Introduction to Gender Equality and Social Inclusion (GESI)
Top Contributors - Robin Tacchetti, Amanda Ager, Tarina van der Stockt, Kim Jackson and Lucinda hampton
Introduction[edit | edit source]
This page has been created to help you understand the role Gender Equality and Social Inclusion (GESI) plays in rehabilitation. The aim is to help clinicians feel comfortable and empowered enough to identify opportunities to integrate GESI considerations into their daily clinical practice.
What is Gender and Social Inclusion (GESI)[edit | edit source]
Gender Equality and Social Inclusion are two intertwined concepts that help improve access to goods and services for all including the excluded, women and those less economically stable. GESI promotes inclusive policies and focuses on increasing the power of the excluded, women and the poor.
According to World Vision, GESI is an approach intended to eliminate existing barriers in order to increase access, enable decision-making and participation of marginalized populations. This definition goes on to say that GESI requires us to create enabling environments for ALL to engage in and benefit EQUALLY from development interventions.
Within the rehabilitation context, GESI is an approach intended to remove barriers and increase access, facilitate greater utilization of rehabilitation services, and improve users' experiences for everyone.
It’s important to note that not all marginalized populations are equally disadvantaged or excluded.
As clinicians, it is important to recognize how social characteristics influence each other and how they can influence the health condition, access to rehabilitation services, use of our services and overall patient experiences.
Social characteristics to be aware of include, but are not limited to:[edit | edit source]
- Marital status
- Immigration status
- Geographical location
- Level of education
As health care providers, we are required to provide the necessary adapted rehabilitation services and assistive technology (AT) and devices to enable individuals to achieve their highest level of function, and ultimately have a positive impact on communities globally by fostering greater participation.
In order to be effective clinicians, it is also important to recognize that each person has multiple social identities with overlapping factors (such as race, gender, age, sexual orientation, occupation, family structure, abilities, to name a few) and may identify with multiple groups. This stems from a new concept of social identity complexity, which refers to a person's subjective representation of themselves and the inter-relationships that they may have with multiple group identities. People are complex and have different social identities and experiences which need to be considered when treating them in a clinical setting.
Gender Equality[edit | edit source]
The goal of gender equality is for men and women to have equal resources, opportunities, human rights and socially valued goods. The world bank defines gender equality as, “ Gender equality or equality between different groups of women and men refers to the equal enjoyment by groups of females and males – of all ages and regardless of sexual orientation or gender identity – of rights, socially valued goods, opportunities, resources and rewards. Equality does not mean that women and men are the same but that their enjoyment of rights, opportunities and life chances are not governed or limited by whether they were born female or male."
The World Bank further classifies gender by the following:[edit | edit source]
- About women, girls, men, and boys, and the associated norms, behaviours, and roles as well as the relationships among these groups. Gender is considered to be a social construct and its definition can vary among societies and change over time. The aim is to adopt a gender-inclusive approach [in rehabilitation] that recognizes that some people prefer to use non-binary terms to identify themselves.
Gender is not:
- Only about women and girls: Men and boys should also be part of the GESI equation
- Only women’s responsibility: For real change to happen, everyone needs to be involved
- A Western or foreign concept: Gender equality is a global goal articulated in national, regional, and international commitments and treaties to which many countries worldwide are signatories
- An attempt to take away the rights of men and boys: Human Rights are universal, which means that they apply to all human beings
- Only an issue for gender specialists: Relying solely on gender specialists cannot tackle the main drivers of gender inequality and social exclusion. Everyone needs to be involved and committed to equality and inclusiveness.
Gender vs. Gender Identity[edit | edit source]
- Gender is our socially ascribed identities
- Gender identity is our preferred identity regardless of sex at birth;
- One’s innermost concept of self as male, female, a blend of both or neither – how individuals perceive themselves and what they call themselves. One's gender identity can be the same or different from their sex assigned at birth.
Gender Expansion[edit | edit source]
- A person with a wider, more flexible range of gender identity and/or expression than typically associated with the binary gender system. Often used as an umbrella term when referring to young people still exploring the possibilities of their gender expression and/or gender identity 
The video below shows Director-General Dr. Tedros of the World Health Organisation discussing gender equality for women and girls:
What is GESI responsiveness? [edit | edit source]
It means taking into consideration the gendered and socio-cultural differences that exist between ourselves as clinicians; and differences between patients to inform the delivery of rehabilitation services.
How to be GESI responsive as a clinician[edit | edit source]
We can think about GESI responsiveness as a continuum, from no consideration of our similarities and differences to actively seeking and engaging in transformative change in rehabilitation access, utilization, and experiences.
Being GESI conscious enables us to understand the fours As of rehabilitation services:
As rehabilitation professionals, we are ideally positioned to advocate for, and actively engage in, transformative change at all stages of rehabilitation.
As clinicians, we need to be more aware of GESI considerations:
- What societal and cultural norms influence us as physiotherapists and our patient
- What patients say and how they act; and how this can be influenced by gender
- How we interpret what we have seen and heard (from our patients) based on our own gender norms, assumptions and gender stereotypes; and how we act on the basis of those interpretations
- What gender and power regimes we can see and identify in organizations; and how they influence our work, working conditions as well as the patient’s reality and health
- Opportunities for social inclusion through improved communication and referral pathways between hospital systems to community-based rehabilitation services
- Provisions of education and training for families to increase the integration and participation of persons with disabilities.
Social Inclusion[edit | edit source]
Social inclusion aims to keep vulnerable groups from being excluded from specific circumstances. Vulnerable groups include the elderly, people with disabilities, religious minorities, women, girls, LGBTQ, etc.  The world bank defines social inclusion as, “ In every country, some groups confront barriers that prevent them from fully participating in political, economic, and social life. These groups may be excluded not only through legal systems, land, and labour markets, but also discriminatory or stigmatizing attitudes, beliefs, or perceptions. The disadvantage is often based on social identity, which may be across dimensions of gender, age, location, occupation, race, ethnicity, religion, citizenship status, disability, sexual orientation and gender identity (SOGI), among other factors. This kind of social exclusion robs individuals of dignity, security, and the opportunity to lead a better life. Unless the root causes of structural exclusion and discrimination are addressed, it will be challenging to support sustainable inclusive growth and rapid poverty reduction.” 
When thinking about social inclusion in a rehabilitation context, it is important to move away from thinking solely of a state of functional dependence and thinking more in terms of functional independence. This means empowering the individual to be as independent as possible and to participate in their community. This includes, but is not limited to:
- Interacting with their surroundings
- Making meaning connections with others
- Empower all individuals to have a voice (learn from their words and their perspective)
A helpful example of social inclusion in rehabilitation comes from a systematic review and meta analysis by Obembe & Eng (2016), which outlines how social participation is instrumental to a person's recovery. 
"Social participation is considered one of the most relevant and pivotal outcomes of a successful recovery. Individuals have been shown to be dissatisfied with their ability to engage in numerous aspects of participation, including socializing, outings, and travel, at three months after sustaining a stroke. The provision of rehabilitation services after hospital discharge may be particularly relevant as it aims to promote patients’ independence and reintegration into the community.
The International Classification of Functioning, Disability and Health (ICF) defines participation as ‘involvement in a life situation’ or as “the lived experience” of people in the actual context in which they live’. Participation is a treatment goal in the context of recovering from stroke and is known to correlate with domains related to quality of life. ... Similarly, the Disability Creation Process conceptual model defines social participation as a means of carrying out one’s life habits in one’s environment (e.g., school, work place, neighbourhood). "
The video below by Healthwest TV speaks to the importance of social inclusion:
GESI and Healthcare[edit | edit source]
Gender determines health responses, care practices, health behaviours, and essentially outcomes.  There is a link between social norms and biological factors that affect health status. Despite gender equality being a basic human right, it continues to be a leading determinant of health inequality. To combat these health inequalities, the World Health Organisation (WHO) and the United Nations have pushed countries to introduce gender issues into their health systems.
GESI and Women[edit | edit source]
Women have a higher risk of morbidities due to their reproductive roles, nutritional inequality and their lower status in society.  In addition, child marriages are more prevalent in girls (5 times higher), and women are the majority of victims in regards to sexual abuse and domestic violence.  Poor access to potable water and sanitation affects women more as they manage household water supply. Lastly, women are at a higher risk for anxiety, depression and cancer. Contrastingly, men are perceived as strong and not needing healthcare.
GESI and Physiotherapy[edit | edit source]
GESI affects healthcare across the spectrum including physiotherapy. Research studies have been performed and concluded there are three areas where GESI and physiotherapists have intertwined:
- gender in clinical practice
- gendered organizational aspects
- gendered socio-cultural norms and ideals
To be GESI responsive in clinical care we should consider:[edit | edit source]
- Availability of men & women therapists
- Therapist education on sex, gender bias & gender identity
- Adapted assistive devices
- Multidisciplinary care
- Automatic referrals
- Early enrolment in rehabilitation
- Collection of disaggregated data
- Advocating for the empowerment of persons with disabilities
Gender in Clinical Practice[edit | edit source]
The following four studies demonstrate how gender can impact physiotherapists in a regular clinical practice:
- Back and neck pain study: When addressing patients in a rehabilitation setting, therapists' message to patients is expressed differently based on gender-specific stereotypes.
- Women hear “be careful” in regards to pain, while men were supported in “heavy work leads to pain.”
- Men were not given as many exercises as women as they were considered to be strong.
- CP study: Interventions for children with cerebral palsy were related not only to their gross motor function but to their gender
- LGBTQ study: LGBTQ patients felt physiotherapists' interactions were uncomfortable with them in regards to touch, physical proximity, observation of their body or undressing.
- Transgender study: Transgender community felt the physiotherapists had a lack of knowledge about transgender-specific health issues
The video below describes issues transgender people deal with when seeking medical care:
Gender Organisational Aspects[edit | edit source]
Gender can also be an influential factor in the healthcare structure and an organization as a whole. Here are things to consider when thinking about an organizational ladder :
- Men typically have more power at the organizational level
- Many men may not consider women's issues thus limiting breadth of programs geared towards specific needs of other genders/gendered identities
- Workplace tools and instruments are often designed with males as the norm:
- leading to disadvantageous outcomes for females and a high risk of musculoskeletal disorders for women
- Working life can affect women more than men
- More women than men end their careers due to sick leave, mental health, and musculoskeletal issues
To be a GESI responsive organisation, it is essential to consider:[edit | edit source]
- Having women, gendered minorities & persons with disabilities in leadership
- Integration of Tele-Rehabilitation
- Community-based rehabilitation programs
- Inclusion of rehabilitation in primary health care
- The administration and management of adapted equipment & adapting facilities for accessibility
- Provision of affordable rehabilitation services and assistive devices under Universal Health Coverage (UHC)
- Inclusion of rehabilitation users in leadership and governance structures
- Integration of GESI into relevant new or existing organizational policies
Gendered sociocultural norms and ideals[edit | edit source]
The construct of gender can be understood differently throughout time and across different cultures. In some societies, traditionally women have been depicted as weaker and more prone to illness than men.
Implications for Rehabilitation[edit | edit source]
To help address traditional gender stereotypes, rehabilitation professionals should be aware of: 
"1) What patients say and how they act, and how this can be influenced by gender;
2) How we interpret what we have seen and heard (from our patients) based on our gender norms, assumptions and gender stereotypes; and how we act based on those interpretations;
3) What gender and power regimes we can see and identify in organizations; and how do they influence our work, working conditions as well as the patient’s reality and health; and
4) What gendered societal and cultural norms influence us as physiotherapists and our patients."
In addition, Stenberg et al., 2020 recommend gender awareness training in PT schools and being gender-sensitive during assessment and intervention decision-making. More research is needed in this arena to help physiotherapists with gender equality and social inclusion.
Helpful Definitions[edit | edit source]
Accessibility: Related to access to health means that health facilities, goods and services must be within safe physical reach for all sections of the population, especially vulnerable or marginalized groups, such as ethnic minorities and indigenous populations, women, children, adolescents, older persons, persons with disabilities and persons with HIV/AIDS, including in rural areas. Accessibility is also the characteristic that products, goods, and services have so that they can be used safely and under equal conditions by all people; it comprises the physical environment, transportation, information, and communications.
Accessibility aims to ensure the opportunity for equitable and meaningful participation in all aspects of society by all people. Accessibility is about removing barriers to participation, including physical, informational, attitudinal, and institutional barriers. While accessibility is often thought of in relation to ensuring the full participation of persons with disabilities it is relevant and important for everyone.
Accessibility is commonly thought of as a mechanism to increase physical accessibility for persons with various impairments, it is not only about physical accessibility of infrastructure, but it is also about accessible goods and services, including events.
Bias (or gender bias): Bias or gender bias is a stated position; an assumption or situation which shows a preferred view or treatment of one sex over the other.
Discrimination: Discrimination is when decisions are made based on a person’s social attributes such as gender, race or ethnic origin, religion, association, physical characteristics and/or other differentiations. Direct discrimination happens when a person is treated less favourably than another person in the same or similar circumstances on a ground of a particular attribute, such as their age, gender, disability, race, region, religion, culture, social status or other grounds. Indirect discrimination happens when there is a policy or rule or a way of doing things that might appear on the surface to be fair or neutral, but which has an unequal effect on certain groups of people with a particular attribute and the policy or rule is unreasonable. Indirect discrimination is unlawful regardless of whether the person discriminating intended to discriminate or is unaware that they are doing so.
Equality: Equality means that all people enjoy the same status. All people have equal conditions for realising their full human rights and potential to contribute to national, political, economic, social and cultural development and to benefit from the results.
Equity: Equity is a process of being fair. It means steps being taken to achieve fairness and justice in the distribution of benefits and responsibilities. It often requires programmes and policies to end existing inequalities. Equity leads to equality.
Gender: Gender describes the different roles and responsibilities of women and men – what males and females do, what they are responsible for, how they are expected to behave, what they are allowed to do, and what is seen as normal and proper behaviour. Gender roles and responsibilities vary according to cultural, religious, historical and economic factors.
Gender awareness: Gender awareness is the recognition of the differences in the interests, needs and roles of women and men in society and how they result in differences in power, status and privilege. It also means the ability to identify problems arising from gender inequity and discrimination. Gender equality means that men and women have equal value, rights and opportunities to participate in every aspect of employment and life. Gender equity is the process of being fair to disadvantaged men or women through specific interventions and actions such as balancing past or current differences that have had a negative impact on a woman or man’s ability to participate fully and equally in employment and other opportunities. Gender inequality means that a man or a woman does not have equal values, rights or opportunities.
Gender equality: Is the realization of equal rights, responsibilities, opportunities, and respect for men, women, and sexual and gender minorities. Gender equity—the process of being fair to women, men, and sexual and gender minorities—involves using strategies and measures to compensate for women’s historical and social disadvantages. Gender equity as a process leads to gender equality as an outcome. In response to unequal access to rights, responsibilities, opportunities, and respect among women and girls, which leads to their heightened social vulnerability and marginalization, the use of a GESI approach will often include a specific focus on women and girls. At the same time, it strives to alleviate gender inequality by engaging men and boys and addressing gendered power relations. You can use the following WHO Gender-Responsive Assessment Scale to determine the extent to which gender is incorporated into programmes and policies. The scale includes five stages for policy and programming:
-Gender unequal: perpetuates gender inequality by reinforcing unbalanced norms, roles, and relations.
-Gender blind: Ignore gender inequalities.
- Gender-sensitive: considers gender inequality but takes no remedial action to address it.
-Gender-specific: considers gender inequality and takes remedial action to address it but does not change underlying power relations.
-Gender transformative: addresses some of the underlying causes of gender-based inequities by transforming unequal and harmful gender norms, roles, and relations in order to foster progressive changes in power relationships between women and men and sexual and gender minorities.
Gender mainstreaming: Gender mainstreaming is the process of ensuring that all women and men have equal access and control over resources, decision making and benefits at all stages of organisational processes, practices and policies.
Sex: Sex describes the biological differences between men and women.
Sexual harassment: Sexual harassment is when an individual makes an unwelcome sexual advance, an unwelcome request for sexual favours, or engages in other unwelcome sexual conduct in relation to another person; in circumstances in which a reasonable person, having regard to all the circumstances, would have anticipated that the other person would be offended, humiliated or intimidated.
Social exclusion: Social exclusion may be imposed by law, resulting from economic circumstances or from failure to supply social goods or services. Groups that are socially excluded include the unemployed, ethnic minorities, homeless, elderly, and people with disabilities. These groups experience worse health outcomes than the general population.
Social inclusion: Social inclusion is defined as “the process of improving the terms of participation in society, particularly for people who are disadvantaged, through enhancing opportunities, access to resources, voice and respect for rights”. It includes the inclusion of groups who are at risk of exclusion within a particular socio-cultural context. Such groups may include: women and girls, adolescents and young people, older people, persons with disabilities, ethnic minorities, religious minorities, people living with a stigmatized illness, internally displaced people, migrant populations, nomadic communities, members of minority clans or sub-clans, people living in urban settlements or geographically inaccessible districts, LGBTQI+ communities, groups with less formal education, and people of lower socioeconomic status.
Groups at Risk for Exclusion May:
1) have inadequate representation and/or participation in leadership and decision making at all levels;
2) be discriminated against and/or experience social stigma and marginalization as a result of their social identities or health statuses;
3) have restricted rights and/or lack power, resources, and agency to exercise their rights and access social protections. Because people always belong to multiple social groups, they may have heightened experiences of marginalization, vulnerability, and exclusion due to the ways in which social identities intersect, or their intersectionality.
At the same time, because of the complex intersectional interactions between people’s multiple social identities, a person can jointly experience marginalization and privilege. For example, a woman with a disability from a high-income group may be awarded some privileges due to her socioeconomic status while also experiencing multiple levels of marginalization as a result of her gender and/or disability.
Social norms: Social norms are rules of conduct or models of behaviour expected by a society or social group. These are rooted in customs, traditions and value systems that gradually develop in a society or social group. It is important to understand that social norms, whilst generally accepted, may not always exhibit ethical or fair treatment of others.
Vulnerable Persons: vulnerable persons encompass the following:
-Persons with disabilities are defined as those who have physical, mental, intellectual or sensory impairments which, in interaction with various attitudinal and environmental barriers, may hinder their full and effective participation in society on an equal basis with others;
-Survivors of war and conflict who have acquired mobility-related injuries, including conditions resulting from interrupted health services;
-Survivors of torture and trauma, including gender-based violence;
-Children below the age of 18 who are: at risk of developmental delays linked to deficiencies in health, nutrition and/or caregiver support; living without permanent and protective care; at risk of losing permanent protective family care; and/or at risk of exposure to violence, exploitation, abuse and/or neglect; and
-Caregivers of the persons identified above.
Additional Resources[edit | edit source]
- What Does Gender and Inclusion Mean for Clinical Practice?
- RELAB-HS: Rehabilitation Through a Gender Lens
- USAID: Gender and Social Inclusion Assessment
- Human Rights Campaign - Glossary of Terms about sexual orientation
Further Readings[edit | edit source]
- Mlenzana, Nondwe B., Jose M. Frantz, Anthea J. Rhoda, and Arne H. Eide. “Barriers to and Facilitators of Rehabilitation Services for People with Physical Disabilities: A Systematic Review.” African Journal of Disability 2, no. 1 (September 19, 2013): 22.
- Stålnacke, Britt-Marie, Inger Haukenes, Arja Lehti, Anncristine Fjellman Wiklund, Maria Wiklund, and Anne Hammarström. “Is There a Gender Bias in Recommendations for Further Rehabilitation in Primary Care of Patients with Chronic Pain After an Interdisciplinary Team Assessment?” Journal of Rehabilitation Medicine 47 (January 12, 2015).
- Hanebuth, Cannon, Holt McPherson, Dashae Smallwood, Samantha Kaplan, David Basirico, Derek Clewley, and Zachary Rethorn. “Social Determinants of Health Are Associated with Physical Therapy Use: A Systematic Review.” British Journal of Sports Medicine 55, no. 22 (November 1, 2021): 1293. https://doi.org/10.1136/bjsports-2020-103475.
References[edit | edit source]
- United Nations Interagency Rehabilitation Programme (UNIRP)https://reliefweb.int/sites/reliefweb.int/files/resources/Gender%20Equality%20and%20Social%20Inclusion_1.pdf
- Roccas S, Brewer MB. Social Identity Complexity. Personality and Social Psychology Review. 2002;6(2):88-106. doi:10.1207/S15327957PSPR0602_01
- Ife J. Human rights and social work: Towards rights-based practice. Cambridge University Press; 2012 May 21.
- The World Bank, https://www.worldbank.org/en/topic/social-inclusion#1
- Human Rights Campaign. Accessible at https://www.hrc.org/resources/glossary-of-terms
- Governance Network,https://www.shareweb.ch/site/DDLGN/topics/governance/socialinclusion/SitePages/Home.aspx
- World Bank, https://www.worldbank.org/en/topic/social-inclusion#1
- Obembe, A. O., & Eng, J. J. (2016). Rehabilitation Interventions for Improving Social Participation After Stroke: A Systematic Review and Meta-analysis. Neurorehabilitation and neural repair, 30(4), 384–392. https://doi.org/10.1177/1545968315597072
- Noreau L, Desrosiers J, Robichaud L, Fougeyrollas P, Rochette A, Viscogliosi C. Measuring social participation: Reliability of the LIFE-H in older adults with disabilities. Disabil Rehabil. 2004;26:346–352.
- Mayo NE, Wood Dauphinee S, Ahmed S, Gordon C, Higgins J, Mc Ewen S, Salbach N. Disablement following stroke. Disabil Rehabil. 1999;21:258–268.
- World Health Organization. Towards a Common Language for Functioning, Disability and Health: ICF. World Health Organization; 2002. [Accessed January 20, 2015]. http://www.who.int/classifications/icf/training/icfbeginnersguide.pdf.
- Mayo NE, Bronstein D, Scott SC, Finch LE, Miller S. Necessary and sufficient causes of participation post-stroke: practical and philosophical perspectives. Qual Life Res. 2014;23:39–47.
- International Network on the Disability Creation Process (INDCP) The Human Development Model - Disability Creation Process (HDM-DCP). What is Social Participation? 2014 http://ripph.qc.ca/node/153.
- Shannon G, Jansen M, Williams K, Cáceres C, Motta A, Odhiambo A, Eleveld A, Mannell J. Gender equality in science, medicine, and global health: where are we at and why does it matter?. The Lancet. 2019 Feb 9;393(10171):560-9.
- Fernández R, Isakova A, Luna F, Rambousek B. Gender Equality and Inclusive Growth. International Monetary Fund; 2021 Mar 4
- Crespí-Lloréns N, Hernández-Aguado I, Chilet-Rosell E. Have policies tackled gender inequalities in health? A scoping review. International journal of environmental research and public health. 2021 Jan;18(1):327.
- Dilli S, Carmichael SG, Rijpma A. Introducing the historical gender equality index. Feminist Economics. 2019 Jan 2;25(1):31-57.
- Hay K, McDougal L, Percival V, Henry S, Klugman J, Wurie H, Raven J, Shabalala F, Fielding-Miller R, Dey A, Dehingia N. Disrupting gender norms in health systems: making the case for change. The Lancet. 2019 Jun 22;393(10190):2535-49.
- Stenberg G, Fjellman-Wiklund A, Strömbäck M, Eskilsson T, From C, Enberg B, Wiklund M. Gender matters in physiotherapy. Physiotherapy theory and practice. 2021 Sep 3:1-4.
- WHO. Gender and Health [Internet]. 2020. Available from: https://www.who.int/health-topics/gender
- UNFPA - United Nations Population Fund. Frequently asked questions about gender equality [Internet]. 2021 [cited 2021 Apr 21]. Available from: https://www.unfpa.org/resources/frequently-asked-questions-about-gender-equality
- Mills JA, Cieza A, Short SD, Middleton JW. Development and Validation of the WHO Rehabilitation Competency Framework: A Mixed Methods Study. Archives of Physical Medicine and Rehabilitation. 2021 Jun 1;102(6):1113-23.
- United Nations. Leaving no one behind: the imperative of inclusive development. Report on the World Social Situation 2016 [Internet]. New York; 2016 [cited 2021 Oct 22]. Available from: https://www.un.org/esa/socdev/rwss/2016/full-report.pdf
- Integrity Action. Gender Equality and Social Inclusion Strategy (GESI) [Internet]. 2016 [cited 2020 Mar 27]. Available from: http://www.ids.ac.uk/files/dmfile/Wp417.pd