INTRODUCTION

Sexual identity is a concept that defines the sexual orientation of an individual regardless of gender, not only by physiological and biological characteristics, but also by the individual’s emotions, thoughts and desires. A discrepancy between what would be expected of an individual’s physiology and their sexual orientation is expressed by various concepts.¹ The most common discrepancies are lesbian, gay, bisexual and transgender (LGBT). Homosexuality is a general expression that includes all of these concepts.² The reason for the occurrence of this condition, which is also called homosexuality, is not fully known. While some studies define these orientations as psychological disturbances, others emphasize that the underlying cause of such an orientation is not fully known.^2,3 Among the situations that could cause homosexuality, nutritional, genetic, hormonal, developmental, social and cultural effects are mentioned.² However, there is no scientifically proven finding.

The differentiation of sexual orientation is incompatible with the habits brought by social culture, whether or not there is any psychological disorder. For this reason, homophobic behaviors against homosexual individuals are observed in society. Homophobia is a negative attitude towards individuals with different sexual orientations.⁴ Social norms suggest that men and women should be romantically attracted to their opposite sex. If this is not the case, unfair and violent approaches such as the exclusion, rejection or humiliation of the person are encountered.⁵ Violence may be psychological as well as physical. Those who practice violence engage in deliberate behavior, with the aim of direct harm or damage to the individual they are opposed to. It was reported that deaths due to violence rank fourth among individuals aged 15–44 in the world, while it is 2.28 per hundred thousand in all age groups in Turkey.⁶ It is inevitable that homophobic and transphobic violence will be directly proportional to the rate of violence in the general population.^7,8 Homosexuals are in a group with a high probability of being exposed to violence due to the perspective of society, and studies have supported this view.^9,10 

Homosexual individuals face different forms of violence such as being neglected by society as well as physical and psychological violence. These negative attitudes and behaviors lead to the deterioration in the health of homosexual individuals over time.^11,12 Like all people in the world, homosexuals have the right to receive fair and quality health care. Health services should be provided equally to everyone, regardless of the individual, their race or language. All occupational groups are expected to act in accordance with professional awareness in the provision of health services. In particular, nursing is an important profession among health care providers as it interacts most with the patients. Unconditional admission, holistic care and humanitarianism are at the core of the profession of nursing. With this understanding, every individual who wants to receive health services should be welcomed equally. In line with the roles of the profession of nursing, nurses are expected to display their advocacy, caregiver, therapeutic and rehabilitative roles towards homosexual individuals when necessary.¹³ The finding in some studies that nursing students’ levels of tendency towards violence are low shows that nurses comply with professional ethics and morals.^14-18 However, some studies have also reported that health workers have negative attitudes towards homosexual individuals.^19-21 

It is extremely important in undergraduate education to train nurses to enhance their professional understanding by teaching them the roles and responsibilities of the profession of nursing. However, the influence of social culture in the formation of these targeted outcomes should not be ignored. The occupational awareness of individuals who have been raised according to the accepted norms of sexual identity and sexual orientation in their society may also be affected accordingly. Although there are studies examining the views of nursing students towards homosexual individuals,^19-21 there is insufficient information on the effect of any possible violent tendencies on their homophobic points of view.²² Therefore, this study was conducted to determine the impact of nursing students’ levels of tendency towards violence on their attitudes towards homosexuals. Thus, knowing about the levels of tendency towards violence and homophobia among nursing students, who are the nurses of the future, will be possible, and how much the concept of tendency towards violence can explain negative attitudes towards homosexual individuals will be determined. According to these results, the differences in gender and gender roles will be emphasized in the course content of the students. This will contribute to making the right decisions and planning appropriate care for patients with different sexual orientations in the process of providing nursing care.

In this context, the research questions of the study were determined as follows:

1. What are the attitudes of nursing students towards homosexuals?

2. What is the violence tendency level of nursing students?

3. How do nursing students’ violence tendency levels affect their attitudes towards homosexuals?

MATERIALS AND METHODS

Objective and Methods

With this cross-sectional and descriptive study, it was aimed to determine the effect of nursing students’ violence tendency levels on their attitudes towards homosexuals.

Population and Sample

The population of this study was determined to be 806 nursing students in their first to fourth years of study at the Health Sciences Faculty of a state university in Turkey between November and December in 2020. Five hundred and two students who voluntarily agreed to participate in the study and were selected by a purposive sampling method participated in this study. The results of the power analysis conducted using the G*Power 3.1 (Heinrich-Heine-Universität, Düsseldorf, Germany) program showed the power of the study conducted with 502 participants to be 95% with type-1 error, setting alpha at 0.05.

Data Collection Tools

The data were collected using the Student Information Form prepared by the researchers, the Violence Tendency Scale and the Attitudes towards Homosexuality Scale.

Student Information Form

This form was prepared by the researchers using the literature. It consists of 14 questions about the students’ gender, academic year, income perceptions, regions of residence, cohabitation situations, whether or not their parents were alive, levels of education of their parents, parental employment statuses, families’ attitudes, presence of people with different sexual orientations around them and their statuses of being friends with those people.^{1,4,5,14,18,19}

Violence Tendency Scale (VTS)

The Violence Tendency Scale was developed by Göka, Bayat and Türkçapar in 1995, in a study conducted on behalf of the Turkish Ministry of National Education to measure the violence tendencies of secondary school students. Later, the scale was re-evaluated, its validity was tested, and it was used in the research of the Turkish Prime Ministry Family Research Institution on “violence in the family and in the social field” (1998). The reliability coefficient of the scale was found to be 0.87 in this study. It is a four-point Likert-type scale consisting of 20 items. For each item, the response options range from (1) not at all suitable to (4) very suitable. Higher scores on the scale indicate higher levels of tendency towards aggression and violence. Violence tendency was categorized according to the scores obtained from the scale. Scores of 1–20 are evaluated as “very low”, 21–40 points are evaluated as “low”, 41–60 points are evaluated as “high”, and 61–80 points are evaluated as “very high” tendency towards violence.²³ In this study, the Cronbach’s alpha reliability coefficient of the scale was found to be 0.83.

Hudson and Ricketts Homophobia Scale (HRHS)

It is a 25-item, six-point Likert-type scale developed by Hudson and Ricketts to measure attitudes towards homosexual individuals in 1980. The scale was adapted to Turkish by Sakalli and Uğurlu²⁴ and the number of items in the scale was reduced to 24 in 2001. Items 5, 6, 8, 10, 11, 13, 17, 18, 21, 22 and 23 in the scale are inversely scored. A single total score is taken from this scale, and higher scores indicate increased negative attitudes towards homosexuals. In Sakallı and Uğurlu’s²⁴ study, the Cronbach’s alpha internal consistency coefficient of the scale was found to be 0.94. In this study, the Cronbach’s alpha coefficient of the scale was found to be 0.88.

Data Collection

After obtaining the necessary preliminary permissions for the study, the implementation of the study was carried out online between November and December 2020, the data were collected according to the principles of the Declaration of Helsinki. Each participant was informed with an informed consent form, and their consent was obtained.

Statistical Analysis

The SPSS version 22 (IBM Corp, Armonk, NY, USA) program was used for data analysis. Frequencies, percentages and means were used as the descriptive statistics of the data. The normality of the distribution of the data was checked with Shapiro–Wilk test, and it was found that the data showed a normal distribution (p>0.05). Therefore, for the statistical analyses, the significance test of the difference between the two means, one-way analysis of variance (ANOVA) and Tukey’s HSD analysis were used. In the comparison of the categorical variables, gender, academic year, number of siblings and region were analyzed as the independent variables, and the total scores of the participants on Violence Tendency Scale (VTS) and Hudson and Ricketts Homophobia Scale (HRHS) were analyzed as the dependent variables. The relationship between the dependent variables was tested by Pearson’s correlation analysis. Simple linear regression analysis was used to determine the impact of tendency towards violence on attitudes towards homosexuals. The level of statistical significance was accepted as p<0.05.

Ethical Aspects of Research

This research was carried out in accordance with the principles of the Declaration of Helsinki, and written consent was obtained from the students who voluntarily agreed to participate in the study. Institutional permission was obtained from the Department of Nursing at the Faculty of Health Sciences where the study was conducted, and approval was obtained from the Kırşehir Ahi Evran University Non-Invasive Ethics Committee with the decision dated 24.11.2020 and numbered 2020-17/128.

RESULTS

The distributions of the HRHS and VTS scores of the students based on their personal data are given in Table 1. The mean HRHS score of the participants was determined to be 95.50 (94.25±22.23), and their mean VTS score was determined to be 36.00 (37.82±8.25). It was observed that there was a statistically significant relationship between the participants’ mean HRHS scores and their academic year, number of siblings, the region they lived in and whether their parents were alive. It was determined that there was a statistically significant relationship between the students’ mean VTS scores and the level of education of their mothers and whether their parents were alive.

Table 2 shows the distributions of the participants HRHS and VTS scores according to the social environment characteristics of the participants. There was no statistically significant relationship between the participants’ social environment characteristics and their VTS scores (p<0.001). A statistically significant relationship was determined between the participants’ mean HRHS scores and the presence of a homosexual person in their immediate environment and their desire to be friends with the homosexual person. It was observed that the participants who said, “I am friends with homosexuals” had a more positive attitude towards homosexual individuals than those who said they were indecisive about the question or not friends with any homosexuals.

Table 3 shows the effect of tendency towards violence on their points of view regarding homosexual individuals. It was determined that 66.3% of the participants had a low tendency towards violence, and 31.9% had a high tendency towards violence. No significant relationship was found between the participants’ tendency towards violence and their points of view regarding homosexuals (p>0.05).

DISCUSSION

Negative and discriminatory attitudes towards homosexual individuals who receive care from the health system are an important problem affecting the right to health of such individuals. Additionally, homosexual individuals encounter discriminatory attitudes in their interactions with health care professionals, and their negative experiences lead them to avoid seeking care when they need it again.^25,26 For this reason, it is important to investigate the attitudes of nurses and variables that affect these attitudes during their student years, as nursing students will provide continuous health care services to homosexual individuals.

In this study, it was determined that the participants’ attitudes towards homosexual individuals were negative according to their HRHS mean scores, and there was a significant relationship of their HRHS scores with regards to their academic year, their number of siblings, their region of residence and whether or not their parents were alive. In a study conducted with 335 nursing students, it was discovered that variables such as gender and parental education levels affected attitudes towards homosexuals.⁴ In another study, it was determined that gender, academic year, family structure and socio-economic status were correlated with the nursing students’ perspectives regarding homosexuals and their willingness to provide care to these individuals.²² In a study conducted with nursing students in Korea, it was established that 92% of students had negative attitudes towards homosexuals.²⁷ In other studies that were conducted with nursing students, it has been observed that the students had negative attitudes towards homosexuals.^28-30 The findings of this study were compatible with the literature. As homosexuality is perceived as taboo by society in Turkey, and as nursing students are a part of society, they often have the same perception regarding homosexuals.³¹ This negative attitude gets stronger, especially with the prevalence of the traditional perspective, and so discrimination against homosexuality increases in rural areas.³² In this study, it was observed that the attitudes of the participants differed significantly based on the regions they lived in and the number of their siblings. It may be stated that differences in eastern and western cultures in Turkey affect both the number of children a family has and their attitude towards homosexuality. As the number of siblings increases, the family structure becomes more traditional, and this traditional perspective makes the family members’ attitudes towards homosexuality more negative. The differences found in this study in the participants’ attitudes towards homosexuality based on their academic year was thought to be due to the courses the students took in nursing education. It may be argued that this situation is related to the internalization of the information that supports the humanitarian and holistic perspective provided in the curriculum.

In this study, the participants’ mean VTS score was 37.82±8.25, and 66.3% of them had a low level of tendency towards violence. It was determined that the mean VTS scores were related to whether the parents of the participants were alive and the education levels of their mothers. In one study, the gender-related perceptions and violent tendencies of nursing students were investigated, the mean VTS score of the participants was found to be 38.86±9.33, and a significant relationship was found between the students’ tendencies towards violence and their income status.³³ In another study, it was found that the students’ tendencies towards violence were low, their mean VTS score was 38.79±9.32, and the mean VTS score was associated with their academic year, gender, smoking and alcohol usage status and their status of exposure to violence. It was determined that the students’ experiences such as resorting to or being subjected to violence increased their tendency towards violence.¹⁷ In the literature, it is seen that the tendencies of nursing students towards violence are at a low level, and the findings in our study were compatible with the literature. Considering that the profession of nursing is based on the concept of providing help (altruism) and that students aim to help and heal people while choosing the profession of nursing, it may be stated that the low tendency of the participants of this study towards violence was an expected result. In this study, it was determined that for those students with high tendencies towards violence, the loss of one of the parents and the education level of the mother made a significant difference. In another study, it was reported that tendency towards violence is related to the family environment in which students grow up, and most students had been exposed to violence within their families.³⁴ In another study conducted with university students, it was stated that 49.4% of those students with a tendency towards violence mimicked violence from their families.³⁵ In line with these studies, it may be stated that variables such as the loss of one of the parents or the education level of the mother, which make a difference in the tendency of individuals towards violence, may cause changes in the family environment, increase the child’s exposure to violence in the family due to increased responsibilities and stress, and this situation may affect the students’ tendency towards violence.

It was determined that the mean HRHS scores of the participants of this study were related to the presence of homosexuals around them and their status of wanting to be friends with homosexuals. It was seen that those students who said, “I am friends with homosexuals” had a more positive attitude towards homosexual individuals than those who said they were indecisive about this question or not friends with homosexuals. In a study conducted with midwifery students, it was reported that the students’ attitudes towards homosexual individuals changed positively after getting to know and becoming friends with a homosexual individual.³⁶ Similarly, in studies conducted with nursing students, it was determined that having a homosexual person around them or getting to know a homosexual person positively affected the nursing students’ attitudes towards homosexual individuals.^4,22,37 In a study investigating the discrimination and prejudice levels of nursing students, it was shown that those who were not friends with homosexuals had more negative attitudes towards lesbians.³⁰ It may be stated that the experiences of students, such as getting to know a homosexual person or making homosexual friends, contribute to their overcoming prejudices against homosexual individuals by spending time together and sharing, and students who say “I am friends with a homosexual person” have positive attitudes towards homosexual individuals with an approach that is less judgmental and more respectful of sexual identities, especially due to their flexible perspective.

In this study, no significant relationship was identified between the participants’ tendency towards violence and their points of views regarding homosexuals. The literature review conducted in this study revealed no other study examining attitudes towards homosexuals and the tendency towards violence together. In Turkey, attitudes towards homosexuality in the social structure continue to be negative, and it can be observed that this situation stems from the gender perception and patriarchal structure of society, and negative judgments against homosexuality are transferred from generation to generation through social learning.³⁸ Another important factor affecting attitudes towards homosexuals is the individual’s perception of gender, and as this perception sets in, the individual’s attitude towards homosexual individuals becomes more negative. A statistically significant relationship was found between nursing students’ gender perception scores and violence tendency scores.^33,39 The relationship between the perception of gender and tendency towards violence is structured and maintained by the patriarchal system as a goal and product of the masculine social structure in the context of the construction of masculinity and male violence.⁴⁰ The reason for the lack of a significant relationship in this study between the participants’ tendency towards violence and their negative perspectives regarding homosexuality may be the fact that 71.5% of the participants were women, the profession of nursing is built with a philosophy of helping people, and the male participants in the study had a perspective that left their patriarchal stereotypes behind, preferring nursing, which is a female dominated profession.

In this study, it was determined that the attitudes of the nursing students towards homosexuals were negative, and there was a relationship between their negative attitudes and their academic year, their number of siblings, their region of residence and their cohabitation statuses. It was also observed that the students’ levels of tendency towards violence were low, and there was a relationship between their levels of tendency towards violence and whether their parents were alive and the education levels of their mothers. It was seen that the levels of the tendency of the nursing students towards violence did not explain their attitudes towards homosexual individuals. In line with these results, since it is thought that the homophobic attitudes of nursing students may be related to their region and their culture, further studies examining cultural variables are recommended. Additionally, it is recommended to increase the number of educational and social environments that will enable students to recognize their homophobic prejudices, respect personal choices and gain an empathetic perspective, add course contents to prevent homophobia in nursing education into the nursing curriculum and integrate more examples of empathy, self-knowledge and anger management into nursing courses.

Limitations of the Study

Although 62% of the population was reached in this study, the fact that it was conducted in a single faculty is among the limitations of this study. Additionally, obtaining the data online may be considered another limitation.

MAIN POINTS

● Negative myths and attitudes may negatively impact the care provided to homosexuals.

● With our study, the participating nursing students had the opportunity to notice their feelings towards homosexual individuals.

● With this study, the attitudes of the nursing students were evaluated, and the results showed that the tendency towards violence, which has become a stereotype, is not actually significant on homophobic attitudes.

● Educational and social activities should be planned to change negative perceptions and attitudes and create awareness among nursing students about differences.

ETHICS

Ethics Committee Approval: Ethics committe approval was obtained from Kırşehir Ahi Evran University Medical Faculty Non-Invasive Research Ethics Committee with the decision dated 2020-17/128 and dated 24.11.2020.

Informed Consent: Each participant was informed with an informed consent form, and their consent was obtained.

Peer-review: Externally peer-reviewed.

Authorship Contributions

Concept: N.A.Ç., H.S.Ö., Design: N.A.Ç., H.S.Ö., Data Collection and/or Processing: N.A.Ç., H.S.Ö., Y.C., Analysis and Interpretation: N.A.Ç., H.S.Ö., Writing: N.A.Ç., H.S.Ö., Y.C., Critical revision: N.A.Ç., H.S.Ö., Y.C.

DISCLOSURES

Conflict of Interest: No conflict of interest was declared by the authors.

Financial Disclosure: The authors declared that this study had received no financial support.