Abstract

Despite acknowledgement that paid caregivers have a significant impact on the lives of people with intellectual disability, the subjective experience of staff gender is rarely considered in research. Qualitative data from a study on the sexual health needs of men and boys with intellectual disability is presented. We designed this study to determine what impact staff gender has on the sexual health needs of men and boys with intellectual disability. Findings suggest that although staff traverse the same geographies of care, they do it in uniquely gendered ways. Staff gender is an important consideration when dealing with sexual health matters and can enhance the type and quality of relationships between people with intellectual disability.

Paid disability caregivers have a direct and significant influence over the lives of the people with intellectual disability whom they support. This influence becomes more significant and pervasive the greater the degree of intellectual and/or physical disability. Further, paid caregivers often constitute the main relationships, beyond families, that people with intellectual disability have (e.g., Bigby, 2008; Chadsey-Rusch, DeStefano, O'Reilly, Gonzalez, & Collet-Klingenberg, 1992; McVilly, Stancliffe, Parmenter, & Burton-Smith, 2006). Clegg (2010) suggested that contemporary service delivery should be refocused on the meaning of relationships between paid caregivers and people with intellectual disability. Therefore, the meaning and value of these relationships deserve careful attention, particularly when potentially delicate topics, such as sexual health, are addressed.

Hatton, Rose, and Rose (2004) reviewed the research literature on staffing issues in intellectual disability services. On the basis of this review, they suggested that research in which investigators explored the role and impact of paid caregivers on people with intellectual disability has three conceptually linked core assumptions: (a) staff behavior has a direct causal influence on people with intellectual disability via staff interactions; (b) staff behavior has an indirect causal influence on the organization's capacity to deliver support to people with intellectual disability; and (c) staff behavior is multiply determined by factors associated with clients, staff, and the organization. Hatton et al. concluded that within the literature there remains a largely unexamined phenomenology of the experience of being a staff member. Instead, the researchers tended to conduct quantitative research, which is often unlikely to uncover such meaning. We hypothesized that the meaning of staff gender is one unexplained aspect of a staff member's experience and potentially a fourth core assumption that is rarely, if ever, incorporated into staffing research. Gender is a highly complex and difficult concept to define quantitatively beyond male and female, so it is possible that the inadequate attention given to the influence of staff gender on people with intellectual disability likewise is a result of the paucity of qualitative research into staffing that Hatton et al. identified.

Background

Community living is diverse and ranges from home-based supports, respite care, domiciliary care, and supported accommodation. One constant, however, is the greater proportion of female caregivers, paid and unpaid, in each setting. Paid caregivers in residential settings are between 80 to 95% female across all sectors in the United Kingdom, with similar proportions in the United States (McConkey, McAuley, Simpson, & Collins, 2007). Likewise, in an Australian study of New South Wales government-employed support staff, Dempsey and Arthur (2002) found that 69.5% of paid caregivers were female. The Australian Community Services and Health Industry Skills Council highlighted several important facts about this workforce, one of them being a greater proportion of female staff who were mostly employed part-time (Community Services, 2005). In light of these gendered differences, and the fact that approximately 60% of all people with intellectual disability are male (Australian Institute, 2003), we find it somewhat surprising that the gender of paid caregivers has not received greater attention.

Hatton et al. (2004) suggested that qualitative research could yield significant insight into relatively unexplored topics related to staffing. Indeed, when qualitative researchers have explored staffing issues, gendered differences emerge. For example, male staff concerns about inappropriate touch affect the way they interact with clients (Dobson, Carey, Conyers, Upadhyaya, & Raghavan, 2004; Dobson, Upadhyaya, Conyers, & Raghavan, 2002). Unpacking this theme further, McConkey et al. (2007) suggested that male caregivers were often conscious of unjust generalizations that pedophilic and abusive tendencies were, perhaps, implicitly male problems. Wilson, Cumella, Parmenter, Stancliffe, and Shuttleworth (2009) found that supporting men and boys with penile hygiene was more uncomfortable for female caregivers than it was for male caregivers, which often led to examples of poor practice and consequently poor male health outcomes. Likewise, Carnaby and Cambridge (2002) highlighted similar gendered differences and degrees of comfort between male and female staff members on performing personal and intimate caregiving tasks.

In her qualitative study about love and sexuality between young men and women with intellectual disability, Löfgren-Mårtenson (2004) made some fascinating insights. She reported on staff members' gendered response to service user behavior while negotiating love and sexuality in the arena of the discotheque in Sweden. For example, the manner that female staff cared while monitoring sexual expression between young men and women with intellectual disability was more restrictive than male staff, who were reportedly more allowing of sexual expression. Löfgren-Mårtenson suggested that one of the consequences of the restrictive feminized monitoring of interactions was a group of young men with intellectual disability who were passive and insecure compared with their female peers. That is, the young men would insecurely wait for interactional and sexual cues from the young women before permitting themselves to respond. Löfgren-Mårtenson asserted that the arena became a deeply gendered setting that reflected “a female world with a restricted set of rules” (p. 205). These are significant findings that highlight just how pivotal staff gendered interactions can be in the lives of people with intellectual disability.

Löfgren-Mårtenson (2004) has drawn attention to the need for staff gendered interactions to be incorporated into the study of sexual health and sexuality. Folkestad (2004) pointed to the preponderance of paid female caregivers in the lives of men and boys with intellectual disability, but few researchers have directly delved into this gendered aspect of service delivery. This is perhaps not that surprising because caregiving stereotypes have historically been associated with female traits. Indeed, O'Lynn (2007) suggested that the reforms Florence Nightingale was able to bring to nursing were underpinned by her belief that women, by virtue of their nature, were more suited to nursing than men. Conversely, few investigators have stopped to consider the effect that the comparatively small number of male caregivers has on the lives of men and boys with intellectual disability.

Paterson et al. (1996) found that male nurses adopted a friendship approach to caring as opposed to a feminine maternal relationship; a friendship approach is formed by an amalgamation of both masculine and feminine characteristics. E. Thompson (2005) described how, through the dominant constructs of masculinity, male caregivers perform their role from a safe emotional distance; engaging in more physical, sports-oriented, social activities may be one way to do this. Likewise, researchers exploring fathers' caregiving role found that they provide less direct care and are less affectively close to their child but were equally as likely to participate in social activities (Essex, Seltzer, & Krauss, 2005). Further, McConkey and Collins (2010) found that female staff were less likely than male staff to rate social inclusion as applicable to their role.

In the present article we present data from a qualitative study designed to explore the sexual health needs of men and teenage boys with intellectual disability (Wilson, 2009). Central to this wider study was the question: What role does staff gender play in conceptualizing and responding to the sexual health needs of these men and teenage boys?

Method

Ethical approval was granted from the University of Sydney Human Research Ethics Committee. Data presented in this article were collected from individual interviews with 18 paid caregivers (3 male and 15 female between 18 and 60 years of age) who worked in three intellectual disability-specific group homes supporting five men and boys with moderate to profound intellectual disability. The organizations who agreed to participate were small- to moderate-sized nongovernment organizations based in the one geographical region of New South Wales. Group Home 1 housed one man and four women with intellectual disability; the staff team were all female, except for one full-time male. Group Home 2 housed two teenage boys, one teenage girl, and two young women with intellectual disability; the staff team were all female, except for two younger males. Group Home 3 housed one teenage boy, one younger man, and one young woman with intellectual disability; the staff team were all female. We reviewed policy and procedure documents in these settings for the presence of gendered procedural guidelines.

The first author conducted the individual interviews in the group home at a time convenient to the routines of the group homes and their occupants. Interviews lasted, on average, one hour and were recorded then later transcribed. Semi-structured interview questions were based on four topics: sexual health, masculinity, gender, and gendered care-giving roles. The first author analyzed the data using the constant comparative method of grounded theory (Strauss & Corbin, 1994). The gradual development of themes from the data analysis emerged through analytical and thematic discourse between all authors over a 6-month period.

Findings

No gendered data emerged from a review of policy and procedure documents except in the area of intimate care tasks; only one organization had a policy for intimate care that considered gender. Their policy stated a preference for same-gender intimate care supports, but recognized the reality that this was not always possible. However, the de-facto policy that all interviewed staff members understood was that male staff did not support women and girls with personal and intimate care. All policy and procedural documents tended to be written in gender-neutral language, which appeared to assume that caregiving and gender are mutually exclusive issues. Staff members reported that they had not attended any gender-specific training, although one male staff member did perceive that the mandatory child protection training he attended tended to represent males in a negative manner. As a result of this training, he adopted a different gendered approach to his role:

I think my line of thought is that we [male staff] are encouraged to distance ourselves. … As a result of that I am not looking out for sexual needs, I am really just focusing on getting the basics done. …. I am terrified of someone saying … “that looked a bit funny.” … [for my post-university life] I have to be cleared to work with children.

Gendered service delivery is the overarching theme drawn from an analysis of the interview data about the role of staff gender in the lives of men and boys with intellectual disability. The data analysis revealed distinct masculine and feminine caregiving roles, powerful gendered stereotypes, and representation of a differently gendered style to performing the role of caregiver. We identified two selective codes: a feminine perspective and a masculine perspective. A feminine perspective to caregiving was portrayed through two axial codes: femaleness is different from maleness and females exercise caution. A masculine perspective to caregiving was portrayed through three axial codes: maleness as different from femaleness, males as caregivers, and males as a conduit to male well-being. Figure 1 illustrates these relationships.

Figure 1

Development of gendered service delivery.

Figure 1

Development of gendered service delivery.

A Feminine Perspective

Femaleness is different from maleness

“Female staff are happy to give affection and cuddles.” Female staff members described the feminine caregiver as possessing attributes that were, ostensibly, in greater abundance than in the masculine caregiver. For example, female staff members described themselves as being “more gentle, in general, than male staff.” Another female staff member felt female staff are “a bit more motherly with clients compared with male staff … females are softer in their approach.” This gentleness was further described:

Obviously, you know, women are more, I don't know, loving and nurturing … not to say that some men aren't; I think, possibly, the female staff can be a little bit softer in their approach than maybe the male staff sometimes.

One female staff member described one of the effects of these attributes: “I think females are, you know, melancholy him a bit more, we like soften him up a bit more.” That is, gentleness and nurturing was seen as one way to soften the challenging behavior of one of the teenage boys in the group home.

Female staff also described self-prescribed gender-specific boundaries that the female caregiver may preferentially adopt during interactions with the men and teenage boys in this study. For example, kicking a soccer ball around the garden was one preferred physical activity of one teenage boy that could be achieved without going on an outing (where additional staff would usually be required). Furthermore, as this individual was visually impaired and was likely to intentionally run away when on an outing, such an activity within a fenced yard represented a form of exercise with minimal risk of absconding or injury. Despite the total absence of male staff in this group home, female staff no longer encouraged this form of exercise:

We had one male staff here that wasn't such a good worker, but he did go out there and play soccer with _____ [Client E] and I thought that was good and maybe _____ [the client] needed that, to be out there and playing soccer with the boys

The first author asked, “Do you see female staff [members] out with ____ [Client E] kicking a ball around? The response was

I think we [female staff] all probably tried in the beginning but he wasn't as interested when it was the girls out there kicking a ball with him … now it seems like he's too lazy and can't be bothered to get off the lounge.

Another female staff member stated: “We've had male staff coming out and kick the ball around outside with [him], which is something that we could do, but being girls we don't do that, because it's socially not acceptable for us to do that.”

Female staff members stated that they felt less comfortable regarding most issues concerning male sexual health. For example, one female staff member mentioned how, compared with male staff, female staff would tend not to want to hear about male clients' sexual experiences: “I don't want to know what you did! … but the male staff was quite happy to sit down and let him brag about his [sexual experiences over the] weekend.” Another female staff member stated:

I suppose I just don't feel comfortable really [dealing with male sexual health] … with the female clients I would, I do, but with the male clients I feel like it's a male to male [thing]. It's probably best … because we [female staff] don't know so much, then its best to have males around.

This feeling was repeated by one other female staff member, although she recognized the role of all staff in supporting individual needs:

As a female you just like to think that the male staff are gonna deal with that sort of thing [sexual health], but that's not always the case because the majority of staff are female … if it [a sexual support strategy] was put in place … then you just do it [whether male or female].

Gendered differences in relation to trust were also enunciated. One older female participant stated that “I think most females don't trust men completely because that's who they [females] are … you have heard lots of stories and lots of things [about male abusers] over the years.” This same female staff member continued by stating “I don't completely trust any man unless it's someone I've known for a long, long time … I find it hard to trust … because, a lot of things have happened to me, over, in my life.” A younger female staff member who openly declared being involved in a past abusive relationship with a man talked more specifically concerning her worry about male staff. For example, she noted:

Then we've got the thing with _____ [the female client] as well, she takes a liking to male staff and you know, as much as it shouldn't, it does worry the girls as males do night shift on their own … and we do worry, [The first author then asked] So the female staff worry about that? [the staff member replied] I think I do, in as much as I probably shouldn't and should give people the benefit of the doubt and what's the difference between the girls working with the boys … but I've talked about it with other girls that work here and we feel the same. … It's _____ [female client] and the way she is promiscuous, she does come running out here naked … wanting a boy friend, wanting to get married … we do worry, you know, how the male staff that are here are gonna deal with that.

Perceived overanalysis of some male sexual expression by some female staff members was another issue. One young male staff member stated:

That interpretation of things [masturbation as more sensory, not sexual], that I have [as a male], is going to be different to female service workers, I think, who do see it [masturbation] more as an offensive kind of thing … and so that influences how they treat him … so [some female staff] should just—don't try to read into it.

One female staff member suggested that females do tend to be more critically observant than males, which may mean a male staff member “is more reluctant to dig too deeply [into sexual issues] for fear of what others might think of his interest in the [topic].” Therefore, although female staff might feel less comfortable talking about male sexual issues, this female staff member suggested that male staff may avoid the issue of sexuality altogether due to the perceptions of peers.

Females exercise caution

The second female axial code is that “[Male clients] are more prone to be attracted to a woman [female staff] … it's [attraction] just a natural part of life.” Female staff described a number of pragmatic issues that had the effect of minimizing the temptation for assault and/or abuse from men and boys with intellectual disability. One important staffing issue is that female staff are less likely to work in settings where the men and boys with intellectual disability have known challenging sexual behaviors: One female staff member noted “That's probably why they don't like to put females in that house in particular, because of the issue [sexual] with the male clients there, they [male clients] don't know their boundaries.” Another female staff member avoided talking about sexual issues:

I just don't like, to sort of, I suppose, I am just more careful around sexual areas when I am working with men, I don't like to, sort of, put any ideas in their heads, or to encourage them in anyway by talking about it … I'd hate to think that they would get some sort of idea about anything [sexual].

One of the older female staff mentioned how their manner of dress may directly affect potential responses to them:

I suppose with female staff … there is always an issue around how we dress, how we present. … it's the risk to us and I think also too it's probably fairer for the guys as well we are working with, there is no point us coming to work with a low cut shirt and a mini skirt … and maybe to a certain extent I don't know how some of the male clients might respond to that, react to that … in a sense it could be a bit of a turn on … if it's seen as provocation. In all fairness for the guys … and also around challenging behaviour … we have to be careful with what we wear.

Although none of the staff wore a uniform, the dress of all staff members was noted by the first author to be very “practical” and reflected the intensive nature of the required care tasks; jeans, shirt, and closed shoes were standard dress.

A Male Perspective

Male perspective on caregiving

Maleness is different from femaleness: “[being a male] it's another world I suppose.” A masculine perspective to caregiving was framed toward a tendency for physicality; that is, male staff members were more predisposed toward “a focus on male clients and doing male things, such as swimming.” Male staff were more likely to, as one staff member stated, “do blokey things than if I had put a casual female in the house.” An example of blokey activities was described by a female staff member:

It is quite important that they do have a bit more time with the guys [male staff] because they [male staff] do different things … recreationally … a guy might want to go to the football, I mean I would probably want to go shopping.

We found that in addition to physicality and activity, a masculine perspective on caregiving was supported by other broad notions, such as bringing a more relaxed perspective toward the role; not relaxed in the sense that male staff were “laid back,” but relaxed by not worrying or overanalyzing sexual expression so much. “A male worker's a bit more relaxed than a female … males can relate to _____ [Client D], they're males … how they talk to him, they call him mate.” Being more relaxed also described a male perspective toward male sexual expression. As a female staff member stated: “a male staff member might understand a bit more how important that [masturbation/erection] was for a male client.” Furthermore, another female staff member felt male clients appeared to respond positively to a relaxed, open approach to caregiving: “[male clients] are more prone to be asking a male staff member [about sexual health issues] rather than asking a female … who they were really comfortable with [more likely to be a male staff member].”

Another aspect of a masculine approach to caregiving was the way some male staff might alter their natural actions and conversation in the presence of some female staff. A male staff member described his behavioral alteration thus:

Most of the scrutiny [of male staff] will be done by females, but there's also policies, rules, instruction manuals, full of saying …” this is how you behave” … I don't believe in that because I think we are all very individual … the variety of our relationships comes in … it robs the whole system [interaction and relationships] of human richness, it becomes a predictable thing. I reckon that you can't function like that [holding back]. … When I have someone [female peer] who is that way inclined, who is likely to misconstrue … I will tailor my behavior, you know I will scrutinize my behavior more thoroughly, so as not to give them any reason for being that way [wary]. I can see that being the natural me …. which I have a clear conscience … this other person might, from what I know about them, might think otherwise. … They might cause me trouble. … It's not a very pleasant situation. … I prefer to curb my impulses to a degree in front of that person to have a peaceful shift.

Another perspective on males as caregivers

“[It's] better to have males around in case they [male clients] want to talk about [sexual] things that they don't feel comfortable with talking to females.” This axial code provided a broad summary of the wider qualities that male staff bring to the role. No comments from interviews with male staff or fieldnote entries were assigned to this category; it emerged solely through the eyes of female staff. Supporting clients with challenging behaviors was one common role of the masculine caregiver:

Male staff are more appropriate when there is a risk of [challenging] behavior. … I've seen male staff who have quelled a situation that was just escalating. … A male staff member has come on board and there has been a bit of a dialogue between the client and [male] staff. … There's been a simmering, there's been a reduction [in challenging behaviour]. … I think male staff … can play a fairly good role with male clients.

Female staff were also quite unequivocal as to the qualities male staff brought to the domestic side of the role, simply that male staff were, in general, “not very good with housework.” A female staff member recalled one male staff member who was

lazy in the house, I suppose it was a gender type thing, with the housework and cleaning … he would sit and watch TV with the client and not do anything else except get out there and kick a ball around when _____ [Client D] was getting disruptive. … As far as the housework went, he thought it was women's duties I suppose and didn't do it.

This theme was reiterated by other female staff: “We've had some good male staff here. … they are not very good at the house work and not very good at cooking but they are very, very good at taking _____ [Client D] somewhere.” One of the younger female staff members suggested this apparently poor domestic quality intrinsic to male staff might be more about female staff seeking perfection: “The male staff will just get in and do it, whereas the females want everything to be perfect [vacuuming, cleaning, etc.].” When asked why the sector did not employ as many male staff members, one older female staff member felt the role was

too, perhaps, hands on. Yes, you would get males but you won't get the males that would want to do the washing, the bathing, and the cleaning, I couldn't see my husband wanting to do that. … and especially not young men.

Interestingly, one of the young male staff members made the comment that male-orientated jobs would often be waiting for him on a Saturday morning such as “ light bulbs … fixing stuff …. fixing the computer, that's a big one.”

Reflecting upon why there were so few males working in the sector, a variety of opinions were proffered by female staff. One related to the stereotype of male nurses being gay:

I mean, I'm not passing comment on males who do work here, but a lot of them are gay, we have a lot of gay men come through this house, because it is seen as a gender-specific [female] work place. … People see any hands-on work [caregiving] as socially gender-specific [a female role]. … Gay men are socially seen as feminine. … A larger proportion of male care workers are gay because of that.

Similarly, another female staff member reflected upon the traditional and stereotypical view of caregiving as a female role:

I think … a lot of males, more macho types go out and find … [more traditional male] jobs. I think the majority of people see it [care work] as a female type job, I guess we don't have a lot of long-term type male people have we? … The guys [two male staff] in the house here are probably going to be gone within a year.

This last comment referred to the two sole male staff members who worked in one house and were studying at a university, using the job as a temporary income earner:

The field is more girls than men. … I think that the guys that do come in here, they do it more as a casual job rather than a serious field [career]. … [he] is more down here for the extra money.

Economic realism was offered as another reason why males might not stay within a paid caregiving role: “It's not a high paid job and they're not going to make [enough to] support a family, and raise kids, and buy a house on what they're going to earn in this type of job.”

Males as a conduit to male well-being: “He [Client C] does blossom with a male staff member. … he is so well behaved with a male staff member.” A male style of interaction can result in male bonding and male warmth, which, for one of the teenage boys, appeared to contribute to a valued and celebrated sense of masculinity: “He has really blossomed from that [1∶1 with male staff]. … He does blossom with a male staff member. … He looks up to the guys, he really, he loves being with men.” A female staff member described the excited and happy response and facial reaction in another teenage boy when a liked and trusted male staff member came on shift one day:

It was beautiful, a beautiful bond with [the male staff member] … a father figure, a male figure … I think it's just a relationship that he has, he obviously knows the difference between male and female.

Another female staff member added to this theme by suggesting male staff of a similar age to the men and teenage boys might also be valuable:

He [Client E] does enjoy male companions [staff ]. … He just enjoys the company. … Normally when they [male staff] are younger too, not so much the older ones … a similar age, early 20s I think it is just that little bit more in common … when you've got someone [a male staff member] around their age, I think you find it, it's like wow!, you know?

Discussion

In this article we have presented qualitative interview data, which were taken from a wider study on the sexual health needs of men and teenage boys with intellectual disability, on the gendered caregiving roles of paid staff in community group homes. These data have shown that staff gender is an important area when considering how to support men and boys with intellectual disability, including with their sexual health needs. Paid caregivers are not gender-neutral beings who can provide a standardized form of care and support. Moreover, these data also demonstrate that the gendered relationships, and the meaning of those relationships, between not only paid caregivers but also the clients in their care are indeed diverse and quite complex. Staff gender does matter and does contribute toward different care and support outcomes; some that promote the meaning in one's quality of life, others that may limit that meaning.

Perhaps the most pervasive issue raised is the described lack of trust between staff members of different gender. We are not aware of any other researchers who have articulated this issue so patently, although this underlying theme can be found in other studies (e.g., McConkey et al., 2007). However, we do caution against generalizing from these data about “trust,” because the strongest statements were made by two female staff members working in the one setting who both openly declared personal information that suggested past abusive relationships with a male partner. Although we can only surmise a connection, and guard against generalizations, it may not be coincidental that there was no male staff member currently working in that house. It would appear that, as Löfgren-Mårtenson (2004) suggested, the setting reflected “a female world with a restricted set of rules” (p. 205).

We propose that an environment where limited trust between genders prevails, quality outcomes for men and boys with intellectual disability are at risk. Examples include, but are not limited to, restricted exercise for male clients, fear of masculinity, an analysis of male sexual expression that is different to the way males perceive it, a perspective that housework is more important than outings and activities, and inadequate penile hygiene practices (Wilson et al., 2009). Although we have framed this lack of trust through its effect on men and boys with intellectual disability, we do acknowledge that other perspectives exist. For instance, D. Thompson, Clare, and Brown (1997) stated that one of the ways female and male staff members differed was that “men lacked women's wider awareness and fear of men's violent sexual behaviour” (p. 585). Whether this gendered difference is about greater awareness or a lack of trust, the underlying drive of both perpetuates the discourse that men and boys equate to risk and are intrinsically more aggressive than women and girls who, in turn, need protection. For example, in their review of empirical investigations into teaching people with intellectual disability abuse-protection skills, Doughty and Kane (2010) highlighted the fact that no study involved male participants.

A feminine style of caregiving was framed within notions of mothering. In the present study paid female caregivers ostensibly possessed intrinsic attributes that are reinforced by the cultural assumption that caring is a female characteristic (Bogle, 2007) and it is the essence of womanhood and women's learned tendency (E. Thompson, 2005). However, how does one measure subjective attributes such as “softness” and “gentleness” without the overt influence of subjective and gendered stereotypes? Furthermore, this notion of mothering as an intrinsic caring quality indirectly raises the issue of male staff and how their style of care and support might be framed differently.

Can paid male caregivers, like paid female caregivers, be loving and nurturing or display softness and tenderness? If male staff do possess these capacities, can the idea of care and support also be framed in masculine terms? Kramer (2005) suggested that there is a historical tendency for the role of male caregivers to be constructed via the lens of female experience. That is, the male caregivers' role was constructed, and subsequently measured, against prominent maternal stereotypes of the feminine caregiver. Fieldnotes taken by the first author suggest that both male and female staff had the capacity to display a harsher and a gentler style of interaction; attributes such as softness and nurturing were not exclusive to one gender. For example, a gentle punch on the shoulder between males was described by participants as a masculine display of warmth, friendship, and tenderness; likewise, a hug between females was seen as a display of the same attributes, but in a feminine manner.

This notion of friendship can be clearly seen in the data about males as a conduit to male well-being (see also Wilson, Parmenter, Stancliffe, & Shuttleworth, in press). In the present study male staff displayed a propensity for developing an open and relaxed relationship based on male-to-male banter and the exchange of male-to-male warmth. These data are significant because this gendered bond between male staff and men and boys with intellectual disability reflects the capacity for the development of a relationship that has meaning to both staff member and client. This is very important when dealing with sexual health matters because it will be far easier to support a man or boy with intellectual disability where openness and trust prevails. This idea of openness has been found elsewhere. Löfgren-Mårtenson (2004) also stated that male staff were more open toward sexual expression between clients. In addition, one of the male participants with intellectual disability in Yacoub and Hall's (2009) study stated that he could talk to other men about sex but not to “ladies.”

Some male-to-male relationships, as described by female staff, were filled with meaning that reportedly enhanced quality of life. Phrases such as “a beautiful male bond; he looks up to the guys; a father figure, a male figure” are extraordinarily heart-warming in comparison to the noted lack of trust between genders; but how do disability services promote the development of gendered meaning in relationships when there are often significant constraints such as recruitment difficulties? The formal policy and procedure frameworks within disability services seem to strive for paid caregivers who can fulfil a gender-neutral job description, yet informal or “in-house” policies, such as intimate care, make gender an issue. Likewise, a recently published code of practice for disability support workers in Australia (McVilly, 2007) reflects the same gender-neutral language; yet gender is a vital part of any ethical and practice framework. We acknowledge that this issue is not always straightforward; however, we feel that these data do show that quality can be based on gender. Sometimes this quality is centered on tasks that are perceived as gendered, such as cleaning and housework, whereas at other times quality is benchmarked by concrete examples of meaningful gendered relationships.

In the recent Counterpoint issue of the Journal of Intellectual Disability Research, Clegg (2010) asked: What if we thought differently? This issue offers a range of novel, and perhaps unorthodox, ideas to shape contemporary services. Among these are some suggestions for how to focus on the care relationships between staff and people with intellectual disability. Reinders (2010) argued that the dimension of personal knowledge, a feature that underpins meaningful relationships, is ignored at the expense of objective measurements of what is commonly termed quality care. He suggested that personal knowledge cannot be standardized; although standardization in housekeeping tasks is possible, this does not necessarily equate to greater quality of care. By contrast, kicking a ball around in the garden of one's home requires a degree of personal, and we also suggest gendered, knowledge. Reinders stated: “In knowing how to relate to their clients, the good practitioners gain insight into their motives, their moods, their problems, their disappointments, their sorrows, their expectations and their hopes' (p. 31). The logic behind this basis for defining quality care lies in the capacity to come to know the individual as opposed to merely working with a client. Our analysis suggests a gendered dimension to personal knowledge exists; such knowledge would place a higher value on tasks that enhance well-being (such as sports/exercise) and enjoyable shared activity.

One final point concerns the gendered nature of data collection and analysis. As mentioned earlier, all data were collected by the first author (a male) with analysis an evolving dialogue between all authors (all male), and the research topic was about male sexual health. Broom, Hand, and Tovey (2009) suggested that gender is both a resource and a potential liability in the collection of qualitative data. Investigating the often delicate issue of sexual health using qualitative methods is, to use the words of Broom et al., an embodied interaction. The question arises: How did the gender of the research team affect the data analysis? The fact that two of the female staff members disclosed experiences of abuse at the hands of previous male partners suggests that the interview technique was nonthreatening, open, and based on confidence in the interviewer's ethical practice. We suspect that a male asking questions about male sexual health afforded a degree of validity that may have been limited if the interviewer was female. However, we do acknowledge that a female interviewer may have tapped into other issues not covered in this study. Likewise, female researchers may have interpreted the data differently from an all male research team.

Conclusion

It is important to reiterate that these data were collected in the context of a wider study about male sexual health. Notwithstanding this factor, the analysis of these data does offer some novel insights into the latent phenomenology of the influence of staff gender on men and boys with intellectual disability. Masculine and feminine caregivers operate within the same geographies of care, but they negotiate and interact with the landscape in uniquely gendered ways. Clegg and Lansdall-Welfare (2010) suggest that although services have led to improvements in the material living conditions of people with intellectual disability, one major shortcoming is the failure to improve meaningful social relationships. Interestingly, these authors also pointed to moral judgments within services as another roadblock. The relationships between men and boys with intellectual disability and their paid caregivers appear to be founded on a number of gendered moral issues. We believe judgments based on gender also need to be addressed if disability services are to foster the types of gendered relationships that these findings suggest can enhance the well-being of men and boys with intellectual disability.

This article is based on the doctoral dissertation presented by the first author to the Faculty of Medicine, University of Sydney, and the Blue Mountains Health Trust is in New South Wales, Australia, in partial fulfillment of the requirements for the doctoral degree. The study was supported by a university postgraduate award through the Faculty of Medicine at the University of Sydney plus a small grant from the Blue Mountains Health Trust.

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Author notes

Editor-in-Charge: Steven J. Taylor

Authors:

Nathan J. Wilson, PhD (e-mail: nathan.wilson@sydney.edu.au), Research Associate; Roger J. Stancliffe, PhD, Professor; Trevor R. Parmenter, PhD, Professor; Russell P. Shuttleworth, PhD, Senior Lecturer. The University of Sydney, Faculty of Health Sciences, 75 E. St., PO Box 170, Lidcombe, NSW 1825 Australia.