OBJECTIVE To determine whether there is a sex bias in a historical cohort of consecutive patients who underwent initial pacemaker implantation at a Canadian teaching hospital by determining whether women were less likely to receive physiological pacemakers. METHODS Retrospective chart review. METHODS A Canadian, tertiary care teaching hospital. METHODS A total of 446 patients (192 female) had a first-time pacemaker implantation between January 1, 1990 and September 30, 1993 at Kingston General Hospital, Kingston, Ontario. RESULTS Physiological pacemakers (dual chamber or atrial only) were implanted in 125 male patients (49.2%) and in 93 female patients (48.4%), for an absolute difference of 0.8%. In patients deemed eligible for physiological pacemaker implantation (absence of absolute or relative contraindications to physiological pacing), 63.8% of male patients and 60.6% of female patients received physiological pacemakers. Pacemakers with rate-modulation were implanted in 109 male patients (42.9%) and in 80 female patients (41.7%). These differences were not significant. CONCLUSIONS No sex difference in the selection of physiological or rate-modulated permanent pacemakers was demonstrated in this study.