_____________________________________________ Promoting the Health of Gender and Sexual Minorities
included in the definition of heterosexism. For example, the use of noninclusive questions while conducting a patient’s sexual history could be considered implicit discrimination because the questions reflect a possible lack of awareness and inclusivity. Mean-spirited, antigay statements or actions by an individual or an institution could be considered explicit dis- crimination because the action is undeniably direct. A hospital visitation policy that prevents GSM individuals from visiting their partners is another form of discrimination included in the definition of heterosexism. The subtle and pervasive ways that discomfort with GSM individuals may be manifested have been examined and, in some instances, categorized as “cultural heterosexism,” which is characterized by the stigmatization in thinking and actions found in our nation’s cultural institutions, such as our edu- cational and legal systems [27]. “Cultural heterosexism fosters individual antigay attitudes by providing a ready-made system of values and stereotypical beliefs that justify such prejudice as natural” [28]. Perhaps the paucity of information about the GSM community in basic professional education textbooks has been a reflection of cultural heterosexism. Writers, funding sources, and publishers have been exposed to the same cultural institutions for many years. Individuals generally begin to absorb these institutional atti- tudes as children and may consequently develop “psychological heterosexism,” which may also manifest as antigay prejudice. Many individuals, as children, have little contact with someone who is openly gay and, as a result, may not be able to associ- ate homosexuality with an actual person. Instead, they may associate it with concepts such as “sin,” “sickness,” “predator,” “outsider,” or some other negative characteristic from which the individual wants to maintain distance [28]. Psychological heterosexism involves (among other factors) considering sexual identity and determining that one does not want to think further about it. The direction of this thinking is undeniably negative, resulting in an environment that allows antigay hostil- ity [28]. The impact of antigay prejudice on the physical and mental health of members of the LGBTQIA community and their families should not be underestimated [1; 29]. Sexual minority individuals also are not immune to societal attitudes and may internalize negative aspects of the antigay prejudice experience. Anxiety, depression, social withdrawal, and other reactions may result [4; 30]. While the study of psychological heterosexism, both blatant and subtle, is in the early stages of research, it has had a measurable impact on the mental health of the GSM community [22; 31; 32; 33]. Examples of the range of manifestations of heterosexism and/ or homophobia in our society are readily available. Without difficulty, each example presented here may be conceptual- ized as related to the emotional or physical health of a GSM individual or family member:
HOMOPHOBIA, HETEROSEXISM, AND INTERNALIZED HOMOPHOBIA Within the general public, controversy associated with the words “homophobia,” “heterosexism,” and “internalized homophobia” exists. Having an opportunity to consider these terms is necessary to enhance the development of culturally competent care and the application of communication skills. Professional literature has frequently combined the use of the terms “heterosexism and homophobia” when discussing the LGBTQIA subculture, both for the sake of clarity and to emphasize that the terms do not carry the same meanings. Although absolute, universal definitions of the terms are still evolving, a general understanding exists and they are widely used in social science literature, by policy makers, and in the judiciary [16]. They have also been applied in the literature for health professionals. Discussions regarding the conceptualization and operational- ization of these terms, and many others related to homosexual- ity, have been taking place in an effort to clarify definitions [8; 22]. The words used when discussing homosexuality and the LGBTQIA experience may have political tones, so they must be used carefully [22]. Much professional literature has documented the negative social attitudes toward sexual minorities [23]. These negative attitudes have been frequently referred to as “homophobia.” The term was coined in 1967 and defined very specifically as “the dread of being in close quarters with [gay people]...the revulsion toward [gay people] and often the desire to inflict punishment as retribution” [16]. Some in the general popula- tion believe that the word “homophobia” always includes a component of violence. The condition was classified as a pho- bia and operationalized as a prejudice. The phobia manifests as antagonism directed toward a particular group of people, leading to disdain and mistreatment of them [16]. Some individuals in the general population deny that they are homophobic on the basis that they do not condone vio- lence. However, it has been suggested that individuals may be homophobic even when they do not support violence [24]. Additional examples of homophobia include when individuals feel: anxious and afraid, thinking that they may be perceived as gay or lesbian by others; anxious or repulsed when they find themselves attracted to a person of their own sex; or fearful that they have gay or bisexual tendencies [24]. A more appropriate term for the phenomenon of negative social attitudes may be “heterosexism” because it focuses on the normalization and giving of privilege to heterosexuality [25]. The term encompasses the prejudice and social stigma from institutional and interpersonal sources encountered by sexual minorities, including a range of discriminatory experiences, not only those related to phobias and violence [26]. Implicit and explicit forms of discrimination have been
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