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Challenges with providing gender-sensitive care: exploring experiences within pediatric rehabilitation hospital

Abstract Purpose The purpose of this study was to explore the perceived challenges with providing a gender-sensitive care approach among pediatric rehabilitation care providers. Methods Using a qualitative needs assessment design and a purposive sampling strategy, we recruited clinicians from a Canadian pediatric rehabilitation hospital. We conducted interviews with 23 pediatric rehabilitation healthcare providers (19 women, 3 men, 1 transgender man) from a range of disciplines. Three coders performed a thematic analysis of the transcripts. Results Our analysis revealed the following themes regarding the perceived challenges in providing a gender-sensitive care approach: (1) a lack of training and experience; (2) gender differences and stereotypes; (3) binary documentation and potential for misgendering; (4) the complexity of gender identity; and (5) the gender of the clinician. Conclusions Pediatric rehabilitation care providers face many challenges in offering a gender-sensitive care approach and need further training and systemic support. Implications for rehabilitation Awareness of the challenges in providing gender-sensitive care could be an important first step in helping to address inequities. Systemic and interpersonal barriers may impede the provision of gender-sensitive care among rehabilitation providers. Clinicians need more training and support in how to provide gender-sensitive care.


Introduction
Providing gender-sensitive care is an important approach in patient-centered medicine [1], which refers to healthcare providers having knowledge and competence in perceived existing gender norms and differences and incorporating these into their decisions and actions [2,3]. It also refers to addressing gender stereotypes, inequalities [4,5] and attributes of care that reflect relational and other preferences such as communication style, same-gender clinician-patient pairing, physical environment, and privacy or safety needs [6]. Focusing on gender-sensitive healthcare is salient because clinician's attitudes towards gender can influence their behaviours and may bias their evaluations of themselves and their patients [2,7]. Further, gender is an important social determinant of health [8] and both the National Institutes of Health Research and the Canadian Institutes of Health Research now mandate that sex and gender are considered in research [5,9]. Exploring this topic is imperative because many healthcare providers report that they lack training in gender-sensitive care approaches, which could lead to health inequalities, incorrect or delayed diagnoses, and suboptimal therapies [10][11][12][13].
Research shows that gender can affect how patients cope with physical and psychological aspects of their condition [1]. Further, gender-related coping strategies have important implications for how clinicians engage and support patients in their therapy [1]. In particular, self-awareness and personal reflection concerning the influences of one's own communication, judgements, responses and behaviour can affect the delivery of gender-sensitive care approaches [14]. For example, there are often different social role expectations for men and women that could influence rehabilitation outcomes in different ways [15]. Evidence suggests that more extensive rehabilitation therapies are typically offered to men than women [16]; however, little is known about such trends within pediatric rehabilitation.
Focusing on pediatrics is relevant because more than 1 in 10 youth in Canada have a disability [17]. Gender norms and expectations start early in life and shape individuals' attitudes, experiences and behaviours and have important health consequences throughout the life course [18,19]. Although sex and gender play a critical role in the incidence, clinical presentation, manifestation and health outcomes of youth with disabilities, they are often viewed as without gender and non-sexual [20][21][22]. Young women with disabilities often lag behind men with disabilities on a variety of health outcomes [23][24][25] and are at risk of inappropriate access to health services compared to people without a disability [26][27][28].
Among the limited research on gender and youth with disabilities, girls with disabilities tend to participate more frequently in leisure [29,30] and social activities and boys more in physical activities [31,32]. Gender differences have been reported with respect to the autonomy and independence for youth with disabilities and research shows that parents of girls are more likely than boys to limit their children's activities due to safety concerns [33].
Further, sex and gender diverse groups such as lesbian, gay, bisexual, trans, queer (LGBTQþ) youth with disabilities have largely been ignored within pediatric rehabilitation research and the provision of care [2,4,34,35]. Such trends are concerning because sexual and gender minority groups often encounter significant challenges within the healthcare system including discrimination, which could influence poor health outcomes and inequities [36][37][38][39][40][41].
Our study addressed a relevant gap in the literature by exploring the perceived challenges that pediatric rehabilitation clinicians have with providing gender-sensitive care approaches. This study is novel in that most previous research on gender-sensitive care focuses on adults and mainly acute populations. Little is known about gender-sensitive care approaches within the context of pediatrics and rehabilitation. Exploring this topic is important given that many healthcare providers lack training in gender-sensitive care approaches, which could lead to health inequalities [4,34]. False perceptions and norms may impede the recognition of symptoms and the delivery of timely health services [42]. Through examining the barriers that healthcare providers face in providing a gender-sensitive care approach, we aim to highlight areas where clinicians need further support and ultimately, help to improve gender as a determinant of health [3,43]. Understanding such perceived challenges in providing gendersensitive care approaches could be an important first step in helping to address inequities resulting from gender relations.

Objective and design
Our objective was to describe the perceived challenges that pediatric rehabilitation healthcare providers have in offering a gendersensitive care approach. We used a qualitative design that involved conducting individual interviews with pediatric rehabilitation healthcare providers. The purpose of our interviews was to gain an in-depth understanding of the experiences of providing a gender-sensitive care approach among pediatric rehabilitation clinicians. We aimed to have representation from different disciplinary fields within pediatric rehabilitation. The research ethics board at a pediatric rehabilitation hospital approved this study. We also followed the consolidated criteria for reporting qualitative research guidelines [44].

Recruitment
We used a purposive sampling strategy to recruit participants from a Canadian pediatric rehabilitation hospital that provides inpatient and ambulatory care services. We recruited participants using invitation letters, referrals or advertisements through a pediatric rehabilitation hospital. Participants met the following inclusion criteria: a pediatric rehabilitation clinician (e.g., physician, pediatrician, nurse, social worker, occupational therapist, physiotherapist, speech therapist, psychologist, etc.) who was currently practicing at the pediatric rehabilitation hospital or a satellite clinic. Participants who were interested in the study received an information letter from the research team. After obtaining written consent, two female researchers with expertise in pediatric rehabilitation and gender-sensitive care approaches interviewed the participants. The researchers did not have any prior relationships with the participants. We conducted interviews with 23 pediatric rehabilitation healthcare providers (see Table 1 for overview). This sample size is considered suitable for a qualitative study to capture the depth and breadth of issues surrounding gender-sensitive care [45,46].

Data collection
Interviews were conducted in-person from August to November 2019 and were audio recorded. The first two authors and a research assistant conducted the interviews using a semi-structured guide (see supplemental file). This guide was informed by a systematic review on gender-sensitive care among healthcare providers [4] and was also piloted with a pediatric rehabilitation clinician prior to conducting the interviews. The interviews lasted an average length of 26 min to fit within clinicians' busy schedules. We asked participants to describe their current clinical role and the types of patients they work with, the importance of gender within their practice and gender-related training.

Data analysis
All interviews were audio recorded and professionally transcribed verbatim then checked for accuracy. We used a narrative, thematic analysis [47] to gain an understanding of participants' experiences of gender-sensitive care approaches. This approach focuses on first-person accounts of experiences and events that have occurred and are linked into current discussions as examples [48]. This method involves familiarizing ourselves with the data, generating initial codes, revising and defining themes [48].
All authors independently read the transcripts while using the objective to guide our analysis. We each developed a list of preliminary codes while noting patterns between them and then met to discuss how they compared and contrasted. We relabelled, split or merged codes and discussed further while re-visiting transcripts until consensus was reached in the final coding framework. We established the meaning of all of the codes within our coding tree. Team discussions helped to resolve any discrepancies in the organization of the themes. The first author applied the coding scheme to all of the transcripts. Another researcher reviewed a sample of the coding to ensure accuracy. We then extracted relevant quotes that represented each theme and sub-theme while also considering the whole context of the interview [47]. Our team felt that we reached thematic saturation in both codes and the meaning of the codes [46] within our sample.
We used several strategies to ensure the rigour and trustworthiness (e.g., transferability, dependability, conformability) of the findings [49,50] including prolonged engagement, peer debriefing and descriptive participant accounts. We kept an audit trail of the decisions we made during the analysis [47,50]. We also had peer debriefing discussions amongst the research team. Further, we included excerpts from the interviews that were reflective of the participants' experiences to illustrate the themes [47,50]. We also considered how our background training and experience may have influenced the development of the themes, while noting this in our audit trail.

Sample characteristics
Our sample consisted of 23 pediatric rehabilitation clinicians (19 women, 3 men, 1 transgender man) from the following backgrounds: occupational therapy, nursing, physiotherapy, speech language pathology, therapeutic recreation, social work, medicine, and assistive technology consultant (see Table 1).

Results
Our analysis revealed the following perceived challenges in providing a gender-sensitive care approach: [1] lack of training and experience; [2] gender differences and stereotypes; [3] binary documentation and potential for misgendering; [4] the complexity of gender identity; and [5] gender of the clinician.

Lack of training and experience
The majority of clinicians (n ¼ 21) reported that a main challenge in addressing gender-sensitive care approaches was a lack of training and experience. For example, in regards to lack of training a healthcare provider explained, "This (hospital) hasn't had any formal training" (#6, occupational therapist). Another mentioned, "I remember a two-hour lecture that talked about different sexual orientations … It was probably 12 years ago; So, there wasn't anything today on gender identity or diversity in that way … I'm very nervous as a clinician to inadvertently do something that is not helpful, or even harmful without being aware of it" (#1, occupational therapist). Despite the lack of training, clinicians indicated a desire to learn more about gender-sensitive care approaches. Specifically a social worker said, "We really need more knowledge. We need to talk about it more, in every way" (#15, social worker).
Gender is not a priority Eight clinicians mentioned that providing gender-sensitive care approach was not a priority for them, in part because they lacked training and time. For example, a clinician said: "gender is important, but it's not primary for me" (#14, speech language pathologist). Others agreed: "I don't think about gender when I'm treating a client … We don't even address gender, to be honest" (#6, occupational therapist). Some healthcare providers said they did not notice gender differences or use a gender-sensitive approach even though there was a gendered incidence pattern to the condition they were treating. In addition, an occupational therapist shared, "It's definitely an important practice issue and it's not something that's typically on people's radar … Gender isn't on people's priority lists, but it should be" (#4, occupational therapist).

Gender differences and stereotypes
Eighteen healthcare providers reported on actual or perceived gender differences within their clinical practice which were often based on stereotypes. For example, healthcare providers stated they often perceived girls as being more independent and more engaged in social relationships, and sometimes more emotional. Meanwhile, clinicians said they often perceived boys as less mature, hyperactive, more engaged in sports while sometimes expressing more anger and experiencing social isolation than girls. For example, an occupational therapist shared, "Our male clients tend to be more angry and frustrated and perhaps, depressed … Sometimes I find that males also can be more socially isolated, because a lot of males make their friends through activities … the social isolation piece can definitely play a role in some of the mental health" (#4, occupational therapist). Another occupational therapist explained, "When I talk to families they talk about their sons being in rehab, about them wanting to get back to their sports and their extracurriculars … usually that's not as highlighted for girls. I would have to say with the females it's more about their peer relationships and getting them back to being able to socialize with their friends" (#13, occupational therapist). Other healthcare providers reported similar trends. For instance, a clinician expressed: "Girls tend to be interested in interacting; So, it's not about convincing them to interact. It's about helping them to do so in a way that's going to be successful; whereas boys might have to start a step further back. We first have to get them interested in communicating with peers. Then, once they are helping them to do so successfully" (#23, health care provider). Further, some clinicians disclosed that they had differential treatment of their clients based on gender. For example, a communicative disorders assistant explained: "I treat the girls with a little bit more of an adult flavour, whereas the boys, I still tend to see them as more childish, which may not be fair to all of them … but I get good results; So, it hasn't stopped me yet" (#5, communicative disorders assistant).
Five clinicians reported on gendered stereotypes regarding children's interests and particularly the toys they used to help engage them in their therapy. For example, an occupational therapy assistant shared, "I find definitely the boys are geared more towards the toys and the trucks and the girls would like to play more with the food-based stuff" (#3, physio and occupational therapy assistant). Another clinician, a physiotherapist, explained, "With some kids, there are more specific likes or dislikes that fit those gender stereotypes. So, I might be having a tea party with a little girl, whereas a little boy might be more interested in the cars and trucks … It's a way of getting them to move so I can see how their gross motor skills are developing" (#12, physiotherapist).
Other gendered stereotypes and misperceptions involved assumptions about a patient's sexual orientation. This trend often occurred amongst clinicians dealing with in-patients or those involved in overnight camps. Healthcare providers reported having assumptions that their patients were heterosexual, especially when assigning roommates based on gender identity. For example, a therapeutic recreation specialist explained within the context of some of their life skills programs: It always was two males that would share a room or two females would share a room and that was the way clients, families, staff were comfortable. But as the world changes and people are more aware and comfortable to share themselves. We've had situations where there were two male clients and one of the clients was openly gay. So, then if we're having two males in a room and they would be interested romantically, then that's now compromised (#10, therapeutic recreation specialist).
Another gender difference that sometimes posed challenges for healthcare providers in practicing a gender-sensitive care approach was with parent's expectations of their child. For instance, a speech language pathologist explained how some parents had expectations of their child that differed by gender: Expectations of the family or where it's very meaningful to them that their son achieves their milestones and they're quite worried about it. It may be that the son is the youngest of four children and the much hoped for boy and the family is very concerned that there are perhaps language delays or physical delays. So, we certainly run into that, where that has been a significant concern. Even a set of twins, where they were about equally delayed, and yet, they were much more concerned about the son than the daughter (#14, speech language pathologist).
In summary, gender differences, whether perceived and based on stereotypes or actual gender differences, often presented challenges for pediatric rehabilitation care providers.

Binary documentation and potential for misgendering
Another key challenge in providing a gender-sensitive care approach was having to cope with an outdated medical documentation system that only allowed clinicians to enter binary choices (e.g., male, female). This trend was noted by eight healthcare providers who reported that it could potentially lead to misgendering and upsetting their patients. For example, an occupational therapist explained, "There's nowhere in the chart; I don't even know if there's an option, besides female/male to document" (#6, occupational therapist). Others mentioned they had similar challenges: "in the chart, it's either male or female. Same with sending forms. I help people with sending forms weekly and there's only ever two checkbox options" (#1, occupational therapist). Clinicians explained how they tried to note patients' gender identity and preferred pronouns in the chart but it was often difficult to find an appropriate place. Challenges also often arose when there was a transfer of information to other healthcare providers working with a patient. For example, a physician explained, There was an inpatient who was transgender and the issue was that the medical chart has an M or an F. Even though in the notes it was very clear this individual wanted to be referred to with pronouns "she" and "her" and go by their chosen name they identified as female, the medical chart was still an M for male and that other name … It was tough because we have different people covering evenings and weekends and you had handover and trying to make it clear if you are called to see this patient, this is what's preferred. But you could see if you were not familiar and you were covering one night and you're just asked to pull up the client, you have to search them by the male name … Our medical record system is not set-up to address that (#19, physician).
Other healthcare providers expressed a difficult issue that they encountered in dealing with transgendered or nonbinary patient when trying to adhere to hospital policies regarding patient identification while also respecting patients' privacy. For example, an occupational therapist explained, On the referral, it was identified that this child was transgender … the dilemma was that this child identified with a new name and gender; however, our hospital has a policy where every time you provide service to a client, you have to ask their legal name and another identifier, such as their birthday; or, we're not allowed to provide service. We need to make sure you're the right person … So, the legal name of this child was still their original legal name of the gender they were no longer identifying with, but the physio had to go out to the waiting room and announce his name, knowing it would probably cause stress for the child, because that was noted in the referral, do not use this name … ethical dilemma. I'm in this system where I have to do this task that I know has a harm to this young person and their gender identity, but it's one of those things where the system hasn't caught up to real life (#1, occupational therapist).
Further, a nurse on the inpatient unit explained a situation with a patient that identified as nonbinary: We had this teenager who had spina bifida and was anatomically male, and our documentation, we would refer to him as male. And then he at his last admission, I started calling him 'him,' and that's not appropriate … Identifies themselves as nonbinary, and it really threw everybody off. There was no way to document that … You couldn't choose nonbinary as an option. So, at the top of all the documentation, we had to state this child wanted to be referred to as zis and their pronouns were ze, and it was challenging … We would just refer to their anatomical sex and that made this child a bit upset with us (#2, nurse).

Misgendering and therapeutic rapport
A key challenge with limited medical documentation (i.e., mainly binary) systems is that it has the potential to misgender a patient and affect therapeutic rapport. An occupational therapist explained, "when I've worked with clients if I've used the wrong pronoun, like how to handle that? … I didn't know how much of the therapeutic rapport have I disintegrated now through this interaction because I can't possibly know what that feels like?" (#7, occupational therapist). Meanwhile, an occupational therapy assistant shared a similar example, "there was a situation where there was a client that wanted to identify as male and we were doing a blitz clinic and unfortunately, the therapist went to the wrong room and started addressing the wrong client because they didn't do any of the identifiers … They ended up figuring out afterwards who it was because they mixed it up" (#3, physio and occupational therapy assistant). Another healthcare provider told us how the outdated binary documentation also affected the development of therapeutic rapport with their patient: "Once it was indicated in the chart that he was female and in that situation, it was something where I never went back to tell health records or change anything, but it changed the way that I had my clinical interaction with them" (#4, occupational therapist). Another example of misgendering and confusion about the proper use of pronouns which occurred on the inpatient unit: One of the inpatients who identified as a trans male, 'came out' in the hospital and that was not communicated about in a respectful way … People saying they don't get it, misgendering the kid, and someone was like, she wanted to be a boy. She said, call me 'he.' And I was like, why are you calling her she?" … You should refer to someone using the pronouns that they are instructing you to use … .the person telling me about it was getting it wrong and was not aware that she was getting it wrong (#20, clinician).
In summary, clinicians experienced challenges with the medical documentation system that only allowed them to enter it as a binary option, potentially leading to misgendering and upsetting a patient.

Complexity of gender identity
Five healthcare providers described how the complex nature of various gender identities was challenging for them, especially regarding how to manage nonbinary and transgender patients and navigating privacy and ethical concerns. For example, clinicians mentioned that they did not know how to address a nonbinary or transgendered patient and worried about saying the wrong thing and potentially offending them. Others reported that they had a few experiences working with transgender patients but felt that they needed more training. For example, an occupational therapist said, "There have been a few clients on (our unit) who are either in the process of transitioning or have transitioned. So, it's definitely becoming more common … It was the hardest thing for me to see someone as one way, but then having to refer to them as something else" (#6, occupational therapist).
Some healthcare providers expressed how most of their experience was with binary genders and that they were unprepared to effectively communicate with nonbinary patients. For instance, a physiotherapist stated, "Most of our conversation was based in a gender binary and we didn't talk a lot about people who don't identify with a binary label, and that's something I don't have a lot of experience with clinically" (#8, physiotherapist). Another clinician shared, "there's so many kids who are nonbinary and I don't think people would understand that quite as easily" (#20, pediatric provider). Meanwhile, an occupational therapist explained the complexity of coping with voice changes among transgendered patients: We had transgender voice clients that came into our clinic and that was the first time I had encountered that, but hadn't really spent time learning about voice issues for people who are changing gender or who are fluid in gender. We had never really thought about it before and the effects of hormones on voice. (#13, occupational therapist) Privacy and ethics Another complexity around a child's gender identity was regarding the privacy and ethical concerns about how and when they disclosed to a healthcare provider and whether or not their parents were aware of their gender identity. For example, an occupational therapist told us about the ethical dilemma of handling a patient who had not yet disclosed their gender identity to their family. Some clinicians described how they made an assumption that parents already knew the child's gender identity, which was not always the case as some of their patients were still contemplating their identity and had not yet discussed it with their parents. An occupational therapist explained, "families typically dictate the gender a little bit as well … They assume male or female … I never question … We don't really talk about it much" (#6, occupational therapist).
Another clinician, an occupational therapist expressed their reaction when a patient disclosed their gender identity: I worked with a client, who partway through an admission identified as transgender … . That's when I felt like, I can't believe I didn't know, and I never gave the space for that client to share … I've had a few clients who identified as transgender or nonbinary. It was a learning curve for sure … I realize I don't actually ever ask directly or indirectly how clients identify. So, it could be possible I'm even saying the wrong pronouns and not knowing it (#7, occupational therapist).
Other healthcare providers described their challenges of dealing with various gender identities and particularly the social acceptance and mental health issues that nonbinary patients often report experiencing. For instance, a social worker explained an experience that she had: I've been working on the emotional piece around identity. But there's that added piece of also being different and having a physical disability … It's not really about the disability and it's not really about the gender. It's about this person feeling that they're fitting in or not … Many of our clients I've seen experience exclusion, bullying and even some mild abuse … There was some mental health concerns and questions around identity and they were really struggling (#15, social worker).
In sum, several clinicians felt that the complexity of gender identity was challenging for them to address within their therapy sessions.

Gender of the clinician
Eleven healthcare providers highlighted that the gender of the clinician sometimes posed challenges in providing a gender-sensitive care approach. Specifically, most clinicians noted the femaledominated nature of pediatric rehabilitation, patient's preference for a certain gender provider, gender-based discrimination, and touching and inappropriate comments.

Pediatric rehabilitation is female-dominated
Most clinicians commented on the gender composition of the profession. For instance, a clinician said: "I'm male, heterosexual and work with young children within [pediatric rehabilitation], which is approximately 96% female. So, right away people see me as a bit of a surprise when they come in to see a [clinician] because I'm not who they are expecting to see" (#23, pediatric health care provider). Others explained that it would be important to have more men clinicians within pediatric rehabilitation. To illustrate, an occupational therapist explained: "OTs deal with very personal activities like self-care, bathing, dressing … it would helpful to have more diversity out there in the profession and more choice for clients. So, if you're a 14-year-old boy who's had a spinal cord injury, do you want to be learning how to get dressed again from some younger woman? Just to have more choice so that clients can voice what they're comfortable with, and diversity, including gender brings new ideas to the table and prevents this inadvertent bias that we probably have … It needs to start earlier in these professions and the more male role models out there." (1, occupational therapist) Patient's preference for a certain gender provider Six clinicians shared many instances where their patients expressed a preference for a clinician of a particular gender for certain procedures. For example, an occupational therapist explained, "I've had a couple of families say, actually, we're not comfortable with a guy (clinician) working with our child. Is there a girl one around?" (#16, pediatric healthcare provider). Additionally, a physician described a similar experience: I was on-call where there was a parent that was quite upset that her child was having a male nurse taking care of her … The client herself, a teenager, had no issues with the male nurse, got along well with them and the male nurse wasn't actually performing any hygiene or activities of daily living; just helping with wound care … The client was happy for his involvement, but mom was not happy at all … Her mom's reasoning was that he was a male and she was a female and that was inappropriate. (#18, physician) Another clinician, a physiotherapist, described patient's gendered preferences for working with a particular healthcare provider. For example, they shared, "It's one of those things that we don't talk about … It's interesting because for me I don't know if I'd be comfortable talking about continence in this setting. I'd be more comfortable with a female than a male … .I wouldn't feel comfortable addressing those issues in this specific environment with male clients" (#22, physiotherapist). Others similarly explained they needed to be cautious when working with male patients. In particular, a physiotherapist described, "I'm a woman and if I'm working with a teenage boy, there's certainly ways that you have to handle and facilitate where you need to let them know, I'm going to be putting my hand on your bum; or I'm going to be doing that type of thing" (#12, physiotherapist).
Meanwhile, a male clinician shared their experience of a time when a patient wanted a provider of a certain gender: There are a lot of patients who will say they don't want a male (provider) and I fully respect that and will go get a female nurse … It is weird when parents will say they don't want a male (provider) for a kid who hasn't expressed a preference, like a four-year-old … We can't have every family having these preferences … Listen, this is my job. I'm not just a random dude off the street. I am a professional person working with kids and I'm okay if you're not comfortable, but I am here as your (healthcare provider) (#20, pediatric healthcare providers).

Gender-based discrimination
Three healthcare providers reported experiencing gender-based discrimination within pediatric rehabilitation. For example, a male clinician described his experiences of gender-based discrimination when he applied for a clinical job and was told, "we can't hire guys for this position because a lot of it is you'd be visiting homes of families that are minorities and often the husbands aren't comfortable with another guy in their home with their wife" (#16, pediatric provider). Another healthcare provider, a transgender man, stated that they encountered gender-based discrimination from co-workers and from patients.
Touching and inappropriate comments Similar to patients' preferences for a clinician of a certain gender, some healthcare providers also reported gender-based concerns in working with certain patients. For example, two women clinicians expressed apprehensions following their experiences in working with boys and young men, particularly around touching and inappropriate comments. For example, a physiotherapist shared: I had an experience early in my career where a client hit on me, a teenage boy. So, because of that I'm always very cautious around teenage boys … In our profession it's not uncommon for people to make inappropriate comments with male clients … It's not acceptable … .In that situation I transitioned him to another male physiotherapist. Until I was able to do that I made his mom attend all of our sessions (#22, physiotherapist).
In summary, the gender of the clinician and past negative experiences posed challenges to their ability to provide a gendersensitive care approach.

Discussion
This study explored the perceived challenges with providing a gender-sensitive care approach among pediatric rehabilitation care providers. Although research on gender-sensitive care is increasing, relatively little is known from a rehabilitation perspective and focusing on pediatrics. Understanding the perceived challenges that healthcare providers face is important for addressing health inequalities and strengthening our awareness of gender as a social determinant of health. Developing gender-sensitive care approaches [34,35] could help to address inequities resulting from gender relations, perceptions, and norms that may cause challenges with recognizing symptoms and seeking timely health services [42].
Our findings showed that healthcare providers reported a lack of training and experience in providing gender-sensitive care approaches. These results are consistent with studies focusing on gender-sensitive care amongst primary healthcare providers [4]. Lacking knowledge in gender-sensitive healthcare approaches is problematic because it is often linked with inequities and discrimination which could adversely affect health outcomes [40,51]. Some researchers argue that healthcare providers who ignore the sexual and gender identity of clients often fail to deliver personcentered care [52,53]. More training and education in gender-sensitive care strategies is needed to reduce or eliminate genderbased inequalities and outcomes [54].
Our results highlighted that many clinicians perceived gender differences and stereotypes about their patients. Other studies similarly show the importance of understanding the role of one's own gender identity within healthcare work for avoiding and reinforcing gender stereotypes [11,55]. Recognizing the gendered socialization of roles and identities is important because some research highlights that male and female patients are treated differently despite other factors being equal, which suggests that some clinicians may be making healthcare decisions based on stereotypes [56,57]. For instance, Mahalik et al. [58] argues that biases, stereotypes and a lack of awareness and training around gender and diversity issues are considered harmful [58]. Additionally, attitudes about femininity and masculinity might differ within rehabilitation organizations and could influence healthcare decisions [15].
Clinicians in our study reported that outdated binary documentation was a key challenge in providing a gender-sensitive care approach. These findings are consistent with other research showing that failing to be identified by the preferred name and pronoun within a medical setting can impact patient satisfaction and quality of care for transgender people [59]. Having a binarygender approach to medical documentation is problematic because it could potentially misgender a patient, causing stress, anxiety or feelings of stigmatization [4]. This could be particularly problematic for a pediatric population having recently or in the midst of transitioning. The World Professional Association for Transgender Health provides recommendations for electronic medical records regarding transgender individuals including identifying preferred name, gender identity, pronoun preference as a means to maintain an inventory of a patient's medical transition history and current anatomy, a smooth transition from one listed name, anatomical inventory and/or sex to another without affecting the integrity of the patient's record [60]. Addressing gender diversity within clinical practice is critical. The World Health Organization [61] advocates for a broad approach to how sex and gender issues are addressed both within and outside of the healthcare sector. Although the landscape of gender identity has been changing over time with growing acceptance, many administrative and systemic processes still lag behind. Therefore, commitment at an organizational and leadership level is needed to advance the implementation of necessary documentation systems that can enhance gender-sensitivity for patients [2,12].
Another key perceived challenge that some clinicians reported in providing gender-sensitive care was regarding the complexity of gender identity. Specifically, some healthcare providers lacked knowledge in how to appropriately communicate with clients who were nonbinary or transgender. Such a lack of confidence about these clients was concerning because they are at a higher risk of mental health conditions such as depression and suicide [62]. The complexity of gender identity reflects a wider issue in healthcare, such that healthcare environments often do not create a space in which transgender patients feel safe to disclose [63]. Our findings also highlighted that clinicians encountered issues regarding maintaining privacy of clients whose parents were not yet aware of their gender identity, an issue that may be specific to pediatric populations. Therefore, further training and sensitivity regarding communication with transgender and nonbinary clients is needed.
Our results showed that the gender of the clinician often posed challenges in providing a gender-sensitive care approach. Specifically, most clinicians noted the female-dominated nature of pediatric rehabilitation. This finding is consistent with trends in allied health professions, medicine and nursing [4]. A potential concern with the over-representation of women within this field is that it could affect the development of rapport with boys and young men who comprise a higher proportion of the pediatric rehabilitation clients, at least within Canada, where this study was conducted [64]. This trend may be specific to the pediatric population as a higher proportion of male rehabilitation clinicians work with adult populations [65]. Studies focusing on physicians have shown that communication style during a medical encounter is an important way that practice behaviours differ by gender [56]. Indeed, views about masculinity and femininity are often built into the structure of work [66]. Those in leadership positions should be aware of such gender-based differences and inequalities so that they can make an effort to address them.
Our findings highlighted that some of the challenges in providing a gender-sensitive care approach also impacted clinicians. For instance, some clinicians experienced gender-based discrimination from co-workers or from patients and families. More education and training on equity, diversity and inclusion in the workplace is needed for staff. Additionally, hospital-based patient and family advisory groups could also offer similar training to enhance respectful and appropriate treatment and communication with clinicians regardless of their gender; as well as those who identify as LGBTQþ. There are also specific challenges for patients and families as they cope with potential misgendering, privacy and ethical issues. Future studies should explore these areas in further depth.

Limitations and future directions
It is important to note the limitations of our study. First, we drew on only one site from a large urban center and the findings may not reflect the challenges in offering gender-sensitive care in other healthcare centers. Future studies should explore rural and suburban areas. Second, the majority of the participants in our sample were women, which is reflective of the gender distribution of pediatric rehabilitation providers and therefore, our findings may not be reflective of other genders. Future research should explore strategies and frameworks for gender-sensitive care. There is a critical need for gender-sensitive training programs and interventions for pediatric rehabilitation providers. Finally, further studies could consider exploring the impact of the female-dominated nature of pediatric rehabilitation on client engagement and outcomes.

Conclusion
Our study explored the perceived challenges with providing a gender-sensitive care approach among pediatric rehabilitation care providers. Our qualitative analysis revealed the following themes regarding challenges in providing gender-sensitive care: lack of training and experience, gender differences and stereotypes, binary documentation and potential for misgendering, the complexity of gender identity, and gender of the clinician. Pediatric rehabilitation care providers encounter many barriers in offering gender-sensitive care to their patients and need further support and training.