Topical Commentary

By: Rochelle C. Furtado & Christina Ziebart

Sex and gender are important components of an individual’s identity, health, well-being, and quality of life (1). Sex is defined as biological attributes referring to the chromosomal makeup, hormone function, and reproductive anatomy of an individual (1). Gender, however, is the socio-cultural role of an individual, recognizing the behaviour and identity of someone as male, female, or gender diverse (1).

Currently, there is limited rehabilitation care and research that strongly incorporates the gender of clients (2). This is particularly evident within the field of physiotherapy (3). Understanding and incorporating the differences between sex and gender can improve overall rehabilitation care and increase shared decision-making between clients, clinicians, and researchers.

Gender affects every dimension of our health and recovery, including our experiences and hardships of daily life (4). By understanding one’s gender and their roles in daily life, researchers and clinicians can better facilitate patient-centered research or treatment plans.

Within Ontario alone, those who identify as transgender or non-binary experience discrimination and microaggressions daily. A high proportion of these individuals have experienced assault and 40% will attempt suicide at least once, compared to 5% of the regular population (5). Further, a significant proportion of transgender and non-binary people have reported limited access to rehabilitation care and judgment from physiotherapists when receiving care (3).

By understanding one’s gender and their roles in daily life, researchers and clinicians can better facilitate patient-centered research or treatment plans.

There is a clear gap in practice when incorporating gender within the field of physiotherapy. The lack of training, research, and resources have created a barrier and limited the care for transgender and non-binary people. Therefore, this commentary hopes to bring awareness and strategies of incorporating a gender inclusive approach to all aspects of physiotherapy: research, curriculum, and practice.

Gender in Research

One of the top institutes within Canadian healthcare research, the Canadian Institutes of Health Research (CIHR), has recognized the impact of gender as a high priority when conducting rigorous research (6). The Institute of Gender and Health (IGH), one of the 13 institutes within CIHR, has provided numerous modules and frameworks to better implement gender within all stages of the research design. The goal and focus of this institute is to increase the awareness and implementation of gender, and its monumental impact on health and research. The IGH also aims to identify sources and consequences of inequalities between groups of people and to develop the appropriate strategies to address them.

Currently, the IGH endorses The Sex and Gender Equity in Research (SAGER) guidelines (1). These guidelines were developed to provide researchers with a tool to accurately consider sex and gender throughout all aspects of the research design, and to identify if treatment responses are truly biologic or related to dimensions of gender (1). For example, it is common that a research survey will collect demographic information of a participant and request the “gender” of a participant, but provide the binary options of either “male or female”. This may create unintended exclusion of transgender and non-binary people within the research study for those that who identify outside these binary constructs.

Specific points from SAGER include reporting whether sex and/or gender difference might be expected, reporting how sex and gender were considered in the design of the study, whether there was adequate representation of males and females, and presenting results by disaggregating for sex and gender (1).

While considering that gender-differences within physiotherapy research can be achieved through the SAGER guidelines, the implementation of these guidelines takes time (7). One major limitation is that a very small proportion of individuals in the research study might identify as transgender or gender non-binary (8). Analyses of these individuals, given the small sample proportions, will not provide sufficient power to detect differences between transgender, non-binary, and those who identify with the binary gender categories.

Further, with so few individuals identifying as transgender and gender non-binary in a given study, there is a risk of being able to identify who those participants are, which breaches confidentiality and anonymity (9). Unfortunately, few opt to identify themselves due to fear, judgment, stigma, or lack of safe spaces that a research study can introduce for transgender or gender non-binary people.

One strategy recommended by the SAGER research guidelines suggests specifically targeting funding agencies to secure funding to ensure a sufficient sample size of gender diverse individuals, and then purposefully sampling from that portion of the population (1). Additionally, researchers can seek resources to make sure their own training is up to date when managing various genders in a research project. For example, CIHR offers numerous free courses on best practices when working with different types of genders in a research study (6). Therefore, while the SAGER guidelines’ strategy can be slow to incorporate due to policy change and buy-in from funding agencies, researchers themselves can immediately take the next steps to ensure they are well equipped to create a safe space for all genders in research.

Gender within the physiotherapy curriculum

It is further important to understand how the use of gender-specific treatments can be incorporated into physiotherapy education. While the current Canadian curriculum for physiotherapy students (a 2-year Master’s program) focuses on a client-centered approach, there is a lack of training for treating clients by gender. By tailoring the education of an early clinician, we can increase the impact of a more immediate change in practice, than research alone.

Currently, there is a lack of education in the curriculum that focuses on the anatomy of transgender people, how to treat transgender or non-binary clients, and how to create a safe practice where all genders feel welcome. While changes in curriculums to professional programs take time, there are small changes that can be implemented quickly. Currently in the physiotherapy program, students learn about case studies that excludes personal pronouns and includes people that do not necessarily identify as either male or female, which exposes students to clients that are non-binary.

Additionally, schools can expand their curriculum to allow guest speakers of either transgender or gender non-binary educators or patient-partners. Implementing workshops taught by these educators or patient-partners would be beneficial to students, and allow for further conversations about gender inclusivity within rehabilitation care. It is of great interest to identify that gender influences a person’s health and quality of life, and by correctly addressing this early on, we can improve overall care for future clients. However, there is a continued need to educate faculty members and ensure that gender conversations become a mandatory part of the physiotherapy program curriculum.

While changes in curriculums to professional programs take time, there are small changes that can be implemented quickly.

Gender within physiotherapy practice

For current practicing physiotherapists, it’s critical to incorporate a biopsychosocial approach when treating clients in clinic. The International Classification of Disease, Health and Functioning (ICF) suggests that a person’s experience with a health condition goes beyond the biomedical concerns and additionally includes the persons activity limitations, participation restrictions, personal factors and environmental factors, Figure 1 (10,11).

This model is a useful tool to incorporate within a clinician’s traditional toolkit. Issues can arise in clinic when a gender diverse individual may have health consequences related to all of the components of the ICF. Ignoring this person’s gender preference can create a large gap in the effectiveness of treatment for that person. For example, if a client’s culture (environmental and personal factors) does not accept their gender identity, it may prevent them from going to cultural gatherings (activity), participating in social events related to their culture, or actively getting the resources needed for their recovery. Therefore, it is the role of the physiotherapist to actively include a more biopsychosocial approach when creating a treatment plan for clients.

A simple recommendation that all physiotherapists should adapt to be more gender inclusive includes asking the client “what would you like me to call you” or “what pronoun should I refer to you by” and then making sure they abide to that name and pronoun. These simple questions can make a large difference in a transgender client feeling accepted in the practice of physiotherapy.

Figure 1. The International Classification of Disease, Health and Functioning (ICF)

Additionally, practicing physiotherapists should always continue to further their education and keep up with current physiotherapy literature. The Canadian Physiotherapy Association (12), an organization for Canadian physiotherapists, offers many courses and workshops on treating transgender and gender non-binary clients. Taught by leading sex and gender specialists in the field, attendees can learn practical strategies to help maintain an environment that is inclusive to all genders. Learning new techniques and treatments for those that are transgender, especially during their transition phase, can help build trust between the transgender community and rehabilitation specialists (3).

Overall, the common goal in physiotherapy is to treat the clients and restore their ideal quality of life. While this commentary does not provide all the necessary answers, it does promote the awareness and strategies behind identifying and treating a client based on their gender, in all aspects of physiotherapy: research, curriculum and practice (see Table 1 for summary of recommendations). It is our job to be aware of the impact that gender can have on a client’s quality of life. As upcoming researchers and clinicians within the physiotherapy field, we pledge to do better when approaching gender in our work and we hope others will do the same.

Gender within…	Strategies
Physiotherapy Research	Using SAGER Guidelines to formulate research design Purposeful sampling to include a gender-diverse sample Free resources and courses from CIHR to expand knowledge on gender inclusivity within a research project
Physiotherapy Practice	Using an ICF approach to working with transgender and gender non-binary clients Making a safe space for all genders to feel welcomed during all sessions Updating personal knowledge and participating in training opportunities from the CPA to better treat transgender and gender non-binary clients
Physiotherapy Curriculum	Using case-based learning for transgender and gender non-binary clients Enrolling in workshops and tutorials to enhance skills of dealing with transgender and gender non-binary clients

Acknowledgements

Featured illustration by Michie Wu for rehabINK.

To refer to this article, it can be cited as:

Furtado RC, Ziebart C. Let’s talk about sex and gender!. rehabINK. 2021:10. Available from: https://rehabinkmag.com

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References

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