Respecting and taking into account the diversity of gender and sexuality as part of rehabilitation work

Everyone has the right to decide what they want to tell a rehabilitation professional about themselves and their lives. In the process of rehabilitation, we want to meet the person with all aspects, and we strive to help the person improve the interaction between him and the environment. The importance of the environment and those networks that operate within it has been increasingly emphasized in the change of paradigm in rehabilitation, and we want to emphasize that the involvement of networks and closest ones is really important.

But what if a person think that they cannot talk about their life or their closest ones, for the fear of discrimination? If we make assumptions about a person’s gender, sexual orientation, and / or the form of relationships already in the initial interview, the person can then withdraw and exclude certain aspects out of their own narrative. However, it may be that their meaning would play a significant role in human empowerment and rehabilitation. If a person thinks that the professional makes assumptions and preconceptions, the commitment to the goals or interaction of rehabilitation may be weakened and the effectiveness of rehabilitation is not realized.

In our work as rehabilitation professionals, we meet different people. With a holistic way and by respecting another person’s own personality and life are a value base and effort board for many of us. We want to meet a human as a human, whole and valued. It is often described that a good encounter is based on sensitivity and an understanding and respect for difference.

The experiences of sexual and gender minorities in health care have been reported to some extent in Finland as well, but more from around the world. Unfortunately, almost all sources show that minorities report significant problems in trying to obtain quality health care in where would be taken into account the specific health characteristics of the minority groups (1). Some have even experienced direct discrimination and inappropriate treatment because of their own identity or orientation (2). It has been reported that some people identified as LGBTQI + have not used social and health services due to the fear of discrimination (3). The most common experiences of LGBTQI + people are generalizations and assumptions made by the rehabilitation worker regarding gender or sexuality, for example, based on heteronormativity (4). In general, users of health services want service providers to have knowledge of the experiences of sexual minorities so that they could experience the feelings of appreciation, and to be heard and seen— people belonging to minorities think that if the service provider actively brings out his or her own knowledge of sexual diversity, it will reduce the stress of the minority groups at the same time (5).

A person’s sexual identity determines who he or she feels sexually attracted to. Sexual interest can be directed at one’s own gender, the opposite sex, or all genders. It may also be that a person does not experience sexual interest in others at all and defines himself through it.

Gender identity tells how a person experiences their own gender. The gender of transgender people is often different from what is assigned to her at birth. In binary experience, a person is defined, for example, as a man, but thinks that he is a woman or vice versa. Some people will define their identities as sliding or between the genders or asexual. (Definitions: Seta)

Sexual or gender identities should not be things that determine, for example, the quality of rehabilitation or the frequency of encounters. These things should not disturb the interaction in matters related to human health or rehabilitation. If a person feels to been encountered and accepted in matters related to sexuality or gender, it can give a significant positive effect on the relationship of trust between the professional and the person himself. Even the single vision and attitude of a healthcare professional can affect how valued and taken into account the client eventually feels they have become. However, one must always remember why a person comes for rehabilitation and treatment. Clients have reported that they have sought medical attention, for example, for a cough, and the doctor has been more interested in their transgender sex and the correctional process than in the effort that caused they to initially seek a treatment.

We all have our own toolboxes in relation to other people and to social situations. Our own personal attitudes and prejudices affect client orientation as well as the therapeutic relationship (6). They may be reflected wordlessly and unintentionally from our own body language or our being. When we dare to look a little closer, we will easily notice how we can expand our encounters. Heterogeneity and gender normalization may come up in secret in our speech, but norms of the physical environment also exist — the waiting spaces and interview forms are these places. If the customer cannot fit in the norm, in the worst case, the communication may end. Hetero- and gender-normative structures prevent and cause fear for the client so that they could communicate openly about their gender or about their gender identity, their self-expression, or their sexual orientation. This causes the customer group to remain invisible already at the level of structures and that they are not identified as users of the services. (7, 8)

It is also important to recognize that diversity affects not just the “mainstream population” but all groups of people, regardless of disability, illness, age, gender, religion or culture. Assumptions about the nature of a particular group of people are sometimes difficult to break.

Heteronormativity, or hetero assumption, refers to the norm that people are assumed to be divided into two sexes that are opposite sex and attractive to each other — women and men. As a result, heterosexuality is seen as more normal and natural than the other sexual orientations. (THL, Finnish Institute for health and welfare.)

Minority stress, in simplified terms, means an extra additional chronic stress that is formed in stages. Distal stress factors are objectively stressful situations or attitudes (discrimination, violence, prejudice). Proximal stress factors (the vigilance, the constant recurrence of experiences of discrimination in mind, the concealment of identity) are formed when a member of a minority begins to anticipate and fear experiences of discrimination. Proximal stress factors arise from distal effects, but also depend on in addition from the own experiences of a discriminated person. This chronic stress has been shown to have adverse effects on overall health. (9)

What can I do?

Identifying one’s own attitude is paramount and professionals have found that while it does not provide direct tools for giving specific information, it helps to manage surprising and less objective situations (10). As it is not possible in education to teach all possible behaviours or situations to professionals, it would be better to teach professionals to identify their own feelings of discomfort with sexuality issues and to go through strategies which can be used to deal with them instead of ignoring them (11). It is valuable to reflect on which in us resonates, as it can greatly develop the therapy process (12). Understanding your own identity helps you understand and face others.

You can view your workspace and functions through these items, for example:

  • Remember the neutral expressions in your own speech. Talking about the partner/partners instead of the husband / wife, allows the client to bring out the gender of the partner themselves, if there is a need for it at all.
  • How have the consideration of different family forms, genders and nicknames been taken into account in the forms?
  • How are the toilets marked? At its simplest, a space can only be marked with the word Toilet.
  • A sign indicating a non-discriminatory area can be placed in the workspace or other premises.
  • If you want to point out that you are particularly familiar with meeting diverse people, you can easily express it with a rainbow sign on your bag or key chain or bring up the matter on the company’s website.
  • What activities do I offer clients in rehabilitation? Regardless of gender, do clients have the opportunity to choose what rehabilitative activities they have available? Do we guide our child clients in games? How do we experience or react to the activities chosen by the client?

Be sure to notice that the person himself has the right to choose whether he wants to share personal things. If the matter is relevant to the name used by the customer, for example, you can ask what name the customer wants to use about himself and use this then in entries and encounters. It is also important to note that a person may not have told all the people involved in treatment or rehabilitation all the things, or that there are close ones who don’t know everything about the person itself for example, sexuality or sexual orientation. It is our job to respect this, and we cannot record things in statements or records unless we are sure of the client’s permission. When we record things about rehabilitation, it is also good to consider whether it is important to bring out the client’s gender or client’s sexual identity. It is also important to be aware that based on the written entries the customer may have to face a different treatment than after neutral entries. The client can also be asked what and how they want things to be recorded if they are relevant to rehabilitation.

If the information provided by the client is not familiar to oneself, one can ask what it means to the client in terms of rehabilitation and how he hopes that it will be taken into account. It may well be that it has no bearing on rehabilitation, and in that case, there is no need to pay more attention to it. However, it is worth remembering that the client should not act as the trainer to the employee, if we don’t know some specific thing ​— we can study the topic independently. If the confusion is related to the fact that the topic feels frightening to you, you may want to consider how these fears have evolved.

It may also be worth thinking in advance situations where you need to undress or touch the client and it is a good idea to be prepared to see chest binder, scars due to chest masculinization, or other body diversity. In advance one can ask oneself how one would react or respond if a client says that their body bruises came from a BDSM session, and they have not come as a result of violence if bruising causes conversation or questions.

 A person’s gender or sexual identity cannot be inferred from a client’s appearance or name. At the same time, one’s own experiences or expressions may also vary. It is also good to be neutral about these. When a customer tells you about their identity, it is a sign of trust — and that is worth facing with respect.

Summary

Heteronormative communication and practices make minority issues invisible and, for example, Valtonen (13) did refer at his dissertation to a study by Belognia and Witten (14) in where up to 80% of the providers of elderly service´ s refused hour-long training on LBTQI + issues on the grounds that those things do not concern them. Thus, there is often a perception among employees that the clients are not humans belonging to gender or sexual minorities at all (15). Sexual and gender minorities are an important subject throughout rehabilitation training programs so that equal care and understanding about diversity can be achieved regardless of sexual orientation (16). At the same time, the individual work of each person to dismantle heterogeneity and gender norms is at the same time, work to dismantle norms that are more damaging and restrictive.

If you consider these situations, presented above and you already find that this is now not a subject and nothing, then stop at those thoughts and feelings. It’s great if you feel like the topic doesn’t evoke any more reaction and you are able to approach the topic in a neutral and open way. However, even this feeling and going through it is important. It is good, if one can state, that one can be aware of the matter. However, it is still necessary to realize that if we ignore the topic completely without dealing with it ourselves, then encountering things may not be easy in everyday work.

Lastly, we would like to emphasize that the most important thing is that the customer is not left alone if challenging situations or questions arise. What matters is not the amount of knowledge, but a respectful, appreciative encounter in which the professional is aware of the effects of his or her own sexuality-related values and attitudes on the encounters. You can safely say that you do not know how to help in this particular case, but you can help to find the right professionals who can help. You can find professionals specializing in sexology, for example, in the Finnish Sexological Society’s expert search at www.suomenseksologinenseura.fi/asiantuntijat, where you can find help and information for yourself or your client. No one needs to know everything on their own.

The authors of the article are happy to educate on taking sexuality into account as part of rehabilitation work, the diversity of gender and sexual identity, and many other themes of sexuality.

Henna Kekkonen, Occupational Therapist (YAMK 2021), Specialist in Sexological Counselling (NACS)

Marjo Viinanen, Occupational therapist, Specialist in Sexological Counselling (NACS)

References

1. Manzer, Dana & O´Sullivan, Lucia & Doucet, Shelley 2008. Myths, misunderstandings, and missing information: Experiences of nurse practitioners providing primary care to lesbian, gay, bisexual, and transgender patients. The Canadian Journal of Human Sexuality. 27 (2) 157–170. 

2. Törmä, Sinikka & Huotari, Kari & Tuokkola, Kati & Pitkänen, Sari 2014: Ikäihmisten moninaisuus näkyväksi. Selvitys vähemmistöihin kuuluvien ikääntyneiden henkilöiden kokemasta syrjinnästä sosiaali- ja terveyspalveluissa. Sisäministeriön julkaisu 14/2014.

3. Jalava, Jenni 2013: Sukupuoli- ja seksuaalivähemmistöjen toiveet ja tarpeet yhdenvertaiseen vanhuuteen. Opinnäytetyö. Satakunnan ammattikorkeakoulu. Vanhustyön koulutusohjelma.

4. Ross, Meghan & Setchell, Jenny 2019. People who identify as LGBTIQ+ can experience assumptions, discomfort, some discrimination, and a lack of knowledge while attending physiotherapy: a survey. J Physiother. 65(2). 99–105.

5. Grigorovich, Alisa 2015. The meaning of quality of care in home care settings: older lesbian ja bisexual women’s perspectives. Scandinavian Journal of Caring Sciences 30. 108–116.

6. Areskoug-Josefsson, Kristina & Fristed, Sofi 2017. Occupational therapy students’ views on addressing sexual health. Scandinavian journal of occupational therapy. 22. 1–9.

7. Hovey, Jaime 2009: Nursing Wounds: Why LGBT Elders Need Protection from Dis-crimination and Abuse Based on Sexual Orientation and Gender Identity. Elder Law Journal 17 (1), 95–123.

 8. Röndahl, Gerd & Innala, Sune & Carlsson, Marianne 2006: Heterosexual assumptions in verbal and non-verbal communication in nursing. Journal of Advanced Nursing 56 (4), 373–381.

9. Jaskari, Onni 2020. Vähemmistöstressi uhkana seksuaali- ja sukupuolivähemmistöjen terveydelle. Pro Gradu -tutkielma. Helsingin yliopisto. Lääketieteellinen tiedekunta. 

10. Kazukauskas, Kelly & Lam, Chow 2010. Disability and sexuality: knowledge, attitudes and level of comfort among rehabilitation counselors. Rehabilitation Counseling Bulletin 54 (1) 15–25.

 11. Pynor, Rosemary & Weerakoon, Patricia & Jones, Mairwen 2005. A preliminary investigation of physiotherapy students’ attitudes toward issues of sexuality in clinical practice. Physiotherapy 91. 42–48.

12. Hedges, Fran 2010. The Reflexivity in Therapeutic Practice. Palgrave Macmillan. China.

13. Valtonen, Saini 2014. Sukupuoli- ja seksuaalivähemmistöihin kuuluvien vanhusten kohtaaminen pitkäaikaisessa laitoshoidossa – hoitajien näkökulma. Helsingin yliopisto. Pro Gradu -tutkielma. Valtiotieteellinen tiedekunta. 

14. Belognia, Lisa & Witten, Tarynn M. 2006: We Don’t Have That Kind of Client Here: Institutionalized Bias Against and Resistance to Transgender and Intersex Aging Research and Training in Elder Care Facilities. American Public Health Association, Gerontological Health Newsletter, Fall 2006.

15. Valtonen, Saini 2012: Yhdenvertainen vanhuus -projekti. Raportti vanhustyöntekijöille suunnatun kyselyn tuloksista. http://seta.fi/doc/raportti_vanhustyon_ammattilaiset_valtonen_saini2012.pdf.

16. Areskoug-Josefsson, Kristina & Gard, Gunvor 2015. Sexual health as a part of physiotherapy: the voices of physiotherapy students. Sex Disabil 33. 513–532.

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