Table 2.

Selected illustrative quotations

Theme	Quotations
Caregiving as a core role
Coordinators of care for partners	“[During clinical appointments] the woman has to come [with their husband], because she is responsible for the cooking and she has to understand what he needs. The wife cares about what the man is allowed to eat.” (Female nephrologist) “Women are not accessing health services as early as they should be because for women the role for the woman is to be the caregiver not to be the patient.” (Female nephrologist) “And my belief was that if it was a woman donating to a man, especially a partner or spouse, she'd say, ʻHey, just take care of my kidney there.ʼ And make sure that he takes his medication.” (Female nephrologist)
Fulfilling family duties over own health	“What I see [in women] is delaying or postponing treatment because they want to fulfill their social role as being a mother or a wife or other.” (Female nephrologist) “She only accepted to be put on the [transplant] list after about 12 years of dialysis. And the reason was that she was working as a nurse or nurse aid, she had two or three children at home, and she felt that she had gotten into a rhythm with dialysis, and she didn't want to disrupt her children's lives. And so, she essentially waited until her children were settled before she agreed to be listed for transplantation.” (Female nephrologist) “[Women] have always cared for others and put themselves second.” (Female nephrologist)
Maternal protectiveness	Women often get this feeling: “OK, I'm responsible for my family, children etc., so I have to make sure that I stay healthy.” (Male nephrologist) “[Women] don't want to think about living transplantation from their kids because that would be a problem, kind of maternal protection of others over themself.” (Female nephrologist) “I'm done, I've lived a good life. Why would I do that [take a kidney] from anyone? Why would I burden the system? There are other people that need it”—I find more altruism in women than in men, when it comes to their appreciation of things.” (Female nephrologist)
Inherent willingness and generosity	“A difference in the transplantation situation is, that the living donation is female. [Women] feel responsible for the illness of their partners, which is much more common in women than in men. Not a lot of men feel responsible for the disease of their wife.” (Female nephrologist) “It's more the giving nature of women. They are supposed to be more caring, and they are the ones who take care of the family. So that I've observed that women are more likely to come out as donors.” (Female nephrologist) “I see men have more fear to donate and men are selfish too.” (Male nephrologist)
Stereotyping and stigma
Authority held by men in decision making	“During the conversation you have with couples, it's often the case that women are more likely to donate because they are under a man's thumb, or don't dare to say no.” (Male nephrologist) “We see many more brothers willing to donate to their siblings, whether male or female, than sisters. Because sisters are unable to, because of their husbands. Once they are married, they cannot then go ahead and donate. They need the consent of the husband, who sometimes will be wary of that.” (Male nephrologist) “Even though you were saying that it may be risky for her because she doesn't know what she wants to do when she wants to, and he was like, ʻbut why can't I have that transplant from her?ʼ Then a little bit more egocentric.” (Female nephrologist)
Protecting the breadwinner	“[Women] don't expect to take part as an active role as a source of income in the future, then they said, ʻI'll go ahead, and I'll donate.ʼ And they don't work. They don't have to ask permission, a leave of absence, to donate. That's another point, because if you ask permission, a leave of absence, it's an unpaid leave of absence if you want to donate.” (Male nephrologist) “In general, the mother is offering the kidney because the father is working. The idea is that if you give the kidney, you will be not able to carry on a full-time job.” (Female nephrologist) “The life of males is more appreciated than the lives of female gender. Because men, they represent the source of income for the family.” (Male nephrologist)
Preserving body image and appearance	“The woman was abandoned by the husband or children, they don't respect the mother, disrespect the wife. The appearance of the women is important in the sexist culture. When women get transplant, because the health problems, they put on weight, the husbands reject them a bit because they are not physically attractive.” (Male nephrologist) “The patient she was a bit older she went for transplant because she wanted to give a child to her husband, she became fat, and the husband just dumped her. Three years later when she stopped the steroids, she became better looking she found another man, a younger one.” (Male nephrologist)
Safeguard fertility	“The fertility issue, when women desperately want to have a child, it is difficult when it comes to deciding which drug to use and in which dosage, or if a transplantation is indicated.” (Female nephrologist) “Women are more likely to choose transplantation because they want to have children.” (Female nephrologist) “So, we don't usually accept women who have not had a family, or completed their family, because any pregnancy in a person who's donated a kidney can be more complicated.” (Male nephrologist)
Social disadvantage and vulnerability
Limited information and awareness	“Women don't dare to inform themselves or ask questions.” (Male nephrologist) “Do I treat [and inform] male patients better? Yes, maybe because they demand [transplant] more, because you can get rid of women faster.” (Male nephrologist)
Coping alone and lack of support	“When women are affected, then the husbands probably on average are less involved in their care.” (Male nephrologist) “She often misses out on her clinic appointments. Her husband is not as helpful. She's working, and she's looking after a young toddler when she's not at work. I really worry that I won't be able to transplant her because she's neglecting herself too much.” (Female nephrologist) “I've got a number a couple of single moms. I don't know, how does the hospital system provide childcare? But for whom that's a big barrier. A social worker can't really find anything except foster care to help them.” (Female nephrologist)
Disempowered by language barriers	“In families that come from the Arab world, you can't primarily talk to the woman, everything runs via the man, or at best via their daughters, because the women don't speak German, although they've been living in this country for 20 years. The man speaks German, or the children. You can't hear anything from the patient, just ‘filtered.’” (Male nephrologist) “I see plenty of Aboriginal women from remote communities, and the quality of the conversation in terms of the level of connection that you get that's a personal connection that enables you to explore some of these issues, is very limited. And I don't think you actually can address it without having an indigenous female nephrologist, basically.” (Male nephrologist) “At least one or two a clinic interpreter conversation. And I'm never sure that his reputation is quite accurate, and they aren't ever very definitive in answering questions [because] I do wonder whether that interpretation aspect of it takes away the humanity side of things.” (Female nephrologist)
Lack of financial resources	“I guess maybe there are some females who are separated or relationship breakdowns and perhaps leading a more difficult life financially, who have got that ESKD, either transplant or dialysis.” (Male nephrologist) “[Men] control the finances of the family, and they're readily able to take part of the fund, to take it to care for themselves. Where the females are involved, and they do not have the funds, it's maybe more difficult to now raise the fund from wherever it is in the family to support that treatment.” (Male nephrologist) “Dialysis is paid out of pocket here, transplant is paid out of pocket, so the person who holds the pass, the families, what happens? I mean, most places it's the men, and then even when it's not the men, men are prized possessions, so even mothers would not want their sons to donate kidney. Or let's say the son and the daughter is ill, she would rather see that the son is treated and working before the daughter because that's just how it is.” (Female nephrologist)
Without access to transport	“Many women do not have a driving license; they are dependent on neighborhood help or public transport.” (Female nephrologist) “The woman only comes to the visit if the man or a child has time to accompany her. Otherwise, it is not possible to have a doctor's consultation.” (Female nephrologist)