Lesbian‐, gay‐, bisexual‐ and transgender‐related inequalities within nursing: A neglected research area

In today's diverse healthcare settings, awareness of gender and sexual diversity and consideration of the needs of patients with distinct sexual orientations are required competencies for healthcare providers (Eliason, Dibble, & Robertson, 2011). Internationally, there has been an increase in social acceptance of and advocacy and policymaking for the rights of lesbian, gay, bisexual and transgender (LGBT) patients and families. In nursing, there has been increased nursing research pertaining to the needs of LGBT individuals in healthcare settings, their healthcare experiences and satisfaction (Cloyes, Hull, & Davis, 2018; Felsenstein, 2018; Lim, Brown, & Kim, 2014), LGBT patients’ perceptions of quality care and health services (Simeonov, Steele, Anderson, & Ross, 2015) and nurses and nursing students’ knowledge and attitudes towards LGBT individuals and their competencies to improve LGBT care (Bilgic, Daglar, Sabanciogullari, & Ozkan, 2018; Lim & Hsu, 2016; Yingling, Cotler, & Hughes, 2017). However, two imperative questions that should be raised are: who is exploring the personal and professional issues and educational needs of nurses who identify themselves as LGBT? Who is looking out and caring for nurses who identify as LGBT? Based on the author's personal acquaintance with a nurse in Pakistan who identified himself as a gay and a transgender; who then experienced stigmatization and insolent behaviour from other nurses, hospital management and patients; and ultimately left the profession in anguish, in this editorial the intention is to highlight the need for exploring and addressing LGBT-related inequalities within nursing. Work place incivility, harassment and discrimination towards LGBT professionals are consistently reported across various disciplines such as science, technology, engineering, mathematics (Cech, 2015), occupational health (Falzarano & Pizzi, 2015), mental health professions, medical sciences and community health (Di Marco, Hoel, Arenas, & Munduate, 2018; Sheridan, Zolobczuk, Huynh, & Lee, 2017). This incivility is persistent in both academic and professional settings (Cech, 2015; Di Marco et al., 2018; Mansh et al., 2015). Sheridan et al. (2017) reported that, of 1,691 LGBT professionals, 1,369 (81%) reported verbal insults and 676 (40%) reported bullying and physical harassment in their workplace. The professionals reported an increased prevalence of anti-gay comments in education (mean = 3.14), community (mean = 2.76) and mental health professions (mean = 2.74). Interestingly, it was found that medical professions received the least training on LGBT health and workplace issues (mean = 1.73). Di Marco et al. (2018) noted that LGBT professionals experienced verbal abuses, insults, jokes, derogatory language, stereotypes, workplace incivility and ostracism. Within healthcare context, Eliason et al. (2011) surveyed 427 LGBT physicians in the US and reported an array of negative workplace experiences. For example, 43 (10%) physicians were denied referrals from their heterosexual colleagues, 65 (15%) experienced harassment, 93 (22%) experienced ostracism and 278 (65%) reported derogatory comments about LGBT people. These findings clearly demonstrate that health professionals who explicitly (i.e. conscious decision to disclose one's sexual identity or ‘come out’) or implicitly (i.e. perceived by others as LGBT due to the common social stereotypes such as perceived appearance, body language and voice intonation) identify themselves as LGBT are devalued and stigmatized within their workplace. Therefore, despite a lack of evidence concerning LGBT nurses, it is possible that such discrimination exists in nursing, and nurses and nursing students encounter these challenges in their classroom and clinical settings. An argument could be put forward that the gender identity and sexual orientation of nurses and other healthcare professionals may not be a concern for patients, but the limited literature indicates otherwise. For example, Druzin, Shrier, Yacowar, and Rossignol (1998) surveyed 500 random patients in Canada. Of 346 patients, a minority, 41 (11.8%) patients indicated that they would refuse care from an LGBT family physician. Their reasons being an LGBT physician would be incompetent (N = 23, 56%), would not be able to relate to their lifestyle (N = 7, 17%) and may sexually harass them (N = 4, 10%). Similar findings are reported in a survey of 502 patients in the US (Lee et al., 2008). Of these patients, 172 (34.5%) indicated that the sexual orientation of their physician is important to them, 214 (43%) indicated that they would be more comfortable to discuss personal relationship matters with a physician with same sexual orientation, and 251 (50.5%) indicated that they would be more comfortable discussing sexual functioning issues with a physician with same sexual orientation. In total, 176 (35.4%) patients reported that they would not visit a clinic or a facility that employed an LGBT physician and would prefer a chaperone if the physician is a gay man (N = 251, 51.2%) or a lesbian woman (N = 220, 45.0%). Although these percentages are lower than those who noted that physicians’ sexual orientation did not matter to them, it is still a considerable percentage. These findings implicate that nurses and healthcare professionals’ sexual orientation can influence provider–patient relationship. Riordan (2004) interviewed 16 healthcare providers, including two nurse practitioners, and reported that the providers had to change their general appearance to fit heterosexual norms (e.g. a lesbian nurse grew out her hair) and to avoid homophobia, sometimes ‘come out’ to indicate to their patients that they are understood and would be safe from homophobia, and often use desexualization strategies, in response to patients’ homophobic remarks, in order to provide effective care. Such homophobic and stigmatized encounters negatively affect the well-being of LGBT providers, who lack the necessary social and professional support systems (Burke & White, 2001). The homophobic comments and harassment from colleagues, management and patients along with the inability to ‘come out’ at a workplace and lack of support groups have been identified as the most common reasons by LGBT professionals for leaving their profession (Wright, Colgan, Creegany, & McKearney, 2006). Almost all of the above-discussed research about LGBT professionals originated from natural, social sciences, medicine and other health disciplines. It is apparent that nursing has lagged behind these disciplines in exploring and addressing LGBT-related issues within the nursing profession. Therefore, there is an urgent need for consistent research in this area. Undoubtedly, over the last few years, the emerging nursing research about LGBT patients has advanced our knowledge and skill set in improving the nursing care experiences of LGBT patients and families. Efforts have been devoted for developing organizational policies and reforms for LGBT patients and families. Nevertheless, research is needed to determine whether LGBT nurses experience the stigmatization and incivility as LGBT professionals in other disciplines. By highlighting this largely ignored research area and proposing some potential research themes in this editorial, a call to action has been iterated, with a hope that nurses worldwide can respond to this call in a concerted manner through incited discussion and research. The author declares no conflict of interest.

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