RE: ‘Gender bias in the medical education of obstetrician‐gynaecologists in the United States: A systematic review’

We thank readers for their interest in our systematic review and anticipate the need to respond to numerous critiques about the inclusion of men in the field of obstetrics and gynaecology (OB/ GYN), which we believe further highlights gender bias that is increasingly pervasive within the field, inclusive of the lens through which our review is read, as well as the subsequent letter to the editor.1,2 Anticipating critique, our review begins by validating gender biases with attention to cases where male OB/GYN providers have taken advantage of their female patients. We acknowledge the vulnerability of patients seen in the OB/GYN context and make no recommendations that these vulnerabilities be overlooked or deprioritised; rather, we explicitly acknowledge the importance of genderconcordant care when needed. However, our review did not conclude that the majority of female patients desired genderconcordant care ‘be it specialists or medical students’, as was suggested by the letter to the editor. Rather, our review noted a clear gender preference only in the case of medical student gender, which should not be generalised to a preference for OB/GYN care provider. Making a statement about patient preference based purely on statistically significant evidence for medical student gender preference would not consider additional confounding factors regarding medical student care such as their lack of experience or potential for forming lasting physician– patient relationships. Further, although none of the analysed articles demonstrated women's preference for a male OB/GYN physician, the majority of studies also did not demonstrate a preference for female OB/GYN physicians. The letter to the editor aptly emphasises the importance of patient preference in the practice of evidencebased medicine. However, the limited quality and heterogeneity of available studies on gender bias support the need for further research on this topic rather than generalisations about patients' gender preferences. The conclusion drawn in the letter to editor regarding patients' preference for genderconcordant OB/GYN care is based primarily on anecdotal experience and studies in small or specific populations. We thus cannot recommend for or against supporting a femaledominated OB/GYN workforce. Instead, we can focus on promoting the need for further research and advocating for affirmative inclusion, with the understanding that the disproportionate sexual and reproductive burdens borne by female patients may be made worse if fewer medical students of any gender enter an alreadylimited OB/GYN workforce.3,4 We draw the reader's attention to the analogous field of urology where affirmative inclusion is being recommended to increase the representation of female urologists,5 in accordance with data unable to demonstrate a clear preference among male patients for male urologists.6 We thus caution readers against inferring that having more OB/GYNs who identify as women would promote better patient satisfaction. The analysed studies in our review suggest that patient satisfaction may be more closely related to patients' ability to choose their OB/GYN and the availability of physician information such that patients may make an informed choice. Further, we highlight that OB/GYNs, given their training and attention to stigmatised subjects, are well positioned to provide care to transgender and genderdiverse individuals. Therefore, we note that a genderdiverse workforce may better align with and treat the diverse gender identities and needs of this growing population of patients.7 We acknowledge concerns that recommendations to increase the proportion of OB/GYNs who identify as men may seem to detract from the hardwon gains and momentum of women in medicine; however, we believe that eliminating gender among all other forms of bias in medical education can improve the absolute number and quality of applicants entering the field.