Self-concept, Gender Identity and Sexuality
Unit Learning Outcomes
At the end of this chapter, the learner will:
1. Examine how the nurse’s personal beliefs and values about human sexuality and gender identity may affect their ability to deliver competent, compassionate, and respectful care to all clients.
2. Discuss the common nursing concerns associated with cultural sensitivity towards a patient’s sexuality and gender identity
3. Describe evidence-based responses to sexual harassment from patients or colleagues.
4. Identify the influence of the professional nurse’s self-concept to patient care.
5. Discuss the professional nurse’s role in the care of patients with alteration in self-esteem, self-identity, role performance, and body image.
Overview of the Chapter
This chapter is will examine the nurse’s personal beliefs about a patient’s sexual health. Many health care providers including nurses do not routinely discuss sexual orientation or gender identity with their patients. Without this information, important health care services may not be delivered (Centers for Disease Prevention, 2022). In addition, we will discuss self-concept and how this impacts the nurse’s role when implementing patient care.
- Human Sexuality and Gender Identity
The World Health Organization defines sexual health as a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence (World Health Organization, 2002).
Increasingly, the more subjective sense of gender identity takes precedence in evaluating patients’ needs. In instances when a discrepancy exists between sex and gender, compassion and empathy are essential to foster better understanding and an appropriate relationship between the physician and the patient, which is also referred to as using an affirmative approach. . [1]
Gender identity, Gender Expression, and Gender Role
Gender identity is defined as a personal and internal sense of oneself as male, female, or other. Gender expression is defined as the way in which an individual publicly expresses their gender, for example, through aspects such as clothing, hair, makeup, and body language. Gender expression can, but does not always reflect a person’s gender identity. This expression can be seen on a continuum, and in most cases allows for a degree of individual variation, but this often depends on the culture and level of acceptance of gender diversity 2.
A gender role is usually determined by a culture or community, and may have rigid or loose definitions depending on the approach by the community for rules placed upon any gender categories. Gender identity, as it develops, is self-identified, as a result of a combination of inherent and extrinsic factors; gender role, on the other hand, is demonstrated within society by a set of expected behaviors or characteristics for a given gender 2.
II. Application in Practice
Virtual Simulation Game (VSG) : Post-operative care of a client who identifies as non-binary
This Virtual Simulation Game (VSG) was developed as a collaborative project between faculty and students in the Bachelor of Science in Nursing programs at Selkirk College in Castlegar and College of the Rockies in Cranbrook, BC. The focus of the VSG, “Andy,” is on post-operative nursing care of a client with non-binary sexual orientation-gender identity (SOGI).
Please access the following links for guidelines for this activity.
Learning Environment: https://pressbooks.bccampus.ca/bcnursingvsgs/chapter/learning-environment/
Learning Preparation: https://pressbooks.bccampus.ca/bcnursingvsgs/chapter/learning-preparation/
Background:https://pressbooks.bccampus.ca/bcnursingvsgs/chapter/background/
Virtual Simulation Game: https://pressbooks.bccampus.ca/bcnursingvsgs/chapter/virtual-simulation-game/
Debrief:https://pressbooks.bccampus.ca/bcnursingvsgs/chapter/debrief/
Optional Activity: Review “Healthy People” 2030 Overview in LGBT Health
https://health.gov/healthypeople/objectives-and-data/browse-objectives/lgbt
Exercises: Simulation
Simulation Care to the Trans* and Gender Non-Conforming Identified Patient
- Pre brief the simulation
| Expected Simulation Run Time: Approx. 15 minutes.
Location: Community Clinic or Primary Healthcare Provider Office |
File Name: Care to the Trans* and Gender Non-Conforming Identified Patient Student Level: Adapted to Cover All Levels
Guided Reflection Time: Approx. 20 minutes. |
Brief Description of the Client:
Name: Joe Ramirez
Gender: FtMTG Age: 25 Race: n/a Weight: n/a Height: n/a
Major Support: Parents & Girlfriend Support Phone: 301-XXX-XXXX
Allergies: NKDA
Primary Care Provider/Team: No current primary provider. Has been under the care of an endocrinologist, Samuel Gordon, MD, for masculinizing hormone therapy treatments.
Past Medical History: Relatively healthy. Taking testosterone therapy for over 1-year.
History of Present Illness: Presents today to obtain a flu-shot and annual physical exam
Social History: In a committed heterosexual relationship for approximately two years. Feels supported in relationship with his girlfriend. Otherwise, history is unremarkable.
Primary Medical Diagnosis:
Surgeries/Procedures & Dates: Mastectomy and Chest Reconstruction
Nursing Diagnoses: To be discussed with participants in debriefing
Simulation Scenario Objectives:
- Demonstrate therapeutic communication skills with the patient.
- Recognize and demonstrate behaviors that create a safe, welcoming and professional working environment.
- Demonstrate effective communication within the context of interprofessional collaboration (Identify, Situation, Background, Assessment, Recommendation, Read back);
- Demonstrate proper assessment techniques in carrying out the tasks of providing care to the trans* identified and gender nonconforming patient.
- Identify primary nursing diagnoses and/or collaborative issues in the context of the scenario.
Report Students Will Receive Before Simulation
Time:
Joe Ramirez is a 25 year old Latino who identifies as a transgender female to male person (TGFtM). His name and gender at birth, and as identified on legal documents, is Josephine Ramirez and female.
Joe presents at the clinic for a flu shot and a physical. His last visit with a primary care physician had been several years ago, and the only other healthcare professional he has seen lately and regularly is his endocrinologist.
Joe has been taking testosterone prescribed by the endocrinologist for well over a year now. Except for a surgical procedure at 22 (a mastectomy and chest reconstruction), he has avoided most doctors. No other masculinizing interventions have taken place or are planned at this time. Joe is in a committed relationship with his cisgender female partner.
The community clinic practice is relatively new–full of young, hardworking nurses and doctors, and unlicensed assistive personnel. The practice prides itself on a team-based approach to healthcare and is committed to addressing the needs of ALL patients in the community.
2. Watch simulation
Link: https://youtu.be/NEHxlmFBRrA
3. Debrief discussions
1. What knowledge have you gained as a result of preparing for and engaging in this simulation that has helped you to understand the trans* and gender nonconforming community?
2. What are the skills, strategies, or interventions a nurse could use to address the barriers and inequities that affect trans* identified and gender non-conforming patients? In what ways did you see those skills utilized in this simulation?
3. What professional nursing values would apply to the situation identified in this scenario (altruism, autonomy, human dignity, integrity, honesty, social justice)? How were those values displayed in the context of this simulation?
4 How has this simulation helped to further develop your understanding of the meaning of nursing and the therapeutic use of self in assisting others—most particularly, the transgender and gender non-conforming population?
5. Is there anything else you would like to discuss?
III. Sexual Harassment
According to the Equal Employment Opportunity Commission(n. d.), sexual harassment is defined as the “unwelcome sexual advances, requests for sexual favors, and other verbal or physical harassment of a sexual nature. Harassment can also include offensive remarks about a person’s sex.” Two types of sexual harassment are recognized. Quid pro quo occurs when a manager makes a sexual demand on a worker, and this demand is perceived as a condition of employment. Actions that create a hostile work environment are another type of sexual harassment. These issues have been used in cases of discrimination based on race and religion as well as sex.
Exercises: Sexual Harassment in Healthcare
This video explains what sexual harassment is and teaches how to recognize it in the workplace, reviews the laws that address it, presents steps a facility must make to prevent it, and discusses specific actions to take against acts of harassment in your own working life. It differentiates among different types of harassment.
- Watch this video on sexual harassment (Link connected to MC library-need M number to access):
https://montgomerycollege.idm.oclc.org/login?url=https://video.alexanderstreet.com/p/k2KnlzPrr
2. Think, pair, share
- Share your thoughts on what is sexual harassments
- How do you recognize at workplace?
- What actions would you take to prevent it?
IV. Self-concept
Just as our perception of others affects how we communicate, so does our perception or view of ourselves. But what influences how we see ourselves? How much of our self is a product of our own making and how much of it is constructed based on how others react to us? How do we present ourselves to others in ways that maintain our sense of self or challenge how others see us? We will begin to answer these questions in this section as we explore self-concept and self-esteem.
Self-concept refers to the overall idea of who a person thinks he or she is. If I said, “Tell me who you are,” your answers would be clues as to how you see yourself, your self-concept. Each person has an overall self-concept that might be encapsulated in a short list of overarching characteristics that he or she finds important physical characteristics, personality traits, roles/ relationships, skills, talents, beliefs etc. But each person’s self concept is also influenced by context, meaning we think differently about ourselves depending on the situation we are in.
In some situations, personal characteristics, such as our abilities, personality, and other distinguishing features, will best describe who we are. You might consider yourself laid back, traditional, funny, open-minded, or driven, or you might label yourself a leader or a thrill-seeker. In other situations, our self-concept may be tied to a group or cultural membership. For example, you might consider yourself a member of the drama club or a member of the track team.
Self-esteem refers to the judgments and evaluations we make about our self-concept. While self-concept is a broad description of the self, self-esteem is more specifically an evaluation of the self (Byrne, 1996). If I again prompted you to “Tell me who you are” and then asked you to evaluate (label as good/bad, positive/negative, desirable/undesirable) each of the things you listed about yourself, I would get clues about your self-esteem. Like self-concept, self-esteem has general and specific elements. Generally, some people are more likely to evaluate themselves positively, while others are more likely to evaluate themselves negatively (Brockner, 1988). More specifically, our self-esteem varies across our life span and across contexts.6
How we judge ourselves affects our communication and our behaviors, but not every negative or positive judgment carries the same weight. The negative evaluation of a trait that isn’t very important for our self-concept will likely not result in a loss of self-esteem.
For example, I am not very good at drawing. While I appreciate drawing as an art form, I don’t consider drawing ability to be a very big part of my self-concept. If someone critiqued my drawing ability, my self-esteem wouldn’t take a big hit. I do consider myself a good teacher, however, and I have spent and continue to spend considerable time and effort on improving my knowledge of teaching and my teaching skills. If someone critiqued my teaching knowledge and/or abilities, my self-esteem would definitely be hurt. This doesn’t mean that we can’t be evaluated on something we find important. Even though teaching is very important to my self-concept, I am regularly evaluated on it. Every semester, I am evaluated by my students, and every year, I am evaluated by my dean, department chair, and colleagues.
Most of that feedback is in the form of constructive criticism, which can still be difficult to receive, but when taken in the spirit of self-improvement, it is valuable and may even enhance our self-concept and self-esteem. In fact, in professional contexts, people with higher self-esteem are more likely to work harder based on negative feedback, are less negatively affected by work stress, are able to handle workplace conflict better, and are better able to work independently and solve problems (Brockner, 1988). 6
Exercises: Self-concept in action
This activity will help students to become more aware of themselves as unique individuals.
- Watch this video on self-concept https://youtube.com/shorts/8VEAgy-tUMc?si=FwESqwi4QlSIbjKM
- Draw a symbol that represents “who you are” . For example (sun, a ball or a tree)
- What is the meaning of this symbol?
- How has it been instrumental in your life?
- Discuss changes that you would like to make as a nurse to maintain the characteristics of the symbol.
Body Image refers to an individual’s body, which generates a sensory message through contact with the environment during internal physiological operations and establishes a preliminary mental understanding of the body 6. Body image is also affected by the external environment. As Plato remarked, “We are bound to our bodies like an oyster is to its shell.” Indeed, our life experiences are integrally influenced by the body we happen to live in6. Because body image is formed primarily by individuals interacting with others, body image is a social entity.
People desire to keep their body image intact and unaffected by changes, damage, or losses in terms of function or body parts. Any change is perceived as a threat and thus induces anxiety and fear2. In caring for a patient facing body-image changes, a nurse may help the patient using her in-depth knowledge of the potential impacts of this change on the body, mind, social relationships, bodily functions, self-concept, and self-esteem.
Under what circumstances do individuals experience body image change? The most common clinical conditions of body image change are: perceiving sensational change (physical discomfort/signs and symptoms), receiving medical treatments/procedures (receiving blood transfusions, injections, punctures), receiving nursing interventions/ procedures (enema, urethral catheterization) pain, taking medications (moon face), experiencing amputation/dysfunction or alteration/disfigurement, becoming pregnant or undergoing labor, acquiring physical diseases or injuries (cancer, HIV/AIDS, skin diseases, burns), and experiencing role failure.
Therefore, when a patient complains to a nurse about physical discomforts, it is necessary to understand that the patient is experiencing body image change and will benefit from timely and effective assistance to overcome and accept this change. Body image change is an important issue that should continue to be better understood and addressed in the field of nursing.
Exercises: Watch and Discuss
- Watch the video
- Share your thoughts on how you as a professional nurse will assist your patient to improve their self-concept and accept their body image.
Exercises: NCLEX QUESTIONS
- A 76-year old patient has a newly created colostomy. After participating in counseling with the nurse and receiving support from the the patient’s wife, the patient decides to change the colostomy pouch by himself. Which behavior suggests that the client is beginning to accept the change in body image? The patient:
A. feelings of depression
V. Reflections
Key Takeaways and Assignment
Type your key takeaways here.
- First
- Second
Assignment: Review this week’s assignment instructions on your course Blackboard site.
VI. Recommended Resources
Body Image After Cancer Treatment : https://www.healthwise.net/myupmc/Content/StdDocument.aspx?DOCHWID=tv4450
The Impact of Body Image on Patient Care: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2911009/
Lippincott Nursing Pocket Card – May 2023 Affirming Care for Patients who are LGBTQ+: https://www.nursingcenter.com/clinical-resources/nursing-pocket-cards/affirming-care-for-lgbtqia-patients
TEDTalks: Abraham Verghese—A Doctor’s Touch
Violence Prevention: Violence Prevention, CDC, http://www.cdc.gov/ViolencePrevention/index.html.
References and Attributes
1. WHO working definition, 2002external icon
2. Chen S. L. (2019). Hu li za zhi The journal of nursing, 66(5), 4–5. https://doi.org/10.6224/JN.201910_66(5).01
3. Rafferty J, COMMITTEE ON PSYCHOSOCIAL ASPECTS OF CHILD AND FAMILY HEALTH, COMMITTEE ON ADOLESCENCE, SECTION ON LESBIAN, GAY, BISEXUAL, et al. Ensuring Comprehensive Care and Support for Transgender and Gender-Diverse Children and Adolescents. Pediatrics. 2018 Oct. 142 (4):[QxMD MEDLINE Link].
4. Equal Employment Opportunity Commission(n. d.): Retrieved from https://www.eeoc.gov/sexual-harassment
5. Films Media Group. (2019). Sexual harassment in healthcare. Films On Demand. Retrieved September 27, 2023, from https://fod-infobase-com.montgomerycollege.idm.oclc.org/PortalPlaylists.aspx?wID=16705&xtid=273942.
6. Open resources: BC Schools of Nursing Virtual Simulation Games: https://pressbooks.bccampus.ca/bcnursingvsgs/
