Professional practitioners’ experiences in their interactions with patients and users

Healthcare and social care services are regulated by various laws, central government directives and municipal guidelines, in addition to professional guidelines for different professions. We will not go through all of these here, as it would be too extensive for the limitations of this study, but we will look at how they are made relevant in studies of how professionals in practice talk about and relate to them. In Part 1, we saw that older LGBTI people’s own experiences of healthcare and care interactions are mainly characterised by heteronormative and cisnormative assumptions and language, and lack of knowledge about the group’s life experiences, identities and needs, which often results in invisibility and silence. What do these encounters look like from the perspective of healthcare and social care providers? What knowledge and experience do practitioners have of gender and sexuality norms and the living conditions and needs of older LGBTI people, and what are their attitudes to the importance of having such knowledge? The material in this part is based on studies of professional practitioners with a background in psychology, social work, health science and medicine.

In general, there is a trend in welfare policy discourses where social services are described as enabling greater user participation, influence and focus on individual needs (Askheim, 2017). Healthcare and social care services are dominated by person-centred care as the philosophical framework of care (Brooker, 2007), with an empathetic perspective forming the basis for meeting the patient’s basic psychological needs in human care. There also seems to be a tendency for gender identity, gender expression and sexual orientation to be increasingly included in government agencies’ policy documents on equal access to good health and equal care, and in strategies for older people in certain Nordic countries such as Leve hele livet (A life lived to the full), a national reform package developed by the Norwegian Directorate of Health in 2017–2018.

Although this has not been systematically investigated as part of this report, one particular example is from the Swedish National Board of Health and Welfare, which carried out a survey on its own initiative in 2013.

Following a request to do so, the association FRI/FRI Oslo Viken provided informants for focus group interviews as part of preparatory work for public health strategy for the City of Oslo, for example.

The survey included the municipalities’ knowledge about and work with LGBTI perspectives, with administration managers responsible for healthcare and social care for older people responding to an online survey: “[…] there are relatively few studies of older LGBTI people in healthcare and social care. This report aims to increase knowledge about how the LGBTI perspective is taken into account in municipal healthcare and social care for older people.” The results were disheartening and showed that few municipalities, only 16%, had taken an LGBTI perspective into account in their policy documents (which are not age-specific), that there were big differences between large and small municipalities (45% vs. 6%), and that there were few educational efforts. In 2023, the study was followed up by a new survey commissioned by the Swedish Government which showed a similar pattern – but with some increase in efforts (National Board of Health and Welfare, 2023). On average, one-fifth of the municipalities report that they carry out CPD activities that include the needs of older LGBTI people: all the metropolitan municipalities of Stockholm, Gothenburg and Malmö, and half of the municipalities with more than 50,000 inhabitants (ibid). According to both reports, CPD activities in Swedish municipalities seem marginal in terms of the living conditions of older LGBTI people (see also the section on CPD). This is confirmed by RFSL’s education unit, which has been commissioned to carry out CPD in elder care activities.

In general, a majority of the studies show that professional practitioners have a positive attitude to equal treatment of LGBTI people and that they are treated with respect and to the fact that knowledge is central to this being possible (Smolle & Espvall, 2021; Traczyk, Wurm & Ahonen, 2013; Sommarö, Baiocco et al.; Solberg, 2017).

This is most evident in those countries who were earliest to include gender expression, gender identity and sexual orientation in their anti-discrimination legislation, and is consistent with a trend in which attitudes to LGBTI people have generally become more positive in line with increased rights and protections against discrimination (Norrman, Eggebø & Stubberud, 2020).

  On the other hand, there are large knowledge gaps in the field, with a heteronormative mindset dominating and an equal treatment rhetoric in which everyone should be ‘treated equally’ with reference to laws and guidelines for the specific service (Norrman et al., 2013; Egede et al., 2019).

Treating everyone equally is interpreted as meaning that different situations and unequal conditions do not need to be taken into account in particular. What is considered important is generally a good response to people. However, this recreates a heteronormative foundation whereby everyone is treated as if they were heterosexual and identified with the gender they were assigned at birth. In Norrman et al.’s interview study with five unit managers of municipal nursing homes in Umeå in Sweden, knowledge about LGBTI people’s living conditions and ageing was not seen as relevant because ‘we treat everyone equally’ and ‘there are none here’ (Norrman et al., 2013): “The unit managers repeatedly restated the importance of equal treatment of older people who lived in their nursing homes and that sexual orientation or identity would not affect how a person was treated” (ibid, 237). The managers referred to the social services’ core values in the municipality, the Discrimination Act and the Social Services Act, but above all to the core values. As they focus on equal treatment, ‘they do not provide staff with guidance on interacting with people who are outside the heteronorm or comment on how operations should handle bullying,’ write the authors (p. 243). An equal treatment discourse also characterised doctors’ and nurses’ understandings of interactions with LGBTI patients in a Danish study (Egede et al., 2019):

This is most evident in those countries who were earliest to include gender expression, gender identity and sexual orientation in their anti-discrimination legislation, and is consistent with a trend in which attitudes to LGBTI people have generally become more positive in line with increased rights and protections against discrimination (Norrman, Eggebø & Stubberud, 2020).

In an interview study on working with LGBTI perspectives at two habilitation institutions in Sweden for people with learning disabilities, several of the 19 interviewees stated that they ‘treated everyone equally’, and that the workplace was good at doing this. At the same time, they described patients with learning disabilities and norm-breaking gender identities or sexuality as an invisible group at the habilitation centre. Few employees had met a patient who had openly identified as LGBTI, and confirmed the general pattern in which people with learning disabilities were desexualised (Löfgren Mortensson, 2009). The patient group was considered to break with norms in several ways, but other themes were prioritised and considered more important than gender and sexuality, which were rarely addressed compared to discussions concerning their capacities or ethnicity, about which there was also more knowledge. Sexuality was considered by many to be too private. However, the units that had undergone LGBTI training had more reflections on how their own prejudices and normative ideas affected interaction, and had also worked on, for example, examining the organisation’s schedules and language use and gender-neutral signs in toilets.

All studies included on professionals in healthcare, social care and social science professions highlight a significant lack of knowledge regarding gender, sexuality and LGBTI perspectives. These perspectives were absent in their education, particularly in compulsory education (Stubberud, Pröitz & Hamidiasl, 2018; Solberg, 2018; Egede et al., 2019). This leads to uncertainty when it comes to raising issues of sexuality and gender identity on your own initiative (Träen & Schaller, 2018; Brekke & Vik, 2017; Egede et al., 2019). In Egede et al.’s interviews with five doctors and two nurses at general practice surgeries, it emerged that they felt a great deal of uncertainty about where to find relevant information about LGBTI people’s specific needs for healthcare (2019, p. 65).  In a survey of 1,064 psychologists, one fifth of them raised the topic of sexuality regularly with patients, but a majority of respondents did so from time to time (Träen & Schaller, 2018). Those who raised it most often had more sexology knowledge and felt more confident about raising issues on the topic. More than half of the respondents thought they had too little knowledge about sexuality to address it. The oldest respondents and those with the longest clinical experience felt more confident about talking about sexuality than the younger ones. Questions about negative and problematic sexuality were easier to raise than positive sexuality; sexual abuse, sexual problems, sexual orientation were the most common. In our Western culture, ‘problematic sexuality’ has a prominent place, and therefore it is no wonder that this is reflected by psychologists, write the authors.

Sexuality was more integrated in psychology education in the past, while today it has become a more specialised field, write Träen and Schaller (2018). 64% of psychologists said they did not have any knowledge of sexology. The result is often that the therapist does not feel confident about addressing sexuality, which affects the patient, and thus topics relating to sexuality may remain unspoken.

Lack of knowledge not only leads to avoidance of the topic. In a survey of healthcare staff, unit managers of four county services in Norway that offer psychiatric support, two of which to adults, were asked about employees’ education and skills in relation to gender identity, gender expression and sexual orientation (Solberg et al., 2017). Few services, only 8.3%, had formal skills in the form of approved CPD:

In the services in which there were employees with competence and skills, the quality of the services was also better in relation to LGBTI perspectives and prioritisation of them as being thematically important in the services:

The studies show that the gaps in knowledge are particularly large when it comes to gender identity and gender expression (Smolle and Espvall, 2021; Brekke & Vik; Sommarö, Anderson & Skagerström, 2020; Tikkinen et al., 2019; Egede et al., 2019). Sofia Smolle and Majen Espvall (2021) interviewed 16 social work professionals who interact with older adults in their work about their understanding and knowledge of older trans people’s needs and norm-critical approaches and perspectives. Social workers usually play a key role in elder care, establishing the assistance required, cooperating with other healthcare and social care, and communicating with relatives. Older trans people have lower confidence in healthcare and social services but are also particularly vulnerable to social isolation and more dependent on healthcare and social services. The analysis focuses on three central topics: the strong dominance of heteronormativity and cisnormativity in the professional field, causes and consequences of invisibility and language and pronouns:

During the interviews, it also emerged that gender identity and sexual orientation were both presented as one and the same and confused, which may indicate a lack of understanding of the difference between them, write Smolle and Espervall (2021, p. 7). Although everyone expressed their willingness to interact with older trans people in an inclusive and affirmative way, most were unsure how to do so without giving offence or making someone uncomfortable by actively asking about pronouns or using gender-neutral language. The result instead was that they continued to maintain a heteronormative approach that caused invisibility by their choice of pronouns and by not addressing gender identity, which also contributed to more invisibility by creating a normative, insecure framework for the interaction:

Knowledge about trans people’s specific history and living conditions is also essential to the ability to contribute to better treatment because you know what to look for and listen for, for example in relation to trans people who are not clearly trans or do not have a trans history but pass as the gender they identify with.

Without recognising individual experience and history, equal treatment principles can help reproduce normative ideas and fail to recognise individuals who fall outside of a cisnormative and heteronormative culture.

In summary, lack of knowledge at different levels leads to several negative consequences: a re-creation of norms through rendering LGBTI people invisible and excluding them, which often stems from a lack of confidence about interacting with non-normative identities and life experiences. At a structural level, lack of knowledge in the management leads to LGBTI perspectives not being considered to be important priorities in staff CPD and they are thus not prioritised by employees either. However, the opposite also applies. The managers who know why it is important were more willing to prioritise giving employees opportunities for CPD in different ways (Solberg, 2018).

Several studies show that cisnormative and heteronormative understandings of gender and sexuality dominate healthcare staff’s practice in their interactions with people seeking gender-affirming care and treatment, with a dominant binary gender norm and an understanding of trans identities and experiences as psychopathology (Linander et al., 2020; Trazcyk, Wurm & Ahonen, 2013; Rosqvist, Nordlund & Kaiser, 2014). Sweden has offered state-funded gender-affirming treatment since 1972, which at the same time means that patients have had to fit into the pathological diagnostic criteria that existed, write Linander et al. (2020). The diagnosis criteria have changed gradually during the 21st century, and are no longer considered to be a psychiatric diagnosis based on a ‘gender identity disorder’. The new WHO standards, ICD 11, were published in 2018 after years of advocacy by trans activists:

That which is diagnosed and treated in the healthcare system is gender dysphoria, a state of severe discomfort in which a patient’s perceived gender identity does not match their body and/or assigned legal gender. The treatment institutions’ understandings of who falls within and outside the diagnostic criteria is particularly important in those countries in which access to changing one’s legal gender still depends on a person having been diagnosed and treated for gender dysphoria (ibid). Although an attempt has been made to move away from a psychiatric diagnosis understanding, it persists. In an attitude survey of what healthcare professionals in Finland perceived to be ‘mental illnesses’, with 1,701 participants, 20–50% said that transsexualism is a mental illness, and roughly half of the doctors agreed in full or in part (Tikkinen et al., 2019). In psychology, a developmental psychology framework dominates rather than a medical understanding of illness (Rosqvist et al., 2014; Linander et al., 2020). This is based on identity development as stages:

Treatment for gender dysphoria then involves achieving maturity and stability. However, a subject position that is ‘perfect’ and without crisis will be considered impossible within this framework of understanding, write the authors. In a study by the gender-affirming treatment investigation team, psychiatrists and psychologists in the team were interviewed about the understandings that characterised their evaluations of patients. Maturity and immaturity are often linked to authenticity, which is equated to age – where the meaning of being young is to be an identity seeker – and of being adult to be finished with identity formation. Thus, a young patient may risk being evaluated as not credible in their experience of their own gender identity and dysphoria because it ‘could be something else’ since a young person is not considered to be fully developed, while a middle-aged patient ‘ought to have discovered their gender identity earlier in life’:

Being evaluated as credible as a person seeking care still depends on age-coded, ageist heteronormative, binary and essentialist understandings of gender and identity, as the quotation clearly shows. This is also evident from transgender people’s own experiences in interactions with the healthcare system reported in Part 1, where several have experienced that they receive gender-affirming treatment ‘too late’ (Siverskog, 2016; Bremer, 2013).  An interview study with five psychologists on their experiences of patients with trans identities also shows that understandings of gender as binary and heteronormative frameworks influence professional practice (Traczyk, Wurm & Ahonen, 2013):

The psychologists were interviewed about their experiences with patients with ‘gender-crossing behaviour’. They were not part of the investigation team for gender-affirming treatment; they were county council psychologists. However, they have a central role as gatekeeper in referring patients in the system when necessary for investigation for gender-affirming care. The material shows that the psychologists had not gained knowledge in their basic education, and when they had gained it, the focus was on psychopathology rather than on approach and treatment:

It was always the patients themselves who addressed gender identity as the topic of conversation, and not something the psychologist initiated. Most demonstrated positive, supportive approaches, but often based on normative and binary understandings of gender, with experiences that broke with these understandings not being recognised.

Normative understandings of gender and sexuality are also created in the treatment of people with vaginal agenesis, a congenital intersex diagnosis in which the vagina and uterus do not develop, for which one treatment is vaginal reconstruction (Roen et al., 2018). In an interview study of 32 medical specialists and psychologists in cross-professional treatment teams in Sweden and England, it appears that the pressure of normality can lead to women being treated for vaginal agenesis minimising the time, effort, physical discomfort and emotional costs of vaginal reconstruction:

Although psychological support is considered important by doctors and psychologists in treatment teams, social norms about how women’s genitals should look and function were rarely questioned. Rather than lead patients (back) to treatment, the team should more explicitly question social norms and help patients do the same, thereby changing the definition of ‘success’ from anatomy to personal agency, and the clinical focus from treatment to the women themselves, write the authors.