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Heteronormativity in the Healthcare System

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Impact on the Gay, Lesbian, and Bisexual Populations with an Emphasis on the Nursing Profession

The gay and lesbian population—especially youth—is one of many vulnerable populations in society.  The social stigmatization and discrimination this group faces are social determinants of health; that is, external factors hindering an individual’s ability to seek and/or attain health and wellness.  Healthcare workers, and the industry at large, are unintentionally fanning the flames of discrimination subsequently leading to even more problems for this population. 

Relevance to the Profession of Nursing

Health Disparities

Some of the health disparities seen in this population include substance abuse, suicide, depression, and HIV/AIDS.  Gay, bisexual, and lesbian people have higher rates of suicide and depression and are more likely to use and abuse illicit substances than their heterosexual counterparts.  Perhaps the most evident disparity relates to HIV/AIDS among the gay and bisexual population (the CDC categorizes this group as MSM or men who have sex with men).  According to a 2009 report from the Centers for Disease Control and Prevention about 49% of the 1.2 million people with HIV in the United States are MSM, and account for roughly 61% of all new HIV infections per year.  While it is estimated that MSM represent only 4% of the U.S. male population, the rate of new HIV infections in this group is 44 times that of other men (CDC, 2011).

Heteronormativity

Heteronormativity “refers to the assumption that heterosexuality is a universal norm…people are assumed to be heterosexual until they do or say something that disproves this assumption…lesbian women and gay men may choose to ‘hide’…owing to fear of negative attitudes” (Röndahl, Innala & Carlsson, 2006).  This places a huge burden on the gay, lesbian, or bisexual patient who may already feel like an outcast in society. 

Manifestations of heteronormativity.  One manifestation of heteronormativity in the physical sense is admission or patient forms.  These documents are filled out prior to receiving any type of medical care and obtain biographical information such as age, date of birth, race/ethnicity, and marital status.  With respect to marital status there are usually three options to choose from: married, single, or widowed.  If a homosexual patient is in a relationship which option are they to choose?  Unless they are lucky enough to live in a state where gay marriage is legal the only real option is single.  This small level of exclusion may make patients feel quite upset that their relationship is not recognized even at this basic level.  This seemingly insignificant point may initiate anxiety or shame in trying to decide how to reveal their homosexuality to the healthcare worker.

Röndahl, Innala, and Carlsson (2006) interviewed gay, lesbian, and bisexual individuals about their experiences with the healthcare industry and describes two main reoccurring themes: assumption of heterosexuality and clinician apprehension concerning homosexual patients.  Several individuals indicated that when nursing staff asked if they lived with anybody they assumed it was someone of the opposite gender.  Furthermore, upon correcting the nurse and stating that they live with their partner, patients noted the nurses “exhibited reactions of surprise and/or perplexity” (Röndahl et al., 2006).  Many individuals could feel the tension and discomfort radiating from nursing staff and attributed this to them being genuinely afraid of interacting with a homosexual person.  Consequently, the nurses’ fears “easily cause insecurity for both patients and personnel, and thereby inhibit communication” (Röndahl et al., 2006).

While not directed at nursing, Neville and Henrickson (2006) collected data from the homosexual population concerning perceptions of primary healthcare services.  In response to whether healthcare providers presumed heterosexuality, 73.7% of respondents felt that they were always or usually assumed to be heterosexual.  When asked if a healthcare provider’s attitude toward homosexuality influenced care 64.3% indicated that it either had no influence or was negatively affected.

Implications for Professional Nursing Practice

Definition of Nursing

The American Nurses Association (2010)—as stated in its Social Policy Statement—defines nursing as “…the protection, promotion, and optimization of health…and advocacy in the care of individuals, families, communities, and populations”.  It is unlikely the nurses involved above were intentionally trying to make their patients uncomfortable; however, they inadvertently did through their body language.  Such actions certainly do not promote an environment where the optimization of wellbeing is paramount.  During any interactions with a client the nurse should always beam with confidence and obscure signs of uncertainty.  Patients are often already in an anxious state and should not have to worry about their nurses’ professionalism.

Hindrance to the nursing process.  The nursing process provides professional nursing the framework in which to practice.  As a nurse it is imperative to actively foster communication and be aware of one’s nonverbal behavior.  Communication is one of the tools of the trade within nursing, allowing the acquisition and trading of information or data not only amongst colleagues but more importantly to patients.  All components of the nursing process are negatively affected by poor communication secondary to heteronormativity.  According to the Texas Nurse Practice Act (2011), “assessment…lays the foundation for the nursing process…judgment is based on the assessment process.”  Assessment of accurate and quality subjective data may not be possible if the patient feels they need to lie about themselves or are embarrassed, and subsequently not forthcoming with potentially vital pieces of information.  A lack of information greatly reduces the viability of a proper nursing diagnosis, which lead to inappropriate or ineffective interventions and planning of care.  As with assessment lack of client input can lead to a misleading evaluation which is vital in determining progress.

Universal Care

Provision 1 of the American Nurses Association (2001) Code of Ethics for Nurses states, “the nurse, in all professional relationships, practices with compassion and respect for the inherent dignity…and uniqueness…unrestricted by considerations of…personal attributes…”.  Regardless of whom the client is nurses have an ethical obligation to treat everyone equally regardless of the nurse’s personal beliefs.  Naiveté concerning a specific population is never a valid excuse for providing less than quality care.  Nurses should always provide competent care; that is, have some working knowledge concerning different groups of people—at a minimum be willing and able to acquire such information.

Advocacy and Social Justice

The patient should never carry the burden of having to make the nurse or provider feel better; the opposite is the basic core role of the nurse as an advocate and clinician.  Dysart-Gale (2010) states, “the value of social justice obligates nurses to identify and minimize social barriers to health”.  With that said nurses have a tremendous opportunity to promote and encourage change.

Reducing heteronormativity.  The nursing field can help in reducing heteronormativity in two ways: directly and indirectly.  An indirect approach would be providing a sound knowledge base concerning gay and lesbian populations within educational programs.  By addressing both psychosocial and physical health disparities nurses can be better prepared and feel more comfortable in communicating with gay and lesbian patients.  A direct approach would be pushing facilities and lawmakers to incorporate policies that would benefit the gay and lesbian population, such as reformatting biographical sections of documents.

Summary

Nurses have the ability to impact care for the good or bad.  Ideally the nurse would always bring positivity; however, this is not reality.  Gay and lesbian patients are taking notice of healthcare workers’ lack of confidence and discomfort concerning their care.  Nurses have an ethical obligation to provide universal care, advocacy, and social justice.  Concerning heteronormativity, nurses have the opportunity to bring about change within the healthcare industry to improve quality care to the gay and lesbian population.

Reflection

As a gay male myself I have experienced heteronormativity both in the healthcare industry and beyond.  Through writing this paper I learned that nurses can really provide change within the industry and that change is possible.

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