Norms and knowledge perspectives in healthcare and social sciences study program­mes in the Nordic countries

How are knowledge and understanding, and competence and skills, requirements made manifest in practice and in healthcare and social sciences study programmes?  There is relatively little research into the knowledge and knowledge perspectives on gender, sexuality, LGBTI people’s living conditions and ageing in different study programmes in the Nordic countries. Their prevalence also varies widely between countries. The greatest lack is in studies that specifically look at older people and ageing, and the studies included therefore focus mainly on gender and sexuality perspectives (see Appendix 3).

The majority of the material is qualitative studies that investigate study programmes in the caring sciences/nursing, social work, psychology, physiotherapy and medicine. The focus is primarily on general syllabuses and subject syllabuses, course literature and students’ experiences of the presence of knowledge about gender, sexuality and LGBTI perspectives. The qualitative analyses carried out in different professional qualification study programmes are seen in relation to patterns in the Norwegian and Swedish indicator mappings referred to in the previous section, since they provide a broad context in which to interpret the results (Schindele et al., 2017; Areskoug-Josefsson & Solberg, 2023). Supplementary interviews and e-mail interviews with people working in the healthcare and social work field at higher education institutions are used in addition to the literature found in the searches. The interviewees were mainly from Finland and Iceland, since no literature has been found there.

Programme syllabuses are an important link between society and education, as they are grounded in specific values and knowledge, and represent the consensus product of ideological struggles in terms of expectations and objectives for learning, write Tengelin et al. (2019) in their study of general syllabuses and course syllabuses for nursing education. Understanding how norms shape professional interaction and help to challenge or maintain social difference in access to healthcare is key.

However, norm-critical perspectives are used as a theoretical framework and methodology tool in several studies included in this reading list to investigate the relationship between explicit knowledge outcomes related primarily to gender, sexuality, class, ethnicity, disability and age in guidelines, programme syllabuses and course syllabuses; and the knowledge perspective on which they seem to be based in terms of norms and power relationships. Norm-critical perspectives are based on feminist, queer and post-structuralist theory. They were introduced in Sweden in the early 21st century and have primarily focused on norms, power and learning within different learning contexts and to a lesser extent health and social sciences professional qualification study programmes (Bjorkman & Bromseth 2019).

All studies included in this knowledge inventory (Schindele et al., 2017; Giertsen, 2019; Tengelin et al., 2019; Areskoug Josefsson & Solberg, 2023) show that programme syllabuses and course syllabuses have a heteronormative knowledge base. In a study of the national intended learning outcomes in nursing study programmes in Sweden, Tengelin et al. (2019) analysed programme syllabuses and 17 course syllabuses for the nursing programmes at a higher education institution, and the compulsory readings specified in the course syllabuses, focusing on the dominant perspectives represented in the texts from a norm-critical perspective.

The authors investigated how national intended learning outcomes are filled out with content and made concrete in programme syllabuses and course syllabuses in relation to the two intended learning outcomes that focus on the word ‘society’. The first – “social circumstances that affect the health of children, women and men” – is reproduced without further concretisation in the programme syllabus, and is not included in the course syllabuses at all, with the exception of one, in which the students are required to “describe societal power structures related to gender, class, culture, and age”. Terms such as LGBTI were not included in any course syllabus, and the course literature conveyed a conventional view of sexuality which equated sexuality with reproduction. One textbook in psychiatry that was course literature included homosexuality and transsexualism in a chapter entitled ‘Sexuality and Disturbed Gender Identities’, a chapter that began by comparing human gender roles with those of animals (ibid, 29). Social justice is not a priority perspective in the socialisation of future nurses, the authors conclude. On the contrary, the study programme’s strong focus on a professional role in which a nurse is encouraged to use self-reflection and empathy as important tools supports the re-creation of a normative knowledge base. Here, the Other (who does not conform to norms) is rendered invisible or presented as deviant and different, as in ‘other cultures’ and ‘queer sexuality’, where the solution is that an increased understanding of the Other should lead to increased tolerance. 

This is a rhetoric in which everyone’s equal value is used in combination with a norm-reproducing knowledge base. A division into ‘us and them’ is common, where the intended learning outcomes of the study programme and the dominant knowledge perspectives are at odds with each other. 

There is also a similar pattern in the nursing study programme in Finland according to Minna Laiti, Senior Lecturer in Nursing at the University of Turku, although it is perhaps rendered even less visible. LGBTI perspectives in research and education are almost non-existent in the fields of health and social sciences in Finland, perhaps because LGBTI policy has long been more restrictive than in the other Nordic countries, thinks Laiti:

A similar pattern appears to exist for social work. Merethe Giertsen (2017) analysed course literature for 2013–2014 in the Bachelor’s programme in social work at 11 institutions in Norway. This was before the introduction of the new national guidelines for health and welfare professional qualification study programmes. In the previous national guidelines for social work, sexuality was only included under social medicine. Despite profession-based guidelines to the effect that social work should actively combat discrimination and marginalisation on the grounds of sexual orientation (International Federation of Social Workers and the Norwegian Union of Social Educators and Social Workers), social work as a field of science is still rooted in a heteronormative base, which highlights lesbians, gays and bisexuals, but rarely heterosexuality, writes Giertsen:

Giertsen’s analysis of the course literature confirms this pattern. Above all, sexuality as a theme is very absent, and is addressed in only 0.08% of the literature (90 pages) in six articles used for the foundation course in five out of eleven study programmes. However, one of these articles, of 15 pages, is used by three study programmes and thus accounts for 45 of these pages. When sexuality is addressed, it is primarily by sexuality researchers from other professional fields. Five out of six have a queer theory approach, while only one highlights LGBTI people’s problems about deviating from the norms without questioning the heteronormative basis that creates them. Sexuality is generally invisible in most of the core literature in the study programmes for social work.

If we look at Areskoug Josefsson & Solberg’s survey of SRHR indicators in health and welfare professional qualification study programmes in Norway, only four out of eight general syllabuses in study programmes in social work have indicators for gender identity, gender expression and sexual orientation (Areskoug Josefsson & Solberg, 2023). However, the course syllabuses for social work lack detailed descriptions of how they are included. A similar pattern also seems to characterise social work in the context of Finland. The research group in the ongoing project Queering social work write on the project’s website that, despite positive development with an increased focus on LGBTI, gender, sexuality and norms in the field internationally, and professional guidelines nationally, essentialist understandings of sexual identity and gender in relation to healthcare and social care services and needs dominate.

The project has not published anything yet, but one of the project participants, Inka Söderström, who teaches social work, says that there are no compulsory courses or any Finnish course literature that addresses LGBTI themes: “This is unfortunate but true. The courses in social work might talk about diversity and intersectionality in a general level, but not specifically about LGBTQ+ identities”.

E-mail interview with Inka Söderström 23 February 2023.

The LGBTI perspective seems to be somewhat better represented in the social work programmes at first-cycle level, which are offered mainly available at universities. Sandra Hagman of Diaconia University of Applied Sciences is a queer researcher and teaches in the Bachelor’s programme:

There is thus interest in the theme, but whether and how norms, gender, sexuality and LGBTI perspectives are included in the study programmes seems to be consistently person-dependent, even when this is explicitly established in national guidelines for intended learning outcomes.

In Iceland, there seems to be a similar pattern, according to interviews with key individuals. Guðbjörg Ottósdóttir, a senior lecturer in social work, says that gender identity and sexual orientation are mentioned in professional guidelines, but are not included in the course literature or as intended learning outcomes in the general Bachelor’s programme in social work:

Students therefore want more knowledge about gender, sexuality and LGBTI perspectives, but do not get enough in their study programmes – a pattern that is repeated in several studies of different health and social sciences study programmes.

In a Swedish study of physiotherapy students’ experiences of SRHR perspectives in their study programmes, it appears that both LGBTI and sexuality perspectives are almost completely absent. The students think that it would be particularly difficult to talk about sexual health with patient groups that break with expectations of gender and sexuality (Areskoug Josefsson and Gard, 2015). Students express that they are positive about working with sexual health, write Areskoug Josefsson & Gard (2015), and that sexual health is an important part of life and therefore should also be part of the physiotherapy study programme. The study also shows that students lack knowledge about LGBTI perspectives, sexual health and sensitive themes:

Increased knowledge in the study programme would probably make it easier to work with sexual health, especially when combined with working in a case-oriented way when training communication skills to deal with sensitive themes. But this also needs to be explored empirically (ibid).

Students’ attitudes to studying sexual health are generally positive in health and social sciences study programmes in Norway, Sweden and Denmark. This is shown in several studies in which researchers have jointly developed national context-sensitive tools to map students’ attitudes and knowledge (Areskoug-Josefsson et al., 2016; Gerbild et al., 2017; Lunde et al., 2022). This is particularly true when it comes to sexual orientation, according to a Norwegian study (Lunde et al., 2022). The studies asked about the students’ attitudes to asking patients about sexual health in relation to age, sexual orientation, gender, gender identity, disabilities, etc. but not directly about older age. 

The physiotherapy, social work and nursing programmes were among the professional qualification study programmes in which there were very few SRHR indicators in programme syllabuses and course syllabuses in both the Swedish and Norwegian surveys.  The programmes for lawyers, police officers, doctors, psychologists and occupational therapists also had few indicators (Schindele et al., 2017; Areskoug-Josefsson & Solberg, 2023). There are only a few Nordic studies of how gender, sexuality and LGBTI people’s living conditions are included in these professional qualification study programmes, and none about older LGBTI people.

Which knowledge perspectives characterise medicine and psychology in relation to gender, sexuality, ageing and LGBTI people’s life experiences? Only one out of five course syllabuses in medicine programmes in Norway has the indicators relevant to this knowledge inventory: sexual orientation, gender incongruence and trans health (Areskoug Josefsson & Solberg, 2023). However, there are a higher number of indicators in the medicine programme syllabuses than course syllabuses, several of which are important for this survey:

However, ageing and sexual health and LGBTI are not represented in either the programme syllabuses or the course syllabuses. In the comparable Swedish mapping, two out of seven professional descriptions in the country’s medicine programmes included a part about HIV prevention and SRHR, but the indicator HBTQ

This is the Swedish term used in the study referred to here. It stands for homosexual, bisexual, trans and queer.

was only included in four course syllabuses (Schindele et al., 2017). However, several key indicators included in the Norwegian mapping were not included in the Swedish mapping that was conducted seven years earlier, such as gender identities, gender expression, gender incongruence, trans health (which have become more established terms in the meantime).

Gender identity and heteronormativity are not included in the course syllabuses of medicine programmes in either the Swedish or Norwegian mapping of SRHR indicators (Schindele et al., 2017; Areskoug Josefsson & Solberg, 2023). This may indicate that the focus is more clinically oriented in relation to trans health, and based on a gender-binary mindset (Linander et al., 2021). Identities, bodies and behaviours that have been considered to break with social and cultural expectations of gender and sexuality have been pathologised in social medicine and psychiatry since the mid-19th century via diagnoses in which the ‘abnormal’ has been regarded as pathologically deviant from the normal (Foucault, 1976; Kveim Lie & Slagstad, 2018). Transsexualism was removed as a psychiatric diagnosis from the WHO ICD-11 diagnostic standard only in 2018 and was replaced with various diagnoses for gender incongruence. This means, above all, that gender identity is regarded as fluid, in contrast to a binary ‘born in the wrong body’ understanding, with the new diagnosis regarding gender incongruence as:

For example, non-binary people will more easily get access to healthcare within this understanding. Although understandings of norm-breaking gender expression and gender identities have changed significantly over the past ten years, pathologising understandings still live on in current guidelines for trans health (Linander et al., 2021). The article Two steps forward, one step back. A policy analysis of Swedish guidelines for trans-specific healthcare analyses which understandings form the basis for the new guidelines for trans-specific healthcare/gender-affirming treatment.

Sweden has only had established guidelines for trans-specific healthcare/gender-affirming treatment for people with trans experience since 2015, despite this treatment having been available since the 1970s. The results show that, despite ambitions to depathologise trans experiences, psycho-medical understandings of gender incongruence still characterise the guidelines for entitlement to treatment. The emphasis remains on a linear understanding between gender identity and social gender expression to be able to access treatment, show Linander (et al., 2021). This means a mindset in which the experiences of binary trans persons are more easily valued as credible than those of non-binary trans persons, in which gender identity and desired gender expression are linear and conform to normative conventions.

The knowledge perspectives on which professional qualification study programmes in medicine and psychology are based, and the guidelines that regulate LGBTI people’s access to medical and psychological treatment, are particularly important for people with trans and intersex experiences, as access to government-funded treatment is diagnosis-related. Gender, gender identity and sexuality were integrated into Nordic ethical professional guidelines for psychology in 2013 (Lundberg, Nordlund and Narvola, 2017). In the article Normkritiska perspektiv: nya möjligheter för psykologisk praktik (Norm-critical perspectives: new opportunities for psychological practice), Lundberg, Nordlund and Narvola describe the guidelines as ‘the most powerful guidelines so far in Sweden, in which it is claimed that psychologists should have knowledge in matters related to gender, gender identity and sexuality’. Although the guidelines are not directly linked to national intended learning outcomes for the study programme, they are also relevant in different parts of the programme.

E-mail interview with Matilda Wurm, March 2023

Since the policy document does not provide guidance on how to take into account the sociocultural context in practice or the underlying perspectives on which the interaction should be based, this needs to be discussed and explored, write the authors. The article highlights the wordings in other countries’ policy documents, examines the critical perspectives used in psychology in a historical context and aims to investigate how psychologists can apply a norm-critical perspective with a particular focus on gender and sexuality in their practice:

The article describes key elements of norm-critical pedagogy, and how they can be used to critically examine norms in both the psychology programme and in professional practice. Norm-critical perspectives are based on a feminist, intersectional and post-structuralist theoretical foundation with the focus on self reflexivity about the influence of power structures on one’s own values and practice. Lundberg, Nordlund and Narvola conclude with concrete proposals for initiatives for working on norms and values in practice, both individually and in a shared workplace, which are later further developed in the anthology HBTQ+. Psykologiske perspektiv på bemötande (LGBTI+. Psychological perspectives on interaction (in the chapter Normkritiska metoder for psykologi (Norm-critical methods for psychology) (Narvola & Nordlund, 2017) and the appendix Riktlinjer (Guidelines), aimed at educators, researchers and practitioners (Wurm & Traczyk, 2017). The book is an extensive anthology focusing on LGBTI perspectives in psychology with a foundation in queer theory and norm-critical perspectives with students and professionals as the target group.

The anthology includes 21 authors – all but one with a scientific background in the field of psychology (Lundberg, Malmqvist & Wurm, 2017). This may indicate that LGBTI perspectives and sexuality are integrated in their own professional field to some extent and do not just come from queer and sexuality research (cf. Giertsen, 2019). In the chapter HBTQ+ och åldrande (LGBTI+ and ageing), Ingela Steij Stålbrand, whose background is in psychology, gerontology and sexology, provides valuable insights into both LGBTI perspectives on ageing and what older age means for sexuality, identity and life experiences, as well as implications for interactions with healthcare and social care institutions.

In the survey of SRHR indicators in Swedish professional studies in psychology, LGBTI is included in 7 out of 10 profession descriptions (Schindele et al., 2017). In 157 out of 251 course syllabuses, there are indicators for sexual health, among which gender, ethics and communication are some of the most common, while LGBTI and heteronormativity are marginally represented with three hits for each.

Despite the small number of studies of how knowledge about gender, sexuality and LGBTI has been implemented in different professional qualification study programmes, there is a clear pattern in the material, regardless of profession and country: whether students gain knowledge in their study programmes varies greatly, both between and within education providers, and is often person-dependent. Why are LGBTI perspectives and knowledge about sexuality taken into account to only a small extent in course syllabuses and teaching despite clear guidelines and requirements in current policy documents? Even in those countries with clear guidelines and policies, such as Norway, these perspectives are lacking. This is despite the introduction of new common guidelines for health and welfare study programmes with the aim of ensuring learning exchange, partly linked to equivalent healthcare and social care services and gender identity, gender expression and sexual orientation. Hilde Lunde, who taught health sciences at Oslo Met for many years, reflects on why:

Despite the fact that the University of Iceland has been working on integrating gender equality and diversity policies in its activities for several years, with educational objectives for more inclusive teaching, there is no active work on knowledge perspectives that integrate LGBTI issues, says Gudbjörg Ottosdottir, professor of social work: “But now policy has to become practice. It must become standard for diversity to be included as a compulsory part of study programmes in health and social sciences subjects as well.” Instead, it seems to be students who are driving demand for LGBTI perspectives in teaching in general, and in relation to LGBTI ageing in particular, say academic staff in the professional qualification study programmes, who shared their experiences as part of the knowledge inventory. Students also discuss this in Bachelor’s essays and Master’s theses.

Since Master’s theses are not included in this study, several relevant works were not included here.

When a majority seems to be positive about including LGBTI perspectives, gender and sexuality in teaching, why is it not being done more ? One of the problems of integrating gender, sexuality and norms in professional qualification study programmes is that there are too few lecturers who are qualified researchers and can research and write course literature in Norwegian, argues Hilde Lunde. She herself is engaged in extensive Nordic collaboration that has been central to the development of a Master’s programme in sexual health at Oslo Met in Norway. A separate course on sexuality and ageing will also be included as one of seven courses there. Working in an interdisciplinary way and with a broad approach linked to sexual health may be a strategy that, in the long term, will also broaden the understanding of its relevance and further integration of the topic, she thinks:

Matilda Wurm, who has been teaching psychology since 2012, says that there are generally positive attitudes among her colleagues to having LGBTI perspectives as part of the teaching in professional qualification study programmes, and that it is increasingly included in course syllabuses at many higher education institutions. At the same time, it can easily be person-dependent. When she left her institution, there was no one who could take over the course in LGBTI perspectives in psychology:

Despite its absence from the compulsory teaching in professional qualification study programmes, there are elective subjects, individual courses and Master’s programmes in which knowledge is available, but it is vulnerable because it depends on individuals and there are few lecturers who are qualified as researchers in the field.

Study resources in Scandinavian languages about sexuality are also important if it is to be included in the teaching, say several of the teachers interviewed. If you search for central publications concerning older LGBTI people’s living conditions, they are included as course literature in individual professional study programmes, which indicates a positive development. Merete Giertsen highlights this point in her review of Hans Knutagård’s textbook, Sexualitet och socialt arbete (Sexuality and social work):

This was also a driving force behind the anthology HBTQ+ och psykologiska perspektiv (LGBTI+ and psychological perspectives); to contribute to the Swedish knowledge base for the professional field. Anna Siverskog, who is one of the few people to have published research into older LGBTI people’s living conditions in the Nordic countries in Swedish, is also pleasantly surprised to see her own thesis (2016) being used as course literature in several different professional qualification study programmes:

Here, knowledge perspectives play an important role in the literature, as several of the authors cited point out. If gender identity only applies to trans people and not to cis people, it is easily perceived as ‘marginal’ and a normative notion of a deviant minority is perpetuated. However, the majority of the literature cited here has a norm-critical approach. Representation in course literature should be followed up in further research, and also how it is used in teaching.

Furthermore, we will look at the knowledge that exists among professional practitioners about LGBTI people’s life experiences and needs, and their experiences of interacting with older LGBTI people as patients and users.