A discussion of politics and access to occupation cannot afford to ignore the concept of diversity, which has only recently begun to enter the professional discourse of occupational therapy (Abreu and Peloquin, 2004, Kirsh et al., 2006 and Trentham et al., 2007). This signifies professional recognition of the influence that varying identities and subjective experiences can have on access to occupation.

Diversity is not merely a matter of ethnicity and gender (Awaad, 2003, Iwama, 2003, Harrell and Bond, 2006 and Kirsh et al., 2006) but refers to a multitude of characteristics, including class, race, linguistic group, sexuality, disability status, age or marital condition, that can influence perceptions of the world, meaning of occupation and access to power. Being different in one or more characteristics from the dominant group in any context can lead to restricted access to services for groups of people. This is not just in terms of service availability but also applies to the quality of interactions with occupational therapists (see, for example, Kirsh et al 2006) because professionals can be unable to recognize nuances in the needs of clients from minority groups.

Diversity can limit access to what Rawls (1973, p. 62) refers to as the ‘primary goods’, including liberties, opportunities, wealth, food and education. Difference leads to the construction of the ‘other’, a conceptual category within which a specific characteristic is singled out and becomes the defining quality (Kristeva 1991). These ‘otherisms’ (Abreu & Peloquin 2004, p. 354) can have a negative bearing on the establishment of collaborations not only within occupational therapy but also between therapists and other people they work with – community members, disabled people’s organizations or other professionals for example. Limited access to primary goods can also create disadvantageous differences, such as class inequalities, which arise from the maldistribution of resources.

It is perhaps surprising that class and gender are rarely considered together, particularly when many of the restrictions experienced by women are also experienced through class and/or sexuality (Skeggs, 1997 and Taylor, 2007). People are classed, engendered and sexual beings all at the same time, all the time. These identities are constantly in operation. This is particularly important in professions, such as occupational therapy, that offer many women the possibility of leaving behind their working-class origins for the middle-class status and access to better earnings that go with professional education (Pollard & Walsh 2000). People seeking careers in occupational therapy are not motivated primarily by the earnings but by ‘people-oriented factors – interests in being of service to the community and in helping people’ (Meredith et al 2007, p. 240; see also Roney et al 2004). This evokes the social activist motivations of early occupational therapists, many of whom were working at a time when, because there was a surplus of women following the First World War, many sublimated their social expectations in a career of service (Nicholson 2007). Occupational therapy pioneers, along with those in nursing and social work, came from a class of women whose visions of social action were aimed at their working class contemporaries (Pollard & Walsh 2000).

Class, gender and sexuality present challenges to the holism espoused by occupational therapy. All three issues are an element of the occupational narratives we receive from our clients in the negotiation of assessment and the planning of intervention, and yet all three have in some way been neglected in the discussion of the profession’s concern with meaningful or purposeful occupation. These exclusions can be defined as sites of conflict and cooperation (see Ch. 1). As yet, little is known about the diversity of the population of occupational therapists beyond the figures showing that in many Western countries most are white and female. It has long been assumed that many occupational therapists are middle class but widening access to educational opportunities has attracted entrants from lower income groups (Beagan 2007). As a consequence of these dominances it may be difficult for professionals, new career entrants and the clients they work with to challenge assumptions that frame the profession. As Beagan (2007) has discovered, for example, a perception that students from impoverished origins should pass middle-class occupational expectations has inhibited their development, and also poses a risk that similar concepts would be imposed in assessments and intervention with clients in practice.

Class, gender and sexuality operate and influence access to opportunities for engagement in occupation including income, wealth, liberties, education and food. These constitute the primary goods that Rawls (1973) asserts need to be distributed equally in a society. For clarity these three elements, class, gender and sexuality, will be examined separately, despite the reality that, far from being exclusive and independent, they are embedded in each other. The last part of the chapter will offer a synthesis of the observed inequality apparatus, using Fraser’s (1997) concepts of distribution and recognition injustices.

The unequal distribution of wealth, access to education and the burden of disease and disability point to the existence of a class system of social stratification (Hartery & Gahagan 1998; see Chapter 14 and Chapter 19). Class is a rather blurred concept because of its complexity and variance across cultures but it is largely determined by and determines access to education, health and wealth (Pincus et al., 1998 and Field and Briggs, 2001). For example, a study of the London Borough of Camden found that life expectancy across the borough varied by 10 years in a pattern mirroring wealth and poverty levels (Stafford & Marmot 2006).

Class refers to a hierarchical system of social stratification based on the possession of power, commonly associated with level of income and education in industrialized societies. The system of social classification used in many countries is mainly based either directly on these two elements or on paid occupation, which is in turn dependent upon education and is a defining factor for earnings (Hartery & Gahagan 1998). These criteria belie the complexity of perceptions of class, which go beyond one’s bank account or job title. Class is also defined by the context within which people are acculturated, the geographical spaces they occupy, their social networks and finally how individuals and groups both see themselves and also perceive how others see them (see Chapter 11, Chapter 13, Chapter 14 and Chapter 19).

Perceived increased social mobility and more importantly the domination of public discourses by a middle-class perspective and the silencing of working-class voices have led to the illusion of a classless society (Wilson 1992), a Utopia where class does not matter. Identity has been proposed instead as an alternative that provides a more stable basis on which social connectedness can be developed. As the example of a working-class writing organization (Woodin 2005) shows, people often base their participation and belonging to a group upon the characteristic they feel has the most prominent role in the way they define and perceive their life (Chapter 13, Chapter 14 and Chapter 20).

Identities connected to gender, sexuality, race or disability provide a platform upon which a sense of belonging and support can be built. These can often be portrayed as exclusive identities, for example individuals may describe themselves as disabled or black or gay. Such identities can also operate exclusions, as Taylor, 2005a and Taylor, 2007 study of working-class lesbians shows. Women in her study could not identify with a queer identity or a gay lifestyle, as these were grounded in a middle-class perspective. Individuals may be disabled and black and gay, and also possess aspects of their identity based on an experience of class. Identity is by definition inclusive of all the personal elements that make people who they are; one for example is both a sexual being and an individual living in a classed society (Taylor 2005a).

The normative ideal of the typical citizen as a middle-class, heterosexual, non-disabled person is an illusion, fed by the invisibility of those who do not fit in with it. People of working-class backgrounds do not often see their stories represented in the mass media, unless they are linked with issues of poverty and deprivation. White working-class women are represented or thought of as ‘loud, excessive, drunk, vulgar, disgusting’, as Skeggs (2005, p, 965) illustrated in her exploration of representations of white working-class women in England. Behind the association of working class with destitution and the presentation of the issue from a normative, capitalistic perspective lies the implication that belonging to the working class is a state most people should avoid and that, given the chance, working-class people would opt to elevate to the powerful middle class (Haylett 2003). Instead of pointing to a solution, this approach becomes part of the problem, as people become reluctant to claim a working-class identity for themselves. Thus a source of community connectedness and support derived from a common identity is lost. But, if working-class people are ‘loud’ and ‘disgusting’, their middle-class counterparts are ‘boring’; thus problems of recognition and representation are not restricted in a single class (Skeggs 2005). Class embarrassment and subsequent class identity denial can be found across the classes. These problems of identity may actually threaten the coherency of some communities (Sayer 2002).

Numerous authors suggest that class correlates strongly with experiences of health (Marmot and McDowall, 1986, Blaxter, 1987, Vagerö and Lundberg, 1989, Karlsen and Nazroo, 2002, Krieger et al., 2003 and Krieger et al., 2005). People belonging to lower socioeconomic classes carry a disproportionate burden of disease and disability, and die earlier (Drexler 2005). The causal explanation behind the link between class and inequalities in health has been shown to be multivariate, mainly centred along three axes, i.e. deprivation, social networks and behaviour patterns (Lundberg 1991). Lack of a sustainable income and lack of access to educational opportunities correlate with lack of exercise (Raudsepp 2006), obesity (Novak et al 2006), environmental injustice, i.e. living in areas with a disproportionately high burden of environmental pollution (Stephens et al., 1999 and Elliott et al., 2004), and nutritional inequities often leading to unhealthy dietary habits (Travers 1996). People in such areas may be reluctant to demand a cleaner environment, since, as the pollution comes from local industries, this might threaten their jobs. Sometimes this can lead to tragic consequences, as in the case of the methyl mercury poisoning outbreak in south Japan in 1956. This affected the central nervous system of its victims with a condition since identified as Minamata disease (see www.nimd.go.jp/english/index.html, www6.ocn.ne.jp/∼mf1997/index.html).

Poverty means that people often have to resort to inadequate housing solutions with no suitable heating or insulation as their resources need to be directed to more pressing needs such as food (Lawrence 2004). In a recent study Morris et al (2007) brought together existing evidence on requirements for housing, nutrition, exercise, psychosocial relations and medical care (but excluding rent, mortgage and council tax) for older people with the aim of establishing the minimum income for healthy living. This was estimated to be 50% higher than the state pension, which at the time of their study was £87.30 per week.

All these situations create inequalities in opportunity, which, through lack of basic resources, lead to increased vulnerability to disease, as people do not have access to education, healthy food or safe drinking water (Armelagos et al 2005). The uneven distribution of wealth both within and between countries under global capitalism often leads to micro- and macroparasitic economic strategies. Through these a select elite of people or countries enjoy a disproportionately high fraction of resources at the expense of those in the lower socioeconomic strata (Armelagos et al 2005).

Social mobility decreased and disparities between the classes increased through the kind of capitalism that re-emerged during the 1980s. In this period economic policy retreated from state intervention in the economy and favoured allowing capital markets to determine their own level. These changes enabled shareholding and private equity companies, concerned primarily with profits, to increase wealth creation for their own members. Much of the wealth of this minority population came from the rest, with the result that the gap between rich and poor has increased (Orton & Rowlingson 2007). Recent studies in the UK have shown not only decreasing social mobility but also decreasing achievement among a large group of the population who have been ignored for several decades (Margo et al 2006). This section, white working-class boys, was a focus of concern in the 1960s (Holbrook 1964), when it was felt that the grammar-school system creamed off children who were educable from those who were not. A consequence of putting children through years of compulsory education in which little is expected of them has been that they raise their own children in turn with little expectation of the education system. However, this leaves them with few skills, and fewer abilities on which to base these skills, with which to gain jobs – or the kinds of job that earn more money (Margo et al 2006).

As the first post-Second World War generation became politicians in the UK in the 1980s and 1990s their peers were among the voters who elected for the retreat from the policies that had given them social mobility. Social mobility refers broadly to the facility with which people can move from one socioeconomic group, or class, to another, between generations. Thus a generation that is upwardly mobile experiences a better quality of life, based on economic measurements, than its parents. In the UK and the USA social mobility has been static for several decades, but in the UK generations born since 1970 have experienced more downward social mobility (Hartery and Gahagan, 1998, Berube, 2006 and Margo et al., 2006). In the UK the trend towards downward social mobility continues independently of the reduction in absolute poverty, because the gap is increased by the rich getting richer (Shaw et al., 2005 and Orton and Rowlingson, 2007).

Downward social mobility is not purely economic in character but is influenced by the loss of social capital, access to facilities, poorer standards of health and education, and reduced life chances. It is sometimes concentrated in specific locations, since those who can do so will move out of poorer housing areas where, for example, there is an increased perception of crime (Berube 2006). Indeed, half of the people on low incomes appear to live in the most deprived fifth of areas of the UK (Palmer et al 2005). These areas often have higher levels of crime (Sampson et al., 1997, Howe and Crilly, 2001, Green et al., 2002 and Innes and Jones, 2006), scarcer free and safe space where children can play (Kapasi 2006) and crime rates that deter older people from going out in their community (Green et al 2002). Taking into account the dearth of resources for socialization and play in poor communities it is not surprising that the literature suggests that it is not only personal socioeconomic position but also the prevalence of poverty in the community that is a contributing factor to poor health (Robert 1999). This lack of social opportunity means that occupational choices according to preference are made harder to make (Rebeiro 2000) and people can be occupationally deprived because of a nexus of social disadvantages, inequalities and environmental constraints (Whiteford, 2000 and Blanden and Gibbons, 2006).

Class is not necessarily fixed, since it is possible to move from one socioeconomic class to others. It also has a generational dimension. Putnam (2000) has described how people who grew up in the years of the baby boom after the Second World War enjoyed prosperity and a number of social measures that gave them easier access to occupational diversity through leisure. In the UK this was to lead to the rapid growth of higher education, investment in primary and secondary education, grants for students and welfare benefits. The consequence, for those who were able to take advantage of these changes, was that people were able to form many networks and learned to develop their personal, social and communication skills to facilitate themselves in achieving occupational goals and so gain in material wealth (Margo et al 2006). This rather intangible social network, for example knowing someone who can fix your car, do your plumbing, having friends on whom you can rely for support and to whom you can give support, is what Robert Putnam (2000), among others, has termed ‘social capital’. Social capital depends on the ability of people to trust each other, to reciprocate actions for the benefit of each other and through this to experience a sense of cohesion and participation (Putnam, 2000, Cummins, 2006 and Roberts and Chada, 2006).

This sense of connectedness based on the idea of a shared class culture and identity is what makes examining social capital so important. It forms a largely untapped asset that can contribute to community development and creating a space where opportunities for engagement in occupation can be constructed (Isaksson et al., 2007 and Pollard), for example through occupations such as volunteerism or civic involvement (see Chapter 12, Chapter 13 and Chapter 14).

Social capital provides a support network, social connections and a sense of safety for a community but it cannot regulate the inclusiveness of this community; in other words, those who belong to the community benefit while those who are outside either do not benefit or even are exploited through the very structures that provide support for other communities (Putnam, 1993 and Farmer et al., 2003). As Poortinga (2006) observes, people can benefit from social capital only if they can access it.

While the link between increased social capital and population health appears to be positive the exact reason remains unclear (Whitehead and Diderichsen, 2001, Henderson and Whiteford, 2003 and Folland, 2007). Islam et al (2006) suggest that the extent to which people living in the same area will individually benefit from the existing social capital depends on personal variables, such as willingness to engage in community actions and participate in social networks (Poortinga 2006). Ability to use social capital therefore infers a competence that is acquired through exposure to it: ‘those who have social capital tend to accumulate more’ (Putnam 1993). Thus any effort to use this dynamic potential should create opportunities for inclusive access to it.

The development of social capital faces several challenges, according to Putnam (2000). One of the emblems of the new post-war prosperity was the television. More recently the wider availability of computers and entertainment systems based on them has created conditions where young people in particular spend a lot of time interacting with this equipment alone. This produces several effects, one of which is that people spend less time talking or doing other activities with each other. It has also replaced reading, as people rely on electronic media for news and information, an effect that has been significantly amplified through the availability of the Internet. Putnam (2000) has claimed that declining newspaper readership is associated with a decline in community engagement, although new Internet communities may be emerging.

Another influence was the redesigning of communities into areas for work, areas for shopping and leisure activities, and areas for living. Previously, in communities in the UK one could encounter every few streets a row of local shops, a few pubs and various community buildings such as church halls and scout huts. These were often the centres of villages that had been swallowed up by urban growth. Many areas have seen the demise of these resources and in newer housing estates facilities such as libraries are a car drive away. Although there are communities that retain strong ties with each other, many people choose or have to move away from their parental home to other towns in search of work or education. The increasing numbers of migrant populations and single parents are less connected to their neighbours in the surrounding community, and less able to access or be aware of local provision, much of which has been centred on the needs of traditional families (Stafford & Marmot 2006).

The changing working environment has also contributed to the demise of social capital. One of the factors that determines the location of companies needing unskilled workers is the price of local labour. Such employees tend to be recruited locally, while professional jobs are advertised in journals and papers on a national basis (Gibbons et al 2005). More of the unskilled job opportunities that have become available since the 1980s have been taken up by women, who have required the local, flexible, part-time nature of these opportunities in order to combine work with raising families, while more men have remained out of work. These new jobs lack training or career development opportunities and are often low paid, increasing a divergence in an already heavily gendered employment market (Bimrose et al 2003). This disparity is perhaps familiar to many occupational therapy departments, where locally recruited support workers work with therapists who may have originated from other parts of the country.

Consequently, says Putnam (2000), people invested their social capital in their workplace rather than in their communities. The increased suburbanization of jobs that Wilson (2003) observed means that people with no access to their own means of transportation may have to travel for a considerable time to work each day with less time spent in the local community. After work, it’s easier to drive home, eat a meal in front of the TV and go to bed. There is less time to invest in playing with children, or even conversation. Human beings become more focused on work and material wealth, with poorer and less skilled workers servicing the leisure and producing the goods that improve the quality of life of those who have more money, professional skills and education (Gibbons et al 2005). In the UK, USA and, through the adoption of American working practices, across Europe people work more hours per week, often many unpaid hours, to maintain their jobs. Work-related stress and depression is a considerable social and health issue (Cooper 2007).

The construction of a space that values, respects and gives meaning to class identity can be an important asset for a community, serving as a resource for the building of more coherent communities and the strengthening of local cultures and identities, as suggested by the culture-led Newcastle/Gateshead regeneration project (Miles 2005). However, improvements in access to social capital cannot be addressed by policies that are aimed just at developing a neighbourhood. A raft of social, educational, health and community measures is required to improve the life chances of those affected by poverty (Gibbons et al 2005). The creation of opportunities for access to research and education can help change impressions of science as elitist and improve the educational and occupational prospects of young people (see for example the ‘It’s our Science, our Society, our Health’ project, www.lshtm.ac.uk/pehru/ourscience). Participatory art projects can provide a safe space where people can build networks and can contribute to building social involvement and community cohesion (Matarasso, 1997 and Schmid, 2005; see Chapter 11, Chapter 13, Chapter 14 and Chapter 20). They can bring people together and facilitate the development of a sense of pride in local cultures, a vital element for community participation and investment of time and effort in the community (Matarasso, 1997 and Schmid, 2005). Community writing and publishing groups can provide access to educational experiences, networking opportunities and increased community participation (see Chapter 13 and Chapter 14, also, for example, QueenSpark, www.queensparkbooks.org.uk and Exposure, www.exposure.org.uk). Other concerns need also to be addressed too in order to make social capital available to community members. Teenage pregnancy, for example, and consequently gender issues and sexual health, play a significant part in changing the occupational trajectories of young people and their access to opportunities for networking, education and occupation. These need to be sustained through educational initiatives.

Provision of facilities where people can connect meaningfully with each other is vital to the maintenance of social capital (Lowndes et al., 2006, Margo et al., 2006, Roberts and Chada, 2006 and Stafford and Marmot, 2006; see Chapter 11, Chapter 13, Chapter 14, Chapter 15 and Chapter 20) but often the kinds of community and voluntary organization that people express their social capital through are unconnected with political structures (Lowndes et al 2006). A fundamental problem of community intervention has been that political structures can tend to be self-serving, particularly among entrenched traditional groupings or areas where there is no overall party control (Tait, 2005 and Lowndes et al., 2006). Policies oriented to community development tend to be more rhetorical than practical, more inclined to make assumptions than to work with actual needs (Kapasi, 2006 and Lowndes et al., 2006). Where more public consultation is in evidence there is more community involvement in developing local social organizations (Lowndes et al 2006). The declining involvement in political parties may point to an increasing perception that power is concentrated among a privileged group and does not connect with the occupational needs of the voters politicians claim to serve.

The same issue applies to occupational therapists. If occupational therapists themselves come from a very narrow base within the population, effective practice can happen only where practitioners are able to work from a principle of curiosity that is disposed to understanding and negotiating rather than assuming and interpreting the needs of the people therapists are working with (Stagnitti 2005).

Generating community involvement depends on a number of factors that are connected with motivation and capacity, supported by informal networks, reciprocity and the construction of shared goals that run across classes (Blokland 2002). People need resources and abilities to be able to develop community initiatives and sustain them through creating local organizations, but they may also need incentives to do so themselves rather than leaving it to officials from local government or public institutions (Lowndes et al 2006). Most importantly, a sense of at-homeness with the community is necessary, a sense that can be developed through the sharing of a common class identity or goal. Although physical communities based on the sharing of a identity based on sexuality or disability exist (see, for example, Pritchard et al 2002), most people do not live in such habitats. Moreover, even in communities structured around sexual identities or disability, dwellers often share a middle-class identity that gives them access to space and to the resources to choose their living environment, and this may be used to exclude others.

In the mediation of community resources, for example care facilities, occupational therapists may be among the officials who wield power and be perceived as agents of social control, outsiders to the community with whom they are working. As Hammell (2007) has indicated, the professional self-interest that occupational therapists may have in meeting the needs of their employers can stand in the way of this engagement and perpetuate an established and exclusive hierarchy (Farmer et al 2003). It takes time to establish the trust and built the social capital necessary to engage other community members in identifying and working towards their needs. Through their consistent engagement with a community, occupational therapists along with other health professionals can become assets for community sustainability and social capital, although it remains unclear whether they would use this potential for altruistic and not personal reasons (Farmer et al 2003).

Access to higher education is highly stratified by class and income, and people from working-class backgrounds are less likely to attend university (Hartery and Gahagan, 1998 and Palmer et al., 2005). This can perpetuate poverty, as higher-paid jobs often require tertiary education. Generally, occupational therapists have received a 3- or 4-year university education leading to a degree, whereas in some countries, such as Canada, a master’s level qualification is now required for professional registration.

In many countries the majority of clients occupational therapists engage with are less likely to have had access to further education and often earn below-average incomes. In some countries where occupational therapists practise, however, occupational therapy will mostly be available through private health care and so will not be accessed by the most impoverished or possibly the most disabled groups of people (Ch. 7). In global terms most of the world’s population of disabled people will be unable to access an occupational therapist and will not even have heard of one.

Being and becoming an occupational therapist involves participation in a distinct professional culture that is grounded in social class and gender divides and informs practice (Abberley, 1995 and Mackey, 2007). Like many other health professions that are seen in gendered terms (e.g. some branches of psychiatry such as those dealing with children, learning difficulties and the mental health of the elderly (Pringle 1998)), and nursing (Diaski 2004), it has been argued that occupational therapists have been disempowered (Griffin 2001).

However, occupational therapists exercise power stemming from their status as members of a profession. This can be seen in the way occupational therapists construct their ‘client’, as illustrated by Abberley (1995). Their occupational perspective of health has yet to gain ground on the biomedical perspective of the medical profession to which they are allied; therefore therapists cannot claim neutrality (Mackey 2007). The benefits of occupational therapy are not well supported in research: most of the research methodologies that occupational therapists use are regarded as weak and often there is little interest in the outcomes (Pollard and Walsh, 2000 and Department of Health, 2006). Mounting a robust challenge to this problem is hindered by a lack of research experience in the profession, itself a problem arising from the opportunities open to its gendered membership (Pollard and Walsh, 2000, Meade et al., 2005 and Department of Health, 2006). Even where the profession, has sought to gain status, for example the arguments during the 1990s in the UK over the ability of senior occupational therapists to act as care coordinators for mental health clients (Wilcock 2002), these trappings have often been bought at a price of increasing genericism. In some cases they have made occupational therapists more useful to a generic culture within the health system and have provided recognition, but not always. Medical practitioners have expressed concerns about such extensions to practice with regard to competence and litigation (Department of Health 2006), and in May 2007 the College of Occupational Therapists joined the Royal College of Nursing, the British Psychological Society and the trade unions Unison and Amicus in leaving the Mental Health Alliance campaign against a new Mental Health Bill, on the grounds that it had failed adequately to represent non-pharmacological interventions to the UK government. One of the key factors in the dispute was a question as to whether mental health professionals other than psychiatrists were capable of determining whether patients should be detained in care under the Act.

The organizations argued that the professionalism of their members was discounted by this decision. Occupational therapists have sought the power that goes with professional status and being an agent of social control (Wilcock, 2002, Hammell, 2004 and Hammell, 2007) but have often been unable to gain recognition of the specialized role they perform within the multidisciplinary teams in mental health settings (Peck & Norman 1999). One contributory factor may be that the availability of post-registration training is very much dependent on the resourcefulness of individual allied health professionals and their access to courses and restricted funding (Department of Health 2006).

Griffin (2001) has suggested that occupational therapists are reluctant to use power to gain recognition, favouring cooperation over conflict situations. The ensuing paradox is that, although occupational therapy is a profession, its disempowered status within the health care arena places it in an insecure position, not knowing with whom it is best to make alliances.

Gender is a cultural identity referring to patterns of behaviour commonly associated with biological sex. As such it cannot be seen as natural nor can it be fixed, but it is entangled in a constant dialectical relationship with the cultural setting or context where it occurs. Gender can be seen as a regulator for the behaviour of women and men, stipulating accepted, preferred and valued behaviours, attitudes and occupations (Loizos and Papataxiarchis, 1991 and Connell, 1995).

Being a woman or man is a role that assumes certain obligations and enjoys specific privileges. Possession of the corresponding biological sex is only one of the criteria one has to fulfil in order to be rendered capable of being a man or a woman (MacWhannell & Blair 1998). While masculinity is embodied in the male body and its performance it is also a social practice (Wellard, 2002, Beagan and Saunders, 2005 and Brickell, 2005). Boys learn that their main goal in life is performing, ‘getting the job done’, dominating women (Connell, 1995, Lazos, 1997 and Tepper, 1999) and they grow up being trained in typical ‘male’ attributes such as toughness, physical activity, bravery, sexual vivacity, virility, independence, dominance, aggression and decisiveness, among others (Connell, 1995 and Tepper, 1999). ‘Real’ men are not supposed to or expected to be weak, emotional or frail, sentimental or even sensual; these are all ‘female’ attributes and not acceptable for a man. This gender-role stereotyping can lead to occupational deprivation, as people are obliged to conform to societal expectations rather than their individual needs (Whiteford 2004).

Gender identity is not a fixed category; it is mutable. It can be deeply personal and can be invented and reinvented, constructed and re-constructed. We can thus talk of multiple gender identities: polymasculinity or masculinities instead of the masculinity. Although it is the prevailing discourse, a phallocentric and oppressive notion of masculinity cannot provide a coherent gender identity for the majority of men (O’Neill & Hird 2001). Murphy, drawing from his own experience as a quadriplegic, illustrates a striking disanalogy between this ideal and men’s lived experiences: ‘paralytic disability constitutes emasculation of a more direct and total nature’ (Murphy 1990, p. 94).

The issue of gender is twofold. One side is represented by the regulation of behavioural patterns. Sexism, androcentrism (i.e. social conditions that favour male dominance) and power differentials constitute another often ignored or taken for granted aspect. The dominant normative conceptualization of gender favours male over female. The restrictions of access experienced by working-class people to primary goods, however one defines them, are also faced by women (Nussbaum 2002). The gender pay gap (Karamessini & Ioakimoglou 2007) and asset gap (Deere and Ross, 2006 and Warren, 2006) have been well documented, although there remains controversy over the mechanisms through which they are constructed. Having limited access to material resources places women in disproportionately greater danger of poverty; indeed women are overrepresented among the poor. Their restricted access to basic resources such as education, housing and food further limits their chances of getting out of poverty.

Reduced income and assets translate into reduced power (Deere & Ross 2006). Without monetary resources women possess little negotiation power, cannot control their representations or the public discourse concerning them and have limited opportunity of exit from abusive situations. Women experience a disadvantage in access to resources and power, when compared with men. Men enjoy liberties, such as nonconsensual sex in wedlock, that may be socially sanctioned or even institutionalized through the absence of legislature and in effect limit the freedom of women. Gender justice cannot be pursued without limiting male freedom (Nussbaum 2003a). For example, if not limited, the right to sexual pleasure can lead to violence towards women, increased risk of unwanted pregnancy and contraction of sexually transmitted diseases (Oriel 2005). The very nature of gender inequality means that it is mostly men who hold the power to instigate change and any equality oriented programmes need to take this into consideration (Connell 2005).

Emancipation, which is structured around strategies of empowerment, is basic in attempts to address gender inequalities. This can be achieved through education; for Nussbaum (2003b) regulation of access to education plays a vital role in the construction of gender inequality. More women than men have not had access to education, and illiteracy is common. This reduces employment opportunities and denies women jobs that would provide financial independence and give them decision-making and action-taking power (Nussbaum 2003b). The intersection of gender and class cannot be ignored (Skeggs, 2005 and McDowell, 2006). Knowledge of legal procedures and one’s own rights, networking, lobbying and in effect being actively involved in political procedures are all largely dependent on literacy. Education gives women better knowledge of their body, the health risks they face and contributes to the development of negotiation power in issues of sexual health and violence (Grown et al 2005). Women with higher incomes generally feel safer and participate more in community activities, since a sense of safety is also important for civic participation (Caiazza 2005).

Being denied occupations or being constrained in their participation, women often face what Wicks and Whiteford (2005, p. 202) call ‘occupational tensions’. The restructuring of economic policies in many countries has given women access to paid employment but in part-time, low-paying and undervalued jobs. Disparities between the genders are perpetuated by the unrecognized domestic labour that remains the remit of women (Warren 2006).

While occupational therapy’s feminine values and underpinning philosophies have been problematized, for example the recognition of restrictions in gendered social expectations for women and consequently for men in a profession perceived as feminine (Meade et al 2005), the gendered aspect of both the profession and occupation is complex (Pollard and Walsh, 2000, Taylor, 2003 and Wicks and Whiteford, 2005). Occupational therapy is both contained within and tries actively to engage with dominant male power structures operating in health and social care services and in the broader social, cultural and political context, but female occupational therapists are dissatisfied with their lack of opportunities for career development (Meade et al 2005). Male occupational therapists appear to gain promotion more quickly than their female colleagues and exercise a disproportionate influence in the profession (Meade et al 2005). In professions where numbers of women are proportionately high turnover is also high, a correlation that is associated with their traditional domestic roles in childcare (Pollard & Walsh 2000). Occupational therapy has a tradition of flexibility in which people have been able to find work according to their requirements. For some it has offered a professional career without the pressures of needing to gain advancement (Frank 1992), although more recent concerns around continuing professional development and changes to pay structures may be changing this perception.

In the USA and the UK occupational therapy originated among middle-class women seeking a professional career, some of whom might be described as early feminists through their connections with the suffragette movement and the radical politics of figures like William Morris and John Ruskin (Wilcock, 2002 and Wicks and Whiteford, 2005; see Ch. 7).

In Britain, according to Trollope (1994), many such women were missionaries with Christian purpose, not so much persuaded that women should boldly take on a male-ordered world, more that they could quietly show the way by good example. Pearsall (1983, p. 521) remarks of Octavia Hill, an important ancestor of the occupational therapy family, that she sublimated her sexuality to an idealized ‘do-gooding’, effective but tending to distort ‘life as it is’ (p. 522). While Elizabeth Casson was one of the first women to qualify as a doctor, and some of the ideas early occupational therapists espoused came from the somewhat utopian socialist Arts and Crafts movement led by John Ruskin and William Morris (Wilcock 2002, e.g. Ruskin, 1862 and Morris, 1890), the challenges they presented to the establishment were necessarily contained within professional boundaries. They sought to work within, to accommodate and be accommodated rather than to confront.