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Research in Nursing

Conceptualising social exclusion and lesbian, gay, bisexual, and transgender


people: the implications for promoting equity in nursing policy and practice
Julie Fish
Journal of Research in Nursing 2010 15: 303 originally published online 15 March 2010
DOI: 10.1177/1744987110364691
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Conceptualising social
exclusion and lesbian, gay,
bisexual, and transgender
people: the implications for
promoting equity in nursing
policy and practice

Journal of Research in Nursing


15(4) 303312
! The Author(s) 2010
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DOI: 10.1177/1744987110364691
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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

Introduction: social exclusion and health


Social exclusion became a key concept in UK policymaking and practice following the
establishment of the Social Exclusion Unit in 1997 by the New Labour Government.
Although social exclusion is often conceptualised as being synonymous with poverty, the
concept has been used to develop approaches to address wide-ranging problems from housing
to teenage pregnancy (Percy-Smith, 2000). Social exclusion is a key marker for health; however,
Corresponding author:
Julie Fish, Hawthorn Building, School of Health and Applied Social Sciences, The Gateway, De Montfort University,
Leicester LE1 9BH, UK. E-mail: jfish@dmu.ac.uk

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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.

In what ways can LGBT people be considered as socially excluded?


Although LGBT people have not been previously considered within debates about social
exclusion, there is acknowledgement that they experience health inequalities (Fish, 2007a;
Hutchinson et al., 2006; Scott et al., 2004). This section analyses some of the theoretical
underpinnings which might lead to recognition of the concept of LGBT social exclusion. In
their discussion of the fundamental causes of social exclusion, Hills et al. (2002) identify
three schools of thought in the literature:
. placing individuals behaviour and moral values at centre stage;
. highlighting the role of institutions and systems;
. emphasising issues of discrimination and lack of enforced rights (Hills et al., 2002; p. 3).
These three approaches will be used to assess (below) whether LGBT people could be
considered as socially excluded.

Placing individuals behaviour and moral values at centre stage


In these debates which Levitas (1998) has conceptualised as the moral underclass
discourse those who are socially excluded are blamed for their circumstances and the

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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.

Highlighting the role of institutions and systems


The notion of being shut out of societal institutions and the non-participation in key social
activities has shaped the patterning of LGBT peoples public lives. Until 2005 in the UK,
there was no social institution equivalent to that of marriage which enabled the public
recognition of LGB peoples intimate relationships; as a consequence, LGB people were
unable to access the social and health benets conferred by marriage-like status (King and
Bartlett, 2006). Their place within other social institutions, such as religion, the Criminal
Justice System and the armed forces, has had a history of contestation and opposition
(Moran, 2007).
Multi-system factors inhibit their access to healthcare and contribute to disparities in
health outcomes: the culture, norms and values of social institutions act as barriers to
eective healthcare (Hutchinson et al., 2006). LGBT people have often been invisible users
of healthcare, and service provision has been sexuality blind in treating LGBT people in the
same way as everyone else without consideration of their dierent requirements (Fish, 2009).
Across public and voluntary sector services, in housing (Gold, 2005), social care (Concannon,
2009) and education (Rivers, 2004), the needs and experiences of LGBT people as service
users have been overlooked in policy development and implementation.

Emphasising issues of discrimination and lack of enforced rights


A third theoretical approach to social exclusion emphasises the denial of civil, political and
social rights. In this formulation, those who are socially excluded are not accorded full
membership of society and are unable to achieve normal levels of social acceptance and
participation (Burden and Hamm, 2000; p. 184). In the social exclusion literature, there is
recognition that the false universalism of citizenship has prevented lesbians and gay men
from attaining the status of citizen (Lister, 1998; p. 29). Until the early twenty-rst century,
LGBT people endured a historic lack of social protections in employment, in the provision
of goods and services, in housing tenure, and in pension rights, and there were a range of
other social rights to which they were not entitled; moreover, they did not have access to
legal systems that could make those rights a reality (Fish, 2006, 2007b). Discrimination and
negative social attitudes are common to the experience of social exclusion (Burden and
Hamm, 2000), and this has led to the inclusion of women, black and minority ethnic
people and faith groups among those who are socially excluded.
On each of these three grounds individuals behaviour and moral values, the role of
institutions and the lack of enforced rights LGBT people can be said to be socially
excluded. They have been considered as a moral underclass, shut out of social institutions
and have been excluded from the rights associated with citizenship.

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Definitions of social exclusion


Denitions of social exclusion encompass exclusion from full participation in society and the
recognition that disadvantage plays a part in limiting peoples life chances and health
outcomes. In such characterisations, social exclusion is described as:
the right (. . .) to participate in the major social and occupational institutions of society. Thus,
social exclusion occurs when citizens are denied these social rights or they are not fully realised
and, furthermore, in such circumstances citizens are likely to experience more generalised
disadvantage (Percy-Smith, 2000; p. 4).

Drawing on the above concepts and on Percy-Smiths (2000) dimensions, I propose a


model of social exclusion with illustrations of indicators for the various dimensions in order
to conceptualise the social exclusion of LGBT people.

Dimensions of social exclusion for LGBT people


The economic dimension
Poverty is often seen to be a dening feature of social exclusion. LGB people are widely
perceived to be employed in professional occupations and to have higher than average
incomes (Women and Equality Unit, 2006). But the notion of the Pink Pound has been
derived, not from population-based surveys, but through the readership of glossy
magazines, whose target audience is not typical of average adults or reective of average
incomes (Badgett, 1998). Recent UK research has suggested that gay men earn less than their
heterosexual counterparts, although the earnings dierential is small (Arabsheibani et al.,
2004). Although their middle class status is contested (Taylor, 2005), perceptions of auence
have led to assumptions that LGB people comprise a socioeconomic elite who are insulated
from discrimination and to their neglect from debates about social exclusion.

The social dimension


The social dimension refers to the wider inuences on health inequalities, often referred to
as upstream factors, including work environment, education and housing (Acheson, 1998).
The Acheson report contended that health inequalities are the outcome of causal and
inter-related chains arising from the basic structure of society (Acheson, 1998; p. 8).
A growing body of research shows that such upstream factors have a detrimental impact
on the health of LGBT people. In relation to the rst factor, work environment, research
showed that one in ve LGB people reported experiences of workplace bullying because of
their sexual orientation (Hunt and Dick, 2008). Working class LGB people were more likely
to experience bullying than those in higher occupational groups. Transgender people report
being verbally abused and physically assaulted in the workplace; as a consequence, a quarter
of them have felt obliged to change their employment (Whittle et al., 2007). The second
factor, education, is often considered to oer a route to participation and active
citizenship. For young LGB people, schools are places where homophobic bullying is an
increasing problem (House of Commons Select Committee Education and Skills, 2007).
Possible outcomes, alongside unauthorised absence from school leading to educational
under-attainment, include depression, attempted suicide and diculty in forming
relationships (Rivers, 2004). Young trans people may experience even higher rates of
bullying and harassment, with 64% of young trans men and 44% of young trans women

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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.

The political dimension


The political dimension refers to peoples ability to engage in decision making which aects
their lives (Percy-Smith, 2000). It can mean being consulted through local involvement
networks about the design and delivery of services. The Local Government and Public
Involvement in Health Act 2007 strengthened the National Health Service (NHS) duty to
individuals and communities in shaping health and social care services. The opportunities for
consultation with dierent groups and communities are aected by the availability of a
public forum with which to engage. The historic and current under-funding of the LGBT
voluntary sector and the consequent lack of an infrastructure through which to seek the
views of users may lead to the under-representation of LGBT concerns within political
processes (Cant, 2006).

The neighbourhood dimension


Unlike (some) other marginalised groups, LGBT communities are, by and large, not located in
a geographic neighbourhood; rather, they form communities of interest which are less
spatially boundaried. There are, however, some well-known exceptions where community
and territory have coalesced. From the late 1970s onwards, LGBT public spaces emerged,
particularly in US and UK cities; for example, the notion of a gay village became known in
New York, San Francisco, London and Manchester, aording a sense of community and
identication. These geographical neighbourhoods often consisted of areas where people
socialised rather than lived and worked, although Brighton and the market town of
Hebden Bridge have become places where people are able to live more integrated lives:
working, engaging in community activities and socialising within a geographic space
together. However, the high visibility of such places has also led to encroachment and the
erosion of gay-friendly public spaces. For example, the area surrounding Manchesters gay
village has one of the citys highest levels of reported assault (Pritchard et al., 2002). For trans
people also, who may not have had the same degree of identication with a particular locale,
there has been a sense of exclusion from their local neighbourhood following transition
(Whittle et al., 2007). Public spaces, then, raise issues about community safety for LGBT
people; the most common incidents recorded in the Criminal Justice System were verbal
abuse, intimidation and physical assault (Wake et al., 1999). Since 2005, the Crown
Prosecution Service (CPS) has reported on the prosecution of homophobic and transphobic
crimes following the introduction of legislation which created the oence of hate crime on the
grounds of sexual orientation and gender identity (Crown Prosecution Service, 2008).

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The individual dimension


The links between poor mental health and social exclusion are increasingly recognised, and a
range of policy interventions seek to mitigate its aects (National Social Inclusion
Programme, 2009). Recent research suggests that LGBT people may be at higher risk of
mental health problems and suicidal behaviour than heterosexual people (King et al., 2008;
Whittle et al., 2007). Depression, anxiety, alcohol and substance misuse were more common:
lesbian and bisexual women were at particular risk of substance dependence, while lifetime
risk of suicide attempts was particularly high among gay and bisexual men (King et al.,
2008). Stigma, prejudice and discrimination are seen to create a social environment that
leads to mental health problems. The increased risk of mental disorder in LGBT people is
linked to experiences of discrimination; they are more likely to report both daily and lifetime
discrimination than heterosexual people (Mays and Cochran, 2001; Meyer, 2003).

The global dimension


There is increasing awareness of the global environment in which LGBT people live their
lives and of uneven state protections (de Gruchy and Fish, 2004). Although the United
Nations (UN) has considered sexual orientation as a status protected from discrimination
for almost a decade (Human Rights Watch (HRW), 2005); in 2008, 86 UN member states
continued to criminalise consensual same-sex acts among adults. In fourteen countries, the
penalty is imprisonment ranging from 11 years to a life sentence. Seven countries impose the
death penalty for homosexuality; in 2005, two teenage boys were publicly hung for same-sex
sexual behaviour in Iran (Ottosson, 2008). It is within this context that human rights
organisations have lobbied national governments to prohibit discrimination on the
grounds of sexual orientation. In 1996, South Africa became the rst country worldwide
to include protections for LGB people in its constitution, leading to a number of legal
decisions which advanced LGB peoples equality claims (Fish, 2009). The lack of human
rights for LGB people has global consequences: it is increasingly likely that they will seek
asylum in those countries which have implemented sexual orientation equality legislation.

The group dimension


Certain groups are potentially at greater risk of social exclusion because of their dierence
from the dominant population. Dierence may lead to discrimination; Percy-Smith (2000)
proposes that obvious aspects of group dierences include ethnicity, religion and age. This
dimension helps to problematise assumptions that LGBT people form a homogenous group:
they are often perceived to be white, young, able-bodied and middle class. However, LGBT
people are represented in every social group: they are young and old, black and minority
ethnic people, disabled and living in poverty (Fish, 2008). The heterogeneity of LGBT
communities and the dierences in experiences of health and healthcare have been
examined through the theoretical lens of intersectionality.
A growing body of literature, then, highlights the legacy of social exclusion experienced
by LGBT people in relation to the historic lack of enforced rights, their marginalisation
within social institutions and in debates which have constructed them as morally inferior. An
individual or group is more likely to be vulnerable to exclusionary processes when they

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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).

Implications for promoting LGBT health equity in nursing policy


and practice
This paper has proposed that everyday experiences of social exclusion for example at
work, in education and in neighbourhoods impact on the health outcomes of LGBT
people. Experiences of discrimination such as bullying and harassment in the workplace,
homophobic hate crime or rejection from their family aect LGBT peoples
conceptualisations of their own health and their health behaviours. The historic eects of
social exclusion have consequences across the lifespan and, in particular, for the health of
older LGBT people who were growing up at a time when homosexuality was criminalised.
Knowing about these life circumstances may help nurses to promote health equity for LGBT
people in nursing practice and to deliver competent care.
The UK NHS is a publicly funded universal healthcare system founded on the principle
that good healthcare should be available to everyone in the population irrespective of their
income or social position. The principle of equity encompasses access to healthcare and
quality of care. The notion that the healthcare system might treat some people less
favourably than others appears to question this fundamental tenet. Studies have shown,
however, that nurses lack basic knowledge of black and minority ethnic patients cultural
and religious requirements and make stereotypical assumptions about them (e.g., Hamilton
and Essat, 2008). As Lynam et al. (2008) have noted, peoples decisions about healthcare are
inuenced by their expectations of how they will be treated by nursing professionals. LGBT
peoples interactions with health professionals have often been characterised by
embarrassment and discomfort (Hinchli et al., 2005). Such adverse experiences may
mean that LGBT people delay seeking care. Furthermore, the quality of care an LGBT
patient receives may be inuenced by the disclosure of their sexual orientation. Patients who
come out are likely to be more satised with the care they receive; they experience greater
ease in communicating with their nurses, and disclosure allows for the possibility of
including a partner in treatment decisions (Fish, 2006). Health information and advice
can then be tailored to the needs of the patient group (for example, lesbians who do not
come out have been advised by sexual health nurses to use condoms).
Research suggests that nurses lack essential knowledge about LGBT health needs and
risks, they are sometimes insensitive in providing care and may not provide information with
which LGBT people can make informed decisions about their health (Polek et al., 2008;
Rondahl, 2009). This may be partly accounted for by the absence of LGBT health issues in
the nursing curriculum, or where it is included, it is often within an illness framework. By
providing a culturally competent educational environment in which nurses develop their
understanding about the lives and healthcare experiences of LGBT people, the attitudes
of nursing students will move from neutrality to patient advocacy (Dinkel et al., 2007).

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

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Table 1. Dimensions of social exclusion for LGBT people


Dimension

Indicators

Economic

Assumptions of middle class status


Stereotype of the Pink Pound
Homophobic bullying in schools
Workplace harassment and bullying
Homelessness
Access to public services
Discrimination
Historic lack of legislative protections
The legacy of section 28 of the Local Government Act 1988
Lack of community infrastructure
Lack of decision-making forums
Community safety and hate crime
De-gaying of urban spaces
Community of interest not geographic community
Mental health
Substance misuse: smoking, alcohol consumption
Eating disorders
Lack of state protection in many countries worldwide
Asylum
Intersecting identities

Social

Political (Civil and legal)

Neighbourhood

Individual

Global
Group

Source: Adapted from Dimensions of Social Exclusion Percy-Smith (2000).

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;

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. 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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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.

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