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Research in Nursing
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Focus
Conceptualising social
exclusion and lesbian, gay,
bisexual, and transgender
people: the implications for
promoting equity in nursing
policy and practice
Julie Fish
Reader in Social Work and Health Inequalities, School of Health and Applied Social Sciences,
De Montfort University, UK
Abstract
Since the early 1980s, there has been increasing recognition that the health of individuals and
communities is affected by social disadvantage. Following the election of the New Labour
Government in 1997, social exclusion became a key concept in UK policymaking. Social
exclusion approaches consider health outcomes to be linked to living and working conditions
rather than, primarily, to healthcare interventions. Social exclusion is thus an important concept
for nursing scholarship for understanding how peoples life circumstances may have an impact on
their health. This paper analyses some of the theoretical underpinnings which may lead to
recognition of the concept of lesbian, gay, bisexual and trans (LGBT) social exclusion. The
paper goes on to propose a model of the multidimensional aspects of lesbian, gay, bisexual and
trans social exclusion drawing on research evidence of the social, political and global inequalities
experienced by lesbian, gay, bisexual and trans people. In conclusion, it considers the implications
for promoting health equity in nursing policy and practice.
Keywords
health equity, lesbian, gay, bisexual and trans (LGBT) health, social exclusion
304
the concept is not widely used in health research and policy (see for exceptions Moran and
Simpkin, 2000; Wilson et al., 2007). Instead, discourses about dierences in peoples health
have been conceived in terms of health inequalities. Thirty years ago, the Black Report
(Townsend and Davidson, 1992) provided evidence of health disparities in access to
healthcare and in health status which existed between social classes; tackling health
inequalities has subsequently become a government priority (Marmot, 2009). Although the
terminology diers, there is considerable overlap between the concept of social exclusion,
deployed in social policy research, and that of the social determinants of health, commonly
utilised in health studies. A notable example of this shared theoretical framework is the model
developed by Dahlgren and Whitehead (1991), which identies a number of factors that are also
considered to underpin social exclusion (discussed below), including unemployment, housing,
education and social and community networks. However, there are a number of key dierences;
for example, social exclusion approaches consider health outcomes to be linked to living and
working conditions rather than primarily to healthcare interventions. Accordingly, eorts to
improve health focus upon addressing the social determinants of health both within and outside
of the healthcare system. There is a shared recognition between the two approaches that those
who are socially excluded have worse health outcomes and reduced access to healthcare.
For nursing scholarship, knowing about the impact of social exclusion may contribute to
promoting equity through more eective healthcare interventions, and lead to a deeper
understanding of the ways in which peoples life circumstances may impact on their health.
Over the past two decades, nursing scholarship, as a discipline, has been at the forefront of
research into lesbian, gay, bisexual and trans (LGBT) health issues and has contributed a
body of evidence on topics as wide-ranging as ethics, disclosure of sexual orientation and
heterosexism in nurse education (e.g., Dinkel et al., 2007; Platzer, 1993; Polek et al., 2008;
Rondahl, 2009). This paper seeks to contribute to these debates by considering how social
exclusion aects the health outcomes and healthcare access of LGBT people.
Fish
305
burden of responsibility for being cut o from mainstream society is placed onto individuals
themselves (Burchardt et al., 2002). The approach of blaming individuals behaviour was
illustrated in the early 1980s by Edwina Currie, then Conservative health secretary, who
criticised the eating habits of northern working class families and suggested that a diet of
beer, fags and chips had contributed to their own ill-health (Blaxter, 2004). The censure of
LGBT peoples moral values was exemplied by the aspiring EU Commissioner, Rocco
Buttiglione, who suggested that homosexuality is a sin (Fish, 2006). The ill-health of
LGBT people has been frequently ascribed to their so-called deviant lifestyles.
306
Fish
307
reporting bullying (Whittle et al., 2007). A third factor identied in the Acheson report as an
inuence on health inequalities is the lack of suitable housing. Homelessness is an issue
which aects young LGB people; when they come out as gay, they risk rejection from
their family they are asked to leave, or they run away from, the family home. Research has
found that when young LGB people leave home they are more likely than their heterosexual
peers to live on the streets than in public care (Gold, 2005). Moreover, a recent survey
conducted by Stonewall (the UK gay rights lobbying organisation) of 1658 LGB people
found that respondents expected poorer treatment from public services including housing,
criminal justice and health services (Hunt and Dick, 2008). This dimension requires
interventions that address wider social inequalities.
308
Fish
309
experience diculties in relation to more than one of the dimensions of social exclusion
(Percy-Smith, 2000, p. 7). For many LGBT people, social exclusion is a multi-dimensional
phenomenon (Levitas et al., 2007) (Table 1).
Conclusion
For the rst time, tackling health inequalities is one of the Department of Healths top
priorities for the NHS (Marmot, 2009); its remit is wide-ranging and based on a
310
Indicators
Economic
Social
Neighbourhood
Individual
Global
Group
partnership approach with local government, social care and local and community
organisations. Specically, the Marmot review has focussed on the exclusionary processes
that present obstacles to the creation of an inclusive society, including political
disempowerment, social exclusion and lack of voice, which are seen to perpetuate social
and wider health inequalities (Piachaud et al., 2009). Social exclusion, then, is a key concept
in current health policy and consequently for nursing scholarship. While sexual orientation
has been included in eorts to mainstream equality and diversity in healthcare through the
NHS Pacesetters Programme and through work undertaken by the Equality and Human
Rights Group at the Department of Health, it remains the case that policy initiatives to
reduce health inequalities largely overlook LGBT people. Future work is needed to embed
research ndings throughout the NHS and to raise awareness of the health impact of
LGBT social exclusion.
Key points
. Knowledge of the social exclusion of LGBT people underpins appropriate care and
should form an important component of pre-registration nurse education;
. Valuing diversity in relation to LGBT patients involves the ability to provide relevant
health information and the expression of positive attitudes and behaviour;
. Eective communication with LGBT patients includes creating an environment where
people feel safe to disclose their sexual orientation and where trans patients are treated
with respect;
Fish
311
. Recognise the right of LGBT patients to be fully involved in decisions about their
treatment and care and to consult with their family of choice;
. Develop a knowledge base of local and national resources to signpost patients to other
sources of support;
. Future research is needed to meet gaps in understanding about LGBT peoples health
needs and of the impact of multiple discrimination on access to healthcare services.
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312
Julie Fish (BA (Hons), MA, PGCE, PhD) is Reader in Social Work and Health Inequalities
at De Montfort University, Leicester. In addition to publishing a number of articles on
lesbian health and on research among LGB communities, she authored Heterosexism in
Health and Social Care. She is a member of the Department of Health, National Cancer
Equalities Initiative and recently collaborated with Stonewall on a large-scale lesbian and
bisexual womens health survey.