A holistic approach to individuals and groups is widely recommended in the nursing literature. The degree to which this approach has been integrated into nursing practice remains largely undocumented and abstractly defined. One way to assess the degree of holistic practice within nursing is to explore the prejudices and biases of nurses toward alienated groups within a given society.
It is a necessary task for nurses to articulate the specific forms in which their biases arise (Travelbee, 1971). These biases and prejudices are often communicated directly or indirectly to students, who in turn alienate themselves from other students and from client groups with whom they come into contact. In addition, research studies (Kiker, 1973; Rauen, 1974; Stuebbe, 1980) have demonstrated that the behaviors exhibited by nursing students are directly related to the behaviors of their instructors.
Educators, as curriculum planners and faculty, make implicit or explicit value choices when they decide what knowledge is valid and should be taught within a curriculum (Humphreys, 1983). These choices are both linked to faculty behaviors (Campbell, 1963; Raden, 1977; Towne, 1979) and transmitted to students. Dittes (1957) revealed that clients were acutely aware of the attitudes of therapists. Nursing students and clients are likely to be equally as sensitive to the attitudes of nurse educators.
Western civilization has traditionally viewed homosexuality and homosexual conduct as deviant, categorizing such behavior or persons as ill, criminal, or corrupt (Szasz, 1970). This negative view remains firmly held (Livergood, 1972), with perceptions in the general population still being based on cultural myths and stereotypes rather than on accurate information (Tripp, 1975; Weinberg, 1972). Levitt and Klassen (1974) concluded that homophobia is widespread among helping professionals and suggests that students in these fields typically do not receive adequate or accurate information about gay-related topics during their professional education. As a helping profession, nursing is probably not exempt from these prejudices.
A search of the nursing theory, practice, and education literature revealed a widespread lack of information regarding lesbians. The absence of this content suggests that the nursing community has not sufficiently evaluated the unique needs of lesbians in today's society. This apparent lack of concern for the needs of lesbians may signal the presence of a value system that works in opposition to the concept of holistic nursing care.
This article reports a study of BSN educators' knowledge and attitudes about lesbians. Although the study (Randall, 1987) cannot be generalized to all nurse educators, it does serve as a starting point in identifying nurse educators' attitudes and knowledge base, as well as how this might affect students and, ultimately, client care.
This descriptive study utilized a cross-sectional survey design. The instrument consisted of a two-part questionnaire. Part I assessed the respondent's knowledge about lesbians and lesbianism by means of 48, four-point (1= strongly agree to 4=strongly disagree), Likert-scaled items. Specific areas addressed included moral and ethical responses, knowledge statements, sexuality or sex related statements, normalness of lesbians and lesbian behavior, social contact with lesbians, and sources of information for educators regarding lesbians and lesbian issues. Part II consisted of 24 demographic questions.
Content validity was evaluated by five experts in the areas of lesbian issues, lesbian concerns, discrimination regarding lesbians, and homophobia in society. The original pool of 87 statements was narrowed to include only 56 that received at least three affirmative judgments from the experts.
Construct validity and reliability were established by a means of a test-retest method. Four weeks separated the first and second administration of the questionnaire to a group of 30 women (17 from a midwestern university master's level nursing research class and 13 from an urban midwestern women's center known to deal with lesbian consciousness raising). It was assumed that the women's center group would have greater awareness of lesbians and lesbian issues. This is supported by a mean score of 90 for the women's center group and 157 for the research class. Lower scores indicate lower levels of lesbian phobia present. Using a zero-one scale (rather than four-point) the Pearson product reliability was r=1.0. The Guttman scalogram score of reproducibility was 88.4%. Statements receiving an error score of four or greater were deleted from the questionnaire, leaving 48 items in the final version.
Faculty members from 13 schools of nursing were identified by a faculty list received from a midwestern state board of nursing. A total of 209 questionnaires were mailed and 112 were returned. A 50% rate of valid questionnaires were used for analysis in this study (seven were returned indicating that the faculty member was no longer at that college, two refused to participate, and three questionnaires were returned after the data had been analyzed).
Consent to participate was implicit in returning the answered questionnaire. Individual anonymity was ensured in that no identifying marks were made on the questionnaire, no written responses were necessary, and no method of follow-up was used.
Ninety-five women (7 identified themselves as lesbians, 86 as not being lesbians, and 2 did not respond) and five men responded to the questionnaire. The sample consisted predominately of married individuals (68%) who lived with their spouse. One fourth indicated that they were single and lived either alone or with someone and 5% indicated that they were coupled and lived with a significant other. Most educators (70%) practiced their spiritual beliefs on a regular (weekly to monthly) basis. A strong majority (84%) indicated that they have known a lesbian; of those, 46% described the relationship as close, and 30% had known a lesbian for more than five years. Demographic data are summarized in the Figure.
SUMMARIZATION OF DEMOGRAPHIC VARIABLES OF BSN EDUCATORS
Responses to the 48 attitudinal items were summed to derive a total lesbian phobia (L-P) score. The total possible range on the index is 48 to 192 with a midpoint of 96. Descriptive statistics are shown in Table 1. Individual Pearson correlations were computed between L-P score and age, number of years teaching, and frequency with which spiritual beliefs were practiced. Individual Spearman rank correlations were computed between L-P score and highest degree held, living arrangements, self-identified minority member, political alliance, spiritual beliefs, has the respondent ever known a lesbian, has the respondent ever closely known a lesbian, and is or could the respondent be a lesbian.
Respondent scores ranged from 109 to 145 with a mean score of 125.54 (Table 1). Responses from BSN educators were indeed mixed, showing conflicting attitudes and information among educators toward lesbians. Although the distribution of individual statements may indicate greater acceptance of the group, the summation scores (L-P scores) indicate some degree of lesbian phobia among every BSN educator in this sample.
Moral and Ethical Issues
Nearly one fourth (24%) indicated that lesbian behavior is just plain wrong, 23% thought that lesbianism is immoral, and 15% felt that lesbians are perverted. An even higher number (34%) thought that lesbian behavior is disgusting. Nearly one fifth (19%) indicated that laws punishing lesbians should not be rescinded from the current legal system.
LESBIAN PHOBIA INDEX*
BSN EDUCATORS' VIEWS ON WHERE LESBIANS SHOULD BE TEACHING
Faculty members had mixed information regarding lesbians. They were clear about the frequency of sexual contact among lesbians with only 3% indicating that they thought lesbians were nymphomaniacs and 2% that lesbians have a life of one-night stands. This is supported by research (Blumstein & Schwartz, 1983; Masters, Johnson, & Kolodny, 1982 ) that has looked at the frequency of sex and promiscuity among lesbians. However, a majority (52%) indicated that lesbianism is not a natural expression of human sexuality.
Lesbianism and AIDS
In addition to sexuality statements, these educators were asked about lesbians and the transmission of AIDS. AIDS is perhaps the most publicized health concern in this decade and a noteworthy number of educators are misinformed about the rate of transmission of the AIDS virus among lesbians. One fifth ( 20%) believed that lesbians are a common source of transmitting AIDS, even though the Centers for Disease Control report that there have been no cases of AIDS sexually transmitted from lesbian to lesbian (Southern California Women for Understanding, 1986). These findings suggest that specific information communicated to nursing students and clients might often be inaccurate regarding AIDS, transmission of the AIDS virus, and lesbian sexuality. Although lesbians are considered to be at low risk for AIDS, they are at high risk for discrimination and misunderstanding of their sexuality by sharing the label of homosexual with gay men.
Lesbianism as Pathology
Although current literature indicates that homosexuality is neither a disease nor curable, 9% indicated that they thought lesbianism is a sickness that can be cured and 8% further suggested that lesbians should be required to undergo psychotherapy to become heterosexual. A clear majority (70%) indicated that there is an element of lesbianism in every woman. This finding conflicts with the majority view (52%) that lesbianism is an unnatural expression of human sexuality.
Social Contact with Lesbians
Faculty members indicated some discomfort at socializing with lesbians. More than one quarter (28%) indicated that they would find it difficult to converse with someone they knew to be a lesbian. More than one fourth (26%) would not be comfortable associating with lesbians. The majority (55%) indicated that they would be greatly distressed if their sister or best friend told them she was a lesbian. When asked about socializing in a predominately lesbian environment, educators indicated once they learned a bar they had entered was a lesbian bar, the majority (73%) would be uncomfortable and 56% would leave.
Lesbians as Educators
Respondents indicated only slightly greater acceptance of lesbians as educators. Sanctions against lesbian educators are inversely related to the level of students being educated (Table 2).
A substantial number (17%) indicated that they thought lesbians would molest children. Fourteen percent would object if their child or best friend's child were being cared for by a nurse who was a lesbian, although only 8% indicated that sexual preference was an issue in determining whether or not a woman should be a nurse.
Educators did not regularly raise lesbian issues in the learning environment (Table 3), yet more than half (56%) of these BSN educators indicated they felt more informed about lesbian issues and concerns than their colleagues. BSN educators reported receiving the majority of their information from sexuality textbooks (56%) (Table 4). The least common sources included the church (1%), a lesbian family member (1%), and military experience (1%).
No statistically significant correlations between demographic variables and attitudes were found within this study. The findings do, however, raise numerous questions regarding the attitudes held by BSN faculty toward lesbians. Since no significant correlations were found between various demographic variables, this suggests that lesbian phobia among these BSN educators is not dependent on age, education, years teaching, sexual orientation or preference, or political or spiritual practices. L-P scores of the entire group were above the midpoint on the L-P Index suggesting that the group as a whole is homogenous and conceivably lesbian phobic.
FREQUENCY OF LESBIAN ISSUES DISCUSSED IN THE LEARNING ENVIRONMENT
SOURCES OF INFORMATION REGARDING LESBIANS
There needs to be clear acknowledgment and operationalization within nursing of Travelbee's (1971) conceptual framework that behaviors are determined in part by an individual's beliefs, attitudes, and assumptions and are reflective of those held by society as a whole. Simply being a member of a helping profession does not insulate nurses from negative biases, prejudices, and assumptions toward lesbians. Nurse educators should be held accountable for the influence they have on students or others with whom they come into contact. This research study begins to document the knowledge base and attitudes held by nurse educators toward an oppressed group with whom they have contact, whether knowingly or not.
The interpretations of this research must be cautiously examined due to the limited sample as well as the newly developed instrument utilized. This cautious approach does not discount the importance of the research but draws attention to the need for further research. It will be important to repeat reliability studies and establish stronger norms for the "phobia" label by the use of broader sampling not only of nursing but of the general population.
Further investigations will be essential to establish whether the attitudes reported here are generalizable among nurse educators. It will be of interest to see if there are differences among ADN, diploma, and graduate educators, as well as among practitioners from the various types of educational programs. Other demographic variables such as family background, religious upbringing of parents, geographic location of childhood experiences, class background, and extended family socioeconomic status could be examined.
Implications for Nursing
The implications of this study for nursing are numerous. The suggestion that nurse educators hold negative attitudes and inaccurate knowledge toward any societal subgroup is of concern. Nurse educators are responsible to those they serve for having a broad understanding of diverse groups of people, identifying injustices, and striving for the humane treatment of others no matter what their differences. The findings from this study suggest that BSN educators from this state have a knowledge deficit regarding lesbians, lesbian sexuality, and lesbian issues or concerns. When a notable number of the educators responding to this questionnaire thinks that lesbianism is not a natural expression of human sexuality, that lesbians would molest children, that lesbian behavior is disgusting, that talking to a known lesbian would be difficult, that lesbians are a source AIDS, or that the civil rights of lesbians should be restricted, there is need for immediate change.
Structured nursing educational opportunities need to be provided where lesbians would have the opportunity to speak for themselves about their needs, teach non-lesbians their concerns, and provide open dialogue among nursing educators regarding the topic of lesbianism. Funding of grants, implementation of conferences, and publication of lesbian-focused research are ways to begin to create an openness and respect for the 10% of the female population who are self-identified lesbians (Kinsey, Pomeroy, Martin, & Gebhard, 1953). Direct action needs to be taken by nurse educators and practicing nurses alike to educate themselves and demystify the issue of lesbianism.
Within the larger framework of nursing, the American Nurses' Association and National League for Nursing need to address civil rights issues and include anti-discrimination statements in their literature and lobbying efforts. In addition, both agencies can make a clear position of acknowledgment and acceptance of lesbians as a group worthy of support, research, and understanding. These nursing agencies are in a prime position to dispell the myths that surround misunderstanding, miscommunication, and misrepresentation of lesbians and lesbian issues by nurses. Incorrect, incomplete, or inadequate information fosters assumptions, attitudes, beliefs, and values that are inconsistent with what nurses and nurse educators maintain nursing is all about.
Attitudes expressed by these educators were indeed mixed. Although the group as a whole maintained lesbian phobic opinions, educators indicated they have had various experiences with lesbians and some maintain that myths regarding lesbians and lesbian behavior are true, contrary to actual studies involving lesbians.
The results of this study indicate that BSN faculty in this midwestern state need to be educated regarding lesbians in the areas of sexually transmitted disease, especially hi terms of specific sexual practices that transmit the AIDS virus. Lesbians have the lowest rate of sexually transmitted diseases among sexually active adults (Loulan, 1987). This low rate transmission and exposure is also true with respect to the AIDS virus.
In addition, narrow definitions of "normal" sexuality and sexual behavior may cloud educators' conceptualizations of family, normal child and adult development, and healthy adult sexual assessment. Numerous studies exploring human sexuality (Blumstein & Schwartz, 1983; Kinsey et al, 1953; Masters et al, 1982) indicate that lesbianism and lesbian behaviors are a natural expression of human sexuality.
Education is also needed in the areas of child molestation. Studies indicate that the majority of child molesters are heterosexual men (Brownmiller, 1975; Rush, 1980). The notion that lesbians molest children is a myth. Perpetuation of these myths needs to be halted since lesbians are sure to have contact with children as pediatrie nurses, community health nurses, and educators.
Finally, educators reported difficulty communicating with a known lesbian. This suggests that they may not interact effectively with lesbian students, clients, or peers. This would definitely affect the quality of education offered to students and set a precedent for continued misunderstanding of lesbians and their lifestyles.
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LESBIAN PHOBIA INDEX*
BSN EDUCATORS' VIEWS ON WHERE LESBIANS SHOULD BE TEACHING
FREQUENCY OF LESBIAN ISSUES DISCUSSED IN THE LEARNING ENVIRONMENT
SOURCES OF INFORMATION REGARDING LESBIANS