Journal of Homosexuality
ISSN: 0091-8369 (Print) 1540-3602 (Online) Journal homepage: http://www.tandfonline.com/loi/wjhm20
Factors Related to Homophobia Among Nursing Students Stefan R. Rowniak RN, FNP, PhD To cite this article: Stefan R. Rowniak RN, FNP, PhD (2015) Factors Related to Homophobia Among Nursing Students, Journal of Homosexuality, 62:9, 1228-1240, DOI: 10.1080/00918369.2015.1037135 To link to this article: http://dx.doi.org/10.1080/00918369.2015.1037135
Accepted author version posted online: 20 Apr 2015. Published online: 20 Apr 2015. Submit your article to this journal
Article views: 167
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=wjhm20 Download by: [University of Florida]
Date: 06 November 2015, At: 06:21
Journal of Homosexuality, 62:1228–1240, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0091-8369 print/1540-3602 online DOI: 10.1080/00918369.2015.1037135
Factors Related to Homophobia Among Nursing Students STEFAN R. ROWNIAK, RN, FNP, PhD
Downloaded by [University of Florida] at 06:21 06 November 2015
School of Nursing and Health Professions, University of San Francisco, San Francisco, California, USA
A convenience sample of 90 nursing students participated in an online survey measuring homophobia or sexual prejudice. Significantly higher scores were seen among those who endorsed the belief that being gay was a matter of personal choice, did not have a friend or family member who was gay or lesbian, and endorsed religiosity. A significantly higher level of sexual prejudice was seen among those who identified as non-Catholic Christians when compared to other religions. Asian/Pacific Islanders showed significantly higher scores on the scales compared to non-Hispanic Caucasian students. Nursing education should focus on those aspects of homophobia amenable to change. KEYWORDS homophobia, sexual prejudice, nursing students, nursing education, gay, lesbian, religion
We are at a point in time in this country when the civil rights of the lesbian, gay, bisexual, and transgender (LGBT) population are a significant part of the public discourse. “Don’t ask, don’t tell” has finally been repealed by the military, Section 3 of the Defense of Marriage Act has been ruled unconstitutional, and the issue of same-sex marriage is being discussed in the media daily. While the country as a whole may be moving forward with regard to social justice and equal rights for LGBT people, the discussions have revealed that there are many whose viewpoints are focused through the lens of homophobia or sexual prejudice. The purpose of this article is to This study was presented at the annual meeting of the Gay and Lesbian Medical Association September 18–21, 2013. Address correspondence to Stefan R. Rowniak, School of Nursing and Health Professions, University of San Francisco, 769 14th Street, San Francisco, CA 94114, USA. E-mail: [email protected] 1228
Downloaded by [University of Florida] at 06:21 06 November 2015
Homophobia Among Nursing Students
1229
describe a study conducted at a Jesuit university in a major West Coast city in the United States measuring attitudes about lesbians and gay men among nursing students. Herek (2009a, 2009b) has written extensively about the concepts of sexual stigma and sexual prejudice. He defines sexual stigma as societal forces and institutions that devalue and denigrate those who are sexual minorities, while sexual prejudice is an individual’s endorsement of the forces that disempower those so stigmatized (Herek, 2009). Key aspects of sexually prejudiced individuals are that they tend to be older, less educated, and male when compared to those who harbor less prejudice. Additionally, they are more likely to be highly religious, meaning self-identifying as having fundamentalist religious beliefs, hold the belief that being gay or lesbian is a matter of personal choice, and are less likely to have close friends or family members who are openly gay or lesbian (Herek, 2009). Other studies have assessed various factors that could contribute to homophobia or homonegative attitudes among a wide range of populations and have reached similar conclusions. Positive correlations have been observed between homophobia and political conservatism and religiosity (Morrison & Morrison, 2002; Morrison, Kenny, & Harrington, 2005; Whitley, 2009). In 2011, the Institute of Medicine released its landmark report, “The Health of Lesbian, Gay, Bisexual and Transgender People: Building a Foundation for Better Understanding” (Institute of Medicine, 2011). The report acknowledged the lack of data regarding LGBT populations and addressed many health disparities experienced by these individuals. Some of the reasons offered were a lack of knowledge and diminished cultural competency on the part of many health care providers regarding LGBT people. Other recent reports have commented on the need for the medical profession to improve its competency with LGBT people in order to help decrease LGBT invisibility and eliminate health care disparities (Makadon, 2011; Sanchez, Rabatin, Sanchez, Hubbard, & Kalet, 2006). Nurses make up the largest force of health care providers in the country. There has been concern that many may be lacking essential competency skills regarding LGBT health issues (Dinkel, Patzel, McGuire, Rolfs, & Purcell, 2007; Eliason, Dibble, & Dejoseph, 2010; Spidsberg, 2007). While many of the published studies indicate that nurses may hold negative attitudes toward LGBT populations, many of these studies have been reported to have limitations in design and use of validated instruments (Dorsen, 2012). College students and nursing students in particular have been found to be in need of improvement in their knowledge and attitudes regarding LGBT people (Dinkel et al., 2007; Rondahl, 2009). That, however, places the real task of change on nursing faculty and the nursing curriculum. Within its codes of practice, the nursing profession has statements that profess the importance of treating individuals in a just and fair manner.
Downloaded by [University of Florida] at 06:21 06 November 2015
1230
S. R. Rowniak
The American Association of Colleges of Nursing stated in its “Essentials of Baccalaureate Education for Professional Nursing Practice” (2008) that one of nursing professional values is social justice, which is defined as “acting in accordance with fair treatment regardless of economic status, race, ethnicity, age, citizenship, disability, or sexual orientation” (p. 28). Likewise, the American Nurses Association Code of Ethics clearly states in Provision 1 that respectful care needs to be provided without prejudice to all patients regardless of their personal attributes or lifestyle (ANA, 2001). However, despite the statements of the professional organizations, evidence suggests that sexual prejudice continues to exist within nursing, and nursing education is in need of addressing and correcting the situation (Dorsen, 2012; Eliason et al., 2010). This study was prompted by experiences I had shortly after I began teaching nurses at the university. This was after a 20-year career as a nurse practitioner in the area of sexual health. When aspects of LGBT health were introduced into a class that the students take in the final semester of nursing school, several students reported that it was the only time in the nursing program that LGBT issues had been discussed. I also observed that many of the students had difficulty separating the concept of sexual orientation from gender identity. These are concepts that are essential to discuss when taking a history for clinical care to help sexual and gender minority individuals feel comfortable in a health care setting (Makadon, 2011). If nurses do not understand how these concepts differ, they will be incapable of helping to provide that comfort. Finally, a homophobic incident validated the need to examine factors associated with homophobia with an emphasis on those factors that could be amenable to interventions within the nursing curriculum. Being lesbian, gay, or bisexual refers to a person’s sexuality, whereas being transgender is an issue of gender identity. These are very different concepts, and, as stated, they are often confused. For that reason, attitudes regarding transgender individuals and implications for education need to be conducted in a separate study. Also, since the scales used were specific to lesbians and gay men, attitudes about bisexual individuals were not assessed in this study.
METHOD This was an initial study measuring nursing students’ attitudes toward lesbians and gay men. The university prepares registered nurses (RNs) in two ways: traditional bachelor of science in nursing (BSN) students who have no previous college and clinical nurse leaders (CNL) for those who already have a baccalaureate degree in an area other than nursing. The purpose of the study was to determine if the previously identified factors of age, sex, religiosity, having friends or family members who are gay, and holding the belief that sexual orientation is a matter of choice were associated with
Homophobia Among Nursing Students
1231
higher measures of homophobia. Since this was a Jesuit university, religious identification was also examined, as was ethnicity. The intent was also to identify those factors that would be amenable to educational intervention in the course of nursing school. Permission to engage in the study was granted by the institution’s Institutional Review Board, IRBPHS #12-107.
Downloaded by [University of Florida] at 06:21 06 November 2015
Participants The goal was to recruit 100 participants, 50 BSN and 50 CNL students in the first semester of nursing school. Recruitment was via e-mail. All students in the target BSN and CNL groups were sent an e-mail requesting their participation in a brief questionnaire concerning sexual attitudes. Students were informed that the questionnaire would be completely anonymous and would not affect their grades. They were also told that each student who completed the questionnaire would receive a $25 gift certificate redeemable at the university bookstore. A convenience sample of 50 students from each group was obtained within 2 weeks. Five participants did not complete the demographic portion of the questionnaire, so their results were excluded. The scales were developed to record heterosexual attitudes, so only those participants who indicated they were heterosexual were included, eliminating five more students who identified as either gay, lesbian, or bisexual. The final number of participants for analysis was 90: 44 BSN students and 46 CNL students.
Measures Attitudes Toward Lesbians and Gay Men Scale (ATLG). This scale was developed by Herek in order to measure heterosexual attitudes toward lesbians and gay men. A 5-point Likert-type scale ranging from strongly disagree to strongly agree was used. The scale consists of 10 questions, five specific to lesbians and five specific to gay men. Higher scores were associated with greater religiosity, limited contact with gay men and lesbians, and endorsement of discrimination of sexual minorities (Herek & McLemore, 2010). Cronbach’s alpha for most college student samples was reported at >.85. This study found an alpha of .89. Modern Homonegativity Scale. This scale was designed to measure contemporary negative attitudes toward lesbians and gay men. It was believed that modern homonegativity differs from the traditional moral and religious objections to homosexuality and is based on beliefs that lesbians and gay men are demanding too much from society (Morrison & Morrison, 2002). The scale consists of 22 items in a 5-point Likert scale ranging from strongly disagree to strongly agree. Cronbach’s alpha has ranged from .81 to .95 in
1232
S. R. Rowniak
Downloaded by [University of Florida] at 06:21 06 November 2015
previous studies (Morrison & Morrison, 2002, 2010). An alpha of .96 was found in this study. Other Demographic Information. Besides the questions in the tools employed, the questionnaire asked demographic questions such as age, sex, sexual orientation, and ethnicity. Other questions pertained to the importance religion played in one’s life, how strong they felt their religious conviction to be, religious identification, whether they had a friend or family member who was lesbian or gay, if they endorsed the belief that being gay was a matter of choice, and how they would rate their political views on a scale ranging from very conservative to very liberal. Data Analysis. Data were analyzed using SPSS version 17 software.
RESULTS Sample The 44 BSN and 46 CNL heterosexual students ranged in age from 17 to 45 with a mean age of 24. The CNLs were not found to be significantly older than the BSNs. There were 17 males and 73 females. The majority, 37, was non-Hispanic Caucasian. Thirty-five were Asian/Pacific Islander, 8 Hispanic, 7 reported multiple ethnicity, 2 African American, and 1 Native American. Since the sample size of the Hispanic, African American, Native American, and other ethnicity categories was too small for comparison purposes, and a single category consisting of these multiple racial and ethnic groups did not make practical sense, only Caucasian and Asian/Pacific Islander were compared. The largest religious group was Catholic with 31 participants, non-Catholic Christian with 24, and Atheist/Agnostic with 21. Three Muslim, 2 Jewish, 4 Hindu, and 5 Buddhist students were collapsed into the category of non-Christian religions, which consisted of 14 participants.
Findings Higher scores indicate greater endorsement of homophobia or sexual prejudice. There was no significant difference using t-tests to compare means between the BSN and CNL groups on the scales and variables; therefore, all results are based on the aggregate of 90 participants. Variables that resulted in significantly higher scores on both scales included not having a friend or family member who was gay or lesbian, the belief that being gay was a matter of choice, political identification as conservative versus liberal, a greater amount of guidance religion provided in one’s daily life, and the participant’s classification of their religious orientation as being religious versus not religious.
1233
Homophobia Among Nursing Students TABLE 1 ANOVA for Religious Groups and Scale Means Religious Groups
Scale
Catholic
NonCatholic Christian
ATLG
18.83a (3.57) 47.83ab (11.34) 31
24.20b (11.18) 58.00b (20.60) 24
Modern Homonegativity
Downloaded by [University of Florida] at 06:21 06 November 2015
N
Atheist/ Agnostic
NonChristian Religion
16.28a (5.90) 41.28a (13.96) 21
18.14ab (5.90) 45.14ab (10.42) 14
F 5.11∗∗ 5.19∗∗
Note. ∗∗ p ≤ .01. Standard deviations appear in parenthesis below the means. Means with differing subscripts within columns are significantly different at the p ≤ .05 based on Tukey HSD post hoc paired comparisons.
A 1-way ANOVA compared the scores on the scales for the four religious groups (see Table 1). There was a statistically significant difference at the p ≤ .01 in scores on both measures. The results for the ATLG were F (3, 86) = 5.11, p = .003. The effect size calculated using eta squared was .18. Post hoc comparisons using Tukey HSD test indicted that the mean score for the non-Catholic Christian group (M = 24.20, SD = 11.18) was significantly higher than both the Catholic group (M = 18.83, SD = 3.57) and the Atheist/Agnostic group (M = 16.28, SD = 5.90). The non-Christian group (M = 18.14, SD = 5.90) did not differ significantly from the other groups. The ANOVA results for the modern Homonegativity Scale were F (3, 86) = 5.19, p = .002. The effect calculated using eta squared was also .18. Post hoc comparisons using Tukey HSD test indicated that the mean score for the non-Catholic Christian group (M = 58.00, SD = 20.60) was significantly higher than the Atheist/Agnostic group (M = 41.28, SD = 13.96). The Catholic group (M = 47.83, SD = 11.34) and the non-Christian group (M = 45.14, SD = 10.42) did not differ significantly from the other groups. An independent-samples t-test was conducted to compare the scores on both measures for the Caucasian and Asian/Pacific Islander groups. Only the scores on the ATLG were significantly different (see Table 2). The results for the ATLG for the Caucasian group (M = 16.62, SD = 5.84) and the Asian/Pacific Islander group (M = 22.82, SD = 8.51) were t (70) = -3.62, TABLE 2 ATLG Means for non-Hispanic Caucasian and Asian/Pacific Islander Students Ethnicity
ATLG Note.
∗∗ p
Non-Hispanic Caucasian
Asian/Pacific Islander
t
df
16.62 (5.84)
22.82 (8.51)
−3.62∗∗
70
≤ .01. Standard deviations appear in parentheses below means.
1234
S. R. Rowniak
TABLE 3 Crosstabulation of Ethnicity and the Belief That Sexual Orientation Is a Matter of Choice Matter of Choice Ethnicity Non-Hispanic Caucasian Asian/Pacific Islander Note.
∗∗ p
Yes
No
Chi-square
Phi Coefficient
11 29.7% 27 77.1%
26 70.3% 8 23.5%
14.38∗∗
.47
≤ .01. % is within ethnic group.
Downloaded by [University of Florida] at 06:21 06 November 2015
TABLE 4 Crosstabulation of Ethnicity and Religious Orientation Religious Orientation Not Very Religious
Ethnicity Non- Hispanic Caucasian Asian/Pacific Islander Note.
∗∗ p
21 56.8% 9 25.7%
Religious 16 43.2% 26 74.3%
Chi-square ∗∗
5.91
Phi Coefficient .31
≤ .01. % is within ethnic group.
p = .001 (two-tailed). The magnitude of the differences in the mean indicated a large effect (eta squared = 0.15). A chi-square test for independence indicated a significant association between religion, ethnicity, and several of the variables. There was a significant association between ethnicity and the belief that sexual orientation was a matter of personal choice (see Table 3), chi-square (1, n = 72) = 14.38, p = .001, phi = .47. There was also a significant association between ethnicity and religious orientation (see Table 4), chi-square (1, N = 72) = 5.91, p = .01, phi = .31. Ethnicity and the likelihood of having a gay friend were also significantly associated (see Table 5),chi-square (1, N = 72) = 8.71, p = .003, phi = .38. As a group, Asian/Pacific Islander endorsed the belief that being gay is a matter of choice, indicated greater religiosity, and were less likely to have a gay friend. Catholic and non-Catholic Christians were more likely than the Agnostic/Atheist group to endorse the belief that being gay is a matter of choice (see Table 6), chi-square (3, N = 90) = 10.29, p = .02, phi = .34.
DISCUSSION Previous studies have examined homophobia among various groups, including college students. This study was unique in the use of subjects who were
1235
Homophobia Among Nursing Students TABLE 5 Crosstabulation of Ethnicity and Likelihood of Having a Gay Friend Gay Friend Ethnicity Non-Hispanic Caucasian Asian/Pacific Islander Note.
∗∗ p
Yes
No
Chi-square
Phi Coefficient
36 97.3% 24 68.6%
1 2.3% 11 31.4%
8.71∗∗
.38
≤ .01. % is within ethnic group.
Downloaded by [University of Florida] at 06:21 06 November 2015
TABLE 6 Crosstabulation of Religion and the Belief That Sexual Orientation Is a Matter of Choice Matter of Choice Religious Groups Catholic Non-Catholic Christian Atheist/Agnostic Non-Christian Religion
Yes
No
Chi-square
Phi Coefficient
20 64.5% 17 70.8% 6 28.6% 6 42.9%
11 35.5% 7 29.2% 15 71.4% 8 57.1%
10.29∗
.34
Note. ∗ p ≤ .05. % is within religious group.
heterosexual nursing students in an American religiously affiliated university. Past reports have documented the health disparities seen among lesbians and gay men, the less than adequate treatment they have experienced from health care providers, and the lack of adequate research in nursing of the health care issues of sexual minorities (Dinkel et al., 2007; Dorsen, 2012; Institute of Medicine, 2011; Kelley, Chou, Dibble, & Robertson, 2008; Makadon, 2011). Nursing students represent a population that will soon be providing health care to patients, many of whom will be sexual minorities. An understanding of the factors associated with increased homophobia can help to direct educational interventions and decrease future disparities. The results indicate several important aspects of attitudes among nursing students toward lesbians and gay men. This study supports previous findings regarding religiosity and a lack of familiarity with gay and lesbian people as important factors with regard to increased negative attitudes. Also of note was the finding that the endorsement of the belief that being gay or lesbian was a matter of choice was found to be associated with significantly higher scores on both scales. Of interest was the finding that of the total sample of 90 participants, 49 individuals endorsed this belief. Unlike previous studies, the factors of increased age and being male were not found to be associated with increased scores. This could be a function of the characteristics of those
Downloaded by [University of Florida] at 06:21 06 November 2015
1236
S. R. Rowniak
individuals who choose to enter the nursing profession, but future research is needed for confirmation. Also, there were noteworthy findings regarding both religion and ethnicity. Of interest is the fact that even in a religiously affiliated university, a substantial minority of the participants, 23%, identified as Agnostic/Atheist. This group scored lower on the scales and the other variables associated with increased levels of homophobia. Previous research regarding religion and homophobia would certainly corroborate this finding (Herek, 2009; Whitley, 2009). The highest scoring non-Catholic Christian group was significantly higher than both the Agnostic/Atheist and Catholic groups. It is likely that the non-Catholic Christian group consisted of many individuals who might be of a more fundamentalist nature than the Catholic-identified participants. This can be determined in future research with a larger population. As opposed to the relative diversity seen in religion, primarily two groups, non-Hispanic Caucasian and Asian/Pacific Islander, represented ethnicity. There were a small number of Hispanic students and only two African American and one Native American student. This meant that the statistical analysis was most relevant to the differences between the non-Hispanic Caucasian and Asian/Pacific Islander students. Asian/Pacific Islander scored highest on both scales and was significantly higher than the non-Hispanic Caucasian students on the ATLG. Asian/Pacific Islander does not represent a homogenous group but includes a wide variety of people from many different countries and cultures. Some could be first-generation immigrants, and others could be from families who have been in the United States for many generations. As a group, the factors associated with increased negative attitudes toward lesbians and gay men, specifically the belief that being gay is a matter of personal choice and not having a gay friend or family member, were significantly endorsed by the Asian/Pacific Islander students. However, in this sample, they indentified as significantly more religious than the non-Hispanic Caucasian students. It is possible that this group of Asian/Pacific Islander students self-selected for a religious university and represented a more religious segment of the larger Asian/Pacific Islander population, accounting for the differences seen.
IMPLICATIONS FOR EDUCATION Despite being a small initial study, there are several implications for nursing instruction specifically at this university and also for nursing schools in general. While it is not feasible or ethical to try to change any students’ religious convictions, it is certainly possible and appropriate to educate future nurses regarding any misconceptions they may have regarding lesbians and gay men. This is especially true for the university in this study since, as an identified religious institution, it will very likely continue to have a religious
Downloaded by [University of Florida] at 06:21 06 November 2015
Homophobia Among Nursing Students
1237
student body that will require continuous education to counter the potential of increased sexual prejudice. Part of that education needs to focus on the misconception that being gay is a matter of choice. While this may seem obvious to those of us who are gay or lesbian or have some background in sexuality studies, personal experience has revealed that many nursing faculty do not share this belief, even though that is the position of the American Academy of Pediatrics, among many other medical groups (Frankowski, 2004). Also, there is a national trend to view sexual orientation as something an individual is born with as opposed to a personal choice, which has been seen as part of a larger trend in the public arena for increased positive attitudes toward lesbians and gay men (Jones, 2013). A recent Gallup poll found that most subgroups of Americans believe that being lesbian or gay is a matter of birth and not choice with the exception of conservatives, Republicans, and those who stated they attended church weekly (Jones, 2013). The contrary belief that sexual orientation is a matter of choice has been associated with higher levels of sexual prejudice (Herek, 2009). It can be argued that even if a nurse believes that sexual orientation is a matter of choice, it should make no difference to their ethical mandate to provide appropriate care to all. Certainly, emphasizing the ethical requirement not to judge patients when providing care is an important first step and constitutes harm reduction. The longer process involves changing attitudes through education. Given the anecdotal evidence that many nursing students lack the ability to differentiate sexual orientation from gender identity points to the real need for a course in sexual health as an essential component of basic nursing education. It is also necessary to increase students’ familiarity with lesbian and gay individuals. On campuses that may lack faculty who feel knowledgeable or comfortable discussing sexual orientation, this can be accomplished through the use of guest speakers. There are a several programs that provide speakers for campuses to help with this process, such as the Safe Zone program or the National Standards for Culturally Appropriate Services (CLAS) through the U.S. Department of Health and Human Services Office of Minority Health. Though the use of guest speakers to reduce homophobia has been questioned with regard to efficacy, there is evidence to suggest that knowledge and attitudes can be improved if presented in a patient-centered context (Kelley et al., 2008). Even more effective, encouraging faculty members who might be lesbian or gay to come out to their students could help them understand that they are responsible citizens and can be health professionals and role models for others. This challenges many schools of nursing to become welcoming environments for both faculty and students who might be sexual minorities. It is also important to weave information regarding sexual minorities within the general nursing curriculum so that students will be prepared
Downloaded by [University of Florida] at 06:21 06 November 2015
1238
S. R. Rowniak
to competently engage with them as patients and coworkers. This means including lesbians and gay individuals in educational scenarios, such as case studies, that have often been either explicitly or implicitly heterosexual. Faculty can make a point of eliminating such invisibility by specifically including lesbians and gay men in discussions of health across the lifespan, including the aging population that will be in need of increased nursing care. It is important that this inclusion not be limited to stereotypical presentations, such as gay men mentioned only in the context of HIV, but that they can also be diagnosed with such conditions as prostate cancer, and the disease will have an impact on their family unit. Similarly, it is important to discuss that some of the new mothers that nurses take care of are lesbians, and the newborn will be part of a lesbian family. Likewise, the burgeoning area of simulation in nursing education is an ideal way of bringing in sexual minorities as patients and discussing with students how they can best work with them. It is clear that the school of nursing represented in this study needs to increase efforts to engage the Asian/Pacific Islander population who may lack the openness and familiarity with lesbian and gay individuals that are taken for granted by much of the dominant culture. One way of beginning this process would be to bring in lesbian and gay guest speakers who are from various cultures within the larger Asian/Pacific Islander category. This introduces the concept of intersectionality with regard to ethnicity and sexual orientation and can help to remove the “other” stigma that often applies to lesbian and gay individuals. This perspective that individuals possess multiple identities and are more than ethnic or racial stereotypes has been incorporated successfully into classroom activities for nursing students to increase their understanding of cultural diversity (Eliason & Macy, 1992). This was achieved by eliciting stereotypes held by the students and using them as the springboard for discussion and education. Such an activity, focusing on lesbian and gay ethnic stereotypes held by students, could prove valuable at the above university as well as other schools of nursing.
LIMITATIONS AND FUTURE RESEARCH The results from this study cannot be generalized to other institutions. The primary limitations were the small sample size and use of a convenience sample. It will be valuable to obtain more data from a larger and much more diverse population of students with regard to ethnicity, age, and religion. Also, comparing a non-sectarian university to a religiously affiliated university would provide important information. It will be valuable to include both nursing faculty and advanced practice nursing students, such as nurse practitioners in future research. Future studies that examine attitudes about transgender individuals and how to incorporate transgender competency into nursing curriculum are also essential.
Homophobia Among Nursing Students
1239
Downloaded by [University of Florida] at 06:21 06 November 2015
REFERENCES American Nurses Association (ANA). (2001). Code of ethics with interpretive statements. Silver Springs, MD: Author. Dinkel, S., Patzel, B., McGuire, M. J., Rolfs, E., & Purcell, K. (2007). Measures of homophobia among nursing students and faculty: A midwestern perspective. International Journal of Nursing Education Scholarship, 4(1), Article 24. doi:10.2202/1548-923X.1491 Dorsen, C. (2012). An integrative review of nurse attitudes towards lesbian, gay, bisexual, and transgender patients. [Review]. Canadian Journal of Nursing Research/Revue canadienne de recherche en sciences infirmieres, 44(3), 18–43. Eliason, M. J., Dibble, S., & Dejoseph, J. (2010). Nursing’s silence on lesbian, gay, bisexual, and transgender issues: the need for emancipatory efforts. [Review]. ANS. Advances in Nursing Science, 33, 206–218. doi:10.1097/ANS.0b013e3181e63e49 Eliason, M. J., & Macy, N. J. (1992). A classroom activity to introduce cultural diversity. Nurse Educator, 17(3), 32–36. Frankowski, B. L. (2004). Sexual orientation and adolescents. Pediatrics, 113, 1827–1832. Herek, G., M. (2009). Sexual prejudice. In T. Nelson, D. (Ed.), Handbook of prejudice, stereotyping, and discrimination (pp. 441–467). New York, NY: Psychology Press. Herek, G. M., & McLemore, K., A. (2010). Attitudes Toward Lesbians and Gay Men Scale. In T. D. Fisher, C. M. Davis, W. L. Yarber & S. L. Davis (Eds.), Handbook of sexuality-related measures (3rd ed., pp. 415–416). New York, NY: Routledge. Institute of Medicine. (2011). The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Washington, DC: Institute of Medicine. Jones, J. M. (2013). More Americans see gay, lesbian orientation as birth factor. Retrieved from http://www.gallup.com/poll/162569/americans-gay-lesbianorientation-birth-factor.aspx Kelley, L., Chou, C. L., Dibble, S. L., & Robertson, P. A. (2008). A critical intervention in lesbian, gay, bisexual, and transgender health: Knowledge and attitude outcomes among second-year medical students. Teaching and learning in medicine, 20, 248–253. doi:10.1080/10401330802199567 Makadon, H. J. (2011). Ending LGBT invisibility in health care: The first step in ensuring equitable care. Cleveland Clinic Journal of Medicine, 78, 220–224. doi:10.3949/ccjm.78gr.10006 Morrison, M. A., & Morrison, T. G. (2002). Development and validation of a scale measuring modern prejudice toward gay men and lesbian women. Journal of Homosexuality, 43(2), 15–37. Morrison, M. A., & Morrison, T. G. (2010). Modern Homonegativity Scale. In T. D. Fisher, C. M. Davis, W. L. Yarber & S. L. Davis (Eds.), Handbook of sexualityrelated measures (3rd ed., pp. 392–394). New York, NY: Routledge. Morrison, T. G., Kenny, P., & Harrington, A. (2005). Modern prejudice toward gay men and lesbian women: Assessing the viability of a measure of modern
Downloaded by [University of Florida] at 06:21 06 November 2015
1240
S. R. Rowniak
homonegative attitudes within an Irish context. Genetic, Social, and General Psychology Monographs, 131, 219–250. doi:10.3200/MONO.131.3.219-250 Rondahl, G. (2009). Students inadequate knowledge about lesbian, gay, bisexual and transgender persons. International Journal of Nursing Education Scholarship, 6(1), Article 11. doi:10.2202/1548-923X.1718 Sanchez, N. F., Rabatin, J., Sanchez, J. P., Hubbard, S., & Kalet, A. (2006). Medical students’ ability to care for lesbian, gay, bisexual, and transgendered patients. Family Medicine, 38, 21–27. Spidsberg, B. D. (2007). Vulnerable and strong—Lesbian women encountering maternity care. Journal of Advanced Nursing, 60, 478–486. doi:10.1111/j.1365-2648.2007.04439.x Whitley, B. E. J. (2009). Religiousity and attitudes toward lesbians and gay men: A meta-analysis. International Journal for the Psychology of Religion, 19, 21–38. doi:10.1080/10508610802471104
ISSN: 0091-8369 (Print) 1540-3602 (Online) Journal homepage: http://www.tandfonline.com/loi/wjhm20
Factors Related to Homophobia Among Nursing Students Stefan R. Rowniak RN, FNP, PhD To cite this article: Stefan R. Rowniak RN, FNP, PhD (2015) Factors Related to Homophobia Among Nursing Students, Journal of Homosexuality, 62:9, 1228-1240, DOI: 10.1080/00918369.2015.1037135 To link to this article: http://dx.doi.org/10.1080/00918369.2015.1037135
Accepted author version posted online: 20 Apr 2015. Published online: 20 Apr 2015. Submit your article to this journal
Article views: 167
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=wjhm20 Download by: [University of Florida]
Date: 06 November 2015, At: 06:21
Journal of Homosexuality, 62:1228–1240, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0091-8369 print/1540-3602 online DOI: 10.1080/00918369.2015.1037135
Factors Related to Homophobia Among Nursing Students STEFAN R. ROWNIAK, RN, FNP, PhD
Downloaded by [University of Florida] at 06:21 06 November 2015
School of Nursing and Health Professions, University of San Francisco, San Francisco, California, USA
A convenience sample of 90 nursing students participated in an online survey measuring homophobia or sexual prejudice. Significantly higher scores were seen among those who endorsed the belief that being gay was a matter of personal choice, did not have a friend or family member who was gay or lesbian, and endorsed religiosity. A significantly higher level of sexual prejudice was seen among those who identified as non-Catholic Christians when compared to other religions. Asian/Pacific Islanders showed significantly higher scores on the scales compared to non-Hispanic Caucasian students. Nursing education should focus on those aspects of homophobia amenable to change. KEYWORDS homophobia, sexual prejudice, nursing students, nursing education, gay, lesbian, religion
We are at a point in time in this country when the civil rights of the lesbian, gay, bisexual, and transgender (LGBT) population are a significant part of the public discourse. “Don’t ask, don’t tell” has finally been repealed by the military, Section 3 of the Defense of Marriage Act has been ruled unconstitutional, and the issue of same-sex marriage is being discussed in the media daily. While the country as a whole may be moving forward with regard to social justice and equal rights for LGBT people, the discussions have revealed that there are many whose viewpoints are focused through the lens of homophobia or sexual prejudice. The purpose of this article is to This study was presented at the annual meeting of the Gay and Lesbian Medical Association September 18–21, 2013. Address correspondence to Stefan R. Rowniak, School of Nursing and Health Professions, University of San Francisco, 769 14th Street, San Francisco, CA 94114, USA. E-mail: [email protected] 1228
Downloaded by [University of Florida] at 06:21 06 November 2015
Homophobia Among Nursing Students
1229
describe a study conducted at a Jesuit university in a major West Coast city in the United States measuring attitudes about lesbians and gay men among nursing students. Herek (2009a, 2009b) has written extensively about the concepts of sexual stigma and sexual prejudice. He defines sexual stigma as societal forces and institutions that devalue and denigrate those who are sexual minorities, while sexual prejudice is an individual’s endorsement of the forces that disempower those so stigmatized (Herek, 2009). Key aspects of sexually prejudiced individuals are that they tend to be older, less educated, and male when compared to those who harbor less prejudice. Additionally, they are more likely to be highly religious, meaning self-identifying as having fundamentalist religious beliefs, hold the belief that being gay or lesbian is a matter of personal choice, and are less likely to have close friends or family members who are openly gay or lesbian (Herek, 2009). Other studies have assessed various factors that could contribute to homophobia or homonegative attitudes among a wide range of populations and have reached similar conclusions. Positive correlations have been observed between homophobia and political conservatism and religiosity (Morrison & Morrison, 2002; Morrison, Kenny, & Harrington, 2005; Whitley, 2009). In 2011, the Institute of Medicine released its landmark report, “The Health of Lesbian, Gay, Bisexual and Transgender People: Building a Foundation for Better Understanding” (Institute of Medicine, 2011). The report acknowledged the lack of data regarding LGBT populations and addressed many health disparities experienced by these individuals. Some of the reasons offered were a lack of knowledge and diminished cultural competency on the part of many health care providers regarding LGBT people. Other recent reports have commented on the need for the medical profession to improve its competency with LGBT people in order to help decrease LGBT invisibility and eliminate health care disparities (Makadon, 2011; Sanchez, Rabatin, Sanchez, Hubbard, & Kalet, 2006). Nurses make up the largest force of health care providers in the country. There has been concern that many may be lacking essential competency skills regarding LGBT health issues (Dinkel, Patzel, McGuire, Rolfs, & Purcell, 2007; Eliason, Dibble, & Dejoseph, 2010; Spidsberg, 2007). While many of the published studies indicate that nurses may hold negative attitudes toward LGBT populations, many of these studies have been reported to have limitations in design and use of validated instruments (Dorsen, 2012). College students and nursing students in particular have been found to be in need of improvement in their knowledge and attitudes regarding LGBT people (Dinkel et al., 2007; Rondahl, 2009). That, however, places the real task of change on nursing faculty and the nursing curriculum. Within its codes of practice, the nursing profession has statements that profess the importance of treating individuals in a just and fair manner.
Downloaded by [University of Florida] at 06:21 06 November 2015
1230
S. R. Rowniak
The American Association of Colleges of Nursing stated in its “Essentials of Baccalaureate Education for Professional Nursing Practice” (2008) that one of nursing professional values is social justice, which is defined as “acting in accordance with fair treatment regardless of economic status, race, ethnicity, age, citizenship, disability, or sexual orientation” (p. 28). Likewise, the American Nurses Association Code of Ethics clearly states in Provision 1 that respectful care needs to be provided without prejudice to all patients regardless of their personal attributes or lifestyle (ANA, 2001). However, despite the statements of the professional organizations, evidence suggests that sexual prejudice continues to exist within nursing, and nursing education is in need of addressing and correcting the situation (Dorsen, 2012; Eliason et al., 2010). This study was prompted by experiences I had shortly after I began teaching nurses at the university. This was after a 20-year career as a nurse practitioner in the area of sexual health. When aspects of LGBT health were introduced into a class that the students take in the final semester of nursing school, several students reported that it was the only time in the nursing program that LGBT issues had been discussed. I also observed that many of the students had difficulty separating the concept of sexual orientation from gender identity. These are concepts that are essential to discuss when taking a history for clinical care to help sexual and gender minority individuals feel comfortable in a health care setting (Makadon, 2011). If nurses do not understand how these concepts differ, they will be incapable of helping to provide that comfort. Finally, a homophobic incident validated the need to examine factors associated with homophobia with an emphasis on those factors that could be amenable to interventions within the nursing curriculum. Being lesbian, gay, or bisexual refers to a person’s sexuality, whereas being transgender is an issue of gender identity. These are very different concepts, and, as stated, they are often confused. For that reason, attitudes regarding transgender individuals and implications for education need to be conducted in a separate study. Also, since the scales used were specific to lesbians and gay men, attitudes about bisexual individuals were not assessed in this study.
METHOD This was an initial study measuring nursing students’ attitudes toward lesbians and gay men. The university prepares registered nurses (RNs) in two ways: traditional bachelor of science in nursing (BSN) students who have no previous college and clinical nurse leaders (CNL) for those who already have a baccalaureate degree in an area other than nursing. The purpose of the study was to determine if the previously identified factors of age, sex, religiosity, having friends or family members who are gay, and holding the belief that sexual orientation is a matter of choice were associated with
Homophobia Among Nursing Students
1231
higher measures of homophobia. Since this was a Jesuit university, religious identification was also examined, as was ethnicity. The intent was also to identify those factors that would be amenable to educational intervention in the course of nursing school. Permission to engage in the study was granted by the institution’s Institutional Review Board, IRBPHS #12-107.
Downloaded by [University of Florida] at 06:21 06 November 2015
Participants The goal was to recruit 100 participants, 50 BSN and 50 CNL students in the first semester of nursing school. Recruitment was via e-mail. All students in the target BSN and CNL groups were sent an e-mail requesting their participation in a brief questionnaire concerning sexual attitudes. Students were informed that the questionnaire would be completely anonymous and would not affect their grades. They were also told that each student who completed the questionnaire would receive a $25 gift certificate redeemable at the university bookstore. A convenience sample of 50 students from each group was obtained within 2 weeks. Five participants did not complete the demographic portion of the questionnaire, so their results were excluded. The scales were developed to record heterosexual attitudes, so only those participants who indicated they were heterosexual were included, eliminating five more students who identified as either gay, lesbian, or bisexual. The final number of participants for analysis was 90: 44 BSN students and 46 CNL students.
Measures Attitudes Toward Lesbians and Gay Men Scale (ATLG). This scale was developed by Herek in order to measure heterosexual attitudes toward lesbians and gay men. A 5-point Likert-type scale ranging from strongly disagree to strongly agree was used. The scale consists of 10 questions, five specific to lesbians and five specific to gay men. Higher scores were associated with greater religiosity, limited contact with gay men and lesbians, and endorsement of discrimination of sexual minorities (Herek & McLemore, 2010). Cronbach’s alpha for most college student samples was reported at >.85. This study found an alpha of .89. Modern Homonegativity Scale. This scale was designed to measure contemporary negative attitudes toward lesbians and gay men. It was believed that modern homonegativity differs from the traditional moral and religious objections to homosexuality and is based on beliefs that lesbians and gay men are demanding too much from society (Morrison & Morrison, 2002). The scale consists of 22 items in a 5-point Likert scale ranging from strongly disagree to strongly agree. Cronbach’s alpha has ranged from .81 to .95 in
1232
S. R. Rowniak
Downloaded by [University of Florida] at 06:21 06 November 2015
previous studies (Morrison & Morrison, 2002, 2010). An alpha of .96 was found in this study. Other Demographic Information. Besides the questions in the tools employed, the questionnaire asked demographic questions such as age, sex, sexual orientation, and ethnicity. Other questions pertained to the importance religion played in one’s life, how strong they felt their religious conviction to be, religious identification, whether they had a friend or family member who was lesbian or gay, if they endorsed the belief that being gay was a matter of choice, and how they would rate their political views on a scale ranging from very conservative to very liberal. Data Analysis. Data were analyzed using SPSS version 17 software.
RESULTS Sample The 44 BSN and 46 CNL heterosexual students ranged in age from 17 to 45 with a mean age of 24. The CNLs were not found to be significantly older than the BSNs. There were 17 males and 73 females. The majority, 37, was non-Hispanic Caucasian. Thirty-five were Asian/Pacific Islander, 8 Hispanic, 7 reported multiple ethnicity, 2 African American, and 1 Native American. Since the sample size of the Hispanic, African American, Native American, and other ethnicity categories was too small for comparison purposes, and a single category consisting of these multiple racial and ethnic groups did not make practical sense, only Caucasian and Asian/Pacific Islander were compared. The largest religious group was Catholic with 31 participants, non-Catholic Christian with 24, and Atheist/Agnostic with 21. Three Muslim, 2 Jewish, 4 Hindu, and 5 Buddhist students were collapsed into the category of non-Christian religions, which consisted of 14 participants.
Findings Higher scores indicate greater endorsement of homophobia or sexual prejudice. There was no significant difference using t-tests to compare means between the BSN and CNL groups on the scales and variables; therefore, all results are based on the aggregate of 90 participants. Variables that resulted in significantly higher scores on both scales included not having a friend or family member who was gay or lesbian, the belief that being gay was a matter of choice, political identification as conservative versus liberal, a greater amount of guidance religion provided in one’s daily life, and the participant’s classification of their religious orientation as being religious versus not religious.
1233
Homophobia Among Nursing Students TABLE 1 ANOVA for Religious Groups and Scale Means Religious Groups
Scale
Catholic
NonCatholic Christian
ATLG
18.83a (3.57) 47.83ab (11.34) 31
24.20b (11.18) 58.00b (20.60) 24
Modern Homonegativity
Downloaded by [University of Florida] at 06:21 06 November 2015
N
Atheist/ Agnostic
NonChristian Religion
16.28a (5.90) 41.28a (13.96) 21
18.14ab (5.90) 45.14ab (10.42) 14
F 5.11∗∗ 5.19∗∗
Note. ∗∗ p ≤ .01. Standard deviations appear in parenthesis below the means. Means with differing subscripts within columns are significantly different at the p ≤ .05 based on Tukey HSD post hoc paired comparisons.
A 1-way ANOVA compared the scores on the scales for the four religious groups (see Table 1). There was a statistically significant difference at the p ≤ .01 in scores on both measures. The results for the ATLG were F (3, 86) = 5.11, p = .003. The effect size calculated using eta squared was .18. Post hoc comparisons using Tukey HSD test indicted that the mean score for the non-Catholic Christian group (M = 24.20, SD = 11.18) was significantly higher than both the Catholic group (M = 18.83, SD = 3.57) and the Atheist/Agnostic group (M = 16.28, SD = 5.90). The non-Christian group (M = 18.14, SD = 5.90) did not differ significantly from the other groups. The ANOVA results for the modern Homonegativity Scale were F (3, 86) = 5.19, p = .002. The effect calculated using eta squared was also .18. Post hoc comparisons using Tukey HSD test indicated that the mean score for the non-Catholic Christian group (M = 58.00, SD = 20.60) was significantly higher than the Atheist/Agnostic group (M = 41.28, SD = 13.96). The Catholic group (M = 47.83, SD = 11.34) and the non-Christian group (M = 45.14, SD = 10.42) did not differ significantly from the other groups. An independent-samples t-test was conducted to compare the scores on both measures for the Caucasian and Asian/Pacific Islander groups. Only the scores on the ATLG were significantly different (see Table 2). The results for the ATLG for the Caucasian group (M = 16.62, SD = 5.84) and the Asian/Pacific Islander group (M = 22.82, SD = 8.51) were t (70) = -3.62, TABLE 2 ATLG Means for non-Hispanic Caucasian and Asian/Pacific Islander Students Ethnicity
ATLG Note.
∗∗ p
Non-Hispanic Caucasian
Asian/Pacific Islander
t
df
16.62 (5.84)
22.82 (8.51)
−3.62∗∗
70
≤ .01. Standard deviations appear in parentheses below means.
1234
S. R. Rowniak
TABLE 3 Crosstabulation of Ethnicity and the Belief That Sexual Orientation Is a Matter of Choice Matter of Choice Ethnicity Non-Hispanic Caucasian Asian/Pacific Islander Note.
∗∗ p
Yes
No
Chi-square
Phi Coefficient
11 29.7% 27 77.1%
26 70.3% 8 23.5%
14.38∗∗
.47
≤ .01. % is within ethnic group.
Downloaded by [University of Florida] at 06:21 06 November 2015
TABLE 4 Crosstabulation of Ethnicity and Religious Orientation Religious Orientation Not Very Religious
Ethnicity Non- Hispanic Caucasian Asian/Pacific Islander Note.
∗∗ p
21 56.8% 9 25.7%
Religious 16 43.2% 26 74.3%
Chi-square ∗∗
5.91
Phi Coefficient .31
≤ .01. % is within ethnic group.
p = .001 (two-tailed). The magnitude of the differences in the mean indicated a large effect (eta squared = 0.15). A chi-square test for independence indicated a significant association between religion, ethnicity, and several of the variables. There was a significant association between ethnicity and the belief that sexual orientation was a matter of personal choice (see Table 3), chi-square (1, n = 72) = 14.38, p = .001, phi = .47. There was also a significant association between ethnicity and religious orientation (see Table 4), chi-square (1, N = 72) = 5.91, p = .01, phi = .31. Ethnicity and the likelihood of having a gay friend were also significantly associated (see Table 5),chi-square (1, N = 72) = 8.71, p = .003, phi = .38. As a group, Asian/Pacific Islander endorsed the belief that being gay is a matter of choice, indicated greater religiosity, and were less likely to have a gay friend. Catholic and non-Catholic Christians were more likely than the Agnostic/Atheist group to endorse the belief that being gay is a matter of choice (see Table 6), chi-square (3, N = 90) = 10.29, p = .02, phi = .34.
DISCUSSION Previous studies have examined homophobia among various groups, including college students. This study was unique in the use of subjects who were
1235
Homophobia Among Nursing Students TABLE 5 Crosstabulation of Ethnicity and Likelihood of Having a Gay Friend Gay Friend Ethnicity Non-Hispanic Caucasian Asian/Pacific Islander Note.
∗∗ p
Yes
No
Chi-square
Phi Coefficient
36 97.3% 24 68.6%
1 2.3% 11 31.4%
8.71∗∗
.38
≤ .01. % is within ethnic group.
Downloaded by [University of Florida] at 06:21 06 November 2015
TABLE 6 Crosstabulation of Religion and the Belief That Sexual Orientation Is a Matter of Choice Matter of Choice Religious Groups Catholic Non-Catholic Christian Atheist/Agnostic Non-Christian Religion
Yes
No
Chi-square
Phi Coefficient
20 64.5% 17 70.8% 6 28.6% 6 42.9%
11 35.5% 7 29.2% 15 71.4% 8 57.1%
10.29∗
.34
Note. ∗ p ≤ .05. % is within religious group.
heterosexual nursing students in an American religiously affiliated university. Past reports have documented the health disparities seen among lesbians and gay men, the less than adequate treatment they have experienced from health care providers, and the lack of adequate research in nursing of the health care issues of sexual minorities (Dinkel et al., 2007; Dorsen, 2012; Institute of Medicine, 2011; Kelley, Chou, Dibble, & Robertson, 2008; Makadon, 2011). Nursing students represent a population that will soon be providing health care to patients, many of whom will be sexual minorities. An understanding of the factors associated with increased homophobia can help to direct educational interventions and decrease future disparities. The results indicate several important aspects of attitudes among nursing students toward lesbians and gay men. This study supports previous findings regarding religiosity and a lack of familiarity with gay and lesbian people as important factors with regard to increased negative attitudes. Also of note was the finding that the endorsement of the belief that being gay or lesbian was a matter of choice was found to be associated with significantly higher scores on both scales. Of interest was the finding that of the total sample of 90 participants, 49 individuals endorsed this belief. Unlike previous studies, the factors of increased age and being male were not found to be associated with increased scores. This could be a function of the characteristics of those
Downloaded by [University of Florida] at 06:21 06 November 2015
1236
S. R. Rowniak
individuals who choose to enter the nursing profession, but future research is needed for confirmation. Also, there were noteworthy findings regarding both religion and ethnicity. Of interest is the fact that even in a religiously affiliated university, a substantial minority of the participants, 23%, identified as Agnostic/Atheist. This group scored lower on the scales and the other variables associated with increased levels of homophobia. Previous research regarding religion and homophobia would certainly corroborate this finding (Herek, 2009; Whitley, 2009). The highest scoring non-Catholic Christian group was significantly higher than both the Agnostic/Atheist and Catholic groups. It is likely that the non-Catholic Christian group consisted of many individuals who might be of a more fundamentalist nature than the Catholic-identified participants. This can be determined in future research with a larger population. As opposed to the relative diversity seen in religion, primarily two groups, non-Hispanic Caucasian and Asian/Pacific Islander, represented ethnicity. There were a small number of Hispanic students and only two African American and one Native American student. This meant that the statistical analysis was most relevant to the differences between the non-Hispanic Caucasian and Asian/Pacific Islander students. Asian/Pacific Islander scored highest on both scales and was significantly higher than the non-Hispanic Caucasian students on the ATLG. Asian/Pacific Islander does not represent a homogenous group but includes a wide variety of people from many different countries and cultures. Some could be first-generation immigrants, and others could be from families who have been in the United States for many generations. As a group, the factors associated with increased negative attitudes toward lesbians and gay men, specifically the belief that being gay is a matter of personal choice and not having a gay friend or family member, were significantly endorsed by the Asian/Pacific Islander students. However, in this sample, they indentified as significantly more religious than the non-Hispanic Caucasian students. It is possible that this group of Asian/Pacific Islander students self-selected for a religious university and represented a more religious segment of the larger Asian/Pacific Islander population, accounting for the differences seen.
IMPLICATIONS FOR EDUCATION Despite being a small initial study, there are several implications for nursing instruction specifically at this university and also for nursing schools in general. While it is not feasible or ethical to try to change any students’ religious convictions, it is certainly possible and appropriate to educate future nurses regarding any misconceptions they may have regarding lesbians and gay men. This is especially true for the university in this study since, as an identified religious institution, it will very likely continue to have a religious
Downloaded by [University of Florida] at 06:21 06 November 2015
Homophobia Among Nursing Students
1237
student body that will require continuous education to counter the potential of increased sexual prejudice. Part of that education needs to focus on the misconception that being gay is a matter of choice. While this may seem obvious to those of us who are gay or lesbian or have some background in sexuality studies, personal experience has revealed that many nursing faculty do not share this belief, even though that is the position of the American Academy of Pediatrics, among many other medical groups (Frankowski, 2004). Also, there is a national trend to view sexual orientation as something an individual is born with as opposed to a personal choice, which has been seen as part of a larger trend in the public arena for increased positive attitudes toward lesbians and gay men (Jones, 2013). A recent Gallup poll found that most subgroups of Americans believe that being lesbian or gay is a matter of birth and not choice with the exception of conservatives, Republicans, and those who stated they attended church weekly (Jones, 2013). The contrary belief that sexual orientation is a matter of choice has been associated with higher levels of sexual prejudice (Herek, 2009). It can be argued that even if a nurse believes that sexual orientation is a matter of choice, it should make no difference to their ethical mandate to provide appropriate care to all. Certainly, emphasizing the ethical requirement not to judge patients when providing care is an important first step and constitutes harm reduction. The longer process involves changing attitudes through education. Given the anecdotal evidence that many nursing students lack the ability to differentiate sexual orientation from gender identity points to the real need for a course in sexual health as an essential component of basic nursing education. It is also necessary to increase students’ familiarity with lesbian and gay individuals. On campuses that may lack faculty who feel knowledgeable or comfortable discussing sexual orientation, this can be accomplished through the use of guest speakers. There are a several programs that provide speakers for campuses to help with this process, such as the Safe Zone program or the National Standards for Culturally Appropriate Services (CLAS) through the U.S. Department of Health and Human Services Office of Minority Health. Though the use of guest speakers to reduce homophobia has been questioned with regard to efficacy, there is evidence to suggest that knowledge and attitudes can be improved if presented in a patient-centered context (Kelley et al., 2008). Even more effective, encouraging faculty members who might be lesbian or gay to come out to their students could help them understand that they are responsible citizens and can be health professionals and role models for others. This challenges many schools of nursing to become welcoming environments for both faculty and students who might be sexual minorities. It is also important to weave information regarding sexual minorities within the general nursing curriculum so that students will be prepared
Downloaded by [University of Florida] at 06:21 06 November 2015
1238
S. R. Rowniak
to competently engage with them as patients and coworkers. This means including lesbians and gay individuals in educational scenarios, such as case studies, that have often been either explicitly or implicitly heterosexual. Faculty can make a point of eliminating such invisibility by specifically including lesbians and gay men in discussions of health across the lifespan, including the aging population that will be in need of increased nursing care. It is important that this inclusion not be limited to stereotypical presentations, such as gay men mentioned only in the context of HIV, but that they can also be diagnosed with such conditions as prostate cancer, and the disease will have an impact on their family unit. Similarly, it is important to discuss that some of the new mothers that nurses take care of are lesbians, and the newborn will be part of a lesbian family. Likewise, the burgeoning area of simulation in nursing education is an ideal way of bringing in sexual minorities as patients and discussing with students how they can best work with them. It is clear that the school of nursing represented in this study needs to increase efforts to engage the Asian/Pacific Islander population who may lack the openness and familiarity with lesbian and gay individuals that are taken for granted by much of the dominant culture. One way of beginning this process would be to bring in lesbian and gay guest speakers who are from various cultures within the larger Asian/Pacific Islander category. This introduces the concept of intersectionality with regard to ethnicity and sexual orientation and can help to remove the “other” stigma that often applies to lesbian and gay individuals. This perspective that individuals possess multiple identities and are more than ethnic or racial stereotypes has been incorporated successfully into classroom activities for nursing students to increase their understanding of cultural diversity (Eliason & Macy, 1992). This was achieved by eliciting stereotypes held by the students and using them as the springboard for discussion and education. Such an activity, focusing on lesbian and gay ethnic stereotypes held by students, could prove valuable at the above university as well as other schools of nursing.
LIMITATIONS AND FUTURE RESEARCH The results from this study cannot be generalized to other institutions. The primary limitations were the small sample size and use of a convenience sample. It will be valuable to obtain more data from a larger and much more diverse population of students with regard to ethnicity, age, and religion. Also, comparing a non-sectarian university to a religiously affiliated university would provide important information. It will be valuable to include both nursing faculty and advanced practice nursing students, such as nurse practitioners in future research. Future studies that examine attitudes about transgender individuals and how to incorporate transgender competency into nursing curriculum are also essential.
Homophobia Among Nursing Students
1239
Downloaded by [University of Florida] at 06:21 06 November 2015
REFERENCES American Nurses Association (ANA). (2001). Code of ethics with interpretive statements. Silver Springs, MD: Author. Dinkel, S., Patzel, B., McGuire, M. J., Rolfs, E., & Purcell, K. (2007). Measures of homophobia among nursing students and faculty: A midwestern perspective. International Journal of Nursing Education Scholarship, 4(1), Article 24. doi:10.2202/1548-923X.1491 Dorsen, C. (2012). An integrative review of nurse attitudes towards lesbian, gay, bisexual, and transgender patients. [Review]. Canadian Journal of Nursing Research/Revue canadienne de recherche en sciences infirmieres, 44(3), 18–43. Eliason, M. J., Dibble, S., & Dejoseph, J. (2010). Nursing’s silence on lesbian, gay, bisexual, and transgender issues: the need for emancipatory efforts. [Review]. ANS. Advances in Nursing Science, 33, 206–218. doi:10.1097/ANS.0b013e3181e63e49 Eliason, M. J., & Macy, N. J. (1992). A classroom activity to introduce cultural diversity. Nurse Educator, 17(3), 32–36. Frankowski, B. L. (2004). Sexual orientation and adolescents. Pediatrics, 113, 1827–1832. Herek, G., M. (2009). Sexual prejudice. In T. Nelson, D. (Ed.), Handbook of prejudice, stereotyping, and discrimination (pp. 441–467). New York, NY: Psychology Press. Herek, G. M., & McLemore, K., A. (2010). Attitudes Toward Lesbians and Gay Men Scale. In T. D. Fisher, C. M. Davis, W. L. Yarber & S. L. Davis (Eds.), Handbook of sexuality-related measures (3rd ed., pp. 415–416). New York, NY: Routledge. Institute of Medicine. (2011). The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Washington, DC: Institute of Medicine. Jones, J. M. (2013). More Americans see gay, lesbian orientation as birth factor. Retrieved from http://www.gallup.com/poll/162569/americans-gay-lesbianorientation-birth-factor.aspx Kelley, L., Chou, C. L., Dibble, S. L., & Robertson, P. A. (2008). A critical intervention in lesbian, gay, bisexual, and transgender health: Knowledge and attitude outcomes among second-year medical students. Teaching and learning in medicine, 20, 248–253. doi:10.1080/10401330802199567 Makadon, H. J. (2011). Ending LGBT invisibility in health care: The first step in ensuring equitable care. Cleveland Clinic Journal of Medicine, 78, 220–224. doi:10.3949/ccjm.78gr.10006 Morrison, M. A., & Morrison, T. G. (2002). Development and validation of a scale measuring modern prejudice toward gay men and lesbian women. Journal of Homosexuality, 43(2), 15–37. Morrison, M. A., & Morrison, T. G. (2010). Modern Homonegativity Scale. In T. D. Fisher, C. M. Davis, W. L. Yarber & S. L. Davis (Eds.), Handbook of sexualityrelated measures (3rd ed., pp. 392–394). New York, NY: Routledge. Morrison, T. G., Kenny, P., & Harrington, A. (2005). Modern prejudice toward gay men and lesbian women: Assessing the viability of a measure of modern
Downloaded by [University of Florida] at 06:21 06 November 2015
1240
S. R. Rowniak
homonegative attitudes within an Irish context. Genetic, Social, and General Psychology Monographs, 131, 219–250. doi:10.3200/MONO.131.3.219-250 Rondahl, G. (2009). Students inadequate knowledge about lesbian, gay, bisexual and transgender persons. International Journal of Nursing Education Scholarship, 6(1), Article 11. doi:10.2202/1548-923X.1718 Sanchez, N. F., Rabatin, J., Sanchez, J. P., Hubbard, S., & Kalet, A. (2006). Medical students’ ability to care for lesbian, gay, bisexual, and transgendered patients. Family Medicine, 38, 21–27. Spidsberg, B. D. (2007). Vulnerable and strong—Lesbian women encountering maternity care. Journal of Advanced Nursing, 60, 478–486. doi:10.1111/j.1365-2648.2007.04439.x Whitley, B. E. J. (2009). Religiousity and attitudes toward lesbians and gay men: A meta-analysis. International Journal for the Psychology of Religion, 19, 21–38. doi:10.1080/10508610802471104
