often face

positive response bias in ratings of patient outcomes [47].

This can be overcome by using analog patients instead.

Additionally, recent studies provide strong empirical evi-

dence that analog patients’ evaluations can be validly

compared with those of real patients [32, 48]. Still, being in

a real consultation with a real health problem certainly

differs from watching a medical consultation in many

aspects. Therefore, future research is needed to replicate

our findings with real patients.

4.1 Practice Implications

In physician training, special attention should be brought to

the female physician–male patient dyad because there is

accumulating evidence suggesting that, for these dyads,

consultation outcomes are not optimal. Female doctors

need to be made aware of the relatively negative perception

and evaluation hostile sexist male patients have of them

and of the consultations. Female physicians facing a hostile

sexist patient might want to put special emphasis on con-

veying patient-centeredness, either nonverbally or, maybe

more effectively, via verbal communication. For instance,

clearly expressing interest in the patient’s experience of

illness or engaging the patient as a partner in decision

making about the medical treatment might counteract

hostile sexist patients’ negative perception and evaluation

of consultations with female physicians.

Acknowledgments and funding The authors thank Gaetan Cousin

for his comments on an earlier version of this manuscript. The

Hostile Sexist Patients and Female Doctors 43

research findings have been presented at the International Conference

on Communication in Healthcare 2010 in Verona. This research has

been supported by a grant from the Swiss National Science Founda-

tion (PP0001-106528/1) to the second author.

Conflicts of interest and guarantor statement We, Christina

Klockner Cronauer and Marianne Schmid Mast, certify that there is

no conflict of interest with any financial organization regarding the

material discussed in the manuscript. Both authors have sufficiently

participated in the planning of this study, acquisition, analysis, and

interpretation of data, as well as the drafting and reviewing process of

this article, and therefore are equal guarantors for the overall content.

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