Policies and frameworks for healthcare and social sciences study programmes

The knowledge base and discourses on gender and sexuality on which healthcare and social sciences study programmes in the Nordic countries are based are closely interwoven with the position of LGBTI people in society. As described above, during the 21st century there have been major changes in LGBTI people’s access to rights and protections against discrimination in the Nordic countries (NIKK, 2020, see Introduction). Several countries have LGBTI action plans at national level, and in parallel with this LGBTI perspectives have been implemented in other policy documents and in national strategies related to human rights, living conditions and health, as well as sexual health and public health (Areskoug-Josefsson, 2023). LGBTI policy usually lies within the area of gender equality. Generally, older adults are rarely the focus of policies for social justice (Debesay, Langhammer & Nortvedt, 202l), and gender equality policy is often both heteronormative and age normative (NIKK, 2017). In surveys of differing conditions for older adults’ access to good health and equality in healthcare and social care services, gender identity and sexual orientation are also rarely included as a power dimension (National Board of Health and Welfare, 2017).

Older LGBTI people have also been a relatively invisible group in national action plans for LGBTI people, but have been highlighted in the latest Swedish, Danish, Norwegian and Icelandic action plans. Concrete measures to boost knowledge about the group’s living conditions, and strategies for more inclusive healthcare and social care services, have been the main themes of these action plans. In a previous Danish plan, there was a measure to increase competence in the healthcare and social care sector via an online course for working healthcare and social care staff. In the current LGBTI action plan for 2022–2025, increased knowledge in professional qualification study programmes is highlighted as one of several measures to improve LGBTI people’s health and well-being, and it is the only plan in the Nordic region that links low competence in health-related professional practice to the knowledge healthcare and social care professionals are taught in their study programmes: ‘Drøftelse med lederne af professionsuddannelserne på velfærdsområdet om LGBT+ viden i uddannelserne’ (Discussion with managers of professional qualification study programmes in the welfare area about LGBT+ knowledge in the programmes) (p. 21, 2022).

The Swedish action plan prioritises the living conditions of older LGBTI people and their access to healthcare and social care in a separate chapter (p. 18, 2022). Older trans people are highlighted as a particularly vulnerable group, supported by the commission of inquiry into trans people’s living conditions (2017). The plan highlights the need for increased competence in municipal services, and how this will be achieved through state-funded competence-enhancing initiatives, to be implemented regionally. The Icelandic plan (2022–2025) aims to investigate the situation and needs of older LGBTI people. The Norwegian action plan refers to knowledge enhancement through this Nordic mapping, but has few measures specifically targeted at older LGBTI people as a target group, saying that all measures must include all life phases and ages (2022–2026). 

Higher education in Europe is characterised by certain common features in its development, with the state as the organiser (responsible authority) and public governance having been affected by market mechanisms and greater autonomy for individual higher education institutions (Huisman and Lyby, 2020, p. 1). Higher education is shaped by common European standards according to the Bologna Process, but is regulated by national guidelines on form and content to assure the quality of education in the Nordic countries. The content of the various professional qualification study programmes is regulated via overarching intended learning outcomes, with the objectives for knowledge and skills being determined by an academic committee under the countries’ councils for higher education and regularly revised. In Finland, the intended learning outcomes are determined by the universities. How these knowledge and skills objectives are then achieved is up to the individual educational institution via the design of study programmes and course syllabuses. When the institutions are then evaluated, it is in relation to whether the national intended learning outcomes of the individual study programme have been achieved. It is therefore of interest to look at whether and how knowledge about gender and sexuality norms and LGBTI people’s living conditions is included in governing guidelines.

Compared to other professional qualification study programmes, there has generally been a bigger change in intended learning outcomes in teacher education programmes over the past 10 years, with knowledge about sexuality, relationships and gender identity having been included in the learning outcomes.

In Norway, all health and social sciences professional qualification study programmes since 2019 have both common guidelines and framework plans (RETHOS), and framework plans and regulations for specific study programmes: ‘[...] for å styrke kvaliteten og relevansen i de helse- og sosialfaglige utdanningene og en konklusjon om behov for bedre styring på nasjonalt nivå, der REHTOS er en del av dette systemet.’ (to enhance the quality and relevance of health and social sciences study programmes and a conclusion on the need for better governance at national level, in which REHTOS is part of this system) (Ministry of Education and Research, 2017).

The work to implement the guidelines is taking place during the period 2017–2024 and is cross-sectoral. The implementation of the new guidelines in the study programmes is being continuously evaluated until the end of the period. One of the new common objectives is closely tied to the Norwegian anti-discrimination legislation, linking intended learning outcomes and competence and skills to the capacity to offer equivalent services regardless of gender identity, gender expression and sexual orientation:

In the intended learning outcomes for Swedish professional qualification study programmes in the field of health and social sciences, the wordings in Sweden’s Higher Education Act’s rules governing the intended learning outcomes of the study programmes vary. They are decided by different academic committees at regular intervals.

In this quotation from the intended learning outcomes, and generally in healthcare and social sciences professional qualification study programmes, human rights are used as a framework for knowledge and understanding, and competence and skills outcomes.  Men’s, women’s and children’s health is named in these learning outcomes, and men’s violence against women is named as a specific challenge. There is the hint of a heteronormative understanding of gender and sexuality here, with the heterosexual nuclear family as the basis for prioritised groups, while other marginalised groups remain invisible and are lumped together as ‘various groups’ that need to be taken into account (cf. Reimers, 2008). A revision of the qualitative targets in the nursing and midwifery programmes was proposed in 2022, with person-centred care being included as examined learning outcome. However, the reason for this is stated to be increased user and patient participation rather than differing conditions for access to equal care (Ministry of Education and Research, 2022, p. 136). Inserting knowledge about the living conditions of LGBTI people and intersex people in caring profession study programmes through the revision of qualitative targets in caring profession qualifications was one of the final recommendations in the Swedish commission of inquiry into trans people’s living conditions, but this has not yet been implemented (Westerlund, SOU 2017).

“We therefore propose that changes be made to the system of qualifications so that knowledge about LGBTI people’s living conditions must be included in relevant professional qualifications, as well as a stronger emphasis on the importance of equal, competent and respectful treatment regardless of sexual orientation, gender identity, gender expression and gender characteristics” (2017, p. 25).

In the Danish intended learning outcomes for professional qualification study programmes in the health and social care field, democracy and human rights are primarily used to support consideration of the conditions of different groups. However, gender or sexuality is not specifically highlighted, while religion and social and cultural conditions are mentioned, as in this text for the nursing programme:

In Finland, competence and skills and intended learning outcomes are defined in professional qualification study programmes by the faculty responsible at each higher education institution, and they consequently vary (Lähteinen, Raitakari, Hänninen, Kaittila, Kekoni, Krok, Skaffari, 2017):

Only the form and content are regulated by the Government in the ‘Government Decree on University Degrees and Professional Specialisation Programmes’: https://www.finlex.fi/en/laki/kaannokset/2004/en20040794.pdf

Competence and skills outcomes for social work are characterised by general wordings for different conditions and social structures according to Sosnet, the Finnish National University Network for Social Work:

In Iceland, gender identity and sexual orientation are explicitly highlighted in relation to intended learning outcomes for teacher education programmes, but not in relation to the health and social sciences professional qualification study programmes.

Interview with AuðurMagndís Auðardóttir, School of Education, University of Iceland

In addition to intended learning outcomes for the study programmes, different professional associations have their own governing ethical guidelines for professional practice, nationally and internationally. They are relevant to the requirements made of the members of the associations, and guidelines for professional education are often included (Giertsen, 2019; Lundberg, Malmqvist & Wurm, 2017; Areskoug Josefsson & Solberg, 2023). However, they do not govern the study programme itself, which is subject to the statutory national or institutional intended knowledge and skills outcomes, only the members of the professional association.

The examples above show how knowledge and skills intended learning outcomes are regulated differently in the Nordic countries – from national governance in Norway to full autonomy at the higher education institution/faculty level in Finland. This results in different conditions for how knowledge content and intended learning outcomes in the study programme may be influenced, changed and evaluated, and the requirements that may be imposed on the study programme through policy regulation.

What is the significance of the national intended learning outcomes for the knowledge and understanding requirements in relation to gender, sexuality and ageing in concrete programme syllabuses at higher education institutions, and in general syllabuses and course syllabuses?  Two comparable surveys conducted in Norway and Sweden investigate the existence of indicators related to sexual and reproductive health and rights (SRHR) in central government regulations, and in general syllabuses and course syllabuses for caring profession study programmes, which are relevant to this mapping (Schindele et al., 2017; Areskoug-Josefsson & Solberg, 2023).

The study programmes covered by the survey also include health and social sciences professions that interact with older adults: social work, ergonomics, physiotherapy, medicine, protective care, psychology and nursing. The Swedish survey, commissioned by the Public Health Agency of Sweden, included 31 indicators of which, among others, LGBTI, sexuality throughout life and heteronormativity occurred rarely throughout:

The Norwegian study investigated the prevalence of 68 indicators for SRHR-related themes,

Compared to the Swedish mapping, the Norwegian mapping contains a larger number of indicators that are relevant to LGBTI people’s living conditions and ageing: trans health, gender incongruence, gender-affirming treatment, older people and sexuality, sexuality in institutions, sexuality and disease, adverse effects of medicines, and sexuality, physical health and sexuality.

but only 11 of these were included in plans at different levels, despite tightened requirements in the new common guidelines in the National Curriculum Regulations for Norwegian Health and Welfare Education (RETHOS).

The Norwegian study investigated roughly one third of all study programmes relating to a professional qualification. The Swedish study covered profession descriptions, programme syllabuses and course syllabuses for 93 study programmes at all 27 higher education institutions in Sweden.

Looking at how the indicators were implemented in concrete programme syllabuses at the higher education institutions included in the Norwegian study, the incidence varied widely both between professional qualification study programmes and within study programmes at the same or different educational institutions. The vast majority of programme syllabuses that included sexual health indicators included the indicators gender, gender identity, gender expression and sexual orientation. They thus reflect the requirements of RETHOS’ section 16, which relates directly to Norway’s Equality and Anti-Discrimination Act. In some study programmes, there are also more indicators in the programme syllabuses than in individual course syllabuses, such as in medicine, where trans health and gender incongruence are included in only a few syllabuses; or sexuality as a social construct in the course syllabus for psychology. Social work included few indicators, but was the only profession to have an elective subject in which sexuality throughout life was included. Graduates’ competence in sexual health therefore seems highly random.

Despite the fact that gender identity, gender expression and sexual orientation were common indicators in the syllabuses, the question remains about how they are included, which needs to be investigated in more detail in further studies. Areskoug Josefsson and Solberg give examples of how these indicators were used in several cases in a superficial and legalistic manner, for example in formulations such as: “good access to treatment, regardless of gender, gender identity, sexual orientation”.

The 68 indicators investigated in the Norwegian study included far more indicators that are relevant to LGBTI people overall, but also a relatively high number of indicators that are particularly relevant to older LGBTI people: sexuality and older people, sexuality in institutions, sexuality and disease, effects/adverse effects of medicines and sexuality, physical health and sexuality, sexuality and disability and sexuality across the life course. There are no or few hits for these indicators in the programme syllabuses and course syllabuses. This suggests that there are very limited requirements for knowledge about older adults in general or older LGBTI people’s living conditions and needs more specifically, but this age dimension is not particularly highlighted in the report’s analysis.

Another key indicator that is rarely included is heteronormativity. This may indicate a perspective on knowledge where norms for gender and sexuality are rendered invisible, and norm-breaking gender identities and sexual orientation are highlighted and problematised on the basis of normative conditions. This is something that is confirmed in several of the reviewed studies of norms and the knowledge perspectives in the programme syllabuses and course syllabuses of professional qualification study programmes that we will look at in the next section (Tengelin, 2019; Giertsen, 2019; Areskoug Josefsson and Gard, 2015).