Homophobia among nursing students

Abstracts

La homofobia es una actitud negativa hacia personas homosexuales, frecuente en profesionales de la salud y con implicaciones en la salud pública. Este fenómeno había sido poco estudiado en estudiantes de enfermería. El objetivo fue conocer la prevalencia y las variables asociadas a la homofobia en estudiantes de enfermería. La revisión sistemática fue realizada de los artículos de investigación formal en EBSCO, Imbiomed, LILACS, MEDLINE, Ovid y ProQuest. Fueron incluidos los artículos publicados entre 1998 y 2008, escritos en español, inglés o portugués. Fueron utilizadas las palabras llave homophobia, homosexuality y nursing students. Se realizó un análisis descriptivo. Se revisaron ocho investigaciones. Entre el 7 y el 16% de los estudiantes presenta algún grado de homofobia. La homofobia es más común en varones y en los religiosos más conservadores. La homofobia es frecuente en estudiantes de enfermería y puede tener implicancias negativas para el ejercicio de la enfermería.

Sexualidad; Actitude; Estudiantes de enfermería

CRITICAL REVIEW

Adalberto Campo-Arias^I; Edwin Herazo^II; Zuleima Cogollo^III

^IMD, Psychiatrist. Master's Student in Sexual and Reproductive Health. Member of the Research Group on Human Behavior at the Research Institute on Human Behavior. Bogotá, Colombia. [e-mail]

^IIMD, Psychiatrist. Master's Degree in Bioethics. Member of the Research Group on Human Behavior at the Research Institute on Human Behavior. Bogotá, Colombia. [e-mail]

^IIIRN. Master's Degree in Public Health. Ph.D. Student in Public Health. Full Professor, School of Nursing, Universidad de Cartagena, Colombia. Member of the Research Group on Community Health Care. Cartagena, Colombia. [e-mail]

Correspondence addressed to

ABSTRACT

Homophobia is defined as a general negative attitude towards homosexual persons, with implications on public health. This fact has been less investigated among nursing students. The objective of this review was to learn about the prevalence of homophobia and its associated variables among nursing students. A systematic review was performed on original articles published in EBSCO, Imbiomed, LILACS, MEDLINE, Ovid, and ProQuest, including articles published between 1998 and 2008 in English, Portuguese and Spanish. Key words used were homophobia, homosexuality, and nursing students. Descriptive analysis was performed. Eight studies were analyzed. The incidence of homophobia in nursing students is between 7% and 16%. Homophobia is more common among males and religious conservatism people. Homophobia is quite frequent in nursing students. This negative attitude toward homosexuality may affect services and care giving by nursing professions and could have negative implications in nursing practice.

Key Words: Sexuality. Attitude. Students, nursing.

RESUMO

A homofobia é uma atitude negativa em relação a pessoas homossexuais, frequente em profissionais da saúde, e com implicações na saúde pública. Este fenômeno havia sido pouco estudado em estudantes de enfermagem. O objetivo foi conhecer a prevalência e variáveis associadas à homofobia em estudantes de enfermagem. A revisão sistemática foi realizada nos artigos de pesquisa formal em EBSCO, Imbiomed, LILACS, MEDLINE, Ovid e ProQuest. Foram incluídos os artigos publicados entre 1998 e 2008, escritos em espanhol, inglês ou português. Foram utilizadas as palavras-chave homophobia, homosexuality e nursing students. Uma análise descritiva foi realizada. Oito pesquisas foram revisadas. Entre 7% e 16% dos estudantes apresenta algum grau de homofobia. A homofobia é mais comum em homens e nos religiosos mais conservadores. A homofobia é frequente em estudantes de enfermagem, e pode ter implicações negativas para o exercício da enfermagem.

Descritores: Sexualidade. Atitude. Estudantes de enfermagem.

INTRODUCTION

Homophobia can be defined as fear, rejection or irrational intolerance towards homosexuality⁽¹⁾. Although a more positive and tolerant attitude has been documented in the general population, homophobia still continues, particularly among people who consider that homosexuality contains an important biological component, among women and younger population groups^{(2, 3)}.

Differences among groups permeate human history. Usually, the largest group imposes its conceptions and arguments on minority groups. That is the case for homosexuality, although this should not exactly be considered a minority group⁽⁴⁾.

In 1974, the American Psychiatric Association and later, in 1992, the World Health Organization removed homosexuality from the category of mental disorders due to political pressure by social groups in defense of human rights and sexual minorities and to the lack of scientific evidence supporting the consideration of homosexuality as a condition with minimal criteria to be defined as a mental disorder⁽⁵⁾. Nevertheless, political changes and new orientations in disease classifications do not necessarily influence daily patient care⁽⁶⁾. Health professions like nurses show conservative and inflexible positions and preserve a discriminatory attitude towards people with a homosexual sexual orientation⁽¹⁾.

Some studies suggest that nursing students preserve some negative attitudes towards homosexuals, lesbians or bisexuals, which is also the case for professionals. Negative attitudes and discriminatory behavior are frequent among health professionals. High levels of homophobia have been documented among physicians, nurses and dentists^(7-9). These attitudes considerably influence the care delivered to homosexual, lesbian or bisexual patients⁽¹⁰⁾.

It is probably hard for nursing students to assume a more tolerant attitude in their professional life as they, like most boys, girls and adolescent students, have been exposed to homophobic messages in different contexts^(11-13). Around 40% of students who start a nursing program inform that working with gays, lesbians or bisexuals bothers them⁽¹⁴⁾. It is well known that attitudes are connected with behaviors and, in nursing professionals, these negative attitudes limit the possibility of offering personal and comprehensive care as early as in their training years⁽¹⁾.

The goal of this systematic review was to know the prevalence and some variables associated with homophobia among nursing students in the last eleven years (1998-2008).

METHOD

This systematic review involved original research papers that inquired about the presence of homophobia among nursing students. Articles published between 1998 and 2008 were included, written in Spanish, English or Portuguese.

The search was carried out in the databases Ebsco, Imbiomed, Lilacs, MedLine, Ovid and ProQuest. The following key words were used for the search: homophobia, homosexuality and nursing students. In addition, a manual search was done in the references mentioned in the articles under review.

Initially, the reviewed data were subject to descriptive analysis. Frequencies and percentages were observed, as well as association measures according to the type of variable used.

RESULTS

In total, nine papers were included. Two articles considered the same population, so that only eight studies were reviewed. Next, the findings of each research will be summarized, in line with the purpose of this review.

In the United States, in a research carried out in 1998 with 116 students (75% women) from different racial groups, it was observed that between 8 and 12% considered that homosexuality should be punished, between 5 and 12% did not like people from sexual minorities (gays, lesbians and bisexuals) and believed they did not deserve any right, and between 51 and 53% informed that homosexuality goes against their religious beliefs. Nevertheless, they informed that people more exposed to people with sexual minorities also showed a higher level of acceptance. Factors predicting a negative attitude towards homosexuality were male gender, younger age and religious conservatism. Test values indicating differences were not specified⁽¹⁵⁾.

In Australia, in 1999, the presence of homophobia was investigated in 288 students from the first, second and third year of a nursing program, using the modified Kinsey scale. It was observed that less knowledge on sexual issues was related with a more negative attitude towards homosexual or bisexual behaviors (r=0.50)⁽¹⁶⁾.

In the United States, another study from 1999 measured homophobia in 174 students (87 first-year and 87 last-year students), using the Index of Homophobia. This 25-item scale attributed scores from 0 to 100; scores above 87 suggest high levels of homophobia, while those under nine suggest low levels. The global average on the questionnaire was 48.1 (SD=15.3). The scores were similar for first and last-year students⁽¹⁷⁾.

In England, a research carried out in 1999 among 192 participants (88.5% women), using the Prejudicial Evaluation and Social Interaction Scale, found greater prejudice against AIDS after reading a case describing one leukemia and another aids patients, one homosexual and the other heterosexual. No significant differences were found in terms of sexual orientation⁽¹⁸⁾.

In Germany, a study done in the year 2000 among 180 students (84% women) inquired about homophobia using a nine-item scale and informed that 7% believed homosexuality should be condemned⁽¹⁹⁾.

In 2002, a group of 137 students (83% women) was studied in England, measuring homophobia on a 13-item scale, with higher scores representing a lower level of homophobia. It was found that 16% felt bothered if they had to take care of a homosexual patient. Likewise, they observed that older participants (r=0.22; p<0.01) and those informing that they rejected care delivery to AIDS patients showed higher levels of homophobia (average 3.88 against 4.30, p=0.02)⁽²⁰⁾.

In 2004, results of a research in Sweden were presented in two papers. Homophobia was quantified in 165 nursing assistants and students (86% women) using the Affect Adjective Checklist and the Attitudes Toward Homosexuality Scale. The first fifteen-item questionnaire covers three factors (guilt, anger and delight), while the second comprises ten items, five related to gays and five to lesbians. It was evidenced that the assistants obtained higher scores for three factors than the students, without differences between women and men⁽²¹⁾. In the second paper, they informed that 62% obtained scores indicating a positive attitude, 30% indifferent and 8% negative. Students who considered homosexuality a congenital disease showed a more positive attitude than those who believed it was an acquired condition⁽⁷⁾.

In a Middle Eastern country, a study was carried out in 2007 among 126 students between the first and fourth semester (87% heterosexual women, 9% homosexual men and 4% non-heterosexual women and men) to quantify the degree of homophobia, using the Index of Attitudes towards Homosexuals. This 25-item scale scored between 0 and 100, with scores above 50 indicating high levels of homophobia. It was observed that, on the average, scores remained below 50. The rejection of religious practice (b=0.38) and not having a non heterosexual friendship or relative (b=0.32) were correlated with homophobia⁽²²⁾.

In summary, the revised studies showed that approximately 7 to 16% of the nursing students expressed some significant degree of homophobia, according to the form used to quantify the degree of negative attitude, almost always through individual questions, although scales were used.

DISCUSSION

In this review, it is observed that an important number of nursing students show an important degree of homophobia. Homophobia is more important among male students and those informing highly conservative religious beliefs.

Moreover, between 7 and 16% of nursing students show some significant degree of homophobia. In a similar review, a somewhat higher percentage was observed among medical students⁽²³⁾. More recently, in a study carried out among medical students in Hong Kong, it was found that 25% of students considered homosexuality a psychological disorder that required treatment, while somewhat over 15% would avoid physical contact with homosexuals to reduce the risk of illnesses, especially AIDS⁽²⁴⁾. Among dentistry and oral hygiene students, however, low levels of homophobia have been informed⁽²⁵⁾.

It is possible that the little attention care professionals pay to aspects of users' sexual life is related with homophobia. Avoiding questions about patients' sexual behavior avoids addressing all aspects related to sexual orientation and, likewise, exempts them from informing and advising about safe sexual behaviors⁽²⁶⁾.

Gay, lesbian or bisexual people have specific health needs which health professionals should attend to without any kind of stigmatization. Homophobia is an obstacle for gays, lesbians and bisexualys to receive friendly treatment at some health services⁽²⁷⁾ and professional nursing care that attends to basic physical and mental health needs⁽²⁸⁾. Some authors observe that homosexual men have particular concerns regarding homophobia among health professionals, who frequently do not openly express their sexual orientation, often to the detriment of their own health⁽²⁹⁾. It is not common for health professionals to take a neutral stand towards the sexual orientation of the patients they are responsible for and, in general, consider it a fact that all are heterosexuals^{(30, 31)}.

Although it was found that less knowledge on sexual themes among students is related to homophobia⁽¹⁶⁾; another study suggests that education itself does not decrease students' degree of homophobia⁽¹⁷⁾. In another study, however, it was observed that nursing students expressed more positive attitudes than nursing assistant students⁽³²⁾. These contradictory data suggest that different factors are related with attitudes towards homosexual or bisexual people^(2,9).

Nursing professionals' training needs to be reinforced in terms of sexual behavior and respectful treatment of these topics during routine interventions⁽²⁶⁾. It was observed that specific courses on sexuality, which included attitudes towards so-called sexual minorities, reduced homophobia in university students⁽³³⁾. Although homosexuality is more tolerated than accepted nowadays, data suggest certain limits to tolerance. The cultural context, knowledge and beliefs about the determinants of homosexuality play a crucial role in attitudes towards homosexuality^{(10, 34)}.

Although in the relation between nurses and patients, knowing the patients' needs and acting as a shock absorber between patients and other entities and protecting patients against all possible infractors are presented as the ideal position, various studies have informed that homosexual patients received an unequal treatment and that the nursing staff denied that this was due to their homosexual orientation^(35-36). Likewise, these professionals face difficulties to demonstrate understanding and sensitivity towards gay, lesbian or bisexual people and deliver them the same care as to heterosexuals^(37-39).

This review updates and summarizes studies published on homophobia in nursing students in recent years (1998-2008). However, it is evident that few studies explore the prevalence and associated factors in developed countries and that there is no scientific production in Latin American countries. It is difficult to compare studies, given that different instruments and psychometric properties were used to quantify homophobia in the reviewed studies, and that only individual items were used, instead of total scores to define the condition and that most studies addressed the theme in the context of care delivery to HIV/AIDS patients. Homophobia and HIV-phobia are undoubtedly two distinct but strongly related attitudes^(9,40).

CONCLUSION

In conclusion, homophobia is frequent among nursing students and this negative attitude towards gay, lesbian or bisexual people could entail negative implications for nursing service and care delivery. Stigma and discrimination are the main obstacles impeding the use of health services for prevention, diagnosis and treatment, restrain the ability to access care services and manage adequate self-care or participate in research aimed at finding solutions. Further research on this topic is needed, particularly in Latin America.

ACKNOWLEDGEMENTS

To the Human Behavioral Research Institute, Bogotá, Colombia, for funding this research.

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Homophobia among nursing students

Homofobia em estudantes de enfermagem

Publication Dates

• Publication in this collection
  07 Oct 2010
• Date of issue
  Sept 2010

History

• Received
  15 May 2009
• Accepted
  21 Sept 2009