Chapter 6 154 e.g. “When I am asked to describe myself, being female/male is one of the first things I think of”) and Gender Self-Acceptance, which refers to how comfortable a person feels as a member of their gender category (7-items, e.g. “I am confident in my femininity/ masculinity”). Each item is scored on a 6-point Likert-scale (1 = strongly disagree to 6 = strongly agree). The mean of all item scores is calculated for each subscale score. The scale has not been validated in a Dutch population; however, this was not deemed a limitation as its function in this study was primarily the establishment of congruent focus groups. Higher scores on the Gender Self-Definition subscale correspond to attributing a greater deal of importance to femininity/masculinity as part of their identity. Higher scores on the Gender Self-Acceptance scale correspond to more acceptance of themselves as female/male without necessarily strongly defining themselves in terms of their notions of femininity/masculinity. The survey is presented in an A (for women) or B (for men) format and includes binary gender congruent statements related to identifying as a woman/being feminine and man/being masculine. The survey contains a final open question which allows participants to define for themselves what the term femininity (for women) or masculinity (for men) means to them. This measure was used as proxy to assess how strongly committed participants were to their gender identity (higher or lower GSC). The Nijmegen Gender Awareness in Medicine Scale (N-GAMS) was included to assess the degree to which participants are sensitive towards the role of gender in medical care (supplement 4).21 The N-GAMS includes three subscales: 1) gender sensitivity and 2) gender role ideology towards doctors and 3) gender role ideology towards patients. The gender sensitivity subscale (12-items) consisted of attitudinal statements about gender concerns in healthcare (e.g., “Do you think that addressing differences between men and women creates equity in healthcare?”). The gender role ideology towards doctors and patients’ subscales assesses the degree to which participants agree with gender stereotypical attitudes towards doctors (7-items, e.g., “Male physicians put too much emphasis on technical aspects of medicine compared to female physicians”) and patients (11-items, e.g., “Women more frequently than men want to discuss problems with physicians that do not belong in the consultation room”). All items were measured on a 5-point Likert scale (1 = strongly disagree to 5 = strongly agree). This scale was developed and validated in the Netherlands. Notably, the N-GAMS has not previously been applied in patient populations and has mainly been used to measure attitudes among medical students and physicians. However, as the survey includes general statements with regards to gender-sensitive healthcare and generic stereotypical statements in healthcare settings with regards to gender role ideology, the N-GAMS could be considered a valuable instrument to also assess attitudes among patients towards the topic of gender in medical care.
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