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Sexuality and Gender: The Theoretical Principles

The whole issue of sexuality and gender is vast with enormous amounts of literature having been published on the subject. (Bonner et al 1989)

In this particular essay we shall consider the issue as it relates to the sexuality and gender of the patient and how this may have a bearing on the role and treatment provided by the physiotherapist.

In broad terms, one's gender is an issue of chromosomes. The vast majority of the population have either an XY (male) or an XX (female) genotype. (Ramage 1998)

In this respect, the issues are comparatively straightforward. There are the rare cases of genetic intersex which we will mention, but not consider further, due to their rarity. By contrast, sexuality may often be determined by one's genotype, but it is also independent of it. (Hunt 1995). Masculinity and femininity correlate highly with genotype, but it is not unusual for a genotypic and phenotypic male to have predominantly female characteristics of sexuality and vice versa. (Pynor et al. 2005),

Discuss how this may influence practice.

From a purely professional point of view, any healthcare professional should treat the patient as an individual, and make a professional judgement of what is needed after consideration of their clinical case. Unless it has a distinct bearing on the clinical problem, in most situations, the patient's sexuality and gender is largely irrelevant. (Pynor et al. 2005)

While the professional should be aware of their patient's sexuality, as it reflects on the overall patient as a whole, it should only be an issue as far as treatment is concerned if there are sex-specific issues in the clinical domain. (Johnson et al. 2002)

As an illustrative example one could envisage the case of a transsexual (genotype male) who needed treatment for an Achilles tendonitis after wearing high heels. The physiotherapist should clearly treat the condition considering the patient as a whole. The patient's sexuality is utterly irrelevant to the clinical treatment issue.

Obviously, different healthcare professionals will work in different situations. Physical therapists, in general, are more likely to be confronted with issues of overt sexuality and sexual concern in their patients in relation to specific disabilities (Brackett, Nash & Lynne, 1996)

An aspect of clinical practice which may well be determined by this issue, however, is the perceived need for chaperones. Although it is accepted that any patient (or practitioner for that matter) may feel that a chaperone is appropriate in any circumstance, it is commonly accepted that same sex practitioner / patient interactions are less likely to need a chaperone. (Weerakoon et al 2002). This is clearly one issue where there may well be a difference of clinical approach. (O'Sullivan et al 1999). One might consider that the male practitioner, if confronted with a patient of obvious feminine sexuality, may feel less vulnerable with a chaperone (even if the gender is male) during treatment. (Weerakoon et al. 2004) and vice versa.

There may also be issues of whether a patient feels more comfortable with a same or opposite sex practitioner. (Weerakoon et al 2001). To a large extent, patients tend to vote with their feet and if it is an issue for them, they will usually attempt to resolve it by attending a healthcare professional of their preferred sex. (Meyer et al 2002)

Clearly, this may not always be possible in certain circumstances, and the healthcare professional should always attempt to be empathetic to perceived needs of the patient. (Weerakoon & O'Sullivan 1998).

Multidisciplinary team working - The Theoretical Principles

As healthcare professionals, we rarely work in isolation. From about the middle of the 19^th century, the explosion of scientific knowledge rendered it virtually impossible for any one person to assimilate all of the known facts relating to the various healing arts. (Beale & Beale 2005)

From that point on specialism became the accepted norm, with individual practitioners tending to focus their intellect and learning on specific areas of interest to them. Arguably, until the early part of the 20^th century, this movement was accompanied by an insular attitude amongst practitioners. (Wilde 2004)

This state has noticeably been eroded, and this erosion may well have been hastened by the advent of the NHS. (Field et al 1997).

Current practice is commonly characterised by inter-speciality referral and the advent of the multidisciplinary team, particularly in health centre and hospital practice is rapidly becoming the gold standard of practice. (Kendrick et al 1997)

Discuss how this may influence practice.

The whole issue of multidisciplinary teams working for the good of the patient is obviously potentially vast, as many different aspects of patient care will ideally call for multi-specialist input. It is almost unthinkable in modern-day practice to consider a surgical team without an integral physiotherapist, equally, the palliative care team could not operate efficiently without the input of a physiotherapy specialist. (O'Brien et al 1998).

The current role of the physiotherapist covers so many modalities, mobility, rehabilitation, restoration of function, to name but a few, that it is difficult to consider a field of modern practice where the physiotherapist cannot be gainfully employed. In terms of the impact on the patient, however, there can be a gulf of difference between theory and practice. (Friere 2001)

The concept of the multidisciplinary team may indeed be embraced by many as the clinical ideal, but as any experienced healthcare professional will tell you, it does not always become translated in to practice. The key is communication. In order for a team of any sort to work efficiently and seamlessly, it is utterly vital for effective communication pathways to be in place. (Coiera et al 1998)

The way that many of the health-related specialities have evolved historically, means that they have often developed their own individual vocabulary and terminology. The physiotherapist may well describe a painful back in different terms to a chiropractor, who may well describe it differently from the orthopaedic surgeon. The nurse may well see and assess exactly the same situation in a completely different way again.

We do not presume to pass an opinion on who is correct, the point to be made is that the assessments are different. They are often made with different criteria and possibly different therapeutic goals as well. Although this may be seen initially as a weakness of the multidisciplinary team, it should also be seen as the key to it's strength. (Zimmerman et al 2004)

To use the case as an example. The patient may present with a painful, immobile back. The surgeon may consider the problem in terms of removing as disc, the nurse may consider the issue as a potential pressure sore and the physiotherapist may assess the situation in terms of restoration of mobility and function. It is the holistic approach that is important, where each member of the team can consider just what particular skills that they can bring to the eventual restoration and healing of the patient. It is not expected that the surgeon has the skill to avoid, or heal a pressure sore, anymore than the physiotherapist would be expected to remove the disc.

It is perhaps incumbent on every member of the team to engage in reflective practice (Gibbs 1998) to ensure that they have added the input that is most appropriate for the long term benefit of the patient (Kuhse et al 2001)

The NHS calls for the general adoption of the principal of multidisciplinary teams (NHS Cancer Plan 2000) (Building on the Best 2003) in many different areas of practice. There is little doubt that the trend in the UK is for this to happen. (NICE 2005).

We have already alluded to the importance of communication within the team. (Coiera et al 1998). It is also becoming common practice for multidisciplinary team meetings to be held regularly, with varying degrees of formality. The key is to allow the various members of the team to share their views and experience with the other team members. It is equally vital for this to be done in an egalitarian and non-confrontational way so that no individual feels intimidated by the group structure. (Willmot et al 2000).

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Conclusion

It has been suggested that the ideal team structure should be formal with a nominated leader to lead discussion, to keep the group focused and to resolve disagreements or variations of opinion. This should ideally be delegated to the team member who has the best leadership skills. Some structures call for the leader to be rotated. More often than not, it is a role assumed by the lead physician who has ultimate responsibility for the decisions. (Willmot et al 2000).

The organisational changes that are necessary for such successful implementation are not a matter of chance. In order to have a good chance of working both efficiently and well, the necessary changes need careful management (Nickols 2004).

We should not lose sight of the fact that although the multidisciplinary team

approach has considerable potential benefit for the overall management of the patient, the various healthcare professionals do not assume a collective cabinet responsibility for the decisions made. Although individual members of the team may well add their skill and experience to the decision-making process, the ultimate legal responsibility for the implementation lies with the lead physician. (Allen 2000)

References

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Beale & Beale 2005 Texts and Documents Evidence-Based Medicine in the Eighteenth Century: The Ingen Housz-Jenner Correspondence Revisited Medical History: Vol. 49, Number 1, Jan. 2005

Bonner, E.M. & Gendel, M.D. (1989) Sex Education in Medicine - Implications for Family life Education International Journal of Adolescent Medicine and Health, 4, 203-212.

Brackett, N.L., Nash, M.S. & Lynne, C.M. (1996) Male fertility following spinal cord injury: facts and fiction. Physical Therapy. 76, 1221-1231

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Meyer M & Weerakoon P (2002). An exploration of intimate aspects of personal care assistance, and the impact this experience has on the body image and sexuality of the recipient. the inaugural conference of the NSW Primary Health Care Research Capacity Building Program 'Research From The Ground Up', The University of New South Wales, Sydney from 20-21 September 2002.

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O'Sullivan V & Weerakoon P (1999). Inappropriate sexual behaviours of patients towards practicing physiotherapists: A study using qualitative methods. Physiotherapy Research International, 4 (1): 28-42.

Pynor, Weerakoon & Jones (2005). A preliminary investigation of physiotherapy student's attitudes towards issues of sexuality in clinical practice. Physiotherapy, 91 (1) 42-48.

Ramage, M. (1998) ABC of sexual problems: management of sexual problems. British Medical Journal, 317, 1509-1512.

Weerakoon P and O'Sullivan V (1998). Inappropriate Patient Sexual Behaviour in Physiotherapy Practice. Physiotherapy, 84 (10): 491-499.

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Weerakoon P, Jones M & Pynor R (2002). 'Allied Health Professional students' perceived level of comfort in Clinical situations that have sexual connotations. The inaugural conference of the NSW Primary Health Care Research Capacity Building Program 'Research From The Ground Up', The University of New South Wales, Sydney. 20-21 September 2002.

Weerakoon, P, Jones, M & Pynor R (2004). Allied health professional students' perceived level of comfort in clinical situations that have sexual connotations. Journal of Allied Health, 33, 3, 189-193.

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Zimmeran C, Rodin G. 2004 The denial of death thesis: sociological critique and implications for palliative care. Palliat Med. 2004;18:121-128.

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