It is widely accepted that sex and gender are not interchangeable. The World Health Organisation (2002) defines sex as biologically determined, and gender as socially constructed. Recently however, the two have been conflated (Stuhlsatz, Bracey & Donovan, 2020), causing debate amongst marginalized groups on issues impacting them. One such issue in nursing is patient choice of carer.
Research uses terms sex and gender interchangeably, with no definition given as to which they refer to. Madsen et al (2017) criticizes this due to the ever-changing lexicon around sex and gender, arguing for standardised terminology both within research and in training for healthcare professionals. Many policies relating to this also choose to use gender to define choice of carer. It is important that policy and research are explicit, for patients to understand their rights: sex is a protected characteristic under the EHRC; gender is not. A Trans person can however change their legal sex by applying for a gender recognition certificate- though few Trans people do (Government Equalities Office, 2018).
There is no legal requirement in the UK to provide same sex care. Nevertheless, the NMC code cites patient choice being considered as something all nurses and midwives must do, stating “recognise diversity and individual choice” (NMC, 2015). The Royal College of Nursing (2021) addresses this directly, stating best practice is to make reasonable efforts to support patients’ right to request a carer of the same or different gender. A case investigated by the Local Government and Social Care Ombudsman (2014) found that not providing a vulnerable client with a same sex carer was compromising her dignity, providing a precedent in law. Additionally, the Equality Act 2010 lists the need for same-sex care as an objective justification when recruiting care workers, and after successful lobbying by sexual violence survivors’ groups, the language used in Forensic Medical Services Act 2021 was changed from gender to sex. We therefore know that this distinction needs to be clear.
Of the almost 732,000 people on the NMC register, 5,046 stated their gender had changed since birth- an increase of 12.5% since the previous year (NMC, 2021). There are no documented instances of a clash between rights of the nurse or midwife to practice in their identified gender, and the rights of the patient to request the same sex. This increase suggests that this may be more likely to happen in the future and we should therefore be prepared for this.
Female patients preferring female caregivers is documented by several authors (Fink et al, 2020; Chur-Hansen, 2002; Ahmad & Alasad, 2007). What is also relevant is the impact that same sex clinicians have on care: Greenwood, Carnahan & Long (2018) noted that when a male physician treated a female patient, mortality went up. Female patients, though, had better outcomes when treated by female physicians. The impact of male violence towards women is accepted as being an epidemic, with 97% of women reporting sexual harassment (All-Party Parliamentary Group on UN Women, 2021) It then follows that many women may prefer being treated by a woman, especially when factoring in the intimate care nurses and midwives provide.
The potential conflict in this issue arises from the perspective of the Trans caregiver. Should the patient request their carer by sex, it would then logically create a potential compromise of privacy and dignity.
The answer to this conflict, is whose rights do we centre? Those of the patient, or the nurse? Both should be considered and are of importance. However, it is our duty as nurses and midwives to centre the needs and wishes of the patient. Informed choice of the patient is rooted in the women’s health movement and midwives (MacDonald, 2018) and a priority for patients today (Hirpa et al, 2020).
The power in the patient-carer relationship lies in the hands of the caregiver (Hewison, 1995). Patients- in particular women and children- have historically been subordinate, passive participants in a patriarchal healthcare system. This is especially notable in scandals such as Nottingham University Hospitals Trust maternity services, and Shrewsbury and Telford NHS Trust maternity services. Registrants should be seeking to restore that power wherever possible.
It's clear that there are issues to resolve that are not being discussed adequately within nursing academia, nor are they covered by NHS policies, which leaves room for discrimination and legal recourse. Women wish to be asked about this and included in the development and implementation of policies for both staff and patients.
Guided by our code of ethics, we have a duty to recognise our power in the patient-clinician dynamic and uphold dignity for all. This means being non-judgmental and providing high standards of care for every patient, regardless of how we may personally view their beliefs, values and behaviours.
To move forward, this must translate into ensuring women and Trans people feel safe discussing their needs.
Ahmad, M. and Alasad, J. (2007). Patients' preferences for nurses' gender in Jordan. International Journal of Nursing Practice, 13(4), pp.237-242.
All-Party Parliamentary Group on UN Women (2021) Prevalence and reporting of sexual harassment in UK public spaces. London: APPG for UN Women
Chur-Hansen (2002) Preferences for female and male nurses: the role of age, gender, and previous experience --year 2000 compared with 1984.Journal of Advanced Nursing, 37 (2) pp. 192- 198.
Fink, M., Klein, K., Sayers, K., Valentino, J., Leonardi, C., Bronstone, A., Wiseman, P. and Dasa, V., 2020. Objective Data Reveals Gender Preferences for Patients’ Primary Care Physician. Journal of Primary Care & Community Health, 11.
Government Equalities Office (2018) Trans people in the UK. London: Her Majesty’s Government.
Hewison, A. (1995). Nurses’ power in interactions with patients. Journal of Advanced Nursing, 21(1), pp.75–82.
Hirpa, M., Woreta, T., Addis, H. and Kebede, S. (2020). What matters to patients? A timely question for value-based care. PLOS ONE, 15(7), p.e0227845.
Local Government and Social Care Ombudsman (2014). Not providing same sex carers can impact dignity, says Ombudsman - Local Government and Social Care Ombudsman. [online] Available at: https://www.lgo.org.uk/information-centre/news/2014/nov/not-providing-same-sex-carers-can-impact-dignity-says-ombudsman.
Madsen et al (2017) Article Commentary: Sex- and Gender-Based Medicine: The Need for Precise Terminology. Gender and the Genome, 1 (3) pp. 122-128
MacDonald, M.E. (2017). The Making of Informed Choice in Midwifery: A Feminist Experiment in Care. Culture, Medicine, and Psychiatry, 42(2), pp.278–294.
Nursing & Midwifery Council. (2021) The NMC register. 1 April 2020- 31 March 2021. London: Nursing & Midwifery Council.
Nursing & Midwifery Council. (2018). The code: Professional standards of practice and behaviour for nurses, midwives, and nursing associates. London: Nursing & Midwifery Council.
Royal College of Nursing (2021) Refusal to treat. London: Royal College of Nursing.
Stuhlsatz, Bracey & Donovan (2020). Investigating conflation of sex and gender language in student writing about genetics. Science & Education, 29 pp. 1567- 1594.
World Health Organisation (2002) Gender: Definitions. https://www.euro.who.int/en/health-topics/health-determinants/gender/gender-definitions
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