Home Support Workers and Older Men: The Implications of Masculinity for Later Life Care

Data Collection

This project sought to better understand the needs of older men using home support services, including the ways in which care providers experience their relationships with them. Data were gathered through qualitative interviews with twenty-two HSWs and two managers in Vancouver, British Columbia. This study was conducted in collaboration with the local health authority, which is responsible for providing a variety of publicly funded health services including home care. To recruit participants, a home care agency affiliated with the health authority provided our research team with a list of employees. A research assistant then telephoned these workers, describing the study and asking them to participate. Research assistants conducted the interviews at the home care agency’s office, at a university research center, or in a coffee shop.

Using a semistructured question guide, the interviews broadly explored participants’ experiences of work in the home care sector, with a focus on their relationships with male clients and their perceptions of older men’s needs in various areas, including personal care, household routines, and mobility. For example, participants were asked to describe any differences they saw between male and female clients in terms of their needs for care and their perspectives on the factors that impact on men’s engagement in health practices such as physical activity. Using these broad topics as a starting point, interviewers probed more deeply into participants’ relationships with older male clients and perspectives on caring for them.

Interviews averaged thirty-three minutes in length and were digitally recorded and transcribed. Participants were given a copy of the questions prior to the interview. They had time to reflect on the questions in advance and were well prepared to share a breadth of in-depth information during relatively short interviews. Participants were compensated $40 (CAN) to cover their wages and transit costs, and all interviews were conducted in 2015. Ethics approval for this study was obtained from the University of British Columbia and from the local health authority. A demographic profile of the interview participants is provided in Table 1.

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Table 1.

Profile of Interview Participants.

Characteristics		N (24)
Job title	Manager	2
	HSW	22
Gender	Women	21
	Men	3
Ethnicity	European	7
	Filipino	10
	Chinese	2
	Japanese	1
	Korean	2
	Other	2
Place of birth	Canada	4
	Outside Canada	20
Education (highest level completed)	Trade school/community college	6
	University (undergraduate)	17
	University (graduate)	1
Characteristics		Mean
Age		53
Length of employment	Years working with current organization	9
	Years working in home care	11

Note: HSW = home support worker.

Data Analysis

We conducted an interpretive thematic analysis of the interviews (Marshall and Rossman 2006). First, to gain intimate familiarity with the data, Barken listened to and simultaneously read each interview in its entirety. Second, portions of the interviews that focused specifically on care for older men were reread to inductively develop themes based on “patterns evident in the setting and expressed by participants” (Marshall and Rossman 2006, 159). Barken then used these themes to reread and code the data. Themes were refined throughout the coding process as reflective memos and discussions between the two authors led to development of more creative interpretations, which accounted for points of convergence and divergence in participants’ viewpoints. Sims-Gould blindly coded a subset of interviews using the identified themes to ensure inter-coder reliability. We also engaged participants in member-checking, sharing early findings with five HSWs. Doing so helped to ensure that the findings fairly and accurately represented participants’ viewpoints. QSR International’s NVivo 10 (http://www.qsrinternational.com/nvivo/nvivo-products), a qualitative analysis software package, was used to facilitate data storage, organization, and retrieval.

While we did not develop themes a priori using theories of masculinity, we did use masculinity as a sensitizing concept that “provided an analytic frame, serving as a point of reference and a guide in the analysis of data” (Bowen 2006, 4). Turning to the theoretical literature was useful for considering how care providers both affirmed and challenged conceptualizations of masculinity when they discussed their work with older male clients. In our analysis, we also considered how the care provider’s gender shaped their relationship with the client, noting some differences in the experiences of male and female participants. Given that the large majority of HSWs are born outside of Canada and are nonwhite, future research should explore how race and ethnicity intersect with gender to shape relationships between clients and care providers. While two managers were interviewed, it is notable that these participants seemed to have less insight into masculinity than the HSWs who work directly with older male clients.

Women and Men Are the Same

Many participants initially commented that they saw no gender-based differences between clients, focusing instead on commonalities associated with age and the need for care. In their capacity as care providers responsible for supporting health and well-being, workers emphasized their efforts to provide equally good care to all clients. One HSW stated, “for me there is nothing as male and female…because the only thing that they need is the care.” Another worker explained how she treated all women and men equally as “clients” in need of help: “When we visit the client, it’s just the client. Not the woman, not the male (…) So we are there to help. So it’s not different.”

Some care providers further emphasized differences between clients based on health status or personality traits, rather than gender. One worker said: “I would say the same because that depends on (…) their personal mobility and stuff. Yeah, their cognitive stage.” Another commented: “I personally think it’s not about their gender. It’s more about their, like, characters.”

Participants’ statements make clear their efforts to distance themselves from gender biases and to maintain professionalism. Throughout interviews, however, they frequently discussed gender-based differences concerning clients’ care needs, responses to home support, and interactions with workers. These are explored in the following three sections.

Care and Sexuality

Many HSWs recounted the challenges of assisting older men with bathing and personal care. Some clients overtly displayed their male sexuality through inappropriate comments and in doing so challenged the boundaries between care and sexuality. Through suggestive comments, some male clients asserted their continued interested in sex. One participant explained:

I mean, we used to have a guy that, you know, even one of them now just always—innuendos (…) would you like to come into the shower with me and scrub my back? Or—I haven’t been with a woman for, oh, I need a girlfriend, for years, you know, stuff like that. Yeah. Icky.

Unwanted sexual attention presented threats to workers’ safety and dignity. When these situations arose, participants discussed strategies they used to communicate clear boundaries between care and sexuality and to mitigate harassment. As a first response, workers “put their foot down” and attempted to confront inappropriate comments themselves. The HSW quoted above explained that, because she had developed a close relationship not only with the client but with his family, she “[tried] really hard” before “[calling] the supervisor to have changes made.”

If clients continued to make sexually inappropriate comments even after workers asked them to stop, they would report the issue to their supervisor. In this study, HSWs typically indicated that their organization had clear policies for supporting care providers who experienced unwanted sexual attention. One participant explained that workers were never made to return to situations that felt unsafe or uncomfortable: “Some of them yeah, little bit make uncomfortable. But we have a policy. So when a male client is sexual obvious, we—client make safety and then we can leave. And then we just go to the supervisor. I’m not going to be there again.”

In these circumstances, the organization would often try to replace the female care provider with a man. While ensuring that older men received assistance from a male HSW could mitigate many instances of (hetero)sexual harassment, challenges sometimes arose when male clients refused care from workers of the same gender. One HSW indicated that some male clients resisted care from other men because it threatened their heterosexual masculine identities:

But there is a certain group, I think you would understand, they don’t want to be showered by a male (…) He said, “I cannot have a male worker give me a shower. I get itchy.” He is just kidding, but to him, he doesn’t want a male worker see him naked or touch his body. He’d rather have female workers.

Taking Control and Accepting Help

Participants also discussed tensions that emerged between male clients’ efforts to be in charge and their willingness to accept assistance. On the one hand, care providers often perceived that men were less concerned with self-sufficiency because women had assisted them throughout their lives. On the other hand, some participants explained how men sought to retain a sense of control over the help provided due to their gendered roles as bosses in paid employment and in their households. As HSWs explained various ways older men accepted and resisted care, they affirmed the continued existence of masculine identities developed over a lifetime of gendered practices in the household and in paid work environments.

The receipt of home care is often considered to signify an experience of discontinuity, as clients relinquish aspects of their independent identities (Barrett, Hale, and Gauld 2012). Some participants commented, however, that assistance from a female HSW did not disrupt but rather extended the care that older men had long received from their female partners. These care providers described men as “less complicated” as they were accustomed to women taking responsibility for household tasks. By contrast, they considered some older women to be “fussier” because they had set routines, developed over a lifetime of responsibility for work in the traditionally feminized home space (Mallett 2004). When asked about gender-based differences between clients, one HSW explained: “Men usually very easygoing (…) The wife organize everything. They don’t care (…) The woman usually very, how to say, very handy or do everything. They’re very fussy. They have specific, how to say, routine.”

While some care providers considered older men more easygoing, others felt that male clients wanted workers to do things in the same manner as their female partner would have done. These older men sought to retain a sense of control even with changes to their care arrangements. One HSW stated:

Men are a little more particular with things, where they like their things, right. When you’re done, just, you know, place it back. Have the label facing you, right, ‘cause they want to make sure they’re grabbing the right thing because their whole life they’ve been married and that’s the way their wife did it for them, and that’s the way they still want it.

When men grow older and encounter needs for care, they carry with them gendered structures and relationships developed throughout the life course. This, in turn, informs their relationships with care providers.

Health and Well-being

Participants also indicated that older men were less likely than women to engage in health practices related to exercise, diet, and social activity. They often commented that women are better equipped to manage their own health through moderate activity, whereas men tend to go to extremes, either not exercising at all or overdoing it to the point of exhaustion. Participants’ perspectives on health and well-being show how changes that can occur in old age, such as loss of physical strength and ability as well as diminished social networks, are at odds with the practices, identities, and activities commonly associated with masculinity.

Some care providers regarded older men as “lazy” and uninterested in maintaining or improving their own health. One HSW stated, “But there is two kinds of clients. Most of them male, they don’t want to exercise (…) they’re couch potatoes. They don’t want to stand up.”

Some participants noted that the need for care could be particularly difficult for older men who had prided themselves on physical strength—a celebrated masculine trait—throughout their lives. One manager said, “I know that some men find it really hard to age because they were so physically active and all of a sudden their physicality is disappearing. They’re not as strong.”

Other participants explained how some male clients did not retreat from health practices but pushed themselves beyond what care providers considered a reasonable amount of activity. These actions show how older men attempted to overcome bodily limitations and assert a masculine sense of strength. This HSW expressed concern that extreme activity could compromise rather than improve health:

I have men who are, like, pretty extreme. Like, they were late 70’s and (…) they would walk from, like, 19th Street to Park Royal and back. And he enjoyed it. And he was tired after, but he still liked it (…) Women are more, they know when to go back.

A manager commented on the potential benefits of activities targeting men, based on her observations of well-attended programs:

I wonder if, like, the male-only exercise programs would be helpful, ran by a man, right? (…) the one in West Vancouver that I see, every time I go there in the morning there’s (…) Fifty men that are probably over the age of 75 in the gym. It’s jam-packed (…) It’s ran by a man who’s in the same age bracket.

Implications for Theory

Through our focus on care providers’ perspectives, this research expands the literature exploring older men’s health (Evans et al. 2011; Davidson 2013; Tannenbaum and Frank 2011) in ways that underscore the relational and situational aspects of masculinity. HSW’s insights, we argue, serve to both challenge and sustain existing ideals of hegemonic masculinity. On the one hand, our findings suggest that old age and the need for care can disrupt some of the privileges commonly associated with masculinity. Participants defined male clients primarily as “care recipients” rather than as men and often felt that men were less resilient than women to age-related changes. On the other hand, our findings show how many older men continue to engage in practices that are consistent with hegemonic versions of masculinity developed through social encounters and relationships over the life course. In these ways, this study echoes other research suggesting that masculinity is reinterpreted and modified—but not lost—in later life and with the onset of chronic health conditions (Bartlett 2007; Davidson 2013; Moss et al. 2007).

The first theme, “women and men are the same,” shows how care workers downplayed the relevance of gender for later life care. Participants defined clients primarily by their needs associated with age and health status (e.g., “they are patients”; “the only thing that they need is the care”), rather than as men or women. It is very likely that workers’ comments reflect their efforts to avoid appearing discriminatory—that is, to make it clear that they treat all clients equally regardless of gender. Still, such comments implicitly render masculinity (and femininity) invisible, while highlighting age and health status as primary characteristics that shape needs, identities, and behaviors. This focus on the commonalities among women and men shows how old age can serve as a “master status” (Calasanti 2003), that along with health status comes to define home support arrangements, and that eclipses other social locations of difference such as gender. Thus, these findings suggest that workers did not necessarily attribute to older men the power and privilege typically associated with hegemonic versions of masculinity.

While views of older women and men as “the same” call into question existing gender relations, findings concerning care and sexuality, taking control and accepting help, and health and well-being demonstrate how older men receiving care may continue to engage in practices that are consistent with aspects of hegemonic masculinity. When some older men made sexual comments while receiving body care, and sometimes refused care from male workers, they asserted their heterosexuality and continued virility. Recall the worker who recounted a client stating, “just because I’m old it doesn’t mean I don’t have a penis.” Not only did this client construct a sense of “manliness” through his encounters with female workers (Bartlett 2007), he also challenged the ageist stereotype that equates old age with a loss of sexuality. Body care often confers social relations of domination and subordination (Twigg 2000), and these sexual comments suggest how some clients might try to assert male power as they objectify female workers and take for granted what has historically been considered men’s “right” to women’s bodies within a patriarchal society.

Some workers downplayed the significance of unwanted sexual attention as they attributed it to cognitive impairment. At the same time, sexual innuendoes were perhaps one way for older men to handle the discomfort of receiving assistance with a bath, and the challenges that body care presented to their self-sufficiency. Still, findings on care and sexuality show how older men reproduce hegemonic version of masculinity in the home support context. These overt displays of sexuality presented very real threats to workers’ safety and made clear the vulnerability that female, often racialized workers face when tasked with caring for men in private home spaces. For the dignity of people both providing and receiving care, and with increased societal awareness of workplace sexual harassment (Kantor 2018), more complex understandings of care, sexuality, and masculinity are needed.

Tensions between “taking control and accepting help” provide further insight into the plural and fluid enactments of masculinity that emerged through care providers’ interactions with male clients. While participants described various ways in which older men accepted and resisted help, their responses reflect gendered practices that are socially constructed over the life course. Some older men easily accepted assistance from others, and workers described them as “easygoing.” This finding reinforces men’s dissociation from the home space, and the extent to which receiving help from women is “in tune with normal gender expectations” (Twigg 1999, 385). Care providers’ comments suggest that this assistance did not threaten their male clients’ sense of self-sufficiency. They described older men in relation to women, who, in their experience, presented more typically “feminine” identities and behaviors. Notably, women who had taken responsibility for care work and for “controlling and ordering” the home space throughout their lives were often more reticent to accept help (Twigg 1999, 385).

Although some men easily accepted assistance, participants also described how others sought to maintain control over the care they received and resisted advice from younger, female, workers. Comments such as male clients “want it their way, all the time” suggest how older men sought to retain their authority as heads of household (Mallett 2004) when care needs arose. Accepting advice from carers perhaps contradicted some older men’s agency. Indeed, some workers equated men’s sense of being “in control” to their work identities and managerial positions earlier in life, where they were accustomed to telling others what to do (Bartlett 2007; Moss et al. 2007). Similar findings have emerged from studies on men’s work as family carers, where researchers describe a task-oriented, take charge, managerial approach as men apply skills learned in paid employment to caring (Calasanti 2010; Campbell and Carroll 2007; Hong and Coogle 2016). Adding to this literature, our findings suggest that a managerial “take charge” approach is relevant in consideration of some older men’s experiences of receiving care. Work identities informed their relationships with care providers in ways that reflected hegemonic versions of masculinity.

As a whole, the tensions between taking control and accepting help show how aspects of masculinity that are socially constructed in the home and in paid work settings are transferred and modified—but not lost—as men move through the life course and enter into situations where they are defined primarily as “care recipients” rather than as “managers,” “bosses,” or “heads of household” (Davidson 2013). Moreover, participants’ direct comparisons between male and female clients emphasize the relational nature of gender. Workers’ conceptualizations of men as “easygoing” or “in control” could only exist in opposition to older women’s responses to care. Participants connected their female clients with the care work they had done throughout their lives. Thus, findings highlight the significant ways in which involvement in care (for many women) and separation from care (for many men) come to shape their relationships with home care providers.

Finally, findings concerning “health and well-being” make evident the challenges that care needs present to masculine ideals of strength and self-sufficiency. Care providers explained that older men were often less likely than their female counterparts to engage in practices considered to maintain or improve well-being, such as exercising, eating healthfully, or socializing. These findings echo other research, which relates men’s reluctance to seek out health care or engage in health practices to masculine notions of independence and “toughness,” because turning to others for support is regarded as feminine (Courtenay 2000; Evans et al. 2011; Tannenbaum and Frank 2011).

Paradoxically, care providers felt that precisely because of their “manliness,” men might need more targeted support, such as individual assistance with exercise and older male role models, to remain healthy in later life. Such statements may be interpreted to suggest that aspects commonly associated with hegemonic masculinity—including identities formed around paid work, a reliance on female partners for care and for maintaining social connections, and a reluctance to seek out support—can make aging more difficult for men. By contrast, participants presented women as more resilient, as drawing upon traditionally “feminine skills” related to caring and socializing served to bolster a sense of well-being (King and Calasanti 2013). Participants’ perspectives suggest how aging and care needs can disrupt the privilege attributed to masculinity and the subordinate status of femininity, as older women were considered better equipped to handle the changes to health, well-being, and social networks that often accompany the need for care in later life. These findings demonstrate how gender and age can intersect in ways that challenge relations of power and privilege, expanding conceptualizations of gender relations as fluid rather than fixed (Connell and Messerschmidt 2005).

Implications for Home Care Policy and Practice

This study has implications for developing policies and practices that promote the safety of workers when caring for older men and that equip them with the resources needed to support clients with diverse gender identities and behaviors. First, and most importantly, organizations must be proactive in preventing sexual harassment—a serious problem in the home support sector that should never be tolerated. In-service training and education is necessary, so that all workers are able to recognize harassment, to ensure they are well-positioned to seek support from their agency, and to make certain they have a safe way out of threatening or uncomfortable situations. In addition to this, upon enrolling for services, home care clients and their families should be provided with information outlining workers’ rights and detailing the types of behavior that constitute harassment. This approach could help to mitigate these situations and to remove some of the onus from HSWs for preventing unwanted sexual attention.

Second, HSWs indicated that men often need high levels of encouragement to engage in practices that support well-being, such as physical activity and social interaction. This speaks to the importance of home care that extends beyond basic personal and clinical care. At present physical activity is not included as an eligible service in most situations. Providing safe and responsive care is a particular challenge, given the severe cutbacks that the home care sector has faced over the past two decades. In British Columbia, long-term clients increased by 2.8 percent in 2016 and 2017, but the hours delivered per client decreased by 2.6 percent (Office of the Seniors Advocate 2017). Ultimately, workers are required to see more clients in shorter bursts of time. This makes it much more difficult for workers to provide care tailored to individual needs. Ensuring that workers have the time and resources to provide diverse forms of care, such as help with physical activity and with getting outside of the house, would be beneficial to meeting needs that vary with gender.

Finally, based on our overall analysis, we suggest that providing high-quality care does not mean treating women and men “the same,” but rather recognizing gender as significant for home support and finding ways to respond appropriately. When developing practice guidelines, we urge organizations to learn from the expertise of HSWs, who work directly with clients and have an in-depth knowledge of their needs and preferences. These practice guidelines should ensure that all care providers have the skills and resources to provide care that takes gender into account.

Questions for Future Research

While this article extends theoretical knowledge on masculinity and later life care, there are some important questions to be addressed in the future. First, interviewing older men themselves, in addition to care providers, would offer a more a complete understanding of masculinity, aging, and health. Second, we have noted that HSWs constitute not only a gendered but also a racialized workforce, with migrants from lower-income countries disproportionately represented in the Canadian home care sector, especially in urban areas such as Vancouver (Martin-Matthews, Sims-Gould, and Naslund 2010). The demographics of our study sample reflected this pattern, with twenty of the twenty-four participants born outside of Canada. It is equally important to note that many older Canadians are also migrants, although fewer older Canadians are visible minorities relative to younger migrants (Martin-Matthews, Sims-Gould, and Naslund 2010). Our interview data, however, do not explore racial or cultural tensions that emerge in care relationships. Such a consideration is essential given the demographics of the home care workforce and of home care clients and would extend knowledge on the intersections of race, ethnicity, gender, and age. Finally, it is notable that there was very little workplace turnover among the HSWs interviewed and that they were on the whole well-educated. These commonalities no doubt reflect that all participants were recruited from a single organization. Research among care providers working for a variety of organizations could extend the findings presented here.