Hetero- and cisnormativity—UK pharmacy education as a queer opponent
Funding: None.
Abstract
Introduction
Queer pedagogy is a lens through which the hegemonic discourses of curricula and the heterosexual assumptions within them can be made visible. Using this lens, sexuality and gender norms incorporated in undergraduate medical and health curricula can be located and the lived experience of a curriculum examined. This paper seeks to determine the extent of hetero/cisnormativity within UK pharmacy education with the aim of problematising the normalisation of heterosexuality; following this, strategies to disrupt structured hetero/cisnormativity are considered.
Methods
Online cross-sectional surveys were distributed to course leads (n = 29) and students enrolled on undergraduate pharmacy (MPharm) programmes. Surveys captured quantitative data on curriculum design and perceived barriers to implementation of inclusive curriculum design (the espoused LGBTQI+ curriculum), as well qualitative data on the lived experience of the hidden curriculum. Quantitative data were analysed using descriptive statistics, whereas qualitative data were analysed thematically.
Results
Responses were received from 19 course leads and students from 25 MPharm programmes, representing varying completion rates. Findings suggest the shared values and goals of pharmacy education act to normalise and legitimise hetero and cis identities within curriculum design that othering as a consequence of heterosexual normativity is experienced and that pharmacy education is an LGBTQI+ opponent and does not adopt an ally attitude. Moreover, both educator and student data suggest that the enacted and experienced curriculum fails to prepare learners to care for LGBTQI+ people.
Discussion
Despite findings suggesting the espoused or enacted curriculum absents LGBTQI+ people, and the hidden curriculum is experienced as homonegative, learners are questioning, resisting and disrupting the hetero- and cisnormative benevolent heterosexism within UK pharmacy curricula. This method of curricula interrogation can be adopted across health professions education as a means for ongoing problematising and disruption of normativity in clinical education.
1 INTRODUCTION
Heteronormativity1 refers to a view of sexuality where ‘heterosexuality is taken as normative within society’.2 The concept of heteronormativity is grounded in post-structuralist feminist theory where heterosexual male dominance is critiqued as both a societal norm and social conditioning. This heterosexual male hierarchy binarises gender and sexual orientation and gives rise to homonegativity or the negative attitude towards sexual divergence.3 Genderfication, the binarised view of gender, involves the standardisation of gender within the heteronormative construct of male/female, boy/girl. Whereas sexual diversity has somewhat mainstream visibility and tolerance, gender diversity has not and continues to be policed, diminished and ‘othered’.4, 5
Queer theory, emerging in the 1990s in response to widespread overt homophobia during the AIDS endemic, argues for a non-binary normality that allows for an ‘open mesh of possibilities’6 deconstructing an ideology of normal heterosexuality within social consciousness, cultural practices, institutions and politics, termed the heterosexual matrix.7-10 Warner11 argues that the construct of sexual normality is not only heterosexual but a defined type of prevailing heterosexuality that is masculine, occurs in monogamous, for life marriage, and forms the morality of many Western cultures. So, although the dominant heteronormative discourse rewards the perceived natural normality, non-conforming sexuality or gender is criminalised, medicalised, policed, punished and ‘othered’.12 In response to this prevailing heteronormative discourse, queer theory deconstructs essentialised heteronormativity and seeks to disrupt binary conceptualisations of sexuality and gender.13
Queer pedagogy draws together queer theory and critical pedagogy to examine, ontologically, the normalisation and default of heterosexual ideology within teaching and learning. The hegemonic normality of heterosexuality persuasively infiltrates every aspect of society; in education, this creates an ‘otherness’ when considering LGBTQI+ identifying people. Queer pedagogy, then, challenges the dominance of heteronormativity within education and the antipathy associated with sexual/gender intolerance.7, 14 From this perspective, it is possible to identify the ways that curriculum design is arranged to incorporate heteronormative values and goals and to critique the face inclusivity and visibility of initiatives intended to disrupt heteronormative discourse, the invisibility of queer sexuality10 and normalised heterosexual sexuality in higher education.15, 16 That transphobia is prevalent despite LGBTQI+ inclusivity having a platform supported by legislation within the United Kingdom (UK) suggests the experienced and hidden curriculum contradicts the inclusivity espoused by education providers. Reports16-19 have highlighted inadequate representation of LGBT people and issues, exposing a normative hidden curriculum in medical, health science and STEM programmes. In health profession education, this can be seen in the ways that patients are presented as heterosexual and are treated as such20-24 and so non-normative people are invisible. The effect of this is to further instil heteronormativity in students' psyche and to reinforce implicit bias.25-27
A national policy mechanism, the UK Government Equalities LGBT action plan,28 recommended education and training to address this implicit heteronormative bias. In the context of pharmacy education, the General Pharmaceutical Council (GPhC), the regulatory body for pharmacists,29 references a need for inclusivity in its standards for initial (undergraduate) education and training29, 30 although the LGBTQI+ pharmacist network group has called on the GPhC and Pharmacy Schools Council (a body that represents all 29 MPharm programmes in the United Kingdom) to revise the undergraduate (MPharm) degree to be LGBT+ inclusive.31 Representation within undergraduate pharmacy education is important in order to prepare graduates to care for non-heteronormative people and in order to understand them both as people and as a structurally disassociated/violated group. This is critically important because it is widely evidenced that LGBTQI+ people suffer health inequalities and the implicit or explicit biases of health care providers that reinforce structural, systemic inequalities.32, 33
It is not just pharmacy education that needs to include representation of LGBTQI+ people. There is evidence that medical and other health profession curricula exclude sociocultural information in case studies or clinical presentations24, 34 at the expense of the role that culture and identity play in health and well-being. Arguments that medical education fails to train doctors to address LGBTQI+ health inequalities, and ignores LGBTQI+ people and/or medicalises queer issues, persist as a product of a training gap.35 This is unlikely to be addressed in the short term given that curricula are not mandated to be inclusive of specific LGBTQI+ competencies and that queer issues remain peripheral.35 Whilst the General Medical Council (GMC) has produced a guide for LGBT patients on what to expect from UK doctors,36 this is in lieu of any material changes to medical education and training. Consequently, in 2022, the British Medical Association (BMA) renewed its call for teaching and learning about LGBTQI+ people and their health needs in undergraduate and postgraduate medical education and for the removal of stereotyped teaching.37
Where previous studies20, 33, 34, 38-40 have sought to establish the extent of LGBTQI+ representation in undergraduate curricula, given medical and health professions curricula still struggle with designing inclusive programmes suggests that either educators are not acting on the findings of this research or that they are unsure of how to enact representation in their pedagogic practice. To this end, the research presented here adopts the lens of queer pedagogy to critique heteronormative hegemonic power. It seeks to interrupt heteronormativity and to uncover the implicit bias that works to create invisibility of LGBTQI+ in UK pharmacy education and agitate thinking in medical and health professions education.
- Establish if, and to what extent, pharmacy curricula are designed as hetero- and/or cisnormative. In addressing this aim, a further objective is to identify examples where the curriculum is used as a tool to disrupt normativity
- Critique the hidden LGBTQI+ curriculum identifying if, and in what ways, the espoused and enacted curriculum differ from that which is experienced.
2 METHODS
2.1 Research approach
We have approached this study from a critical realist standpoint41 and use queer theory—in particular queer pedagogy—to deconstruct UK undergraduate pharmacy education, with a view to making visible the practices of normalisation within curricula. Our research approach combines a quantitative survey to capture descriptive data on pharmacy curricula (and in so doing, address the first aim of our study); we also collected qualitative data to deepen our understanding of pharmacy curricula and to allow us to hear the student voice regarding the hidden curriculum and their experiences of the enacted curriculum. We believe that using both quantitative and qualitative approaches is important in order to fully explore and understand curricula structures and practices as both observable and experienced.
2.2 Setting and participants
Data were collected using an online cross-sectional survey design. Eligible participants from two distinct groups of stakeholders were invited to take part between June and December 2021: Undergraduate (MPharm) course leads working at UK universities offering an MPharm programme at the time of the study (n = 29), who were approached using contact details found online; and undergraduate pharmacy students who were recruited through contacts identified by searching online directories at their education institution and additionally via the British Pharmaceutical Students Association, the Pharmacist Defence Association mailing lists and via Twitter. An initial estimated sample size for UK undergraduate pharmacy students included in the study was based on published intake numbers to Year 1 of the MPharm programme for each respective year from 2018 to 2021 as n = 15 635, not including attrition.42-45
Each stakeholder group was invited to complete an anonymous online questionnaire designed specifically for that respondent group.
2.3 Measures and survey development
Course leads: Assessment of hetero and/or cisnormativity in pharmacy curriculum design was based on Tollemache et al.38 and Obedin-Maliver et al.39 measures, with wording adapted to pharmacy education as the original tools were designed for medical education. Survey items (n = 24) captured number of hours of LGBTQI+ teaching across the whole undergraduate course, teaching methods and barriers to LGBTQI+ teaching in the MPharm. An additional 10 items related to hetro- and cisnormativity, gender, allyism and two questions about MPharm education and training standards were also included.
Students: A similar questionnaire design including measures aligned with the study's conceptual framework was administered to students, consisting of 32 items derived from previous studies reworded for pharmacy students, together with an additional nine items collecting data related to hetro- and cisnormativity, gender, allyism and MPharm education and training standards.
Questionnaire responses were captured using multiple-choice questions, free-text questions, Likert scales and matrix tables. An open-ended question invited participants to provide further detailed views on LGBTQI+ curriculum design, barriers and experiences.
Questionnaire responses were collected using Qualtrics® following pilot work to establish face and content validity. Informed consent was obtained electronically prior to providing survey responses.
Ethical approval was sought and obtained from the home institution of the researcher: project ID 11543.
2.4 Data analysis
To establish whether curricula design is hetero- and/or cisnormative, descriptive statistics were calculated using IBM SPSS Statistics version 25®. Responses from course leader and students were then compared to identify possible differences in the espoused/intended curriculum and the experienced/hidden curriculum. Qualitative data from free-text responses were analysed using a comparative method.46 This is an iterative process of coding and thematic analysis that provided additional meaning to the descriptive statistics concerning how LGBTQI+ teaching is positioned and considered. The qualitative data further provide insight into how discursive strategies are used to other LGBTQI+ people. Following this, quantitative and qualitative datasets were interpreted through the lens of queer pedagogy.
AM constructed and distributed the surveys. AM and SW were both involved in data analysis and interpretation. This was particularly important for the qualitative data, where although our approach was primarily inductive, the quantitative data were used initially to frame coding deductively under broad categories for understanding the experienced and hidden curriculum. Following this, inductive analysis was undertaken by each of the authors independently, with us coming together to discuss coding and interpretation. Through reflexive discussions, we were able to generate understanding of codes and apply our conceptual, theoretical standpoint of queer pedagogy.47
3 RESULTS
After reviewing responses from course leads to ensure they reached a minimally acceptable level of completion, 19 valid cases were analysed, yielding a 65.5% response rate. Of these 19 responses, 18 completed 100% of the survey, and one respondent completed 71% of the survey. The student survey received 458 responses from students based at 25 universities with mixed completion rates. The quantitative findings are presented to reflect the percentage of valid responses.
Analysis presented both describes, quantitatively, the current state of play reported to us in the survey, with qualitative data used to provide a narrative account of these numerical data. We deconstruct pharmacy curricula to identify the ways that curricula are enacted in a hetero−/cisnormative paradigm. As a consequence, we show the ways that this then creates a hidden curriculum where LGBTQI+ people are represented in a reductive, invisible and stereotyped way, which we argue results in producing graduates who are unprepared for practice within a diverse society. This deconstructive approach can be adopted across medical and health professions curricula.
3.1 Pharmacy curriculum design—To what extent are curricula hetero- and cisnormative?
Both course lead (61.1% [n = 11] of 18 respondents) and student participants (71.3% [n = 97] of 136 respondents) viewed pharmacy curricula as heteronormative in design. The same pattern of response was also recorded in relation to whether the curriculum is cisnormative (61.1% [n = 11] of 18 course leads and 71.3% [n = 97] of 136 students agreed that their MPharm programme is cisnormative). Table 1 outlines what LGBTQI+ content is covered, and to what extent, as a comparison between course lead and student responses. Across all items included in the questionnaire, educator respondents acknowledged either no, too little or basic coverage, with 47.4% (n = 9) of 19 respondents viewing their LGBTQI+ content coverage as poor and 26.3% (n = 5) as very poor, with only a very small minority viewing it as very good (5.3% [n = 1]) or fair (10.5% [n = 2]).
| Curriculum design: LGBTQI+ teaching and learning | Yes in the core curriculum | Yes as part of an elective unit/module | No | Don't know | Coverage not needed | No coverage | Too little coverage | Basic coverage | In-depth coverage | Too-much coverage | Don't know | |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Heteronormativity or social assumptions that people are heterosexual | Educator response | 9 (47.4) | 0 (0) | 8 (42.1) | 2 (10.5) | 0 (0) | 3 (15.8) | 9 (47.4) | 5 (26.3) | 2 (10.5) | 0 (0) | 0 (0) |
| Student response | 12 (6.7) | 2 (1.1) | 126 (70.4) | 39 (21.9) | 8 (4.5) | 101 (56.4) | 22 (12.3) | 11 (6.1) | 6 (3.4) | 2 (1.1) | 29 (16.2) | |
| HIV/AIDS in LGBTQI+ people | Educator response | 9 (47.4) | 2 (10.5) | 4 (21.1) | 4 (21.1) | 0 (0) | 3 (15.8) | 6 (31.6) | 5 (26.3) | 3 (15.8) | 0 (0) | 2 (10.5) |
| Student response | 55 (30.9) | 18 (10.1) | 66 (37.1) | 39 (21.9) | 7 (3.9) | 52 (29.1) | 40 (22.3) | 35 (19.6) | 18 (10.1) | 3 (1.7) | 24 (13.4) | |
| Sexually transmitted infections (not HIV/AIDS) in LGBTQI+ people | Educator response | 8 (42.1) | 1 (5.3) | 6 (31.6) | 4 (21.1) | 0 (0) | 5 (26.3) | 8 (42.1) | 3 (15.8) | 2 (10.5) | 0 (0) | 1 (5.3) |
| Student response | 21 (11.7) | 13 (7.3) | 111 (62) | 34 (19) | 6 (3.4) | 73 (40.8) | 42 (23.5) | 20 (11.2) | 12 (6.7) | 3 (1.7) | 23 (12.8) | |
| Mental health in LGBTQI+ people | Educator response | 7 (36.8) | 2 (10.5) | 6 (31.6) | 4 (21.1) | 0 (0) | 5 (26.3) | 9 (47.4) | 3 (15.8) | 1 (5.3) | 0 (0) | 1 (5.3) |
| Student response | 6 (3.4) | 5 (2.8) | 126 (70.4) | 42 (23.5) | 8 (4.5) | 94 (52.5) | 33 (18.4) | 9 (5) | 8 (4.5) | 2 (1.1) | 25 (14) | |
| Gender identity | Educator response | 7 (36.8) | 0 (0) | 9 (47.4) | 3 (15.8) | 0 (0) | 7 (36.8) | 7 (36.8) | 2 (10.5) | 2 (10.5) | 0 (0) | 1 (5.3) |
| Student response | 3 (1.7) | 2 (1.1) | 141 (79.2) | 32 (18) | 11 (6.1) | 102 (57) | 28 (15.6) | 6 (3.4) | 6 (3.4) | 1 (0.6) | 25 (14) | |
| Consultation/communication skills with LGBTQI+ people | Educator response | 7 (36.8) | 2 (10.5) | 9 (47.4) | 1 (5.3) | 0 (0) | 3 (15.8) | 9 (47.4) | 5 (26.3) | 2 (10.5) | 0 (0) | 0 (0) |
| Student response | 9 (5) | 5 (2.8) | 133 (74.3) | 32 (17.9) | 8 (4.5) | 99 (55.3) | 26 (14.5) | 9 (5) | 11 (6.1) | 1 (0.6) | 25 (14) | |
| Safer sex for LGBTQI+ people | Educator response | 7 (36.8) | 1 (5.3) | 8 (42.1) | 3 (15.8) | 0 (0) | 5 (26.3) | 8 (42.1) | 3 (15.8) | 2 (10.5) | 0 (0) | 1 (5.3) |
| Student response | 19 (10.6) | 11 (6.1) | 110 (61.5) | 39 (21.8) | 4 (2.2) | 81 (45.3) | 44 (24.6) | 19 (10.6) | 9 (5) | 1 (0.6) | 21 (11.7) | |
| Cisnormativity or social assumptions that people are cisgendered | Educator response | 6 (31.6) | 0 (0) | 11 (57.9) | 2 (10.5) | 0 (0) | 7 (36.8) | 9 (47.4) | 3 (15.8) | 0 (0) | 0 (0) | 0 (0) |
| Student response | 11 (6.1) | 1 (0.6) | 126 (70.4) | 41 (22.9) | 9 (5) | 104 (58.1) | 23 (12.8) | 7 (3.9) | 6 (3.4) | 2 (1.1) | 28 (15.6) | |
| Transitioning | Educator response | 5 (26.3) | 0 (0) | 11 (57.9) | 3 (15.8) | 0 (0) | 7 (36.8) | 7 (36.8) | 3 (15.8) | 1 (5.3) | 0 (0) | 1 (5.3) |
| Student response | 6 (3.4) | 4 (2.2) | 134 (74.9) | 35 (19.6) | 8 (4.5) | 104 (58.1) | 23 (12.8) | 10 (5.6) | 7 (3.9) | 0 (0) | 27 (15.1) | |
| Sexual orientation | Educator response | 5 (26.3) | 2 (10.5) | 9 (47.4) | 3 (15.8) | 0 (0) | 5 (26.3) | 9 (47.4) | 2 (10.5) | 2 (10.5) | 0 (0) | 1 (5.3) |
| Student response | 3 (1.7) | 3 (1.7) | 141 (78.8) | 32 (17.9) | 7.8 | 54.2 | 17.9 | 5 | 3.9 | 0.6 | 10.6 | |
| LGBTQI+ discrimination in health care | Educator response | 4 (21.1) | 1 (5.3) | 12 (63.2) | 2 (10.5) | 0 (0) | 7 (36.8) | 9 (47.4) | 1 (5.3) | 2 (10.5) | 0 (0) | 0 (0) |
| Student response | 6 (3.4) | 4 (2.2) | 136 (76) | 33 (18.4) | 7 (3.9) | 101 (56.4) | 27 (15.1) | 10 (5.6) | 9 (5) | 1 (0.6) | 24 (13.4) | |
| Preventative medicine and screening in LGBTQI+ people | Educator response | 4 (21.1) | 0 (0) | 13 (68.4) | 2 (10.5) | 0 (0) | 7 (36.8) | 8 (42.1) | 2 (10.5) | 2 (10.5) | 0 (0) | 0 (0) |
| Student response | 7 (3.9) | 2 (1.1) | 130 (72.6) | 40 (22.3) | 8 (4.5) | 101 (56.4) | 29 (16.2) | 7 (3.9) | 9 (5) | 1 (0.6) | 24 (13.4) | |
| Relationships and LGBTQI+ families | Educator response | 4 (21.1) | 0 (0) | 14 (73.7) | 1 (5.3) | 0 (0) | 11 (57.9) | 7 (36.8) | 1 (5.3) | 0 (0) | 0 (0) | 0 (0) |
| Student response | 2 (1.1) | 1 (0.6) | 140 (78.2) | 36 (20.1) | 13 (7.3) | 105 (58.7) | 23 (12.8) | 8 (4.5) | 5 (2.8) | 1 (0.6) | 24 (13.4) | |
| Alcohol, tobacco or drug use amongst LGBTQI+ people | Educator response | 4 (21.1) | 0 (0) | 13 (68.4) | 2 (10.5) | 0 (0) | 8 (42.1) | 7 (36.8) | 2 (10.5) | 2 (10.5) | 0 (0) | 0 (0) |
| Student response | 4 (2.2) | 5 (2.8) | 137 (76.5) | 33 (18.4) | 9 (5) | 99 (55.3) | 31 (17.3) | 12 (6.7) | 6 (3.4) | 1 (0.6) | 21 (11.7) | |
| Barriers to accessing medical care for LGBTQI+ people/LGBTQI health inequality | Educator response | 4 (21.1) | 2 (10.5) | 10 (52.6) | 3 (15.8) | 0 (0) | 4 (21.1) | 13 (68.4) | 1 (5.3) | 1 (5.3) | 0 (0) | 0 (0) |
| Student response | 6 (3.4) | 10 (5.6) | 126 (70.4) | 37 (20.7) | 5 (2.8) | 89 (49.7) | 46 (25.7) | 12 6.7) | 5 (2.8) | 1 (0.6) | 21 (11.7) | |
| Sex reassignment surgery | Educator response | 3 (15.8) | 0 (0) | 11 (57.9) | 5 (26.3) | 0 (0) | 8 (42.1) | 6 (31.6) | 3 (15.8) | 0 (0) | 0 (0) | 2 (10.5) |
| Student response | 1 (0.6) | 1 (0.6) | 139 (77.7) | 38 (21.2) | 12 (6.7) | 106 (59.2) | 24 (13.4) | 7 (3.9) | 6 (3.4) | 0 (0) | 24 (13.4) | |
| Disorders of sex development/intersex people | Educator response | 3 (15.8) | 0 (0) | 12 (63.2) | 4 (21.1) | 0 (0) | 9 (47.4) | 7 (36.8) | 1 (5.3) | 0 (0) | 0 (0) | 2 (10.5) |
| Student response | 5 (2.8) | 5 (2.8) | 133 (74.3) | 36 (20.1) | 6 (3.4) | 109 (60.9) | 23 (12.8) | 8 (4.5) | 7 (3.9) | 0 (0) | 26 (14.5) | |
| Chronic diseases in LGBTQI+ people | Educator response | 2 (10.5) | 0 (0) | 14 (73.7) | 3 (15.8) | 0 (0) | 10 (52.6) | 6 (31.6) | 3 (15.8) | 0 (0) | 0 (0) | 0 (0) |
| Student response | 10 (5.6) | 4 (2.2) | 131 (73.2) | 34 (19) | 7 (3.9) | 96 (53.6) | 35 (19.6) | 6 (3.4) | 10 (5.6) | 2 (1.1) | 23 (12.8) | |
| Coming out | Educator response | 2 (10.5) | 0 (0) | 14 (73.7) | 3 (15.8) | 0 (0) | 11 (57.9) | 7 (36.8) | 1 (5.3) | 0 (0) | 0 (0) | 0 (0) |
| Student response | 2 (1.1) | 0 (0) | 146 (81.6) | 31 (17.3) | 20 (11.2) | 106 (59.2) | 23 (12.8) | 8 (4.5) | 2 (1.1) | 1 (0.6) | 19 (10.6) | |
| LGBTQI+ adolescent health | Educator response | 2 (10.5) | 0 (0) | 15 (78.9) | 2 (10.5) | 0 (0) | 9 (47.4) | 8 (42.1) | 1 (5.3) | 1 (5.3) | 0 (0) | 0 (0) |
| Student response | 0 (0) | 5 (2.8) | 143 (80.3) | 30 (16.9) | 11 (6.1) | 105 (58.7) | 23 (12.8) | 8 (4.5) | 7 (3.9) | 1 (0.6) | 24 (13.4) | |
| Body image in LGBTQI+ people | Educator response | 2 (10.5) | 1 (5.3) | 13 (68.4) | 3 (15.8) | 0 (0) | 11 (57.9) | 6 (31.6) | 2 (10.5) | 0 (0) | 0 (0) | 0 (0) |
| Student response | 3 (1.7) | 2 (1.1) | 137 (76.5) | 37 (20.7) | 12 (6.7) | 106 (59.2) | 23 (12.8) | 8 (4.5) | 4 (2.2) | 1 (0.6) | 25 (14) | |
| Maternity and childbirth in LGBTQI+ people | Educator response | 1 (5.3) | 0 (0) | 16 (84.2) | 2 (10.5) | 0 (0) | 11 (57.9) | 8 (42.1) | 0 (0) | 0 (0) | 0 (0) | 0 (0) |
| Student response | 0 (0) | 3 (1.7) | 146 (81.6) | 30 (16.8) | 11 (6.1) | 105 (58.7) | 24 (13.4) | 7 (3.9) | 6 (3.4) | 0 (0) | 26 (14.5) | |
| Domestic violence in LGBTQI+ people | Educator response | 0 (0) | 0 (0) | 16 (84.2) | 3 (15.8) | 0 (0) | 11 (57.9) | 8 (42.1) | 0 (0) | 0 (0) | 0 (0) | 0 (0) |
| Student response | 1 (0.6) | 1 (0.6) | 143 (79.9) | 34 (19) | 14 (7.8) | 103 (57.5) | 21 (11.7) | 11 (6.1) | 3 (1.7) | 2 (1.1) | 25 (14) |
We have an 80% BAME cohort where culture and religion can be a barrier for students to accept equality and fair communication and service provision for LGBTQ+ people.
We don't include much/enough … we have a high number of students from [country X outside of the UK] … where homosexuality is illegal, and discrimination widespread and accepted … promotion of LGBTQI+ in educational settings is illegal [to these students] and our staff are understandably nervous they might be reported or prosecuted.
These barriers haven't really been overcome, hence the limited coverage of these issues. From discussing this survey with colleagues, there is a strong desire to do a good job in this area, but staff lack of confidence/experience in dealing with what are perceived to be sensitive topics is a big barrier … time [in the curriculum] is probably the second biggest barrier.
As a consequence, what emerges from the data is that pharmacy education is not an ally of LGBTQI+ people, with only 24.3% (n = 33) of 136 learner respondents and 38.9% (n = 7) of 18 course lead respondents agreeing that their MPharm is an ally of LGBTQI+ people.
[We] advised students of the nature of the content in advance of sessions and set clear ground rules for sessions.
We don't do much, from surveying my colleagues we specifically cover LGBTQI+ issues in relation to substance misuse and health promotion as part of certain sessions.
The curriculum is very reductive when it comes to gender identity, with staff sometimes expressing irritation when we bring this up … any teaching around safe sex is heteronormative, sexist and only relevant to straight monogamous relationships.
Pharmacy students need to be educated on issues specific to LGBT people because every piece of information taught assumes that they don't exist.
The barrier would be sensible individuals who believe that there is no need to include the LGBTQ community in every aspect of peoples' lives, including what they are taught. We are paying £10 000 per year to study and learn about pharmacy, not to have lessons given to us about the importance of ‘coming out’ … please, focus on more important things in your lives and leave students alone that do not want their time wasted with such irrelevant matters.
Results indicate that pharmacy students are trained to approach patient care and consultations within a heteronormative paradigm and are only equipped to practise in a normative world. Whereas 52.6% (n = 10) of 19 educators considered that LGBTQI+ content was taught in their programme, only 5.4% (n = 24) of 446 student respondents agreed. Specific content was most likely given between 0 and 5 hours and interspersed throughout the curriculum; only 26.3% (n = 5) of 19 programmes had specific teaching sessions dedicated to LGBTQI+ content. When considering LGBTQI+ teaching as a part of patient care or professional skills training, none of the educator respondents had any specific work based placements designed to focus on LGBTQI+ patient care (100%, n = 19 of 19). Only 26.3% (n = 5) of 19 programmes included same-sex history taking teaching in consultations skills training, and 42.1% (n = 8) of 19 programmes included gender history taking, but only 15.8% (n = 3) of 19 programmes taught the difference between behaviour and identity, that is, a man may have sex with men but identify as heterosexual. Whereas 57.9% (n = 11) of 19 course leaders indicated that their programme included teaching and learning about sexual orientation, only 31.6% (n = 6) of 19 programmes included teaching around gender identity. Similar responses were recorded by student respondents; in terms of consultation skills and history taking, 67% (n = 120) of 179 students indicated there was no training for asking patients about their gender, 74.3% (n = 133) of 179 students stated that there was no training for same-sex sexual history taking and 80.4% (n = 144) of 179 students stated that there was no teaching on the difference between behaviour and identity. In terms of assessment, 72.6% (n = 130) of 179 students indicated no assessment against intended learning outcomes regarding LGBTQI+ content.
3.2 The curriculum as a tool to disrupt normativity
In year 1, students currently have online content from [external LGBTQI+ group] … bespoke unconscious bias training via an EDI team … for person-centred care we have a patient session … the gentleman works with our students and reflects on his experiences with healthcare services as a gay man … however, no specific learning outcomes are set up around LGBTQI+ and this will need to be all reconsidered with the new MPharm.
Teaching activities in this space tend to be led by the same, relatively small group of people, who are more confident in their ability to develop and deliver teaching materials … we actively involve LGBTQI+ actors in communication sessions (both teaching and assessment) across all years of the MPharm programme, focusing on things like unconscious bias, preconceptions etc. rather than fact/clinical knowledge based content.
In the context of disrupting normativity, there is little evidence in the data to suggest that this LGBTQI+ teaching is sustained, conscious or commonplace, and it is usually assigned to an LGBTQI+ community member or ally to teach. However, there is evidence that educators intend to incorporate more LGBTQI+ content in direct response to the revised GPhC accreditation standards for the initial training and education of pharmacists29; 89.5% (n = 17) of 19 respondents are planning to implement new LGBTQI+ content within the next 3 years to meet these standards in areas already identified as having existing curricula coverage (see Table 1), and 71.3% (n = 102) of 143 learners agree that change is needed for their programmes to meet these standards. Although these new accreditation standards could be a vehicle for more inclusive curricula, 44.4% (n = 8) of 18 educators and 66.2% (n = 90) of 136 students either did not agree or did not know if these new standards specifically promoted inclusivity of LGBTQI+ people. These findings suggest that although policy change may have a positive impact on curricula design and inclusivity, change is not organic and exemplifies pharmacy as an opponent, not an ally, of LGBTQI+ people as it knowingly operates and maintains a structurally normative approach to inclusive education unless externally challenged by curriculum regulators.
3.3 The hidden curriculum—The gap between the espoused, enacted and the experienced
Tolerance at arm's length does not equal inclusion and acceptance (this is really a way of showing cognitive dissonance and distancing yourself from the community to avoid your own bias/prejudice). There can be no place for homophobia/transphobia among future pharmacy professionals, period.
Absolutely no content relating to LGBTQI+ individuals is taught.
It would be good to have scenarios that … weren't all cisheteronormative nuclear family led. I would much rather casual representation than being studied as other.
All of our OSCEs are needlessly gendered. It's always a man asking about his wife or woman her husband.
The only mention of LGBTQ+ people was in a HIV lecture which, whilst important, serves to perpetuate stigma seeing as other LGBTQ+ health inequalities are not covered.
There was a lecture on transgender hormone treatment … also MSM when we covered HIV and chemsex … I was not particularly happy that the only representation I have seen is limited to this.
Students need to be aware that they cannot disguise their homophobia or absolve themselves of responsibility by claiming ‘keep politics out of this’ … currently students are not prepared to deal with LGBT+ issues as we are not given the tools or knowledge to handle this. Additionally, homophobia/transphobia remains among student cohort, which is deeply worrying.
Any coverage of LGBTQI+ issues would be a start … currently, the entire curriculum has been hetero/cis-normative, assuming that all patients are male or female, and therefore have a penis or a vagina, respectively.
Teaching on LGBTQ+ identities, and the inequalities LGBTQ+ people face … teaching on gender-affirming care, particularly the pharmaceutical aspects of this. How to be an ally.
I think transitioning should be taught in depth. More people are using hormones as they transition and community pharmacies have been insensitive and ignorant to their use when collecting prescriptions.
More awareness of trans people and the difficulties they face accessing care. More awareness on how pharmacy services can be targeted to LGBTQIA+ groups. Ensuring students do not assume every patient they encounter is cishet and know how to broach topics such as gender and sexual orientation with sensitivity.
Everything is taught from a very binary gendered viewpoint especially, making no differentiation between sex and gender and no mention at all of intersex people. It is clear the course was designed by a white, cishet, middle class man despite a very diverse student base.
4 DISCUSSION
This is the first national study of LGBTQI+ teaching and learning problematising dominant hetero and cisnorms and beliefs within pharmacy education. Our study considers how this then works to exclude or other LGBTQI+ people, thus reproducing processes of exclusion, and through this, we have been able to make visible the impact of normative bias. Moreover, the findings of this study establish that undergraduate pharmacy education in the United Kingdom is hetero- and cisnormative and that there is a sector wide failure to enact the values of equality, diversity and inclusion of LGBTQI+ people and issues within curriculum design and delivery. We interpret this as providing evidence of consistent homonegativity and genderfication. Although we do note that educators reported being allies of LGBTQI+ people, this was not evident in the depth or breadth of LGBTQI+ inclusivity in curricula, and as a consequence, the design of many programmes would appear to be hetero- and cisnormative. Thus, our results demonstrate a pervasive inequality where although educators acknowledge their curriculum is lacking and making queer people invisible and ‘other’, there is little evidence to suggest educators are actively addressing this inequality structurally within curriculum design; rather, policy and course accreditation is used as a narrative device to justify a potential future change in learning outcomes. On this basis, it appears that educators are disguising the agency they have in the design and enactment of a curriculum and operating within a culture of undisrupted benevolent heterosexism. The ontological importance of this is in highlighting that whilst it may be well established that LGBTQI+ people and issues are absent from medical and health professions curricula, the pervasive nature of normativity therefore requires educators to challenge their practice and curricula consistently and regularly; otherwise, the ‘norm’ remains normalised, and structural inequalities persist.
That we found examples where overt homophobia is tolerated and perpetuated, particularly when a curriculum includes students from countries where homosexuality is illegal, is of concern. Here, narratives incorporate examples of avoiding any discussion or education of sexuality or gender that would disrupt normativity as a response to perceived cultural sensitivities of some students. The researchers see this as a real failure of educators within the sector to confront structural homophobia, and evidence of how discursive strategies to validate and justify heteronormativity are constructed.
Although the results show acceptance of, and education around, sexual orientation, there is little evidence that education around gender and gender identity from a practical or patient perspective is included in curricula. Where sexual orientation is taught, this is within the context of inequality, that is, HIV and gay men or trans health and hormone therapy and not in a normalised way around relationships and modern lifestyles. This further evidences the ubiquity of normativity and is seen in the overwhelming student acknowledgement that UK pharmacy curricula ‘others’ LGBTQI+ issues and are not allies of LGBTQI+ people, with students expressing feelings of being ill equipped to care for patients that are not heterosexual and/or cisgender.
‘Otherness’ is perpetuated in pharmacy curricula by the invisibility of LGBTQI+ representation and the pathologised and medicalised way in which people and groups are studied and taught. As indicated by the results, and as also found in the literature, gay men are often confined to a dialogue around HIV/AIDS and thus death and unsafe sex.20, 24 Trans people are discussed in relation to mental health and suicide. Gender is exclusively a biological sex and physiology issue. The study of LGBTQI+ in ‘normal’ areas such as relationships and maternity does not exist—the so called ‘acceptable form of homosexuality’ (lifestyles endorsed and allowed by heteronormative society)48 adopted by LGBTQI+ people is absent. This oppressive discourse ‘others’ queer learners, staff and patients and is further evidence of a benevolent heterosexism within pharmacy curricula. This is seen within the findings where LGBTQI+ issues are absent in the enacted curriculum and a preference from some learners that ‘othering’ is maintained. So although educational institutions have the intent of equality, the invisibility of sexuality other than heterosexuality is insidious. Although this may not be based on overt homophobia or obvious discrimination, the effect is that a subtle undercurrent of not acknowledging deviation from normativity is reproduced within curriculum design, and as such, structural social violence and institutional heterosexism become part of undergraduate pharmacy education, something that is recognised by pharmacy students.20, 49 This finding reflects the struggle medical curricula have in embedding a normalised, non-pathologised worldview of LGBTQI+ people.38, 39 Our data did not include any examples of educators challenging the heteronormative privilege and the systems that support it, and so we suggest that educators should focus on interrogating their curricula for binary sexuality and gender with a view to dismantling and disrupting hetero-masculinity in pursuit of diversity and inclusion. A lack of confidence, experience, time and naivety of understanding LGBTQI+ issues can no longer be used as a legitimate argument for why hetero and cisnormativity dominates higher education.
Educators should acknowledge that practices that keep LGBTQI+ people as others reproduces heteronormativity unless the normativity itself is challenged and diminished. In other words, a curricula situated within a heteronormative construct allowing a certain amount of queerness in is not equal and does not challenge normativity—what is needed is a conscious acknowledgement of heteronormative privilege and how that operates, often unknowingly, within education systems coupled with mindful interrogation of curricula to dismantle normative discourse.7 Strategies to dismantle normativity and incorporate queer pedagogy include analysing the structure of programmes to avoid incorporating tokenistic representation as ‘others’ or episodic teaching; highlighting the language of heteronormativity; being explicit about the inherent power of heteronormativity and deconstruction of this power, being explicit about societal discourse in curricula (gendered, political, historical underpinnings) and opening dialogue with learners (and educators) to illuminate and challenge it.50, 51
Whilst participants often referred to gay men and trans women in their responses to highlight what is and is not taught or present in curricula, the broader spectrum of sexual identities and gender expressions were absent in the data. It should be recognised that this absence of discussion of lesbians, bisexuals and the wider spectrum of gender and sexual identities such as the transmasculine voice mirrors a phenomenon of acceptance of a certain binary homosexuality in politics and culture and an opposition to other LGBTQI+ expressions; that is, a certain type of tolerable homosexuality is now acceptable in certain cultures whilst allowing the omission of broader LGBTQI+ life and issues.52 For example, gay marriage is widely acceptable but in itself is being fit within a hegemonic heteronormative structure as it preserves the institution of marriage, monogamy and two-person coupling that fits with normative models and assumptions.53
An area where disrupting normativity can be achieved, particularly in repositioning the espoused and enacted curriculum, is through heterosexual allies who interrupt prevailing ideology with a cooperative approach to pedagogy and not, as this study finds, leaving LGBTQI+ education to queer staff or external agencies.7 As outlined by Seal,7 heteronormativity is best challenged by a whole team or programme approach where allies are fundamental to the disruption of hetero-hegemony within a curriculum. Another area of focus is the visibility of non-heterosexual and non-binary genders within teaching content as normal, that is, as usual examples and not solely used when teaching topics such as sexual health and mental health. Here, co-creation of curricula content with learners is a useful tool to achieve this. This has been termed LGBT competence.49 Repositioning social education to enable learners to challenge political, structural and institutional hegemony and think critically about privilege and the heteronormative, cisnormative worldview. The Ward–Gale Model for LGBTQ-inclusivity17 may be useful for educators to consider the language, role models and content present in a curriculum.
Some respondents described positive practice in LGBTQI+ inclusivity, and this best practice should be disseminated across medical and health professions education. On a broader scale, the bodies representing the medical and health care professions and their respective education standards have a duty to disrupt heteronormativity and make visible efforts in queering the curriculum. Explicit curricula outcomes and standards regarding LGBTQI+ health should be incorporated in to education standards by curriculum regulators. Respondents in this study were not clear whether the GPhC achieve this in their accreditation standards and this lack of explicit training standards also exists within medicine.37
These results demonstrate disconnect between the espoused, enacted and experienced curriculum. The hidden curriculum is experienced by a student body that is frustrated and angered with LGBTQI+ invisibility and found to be knowingly hetero- and cisnormative in design and culture producing graduates ill equipped to care for all patients within an inclusive society.
A limitation of this study may be the extent of knowledge the participant has about their curriculum particularly if and where LGBTQI+ content is taught, if at all. This could explain why some programmes espouse to enact an inclusive curriculum, but they actually cannot easily evidence the fact. The student survey may have attracted queer identifying participants and may not reflect the sentiment of the whole student body.
Whilst this study took a quantitative and descriptive approach to establish a national picture of LGBTQI+ teaching in pharmacy education, it acts as a conceptual lens for medical and health professions educators to interrogate, establish and dismantle their own hidden curriculum. Our work intends to move away from describing the volume and place of content and seeks to encourage educators to embed an inclusive ethos and culture in their curricula. The next steps for this work are to evaluate the attitudes and beliefs pharmacy educators hold towards hetero- and gender normativity to establish and disrupt homonegativity within the sector to move past the shortcomings within pharmacy education as established here.
Hetero- and cisnormativity does not discriminate and is present across the spectrum of medical and health professions education despite the issue being well accepted. This article concludes that once this phenomenon is acknowledged, educators can hold a critical queer lens to the espoused, enacted and the experienced curriculum, and through this uncover what is hidden. Through this practice, it is then possible to take a stance of continual, sustained and systematic disruption of hetero- and cisnormativity as a means to overcome it.
ACKNOWLEDGEMENT
None.
CONFLICT OF INTEREST
There are no competing interests.
ETHICS STATEMENT
Ethical approval was sought and obtained from the home institution of the researcher: project ID 11543—The University of Manchester.
AUTHOR CONTRIBUTIONS
Andrew Mawdsley designed and facilitated the survey, analysed the findings and wrote the manuscript. Sarah Willis analysed the findings and contributed to the manuscript. Both authors give approval to the submitted work.
