Work Experiences of Male Dental Hygienists: A qualitative study

Introduction

Traditional female dominated professions such as nursing, teaching, library science, and social work are highly gender segregated, with the number of men entering these professions remaining low dating back to 1975.¹ Nearly twenty years later, fewer than 1% of dental hygienists identified as male.^2,3 However by 2020, there had been an increase to 6.1%, suggesting that more men are entering the profession.^2-4 In spite of this trend, the overall number of men entering the dental hygiene profession remains low. Drawbacks reported by men who work in traditionally female dominated professions have included gender discrimination and negative stereotypes surrounding their male sexuality.¹ However, on a more positive note, men tended to have higher wages; and have been viewed as being more competent and better leaders in female dominated professions.¹ Within the healthcare professions, nursing has documented negative experiences for men that mirror what is found in other female dominated professions including gender discrimination and gender stereotypes.^5-10 Men in the nursing profession also reported identity issues, isolation, lack of role models, and salary gaps.^5-10

Literature regarding the experiences of male dental hygienists is limited. Darr conducted qualitative research to explore the barriers to men entering dental hygiene programs and found discrimination, stereotypes, and lack of role models were issues as well as the perception that males entering the profession were using it as a stepping stone to becoming a dentist.¹¹ Faust also conducted a qualitative study to explore the experience of male dental hygienists in the profession which revealed four themes that included: no job search difficulty, feelings of discrimination, mixed feelings about acceptance, and career satisfaction.⁴ Research conducted by both Darr and Faust identified issues such as discrimination, stereotypes, public perception and lack of role models which are consistent with research in other female dominated professions.^1,4-11 While male dental hygienists remain a minority in the profession, the number is slowly increasing and little is known about their experiences.^3,4,11 The purpose of this study was to explore and understand the experiences of male dental hygienists in the workplace.

Methods

This study was approved by the MCPHS University Institutional Review Board (IRB) and was awarded "exempt" status and assigned protocol number IRB040820BD. A qualitative phenomenological research design was used with a purposive sample of male dental hygienists (n=19). This design was chosen because qualitative phenomenological research seeks to understand the perspective of a specific population as well as a more in-depth and meaningful understanding of a phenomenon.¹²

Participants

A purposive sample of male dental hygienists was recruited to participate, with a minimum of 12 participants set as the target sample size. Literature suggests data saturation is reached after 12 interviews, however, to ensure saturation this was set as the minimum sample size.¹³ The inclusion criteria for participation were male dental hygienists who graduated from an accredited dental hygiene program; and who had been providing clinical dental hygiene patient care or working in dental hygiene education for a minimum of one year.

Instrument

The data collection instruments included a demographic survey (8 items) to gather the characteristics of the participants. The interview guide consisted of five open-ended questions developed based on the literature review of the experiences of men in nursing.^8,14 The focus groups were held via a video conferencing platform (Zoom; San Jose, CA) which is web-based and allowed for the recruitment of a national sample. A pilot focus group was conducted with three expert male dental hygienists to obtain feedback on the virtual focus group process and clarity of the open-ended questions. The principal investigator (PI) served as the facilitator of the focus group; each session lasted approximately one hour. No revisions were made to the procedure or interview guide based on feedback from the pilot focus group.

Procedures

Participants were recruited via social media platforms (Facebook, Instagram, and LinkedIn) and through dental hygiene professional associations. Interested participants who met the inclusion criteria provided their email to the PI via an electronic survey platform (Qualtrics; Provo, UT) and were emailed a link to an anonymous poll to select dates and times to participate in a focus group. Once a time and date were established, each of the focus group participants were emailed information about logging into the assigned session in addition to reminders regarding the session. Participants were able to choose to opt-out of using their webcam and join with audio only and could also choose a pseudonym when joining the focus group session for confidentiality.

Informed consent was obtained prior to beginning the focus group session. Participants also completed a short demographic survey and were given a participation number to maintain confidentiality and the PI reviewed the ground rules before starting the session. The PI then asked five open-ended questions, one at a time, allowing each participant the opportunity to respond without interruption. Probing questions were used to encourage participants to elaborate on their answers as needed. Each focus group lasted approximately one hour and was audio recorded. All audio recordings were transcribed within 24 hours, whenever possible.^12,15

Analysis

The PI prepared the data for analysis by transcribing each audio recorded session verbatim. Each recording was listened to multiple times to check for accuracy. The transcribed data was read and re-read multiple times to identify ideas, themes, and tones and notes were taken by the PI. When available, audio-visual data was also analyzed.¹⁶ Recurring themes, tones, and ideas were grouped together and coded. The coding process organized the data in chunks and used a word or short phrase to describe the category identified.¹⁶ A second investigator independently analyzed and coded the data using a qualitative data analysis software (MaxQDA, VERBI GmbH, Berlin, DE). Discrepancies were reviewed, and agreement reached before finalizing the themes. Two participants reviewed the transcript to confirm the focus group data themes were correctly captured, to aid in validity (trustworthiness) of the findings.¹⁶ The identified themes were used to generate a description of the major findings. Quotations from participants were used to strengthen and present the findings.

Results

Data saturation was achieved with 19 participants and a total of five focus groups. The participants included an international sample of male dental hygienists, with the majority from the Western United States (47%, n=9). Of the 19 participants, 45% identified as White, 30% identified as Asian, 10% as Black or African American, and 15% identified as other. The year of graduation ranged between 1992 and 2018, with 2011 as the median graduation year. A majority of participants reported holding a bachelor's degree or higher (n=16). Two participants reported holding a doctoral degree and six participants reported a master's degree. Most participants were employed exclusively as clinicians (n=12). Sample demographics are shown in Table I.

The qualitative data analysis generated themes related to the research question: "What are the experiences of licensed male dental hygienists?" and the specific focus group questions (Table II). Five major themes, 1) stereotype, 2) "not just because I'm a guy, I'm a dental hygienist", 3) discrimination, 4) reverse discrimination/special treatment, and 5) bringing balance to the work setting, emerged from data associated with the experiences of male dental hygienists. Major themes and illustrative quotes are shown in Table III.

Theme 1: Stereotype

The data revealed shared sentiments about stereotypes in dental hygiene. The expectation of a dental hygienist being female was conveyed to participants by not only the patients but also the dentist or potential employer. Participants shared experiences in which they were deliberately asked a question, or a comment was made suggesting the "expectation of a female hygienist." Two participants shared a strategy that their front office staff used to emphasize male pronouns for the provider to the patient over the phone when scheduling an appointment. Quotes to illustrate this theme included:

"I think the stereotype is kind of hard to break. Like a majority of the patients typically see a female hygienist."

"I remember when I was at a job interview and a male dentist, his first question to me was, like, why don't you become a dentist? And I was like, I went to school to become a hygienist."

"And then I had one lady who didn't want to see me because she felt like before she even saw me that I was going to have big hands . . ." (P9)

Theme 2: Not just because I'm a guy, I'm a dental hygienist

Participants in the study shared their feeling that there are no specific differences between being a male or a female dental hygienist. The data revealed that participants felt they were "good" or "successful" as oral health care professionals because they possessed "a skill set" and not because they were a "guy." Examples of this theme included:

"I wouldn't say that being a male, you know, brings anything special, positive or negative." (P1)

"It's not about male or female, in my opinion, like it's about how you work, how you manage your time and how you manage your patients."

Theme 3: Discrimination

Discrimination was a common theme discussed in the focus groups. There was a notable finding that this discrimination was based on gender. Participants expressed being told by temporary agencies that dental offices were "not looking for males." Gender discrimination was also made by patients who refused to be seen by a male dental hygienist. Participants who had patients refuse to see them did not take it "personal" or feel "offended." Sample quotes from participants included:

"There was one temp that I was initially appointed to and the morning I was supposed to drive to the office, I was told not to bother going in. The dentist said to the temp agency owner that he would never let a male dental hygienist work for him." (P1)

"When I walked in the first thing the dentist told me, she looked at me and she said, I'm going to give you a try, I don't hire males, you're the first male worker in this office. I said okay. So I worked there, the patients loved me blah blah blah, and so at the end of the day, we sat in her office and she was like, I'm gonna be honest with you, I don't hire males because patients see you as the dentist and it takes the power away from me." (P2)

Theme 4: Reverse discrimination/ special treatment

The participants also reported male dental hygienists may be treated better by the office staff. Participants referred to this as "reverse discrimination" or "special treatment." Some participants reported having their requests met much faster as compared to their female counterparts. The following are sample quotes associated with this theme:

"Since I'm the only guy I feel like I get special treatment because, I don't know, when I ask for things they get done pretty quick, and when she asks for the same things, it takes longer to accommodate her." (P4)

"So I don't know if it's reverse discrimination or what, but yeah, it actually worked to my advantage and the dentist and the office staff were both excited to give a male an opportunity." (P19)

Theme 5: Bringing balance to the work setting

 Several participants reported bringing "more balance" or a "different vibe" to their work environment. This was often seen as a positive aspect by the participants. This balance to the work setting was perceived not just by the participants but also communicated to the male dental hygienists by their co-workers. Quotes to illustrate this theme included:

"One of the biggest things of being a male in a female dominated career, is that we break up the norm." (P9)

"As males we're able to bring just a different dynamic to the office." (P17)

Minor Themes

Additionally, several minor themes emerged including the need for male representation in the profession, a positive work experience, increased sensitivity to treatment of female dental hygienists, a lack of role models, role identity issues, concerns about long-term stability, a lack of mentorship, the ability to connect with male patients, camaraderie with male dentists, and/or staff, and positive attributes surrounding physical strength. Sample quotes to illustrate these themes are displayed in Table IV.

Discussion

The major themes found among male dental hygienists in this study mirror the nursing literature regarding gender stereotypes and gender discrimination.^6-9,10 Sayman's findings of negative stereotypes experienced by male nurses from doctors and their patients were also found among dental hygienists in this study.⁶ Younas et al. found that discrimination was reported in various countries among male nursing students as it was also seen with male dental hygiene students.^9,11 This was also a finding in the 1999 Faust study which suggested the need to for dentistry and dental hygiene to address the discrimination issues.⁴

The major theme of "not just because I'm a guy, I'm a dental hygienist" was also found by Younas et al. which took into account various countries in which the male nursing students preferred to be referred to simply as a nurse rather than a "male nurse."⁹ Reverse discrimination or special treatment among male dental hygienists mirrors the findings cited by Younas et al. of the nursing educational experience.⁹ In the nursing literature, reverse discrimination/special treatment was referred to as "tokenism" by Kleinman in which a male nurse, as the minority, stands out and is viewed positively by others.¹⁷ Meadus and Twomey identified male nurses as being both visible and invisible,¹⁰ which was also reflected in comments from the focus group participants. However, in the study of male nurses, they felt that standing out amongst their colleagues in the workplace was a negative aspect.¹⁰ The major theme of "bringing balance to the work setting" was similar to research conducted by Cheng et al. which found that female nurses were pleased to assist male nurse colleagues.¹⁴ Themes of "reverse discrimination/special treatment" and "bringing balance to the work setting" bring new knowledge to the male experience in the dental hygiene profession as these concepts have not been previously identified in the literature.

Several minor themes emerged from the focus groups. One minor theme was the need for more male representation in the profession, which was also reported in the nursing literature.^7,9 Another minor theme was related to lack of male role models in dental hygiene which was also described by Hodges et al¹⁸ regarding the need for a better facilitation of the educational pathway for men in nursing. The male dental hygienists in this study identified the need to make the profession more inviting for males by increasing visibility of men in the profession and general awareness about dental hygiene as a career choice. Younas et al. identified role identity as an issue among male nursing students who were sometimes mistaken for medical students,⁹ similar to the participants in this study who were mistaken for the dentist. Physical strength was another minor theme, with male dental hygienists viewing their physical strength as a positive aspect of their clinical abilities. This differed from the findings of Meadus and Twomey in which men in nursing felt that their strength was exploited in their patient care assignments.¹⁰ Cheng et al. identified both positive and negative experiences related to the male's physical strength in the nursing profession.¹⁴

Participants in this study also shared their experiences with discrimination based on their male gender, reflecting the similar themes of gender discrimination previously reported in the dental hygiene literature.^4,10 Participants shared that patients made comments about never having seen a male hygienist and at times patients refused to be seen by them because of their gender, as reported in the Faust study conducted over twenty years ago.⁴ It is interesting to note males experienced some of the same issues with discrimination and stereotypes prior to entering the profession and as they did once they were engaged in the dental hygiene profession as licensed clinicians. These issues need to be a focus throughout the continuum from identifying dental hygiene as a career, through the educational experience and into clinical practice.

The male participants in this study chose to pursue dental hygiene as a career for reasons similar to men in nursing.¹⁰ Having a relative in the healthcare profession appears to play an important role in career choice regardless of the specific career. Some participants in this study also reported having had prior dental experience as a dental assistant or dental technician which influenced their career choice.

Findings from this study support previous research regarding gender discrimination by employers, dental staff, and patients. While many of the findings in this study have been previously reported in nursing literature, there were new findings specific to the dental hygiene profession. Results from this study expanded on the experiences of male dental hygienists regarding their identity as a dental hygienist; reverse discrimination or special treatment; and the ability to bring balance to the work setting. One unique finding was the increase in "sensitivity" that male dental hygienists reported while working in a female-dominated profession. The development of empathy for women and their experiences in the workplace, particularly as dental hygienists, is a topic for further research. Minor themes added to the understanding of men in the profession and included positive work experiences and the need for more male representation, which may help encourage other men to pursue dental hygiene. Issues of long-term financial stability should be addressed profession-wide, not just for male dental hygienists.

A limitation of this study was that the PI/moderator of the focus groups was a female; this may have influenced how the participants answered the focus group questions. Every effort was made to manage bias or assumptions of the researchers during the focus groups and analysis. Another limitation was that the majority of participants were from the Western US and possessed a bachelor's degree or higher which may not be representative of all dental hygienists who are male. Participants in this study were self-selected and shared their personal experience, which leaves room for personal bias and limits generalizability of the findings.

The findings of this study provide an opportunity for further research on gender pay disparities. As discussed in the nursing literature, as it is common for men to out-earn women in predominately female-dominated professions.¹⁹ Another topic for further research is the perception of the patient about care by male dental hygienists, as well as the dentist's perspective on hiring and working with male dental hygienists. Further research about gender discrimination is key for the dental hygiene profession to begin to identify prevention strategies and promote more males entering the profession.

Conclusion

Results of this study parallel the positive and negative experiences of nurses who are male. Accentuating the positive experiences of dental hygienists who are male may encourage other males to enter the profession, but it will be important to develop strategies to support them in overcoming the negative aspects such as gender stereotypes and discrimination. The themes also suggest a need to be more inclusive of men as dental hygienists by creating a new norm with more faces of men in clinical practice; marketing and advertising strategies; dental hygiene education; and representation in leadership within the dental hygiene professional associations.

Jeannette Diaz, RDH, RDHAP, MS, is the Dental Liaison to the California Department of Developmental Services and a candidate for a Master of Public Health degree; Linda D. Boyd, RDH, RD, EdDis a professor and the Associate Dean for Graduate Studies Forsyth School of Dental Hygiene; Lori Giblin-Scanlon, DHSc, RDHis an associate professor and the Associate Dean for Graduate Studies Forsyth School of Dental Hygiene; Robert D. Smathers, RDH, MSDHis an assistant professor; all at MCPHS University, Boston, MA, USA.

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