Board Editorial: LGBT equality and nursing research

This is one of the many important conclusions in the report of a large scale, representative survey of the treatment of lesbian, gay, bisexual and transgender (LGBT) people in health and social care services in Britain. The report ‘Unhealthy Attitudes’, which is mentioned in several contributions to this focus issue of the Journal of Research in Nursing (JRN), demonstrates that despite research showing that sexual orientation has an impact on both physical and mental health, services are not adequately meeting the needs of LGBT people (Somerville, 2015). While many western liberal societies have passed significant equality legislation in recent years, it is still the case that heteronormative assumptions pervade social policy, serious gaps in provider knowledge and understanding remain, and harassment and bullying of LGBT patients and staff are not uncommon. While there is then clearly a way to go in achieving equality for LGBT people in health and social care, it is good to see a growing number of nursing researchers taking on board the need systematically to explore the experiences and health outcomes of diverse communities, and make recommendations for equipping healthcare professionals to challenge prejudice and improve care.

The papers in this volume present work from four countries across three continents. In the first paper, Laura Legere and Judith MacDonnell use a qualitative approach to explore the healthcare encounters and support needs of lesbian and bisexual cancer survivors in Ontario, Canada. Although based on a small sample of just seven participants, this in-depth exploratory work provides many important insights that could be usefully extended to a larger scale project. The ways in which the persistence of heteronormative assumptions can also disadvantage gay men is central to the second paper in the issue. Michael Connolly and Kathleen Lynch argue that the combination of specific religious discourses and institutional homophobia in the Republic of Ireland produces a stigmatising context, which results in the marginalising or silencing of differences in sexual orientation. Among the important data here are those which relate to an issue that features in several contributions to this issue – the experience of coming out to healthcare professionals. Through their detailed interviews with a sample of 20 gay men, the authors show a diversity of experiences in this regard, although most patients experienced some anxiety and several reported discomfort on the part of professionals. This and other work suggests that this is an important issue for academic and clinical educators to address in diversity and awareness training.

Given that relatively little research has been undertaken on the health and healthcare of LGBT people in the Republic of Ireland, it is good to see a second contribution from this part of the world, this time focused on mental health and wellbeing. Nerilee Ceatha explores the relationship between LGBT identity and interest sharing. This is a further small scale qualitative study, this time with 11 participants from a range of LGBT communities, but nevertheless offers interesting insights that challenge stereotypical representations of LGBT mental health and shows how LGBT patients are active agents in mastering wellness.

As the authors of the next paper point out, despite the widespread use of the acronym ‘LGBT’, the ‘T’ is often ignored. A recent report by the UK House of Commons Women and Equalities Committee (2016) concluded that ‘transgender people encounter significant problems in using general NHS services, due to the attitude of some clinicians and other staff who lack knowledge and understanding – and in some cases are prejudiced’ (p. 3). The paper by Damien Riggs and Clare Bartholomaeus focuses on mental health nurses in Australia and once again shows a highly variable level of understanding and clinical knowledge of nurses in relation to transgender people. The authors highlight the lack of resources for mental health nurses working with this specific client group, but also very usefully go on to show how such resources and guidelines could be developed to provide up-skilling of the mental health nurse workforce in terms of engaging with transgender clients.

The final research paper discusses the vital task of how we translate the knowledge gained from research into policy and practice. This is very much part of the mission of JRN and it is good to see an example of the way in which research and practice can connect to enhance service provision. We can see in this contribution from Julie Fish that successful knowledge exchange relates very much to the nature of the underpinning research practice. Using participatory action research with a high degree of user involvement ensured the commitment of service users and professionals from the outset. Furthermore, a strong theoretical base in implementation research was an important feature in enabling the original research on lesbian and bisexual women with breast cancer to be transferred to the work of two UK cancer charities. This paper represents a relatively rare discussion of how we can move forward to maximise the impact of research and promote sustainable interventions to improve services. While this example relates to lesbian and bisexual women in particular, the insights into knowledge exchange are much more widely applicable.

In the final piece in this volume, Maurice O’Brien and Caroline Ellis provide an overview perspective on current practice in the UK and emphasise the importance of embedding an understanding of LGBT issues in the education of healthcare professionals. They also outline an innovative collaboration between educators in a UK university and Stonewall, a major LGBT campaign and advocacy group. Through this training programme nurse educators and other healthcare academics are being encouraged to reflect on their curricula and are provided with an opportunity to gain the knowledge, tools and resources to assist practitioners to provide equitable and inclusive healthcare.

It is regretted that the call for contributions to this volume did not generate papers relating to the experiences of LGBT members of the healthcare workforce. As Somerville (2015) has shown for the UK at least, it is not just patient experience that needs to be addressed. LGBT health and social care staff frequently face discrimination, bullying and harassment from colleagues, patients and service users, and there is often an institutional failure to support such staff. Many health and social care providers in the UK say they do not feel able to challenge discriminatory language and behaviour from their colleagues or from patients, and many are unable to be open about their sexual identity in the workplace (Einarsdóttir et al., 2015). This underlines the importance of leadership in bringing about change and the need for organisations to ensure that LGBT staff are supported in the workplace. Healthcare organisations should communicate a clear message that abuse, including abuse from patients towards staff, is unacceptable and should provide guidance on how to respond to homophobic, biphobic and transphobic bullying. LGBT staff network groups, forums and mentoring schemes can also provide important support for staff (Somerville, 2015).

At JRN we argue that it is crucial that researchers publish robust, high quality studies, which can inform advocacy, policy and practice. The contributions in this issue are largely drawn from small scale, qualitative studies and this is the most common form of nursing research on LGBT issues. While there is considerable value in such work that gives voice to marginalised groups and highlights issues of concern to participants, it is also important that we complement this work with larger datasets. Seeing the bigger picture is made more difficult given the absence, in most countries, of decent monitoring data relating to sexual orientation and gender identity. The lack of monitoring is an issue that hampered researchers and policy makers in the field of ethnic and racial inequality until relatively recently, and it is still the case in many countries that ethnicity monitoring is non-existent or woefully inadequate. This is even more so in the case of sexual orientation, in which there are equally tricky methodological and political challenges to conceptualising and collecting data regarding sexual orientation (Aspinall, 2009; Haigh and Jones, 2007). In the UK, while some national surveys do include questions on sexual orientation, this is the only statutory equality strand not captured by the decennial Census, whose outputs serve important public policy needs (Aspinall, 2009).

In healthcare research, we need to develop further sensitive ways of collecting information on the sexual orientation and gender identity of research participants, not only in specific studies such as those presented in this issue, but across more general surveys. How much better would it be if we were able to look at all healthcare satisfaction surveys and experience questionnaires at national, regional and local levels and compare and contrast the perspectives of LGBT service users and staff members with those of others? Furthermore, by accessing a wide population who are invited to participate in research simply by virtue of their experiences rather than their ethnicity or sexual orientation, more balanced and rigorous data are possible. Such studies would also assist in applying the important concept of intersectionality – recognising the significance of multiple structures and identities that create inequalities – as a tool for analysis, advocacy and policy development. Equality and inclusivity are as important in research as they are in wider society, and by expanding our demographic data collection, the richness and diversity of the service user and provider populations will be more truly reflected in our service evaluation and organisational development.

This is not for a moment to suggest that researchers should not continue to undertake LGBT-specific research – the voice of these communities needs to be acknowledged and to be heard – but it is time that LGBT research data came in from the cold. Policy makers, advocates and practitioners need evidence in relation to sexual orientation; those educating our healthcare workforce need it and the onus is on researchers to supply it.

Finally, while we should continue to search for the best way to carry out studies and to transfer that knowledge into healthcare policy and practice, we also need to remember that while marriage is open for same-sex couples in 18 countries, and discrimination in employment on the grounds of sexual orientation is now illegal in 62 countries, one third of the world’s states (in excess of 75 countries) still criminalise same-sex sexual acts between consenting adults. Ten of those countries (with a combined population of over 400 million people) have legislated the death penalty for same-sex sex, and five of them – Mauritania, Sudan, Iran, Saudi Arabia and Yemen – apply it (Caroll and Itaborahy, 2015).

We hope you enjoy this collection of papers, editorials and a specially commissioned perspective from authors committed to making a difference in LGBT healthcare, and we would very much welcome your comments and feedback. You can connect with editors and other readers via Twitter at @JRN_latest.