Homophobia, according to Blumenfield (1992) is both the belief that heterosexuality is or should be the only acceptable sexual orientation and the fear and hatred of those who are sexually attracted to those of the same sex. This definition forms the basis for this article, which explores whether living in a homophobic society affects the mental health of gay people and whether gay people are able to access appropriate services should they suffer from a mental illness. The article also examines whether nurses hold homophobic attitudes and if so, the extent to which these affect their work with mentally ill gay clients.
It is evident that homophobia is prevalent in the UK. Oppressive legislation includes a differential in the age of consent for male heterosexual and homosexual activity (16 and 18 years); section 28 of the Local Government Act (1988) forbids local authorities from promoting the acceptability of homosexuality; homosexuality is condemned by the Church of England; banned by the armed forces; and employers possess the legislative right to dismiss employees for their sexuality.
This article examines whether similar homophobic views are held by nurses and if so, whether these views affect the type and quality of their nursing care.
Attitudes of mental health nurses
Some nurses may remember as students feeling uncomfortable when gay clients were to be cared for. Perhaps they condoned malicious gossip and amusing asides about gay clients or used derogatory labels to describe gay people. Since it is likely that nurses share the attitudes of the society in which they live, it is likely that they too possess homophobic views. Smith (1993) found that 77% of mental health nurses were either moderately (57%) or severely homophobic (20%). Synoground and Kellmer-Langan (1991) found that 43% of student nurses would not condone homosexual practices.
Rose (1993) conducted a survey in which over a quarter of the nurses who responded had recollections of colleagues refusing to care for gay clients. Such observations confirm the belief that metal health nurses are as likely to be homophobic as the general public. Similarly, Rose and Platzer (1993) maintained that nurses are not immune from the prejudices of mainstream society so perhaps it is not surprising that they share similarly negative attitudes of gay people.
Attitudes and behaviour
On the other hand, it could be argued that the attitudes of mental health nurses are irrelevant so long as homophobic attitudes do not influence their practice. However, Webb and Askham (1987) showed that attitudes are linked closely to behaviour and Phillips (1994) suggested that by bringing their prejudices to clinical practice, nurses who have not considered their feelings about homosexuality may jeopardise the care of gay clients.
Nurses' attitudes and nursing practice
Smith (1992) observed that if mental health nurses were insensitive to patients' sexual feelings, they may also ignore relevant clinical needs. He stated that by not dealing with their own negative feelings, nurses may ignore relevant information in planning and providing care for the homosexual psychiatric patient. Given that there seems little doubt that negative attitudes among nurses are transmitted to the patient, it is necessary to consider the possible impact of this behaviour on the mental health status of gay people.
The mental health of gay people
There is some evidence that the gay population experiences a higher incidence of substance misuse, para-suicide, bipolar psychiatric disorders and depression (Taylor and Robertson 1994). It could be argued that these facts are merely evidence of the mental imbalance of gay people, but the literature suggests a more complex explanation. Homophobia may influence many important areas of a gay person's life. Platzer (1990) stated that being gay is not an easy option in a society where there is overt discrimination. Prejudice affects all aspects of life, particularly housing, employment, child custody and the law. The effects of discrimination in these major areas of life can lead to stress and a detrimental effect on health and wellbeing.
Isensee (1990) implied that gay people themselves may be or become homophobic. He suggested that homophobia may become a self-fulfilling prophecy of internalised negative self-image, which results in low self-esteem, a fear of sharing feelings with friends and family, and isolation. This implication appears to be borne out in reality as many gay people may experience discomfort regarding their sexuality. It is unlikely that gay people are particularly prone to instability, rather that homophobia in its many forms increases the likelihood of homosexual people developing mental health problems.
Perhaps this is not so surprising considering that gay people are an integral part of society and have been brought up in the same atmosphere of negative attitudes. If gay individuals have a negative self-image, as well as a negative social image, the high incidence of mental illness in this minority could be explained.
The effects of homophobia
Platzer (1993) said that in general gay people are at risk of having their sexuality pathologised and are vulnerable to inappropriate psychiatric treatment, such as unwanted and ineffective cures. She continues by explaining that when gay people do have mental health problems the way these interact with the stress of being homosexual in a homophobic society must be addressed. Irwin (1992) suggested that gay clients face avoidance, ridicule and are exposed to a range of negative and disapproving non-verbal behaviours as they seek help for mental illness.
Negative interactions can have repercussions in many areas of a gay person's life. Taylor and Robertson (1994) explained that the ethic of confidentiality becomes particularly important for the gay client, who may fear the consequences of disclosure or discovery. She or he may not want certain people to know about their sexual orientation and mental health nurses may not consider the importance of these issues for gay clients.
The RCN (1994) recognises that gay people have three key areas of concern when they come into contact with healthcare professionals. These are -
- Concerns which relate to homophobia or anti-gay feelings in doctors and healthcare providers in general.
- Fear of the consequences of being open about their sexuality and a belief that they cannot always obtain the care they need.
- Fear of being physically harmed if healthcare practitioners are homophobic and/or that a breach of confidentiality will have negative consequences for them in relation to employment, housing, child custody or future health care.
Box 1. Gay peoples' requirements of health services (RCN 1994)
The nursing care of mentally ill gay people
Nurses caring for mentally ill gay clients should adopt a range of good practices -
- Perform a self-assessment of attitudes and feelings towards gay people and evaluate the impact of those attitudes and feelings on client care (Smith 1993).
- Challenge homophobic behaviour and attitudes of colleagues (RCN 1994) and service users (Phillips 1994).
- Abandon the assumptions of heterosexuality when assessing clients. Avoid questions about spouses and replace with partner (Taylor and Robertson 1994).
- Encourage gay clients to deal with prejudice and homophobia in others in a healthy manner (Smith 1992).
- Support gay clients in coming to terms with their beliefs about homosexuality (Smith 1992).
- Respect the right of gay clients to express their sexual orientation (Smith 1992) and to make disclosures only with consent (UKCC 1992).
Box 2. Guidance for the nursing care of mentally ill gay people
It is apparent that homophobia in its various forms can have negative effects on the mental health of gay clients and the care they receive. The additional stresses of homophobia make gay people more inclined than others to experience mental health problems. Furthermore, gay clients have specific and justified concerns regarding the quality and appropriateness of their care. This suggests that mental health nurses may be shirking their professional responsibilities for this client group. The UKCC demands that nurses recognise and respect the uniqueness of each patient and client and respond to his or her need for care (UKCC 1992). Guidance for the care of mentally ill gay clients appears in Box 2.
Discussions about the causes of homosexuality have been avoided in this article. Rather than enhancing the arguments, this would have reinforced the idea that homosexuality is unacceptable and wrong. Gay people are part of life, present in all cultures and all ages. Homophobia increases the likeliness of mental illness in gay people and may have serious consequences for their access to appropriate health care.
Mental health nurses should consider their professional obligations for this client group. They should recognise and respond to the specific needs and concerns of gay clients. For as long as mental health nurses fail to recognise homophobia as a problem in themselves, gay clients will continue to suffer the consequences of inappropriate and substandard care.
- Blumenfield WJ (1992) Homophobia - How We All Pay the Price. Boston MA, Beacon.
- Inwin R (1992) Critical re-evaluation can overcome discrimination. Professional Nurse. 7; 435-438.
- Isensee R (1990) Love Between Men, Enhancing Intimacy and Keeping your Relationship Alive. New York NY, Prentice Hall.
- Local Government Act (1988) Department of Health and Social Security, London, HMSO.
- Phillips A (1994) Out in mind. Openmind. 68; 14-15.
- Platzer H (1990) Sexual orientation: improving care. Nursing Standard. 4; 38; 38-39.
- Platzer H (1993) Nursing care of gay and lesbian patients. Nursing Standard. 7; 17; 34-37.
- Rose P (1993) Out in the open? Nursing Times. 89; 30; 50-52.
- Rose P, Platzer H (1993) Confronting prejudice. Nursing Times. 89; 31; 52-54.
- Royal College of Nursing (1994) The nursing care of lesbian and gay men, a Royal College of Nursing statement. Issues in Nursing and Health. 26.
- Smith GB (1992) Nursing care challenges: homosexual psychiatric patients. Journal of Psychosocial Nursing. 30; 12; 15-21.
- Smith GB (1993) Homophobia and attitudes toward gay men and lesbians by psychiatric nurses. Archives of Psychiatric Nursing. 7; 6; 377-384.
- Synoground SG, Kellmer-Lanmgan D (1991) Nursing student's attitudes toward AIDS. Nurse Education Today. 11; 3; 200-206.
- Taylor J, Robertson A (1994) The health needs of gay men, a discussion of the literature and implications for nursing. Journal of Advanced Nursing. 20; 3; 560-566.
- United Kingdom Central Council for Nursing, Midwifery and Health Visiting (1992) Code of Professional Conduct. London, UKCC.
- Webb C, Askham J (1987) Nurses' knowledge and attitudes about sexuality in health care, a review of the literature. Nurse Education Today. 7; 2; 75-87.