Registered Nurses’ Attitudes Towards Gays and Lesbians: An Examination of Homophobia and Discriminatory Beliefs

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Registered Nurses’ Attitudes Towards Gays and Lesbians: An Examination of Homophobia and Discriminatory Beliefs

  • Christopher W. Blackwell, PhD, ARNP, ANP-C
  • Ermalynn M. Kiehl, PhD, ARNP, CNS


  • The widespread existence of discrimination, both direct and indirect, including hate crimes and violence, oppression, and heterosexist hatred against homosexuals is widely supported in the research literature pertaining to homosexuals

Gay Civil Rights Movement

  • Freud’s Psychoanalytic Theory
    • Claimed homosexuals were in arrested development.
    • Led to belief that homosexuality was pathological and resulted from dysfunctional parent-child relationships.

Gay Civil Rights Movement

  • US Military
    • After WWII began discharging gays and lesbians, branding them “undesirable”
    • Conducted lectures on the pathology of homosexuality in the training of new military troops

Discrimination Against Gays and Lesbians

  • Although altered through the “Don’t Ask, Don’t Tell, Don’t Pursue” Policy of the United States Military (the 1994 National Defense Authorization Act), homosexuals cannot openly serve in the Air Force, Army, Marine Corps, Navy, or Coast Guard.

Discrimination Against Gays and Lesbians

  • Spiritual violence, the validation of hatred and discriminatory practices against homosexuals secondary to a religious-associated belief of homosexuality as immoral, is also a prevalent issue in America today (Swigonski, 2001).

Discrimination Against Gays and Lesbians

  • Strong correlation between a Christian religious identification, male gender, belief in the “free choice” model of homosexuality, and other variables such as lack of association with gays, lower educational levels, and high regard for traditional family and discriminatory practices

Discrimination Against Gays and Lesbians

  • Societal prejudices have equated to discriminatory practices within state and federal judiciary systems and public policy drafting.
  • Sodomy statutes (repealed in 2003).

Discrimination Against Gays and Lesbians

  • Inequalities laws that relate to custody and parental rights
  • Vague definitions of “family” has resulted in laws and regulations that fail to acknowledge gay parents in a court of law (Florida’s ban on adoption).

Discrimination Against Gays and Lesbians in the Workplace

  • Research suggests that discrimination against homosexuals is pervasive in America’s workplaces.
  • Individuals have reported that they believed that discrimination would occur if their sexual orientation was discovered by management; research has indicated that this fear or anticipation of discrimination is the major factor in workers hiding lesbian, gay, or bisexual identities (Croteau, 1996).

Discrimination Against Gays and Lesbians in the Workplace

  • Homosexuals experience discrimination in wages and earning, perpetual harassment and homophobic treatment, and lack many essential rights related to employment.

Discrimination in the Workplace

  • Working gay, lesbian, and bisexual people are no better off and in some ways are disadvantaged economically in relation to comparable heterosexual people.
  • Human Rights Campaign: The Corporate Equality Index and The State of the Workplace for Lesbian, Gay, and Transgender Americans.
  • Significant lack of research (Saunders, 2001).
  • Lack of inquiry in nursing even greater. Only one qualitative essay found (Stephany, 1992).

Purpose of Study

  • Examine registered nurses’ homophobia and overall attitudes toward the protection of gays and lesbians in the workplace. The dependent variable of this study is the homophobia scores represented by the ATLG.

Independent variables

  • Gender
  • Age
  • Race/ethnicity
  • Education level
  • Religious association
  • Belief in the “free choice” model of homosexuality
  • Interpersonal contact with homosexuals as friends and/or family members
  • Support workplace nondiscrimination policies

Research Hypotheses

  • There will be a difference in homophobia related to gender, age, race/ethnicity, and education
  • There will be a positive relationship between
    • religious association and homophobia
    • belief in the “free choice” model of homosexuality and homophobia
  • There will be a negative relationship between
    • interpersonal contact with homosexuals as friends or family and homophobia
    • support for a nondiscrimination policy in the workplace and homophobia

Literature Review

  • Explored literature related to the dependent variable of homophobia and independent variables of the hypotheses of this study: 1) age; 2) gender; 3) race/ethnicity; 4) education; 5) religious association; 6) belief in the “free choice” model of homosexuality; and 7) interpersonal contact with homosexuals as friends and/or family members and how these variables correlated with overall homophobia and discriminatory beliefs.
  • Additional studies explored that empirically researched the use of the ATLG Scale, workplace nondiscrimination policies, gay/lesbian workplace discrimination, and gay civil rights initiatives.

ATLG Scale

  • Developed by psychologist Gregory Herek (1988)
  • Purpose of the scale is to gauge heterosexuals’ affective responses to homosexuality, gay men, and lesbians
  • Items were developed for the ATLG through scrutiny of the public discourse surrounding sexual orientation
  • Instrument has completed factor analyses, item analyses, and construct validity studies
  • The higher the overall score of a respondent, the more homophobia he or she possesses.
  • Reliable with alpha levels greater than .80


  • Sample (n = 165)
  • Instruments (ATLG Scale)
  • Data collection (stratified systematic sample of Florida RNs)
  • Treatment of the data (SPSS®/AMOS®)


  • Surveys sent to 520 nurses, 40 returned undeliverable.
  • One hundred sixty-five (34%) of remaining 480 were returned and included in the analyses.
  • The typical respondent was a Caucasian heterosexual female, between the ages of 40-49 years, with an Associate Degree in Nursing. With regard to religiosity, the majority were moderate Christian who attend church weekly. (Consistent to DHHS 2001 Florida demographic data.)
  • Seventy-three percent (73%) of participants have at least one friend or family member who is a gay man or lesbian and 62% indicated they would support a nondiscrimination policy in their workplace that protects gay men and lesbians.

ATLG Scores

  • The ATLG scores range: 20 - 100
  • 78% ATLG score of 60 (mid-range) or less
  • 22% ATLG score greater than 60.
  • Confirmatory factor analysis and Cronbach’s alpha were used to validate the research instrument

Hypothesis 1

  • Hypothesis 1 predicted that there would be a difference in the level of homophobia related to gender, age, race/ethnicity, and education.
  • Results indicated
    • Age: statistically significant (p < .05) differences between the age groups
    • Ethnicity: statistically significant (p < .05) differences among ethnicities
    • Education: no statistically significant difference in ATLG scores based on educational preparation
    • Gender: no statistically significant difference between males and females (perhaps due to small number in sample)


  • Research suggests that as age level increases, overall homophobia also increases and although age was statistically significant in this study, nurses aged 40-49 in this sample had an overall homophobia level close to those nurses under the age of 30.
  • Perhaps using the age of 30 (as identified in the literature) as a distinction point is inappropriate, especially in the nursing population.


  • Statistically significant differences were also found between the various ethnicities of the nurses in this study.
  • In this study ethnicity as an overall collective independent variable was a predictor of homophobia. However, the differences between the races themselves were not significant. Thus, we can conclude that race/ethnicity is a significant predictor of homophobia, but we cannot label one race as being more predictive than another.


  • Lewis (2003) found African Americans to have higher levels of homophobia compared to Caucasians. However, the exact reason for this is not known (is speculated to be related to education, religious association, and gender; however, this study underrepresented males and religious association was not a statistically significant predictor of homophobia.
  • With a higher proportion of Caucasian women participating in this study compared to African American women, it is possible that lower ATLG scores among African Americans standout and are more obvious.


  • Education: Although the educational levels of this sample were not statistically significant, the question was flawed leaving this variable in the hypothesis unclear.

Hypotheses 2, 3, 4, and 5

  • To test hypotheses 2, 3, 4, and 5, structural equation modeling (SEM) was used.
  • All independent variables were placed on the left side of the model and were correlated with the latent construct of homophobia, which was then correlated with the 20-item ATLG scale.

Original SEM

Hypotheses 2, 3, 4, and 5

  • Hypothesis Variables CR Value
  • 2 Religion .96 Ideology -.68
  • Frequency -1.32
  • 3 * Free-Choice 5.91
  • 4 * Interpersonal Contact 3.61
  • 5 * Support -4.01
  • Not-Support 3.23
  • * Statistically significant at p <.05

Reconfigured SEM

Discussion: Hypothesis 2

  • Hypothesis 2 suggested that there would be a positive correlation between religious association and homophobia.
  • The literature indicates that religion, religious ideology, and frequency of church attendance are positive predictors of homophobia
  • In this study, none of the three indices used to gauge religious association were statistically significant correlates with overall homophobia.
  • It is possible that there are more inputs to this latent construct than religion, religious ideology, and frequency of church attendance.

Discussion: Hypothesis 2

  • Perhaps a survey instrument examining religion outside of the context of spirituality is insufficient for nurses.
  • Thus, personal religious identity may not be as influential to a nurses’ overall religious association as it is to the general heterosexual population.
  • Another possible explanation for the lack of correlation between religious association and homophobia pertains to the differences in the importance of religion to healthcare workers compared to non-healthcare workers. Many nurses incorporate spirituality into the care provided to clients; but spirituality extends beyond religion (Cavendish, et. al, 2004).

Discussion: Hypothesis 3

  • Hypothesis 3 supported a positive correlation between belief in the “free choice” model of homosexuality and homophobia.
  • This finding echoes that of the literature which suggests that individuals who believe gay men and lesbians consciously choose to be homosexual are more homophobic than those individuals who believe biological and psychosocial influences are responsible for the development of a person’s sexual orientation

Discussion: Hypothesis 4

  • Hypothesis 4 claimed there would be a negative correlation between interpersonal contact with gay men and/or lesbians as friends and/or family members and homophobia.
  • Support for this hypothesis also echoes the findings within the literature.
  • Perhaps more interactions heterosexuals have with homosexuals, the more integrated such interactions become in heterosexual life. Thus, heterosexuals deem homosexuality as an expected component of human existence.

Discussion: Hypothesis 5

  • Nurses who supported the workplace policy were significantly less homophobic than those who did not support the policy.
  • Nurses are taught a holistic approach to healthcare and holism emphasizes respect for the person as a whole physical and spiritual being.
  • Because of the emphasis of this in nursing, perhaps nurses believe workplace protection policies help provide respect for homosexual persons by maintaining their integrity and individuality.

Serendipitous Findings

  • Of the 165 surveys included in this study, 16 had personalized comments hand-written by the participant on the survey instrument (one nurse wrote on the cover letter sent with the survey and another sent a detailed letter expressing her reflections).
  • Six (6) of the responses could be interpreted as gay-affirming while 7 of the responses were homonegative; the researcher had difficulty classifying 3 of the responses as gay-affirming or homonegative.

Future Research

  • National or global research
  • Studies that explain differences and the evolution of homophobic thought processes
  • Qualitative research to
    • explain causality in homophobia
    • analyze differences in attitudes and beliefs
    • bridge the current gap between phenomenon and explanation.

Implications for Nursing Administrators

  • Policy Development
  • Managing of personnel
  • Privacy
  • Education
  • Workplace Environment
  • Workplace Safety
  • Benefits
  • Recruitment & Retention

Policy Recommendations for Nursing Administrators

Amend Non-Discrimination or Equal Employment Opportunity Policies

  • Declare in clear, unequivocal terms a policy prohibiting discrimination against transgender employees equal to other protected categories by including “gender identity or expression” along with “sexual orientation” among the list of protected categories in your primary, workplace-wide, non-discrimination or EEO policies.

Establish Written Guidelines Regarding Process and Roles That Clarify Responsibilities for Management and Staff

  • Institute protocols that make it clear to transitioning employees, their supervisors and other staff who is responsible for issues that arise when an employee transitions.

Provide Information and Training

  • Incorporate education about transgender issues in the workplace in diversity training programs.

Ensure Employee Privacy

  • Treat an employee’s transgender status as private and confidential.

Change Personnel and Administrative Records

  • Upon an employee’s request, change the employee’s name and sex in all personnel and administrative records, including internal and external e-mail and business cards.

Grant Restroom Access According to an Employee’s Full-time Gender Presentation

  • Permit an employee to use restrooms that correspond to his/her full-time gender presentation, regardless of what stage that individual is in terms of his/her transition process.

Grant Locker Room Access According to an Employee’s Full-time Gender Presentation

  • Unless there is unavoidable nudity, grant locker room access according to an employee’s full-time gender presentation regardless of what stage that individual is in terms of his or her transition process.

In the Case of a Dress Code, Make It Gender-Neutral and Apply Consistently

  • If an employer has a dress code, it should create or modify it to avoid sexual stereotypes and then enforce it consistently

Remove Health Insurance and Short-Term Disability Exclusions for Medically Necessary Treatments and Procedures

  • Wherever possible, remove exclusions for medically necessary treatments and procedures, such as those defined by the Harry Benjamin International Gender Dysphoria Association’s Standards of Care for Gender Identity Disorders, from company provided health care and short-term disability coverage.

Extend Wellness-Related Benefits to Transgender Employees

  • Modify health- or disability-related leave policies to allow transgender employees to take leave associated with medically necessary treatments and procedures.

Treat a Transgender Employee’s Spouse as You Do Other Employees’ Spouses in the Provision of Employment Benefits

  • One way to ensure that employees’ partners are treated equitably is to extend domestic partner benefits to both opposite- and same-sex partners.

What can you do right now??

  • Attain a safe workplace environment that is rich in cultural diversity.
    • Hiring employees based on qualifications who are diverse in gender orientation
    • Encourage discrete openness among staff (gender orientation is not appropriate for sharing with patients in any form)
    • Maintain an environment of tolerance among employees

What can you do right now??

  • Conduct education programs aimed and increasing awareness and evaluating personal values related to gays and lesbians.
  • Invite gays and lesbians in professional jobs to conduct education programs to expose employees.
  • Invite gay and lesbian professionals in health care to consult on existing workplace policies and make recommendations for revision

What can you do right now??

  • Develop programs that increase exposure through a greater number of outreach programs for GLBT clients.
    • Collaboration between health department’s and local gay and lesbian organizations in health promotion activities
    • Substance abuse, HIV, depression, and suicide are more prevalent in homosexuals than the general population

Policy Development

  • Federal and Florida State laws do not mandate employers to legally protect gay men and lesbians from discrimination in the workplace…BUT YOU CAN!!

Drs. Kiehl & Blackwell: Graduation 2005

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