Within the field of nursing, it is important to honor the voices of patients, especially when it comes to minoritized groups that experience mistreatment. Over the summer of 2021, I worked on an integrative literature review to study the experiences of sexual and gender minority (SGM) people in inpatient psychiatric care. Research on this topic is incredibly important, as SGM people, or those whose sexual orientation is not heterosexual and/or whose gender is not the same as their sex assigned at birth, face discrimination in many aspects of their lives and subsequently face poor mental health outcomes. My work on this project, funded by the Research Experience and Apprenticeship Program (REAP), sought to emphasize the importance of listening to the lived experiences of SGM people and document some of these discrepancies in psychiatric care.
Previous research has shown that SGM people face higher risks of poor mental health outcomes when compared with the general population, with the rate of lifetime suicide attempts being 40 percent in gender minorities, compared with about 0.5–4.6 percent among adults in America, a staggering statistic (Bockting et al., 2013; James et al., 2016). Sexual minority youth also have higher rates of suicide than their heterosexual peers (Johns et al., 2020; Marshal et al., 2011). These disparities in mental health outcomes have been attributed to the stigma SGM people experience related to their sexual orientation and/or gender identity and may bring about a higher observance of inpatient psychiatric hospitalization (Meyer, 2003; Testa et al., 2017). Inpatient psychiatric units harbor unique obstacles to inclusive care for SGM people, such as gender-based rooming systems and loss of access to gender-affirming items. Despite these concerns, there is a paucity of literature on the subject, especially in terms of patient experiences themselves. Much of the literature that does exist focuses on clinician perspectives, which further exacerbates the suppression of SGM people’s voices. Because of this, the goal of the project was to synthesize and analyze the literature that does exist, find major themes, and describe specific areas of need for more research to amplify the voices of SGM people. Research like this is critical because it centers the voices of SGM people to be heard so that they can receive inclusive, lifesaving care.
Methods and Data Extraction
An integrative literature review characterizes a unique subset of research, based on the gold standard: a systematic review. Although systematic reviews are the standard, being incredibly rigorous in their literature search and writing process, it can be hard to meet these expectations in topics for which there is less literature available. Systematic reviews usually derive data only from data-based studies and articles and require in-depth quality assessment of the literature. Originally, my mentor, Dr. Kristen Clark, and I wanted to conduct a systematic review, but there simply was not enough literature to do so. The existing literature mainly consisted of case studies and other types of research that are not considered proper for a systematic review. Integrative reviews are important resources when researching areas with scarce literature, especially when they relate to people’s experiences. By conducting an integrative review rather than a systematic review, we were able to include sources such as case studies in our research, allowing for more personal perspectives and narratives.
The first step of this project was exploring existing literature. It was essential for me to begin by gaining background knowledge and exploring the literature on SGM people’s health disparities and experiences in health care as a whole. Once I was familiar with the intricate and unique perspectives surrounding the topic, I began to identify search terms to narrow in specifically on the experiences of SGM people in inpatient psychiatric care. I thought about the main key points that were important to our topic, and curated search terms based on the most prominent themes and previously published literature reviews. It took some trial and error to get the search terms right. I had to be selective in the terms I chose but include enough detail that we would find targeted articles. I used important keywords like sexual minority and gender minority as well as similar terms such as transgender to encompass different kinds of perspectives. I also added terms such as psychiatric inpatient treatment, experience, and stigma to target the results toward our research question.
Once search strings were finalized, I searched multiple databases. I worked alongside my mentor as well as a graduate student from Northeastern who was completing a research internship. Together, we explored the literature systematically, identified pertinent articles, and then narrowed them down to those that were most relevant to our search. An important aspect of choosing literature to include was making sure that (1) the setting examined was the inpatient psychiatric setting rather than a general health care or outpatient setting, and (2) that the article included patient perspectives and experiences. Upon reducing to only the articles that met these criteria, we began data extraction.
Data extraction was performed in a spreadsheet to organize data into homogeneous categories. When assessing the existing literature, we organized patient experiences based on three types of stigma: structural, interpersonal, and individual (Link & Phelan, 2001). Structural stigma is characterized by societal regulations and procedures set in place that discriminate against a minority group. Interpersonal stigma is discrimination that takes place in relationships between people and can be overt or covert. Lastly, individual stigma is the internal manifestation of experienced discrimination and can be shaped by past experiences of structural and interpersonal stigma that cause anticipation of future discrimination.
Through the process of data extraction, I tried to identify relevant content and categorize according to the themes of structural, interpersonal, and individual stigma. For example, results related to disparities in policies or systems that negatively impacted treatment would be summarized and categorized as structural stigma. Patient descriptions of mistreatment would be summarized and categorized as interpersonal stigma. When I noticed an account of feelings of insecurity or fear caused by anticipated mistreatment, I summarized and categorized it under individual stigma. Sorting patient experiences into these categories allowed us to categorize our findings in a way that mapped out the complexity of stigma experienced by SGM people in the inpatient psychiatric setting. This data extraction spreadsheet has been very helpful at all stages of the research process and is something we have referenced frequently throughout the writing process of our integrative literature review.
Writing and Results
After much preliminary work, I began drafting our literature review with help from my mentor and colleagues from outside institutions who are experts on stigma and mental health. This process included mapping out a structural framework of how we wanted to organize the review. A literature review has many different sections and subheadings, such as an abstract, introduction, methods section, results section, discussion, clinical implications, and conclusion, requiring meticulous and succinct writing. This was my first time writing in this style, so I started drafting some of the smaller sections while coauthors drafted other parts of the manuscript, such as the findings based on the data extraction spreadsheet I created, the discussion, clinical implications, and subsequent revisions. The paper is undergoing final revisions, and we hope to submit it for publication by the end of the school year.
In our research, a prominent example of structural stigma found was faulty admission protocols that did not include inclusive language or give patients a safe space to address their sexual and gender identities. We observed themes of interpersonal stigma in the form of discrimination from providers or other patients toward sexual and/or gender minorities. Individual stigma is more of an internal manifestation, and we observed this in patients’ experiences avoiding treatment because of past encounters with health care providers. These types of stigma, when compared with the experiences of non-SGM people, elicit important information about discriminatory practices in all aspects of psychiatric care.
Discussion and Personal Reflection
Working on this project allowed me to gain incredible amounts of insight into an underrepresented and marginalized group of people, and garner information I can use in my nursing career to provide inclusive care for all patients. It took much collaboration and arduous work for the project to reach the point it is at now, and I am extremely thankful for the opportunity to get to work alongside these amazing people and have such a remarkable learning experience.
Although I was previously familiar with systematic reviews, completing an integrative literature review allowed me to see that there are many different stages of research. Research surrounding the intricacies of transgender rights and gender-affirming health care in the inpatient psychiatric setting is in the stages of identifying what little we do know, highlighting the key issues, and identifying the need for future research. As awareness is spread about the needs of SGM people, especially pertaining to their unique needs within inpatient psychiatric treatment, more targeted research can be performed. Ideally, this project will establish the need for more research and take us a step in the right direction toward better care for SGM people. Perhaps one day enough rigorous, data-based research will exist to make a systematic review possible. That systematic review could then be used as a clinical standard, so that the needs of SGM people will be properly addressed in all aspects of care.
I would like to give special thanks to my mentor, Dr. Kristen Clark, who took me under her wing and helped me through every step of this process. I also give my thanks to the Hamel Undergraduate Research Center and the Research Experience and Apprenticeship Program (REAP), as well as Mr. Dana Hamel and Dr. Paul Tsang, for giving me the opportunity and the resources to work on this project. I am so thankful for everyone I met along this journey and for everyone who helped along the way. Working on this project has enriched my academic career, and I will carry the lessons I’ve learned with me throughout my nursing career.
Bockting, W. O., Miner, M. H., Swinburne Romine, R. E., Hamilton, A., & Coleman, E. (2013). Stigma, mental health, and resilience in an online sample of the US transgender population. American Journal of Public Health, 103(5), 943–951. https://doi.org/10.2105/AJPH.2013.301241
Cicero, E. C., Reisner, S. L., Silva, S. G., Merwin, E. I., & Humphreys, J. C. (2019). Health care experiences of transgender adults: An integrated mixed research literature review. ANS Advances in Nursing Science 42(2), 123–138. https://doi:10.1097/ANS.0000000000000256
James, S., Herman, J., Rankin, S., Keisling, M., Mottet, L., & Anafi, M. (2016). The report of the 2015 U.S. transgender survey. https://ncvc.dspacedirect.org/handle/20.500.11990/1299
Johns, M. M., Lowry, R., Haderxhanaj, L. T., et al. (2020). Trends in violence victimization and suicide risk by sexual identity among high school students — youth risk behavior survey, United States, 2015–2019. Morbidity and Mortality Weekly Report, 69(Suppl-1), 19–27. http://dx.doi.org/10.15585/mmwr.su6901a3
Link, B. G., Phelan, J. C. (2001). Conceptualizing stigma. Annual Review of Sociology, 27(1), 363–385. https://www.annualreviews.org/doi/10.1146.annurev.soc.27.1.363
Marshal, M. P., Dietz, L. J., Friedman, M. S., Stall, R., Smith, H. A., McGinley, J., Thoma, B. C., Murray, P. J., D’Augelli, A. R., & Brent, D. A. (2011). Suicidality and depression disparities between sexual minority and heterosexual youth: A meta-analytic review. Journal of Adolescent Health, 49(2), 115–123. https://doi.org/10.1016/j.jadohealth.2011.02.005
Meyer, I. H. (2003). Prejudice as stress: Conceptual and measurement problems. American Journal of Public Health, 93(2), 262–265.
Testa, R. J., Michaels, M. S., Bliss, W., Rogers, M. L., Balsam, K. F., & Joiner, T. (2017). Suicidal ideation in transgender people: Gender minority stress and interpersonal theory factors. Journal of Psychopathology and Clinical Science, 126(1), 125–136. APA PsycArticles. https://doi.org/10.1037/abn0000234
Author and Mentor Bios
Jaylyn Jewell, from Rochester, New Hampshire, is a sophomore at the University of New Hampshire (UNH) working toward a bachelor of science degree in nursing. Jaylyn is part of the University Honors Program and serves as an ambassador for both the Hamel Center for Undergraduate Research and the Student Nursing Organization. Before engaging in her own undergraduate research, Jaylyn pictured research only as lab work. However, after learning of the REAP program from one of her honors professors, she learned of all the different research opportunities in the social sciences and healthcare fields, which included being able to do research from home given the restrictions of the COVID-19 pandemic. After looking for a mentor, Jaylyn met Dr. Kristen Clark. Inspired by Dr. Clark’s hard work and research surrounding the rights of marginalized groups, she could not pass up the opportunity to work with her through a REAP grant. Jaylyn feels that working on this project opened her eyes to the injustices that sexual and gender minority groups face in inpatient settings, and how these injustices and stigma can result in many adverse outcomes. In the future Jaylyn hopes to go to graduate school to become a nurse practitioner, and with this in mind she believes exploring and being aware of disparities in healthcare is extremely important. It is also because of the importance of the research that Jaylyn decided to submit her work to Inquiry. To Jaylyn, submitting to Inquiry was a way to reach out to the student body of UNH and spread awareness about the disparities in the healthcare system, while also serving as an ally and advocate of equitable healthcare for all.
Kristen Clark, Ph.D, R.N. (she/her) is an assistant professor in the Department of Nursing at the University of New Hampshire (UNH). Dr. Clark began teaching at UNH as an adjunct instructor in 2019 and began her role as an assistant professor in 2021. Dr. Clark’s research stemmed from her experience working as a psychiatric nurse. Her program of research focuses on the multi-level sources of stigma and its relationship with healthcare access and mental health outcomes among transgender and gender diverse people. This project was the leading step to inform a qualitative study design and interview guide that involved interviewing transgender and gender diverse people admitted into inpatient psychiatric care. At the beginning of this project Dr. Clark was hopeful that there would be a wide range of literature that had emerged since her own time working in inpatient psychiatric hospitals, but, to her disappointment, little progress had been made. However, she was encouraged by Jaylyn’s ability to skillfully engage the scientific literature that was available. Having also mentored an undergraduate student for her honors project, Dr. Clark expressed that students don’t always get to see the variation in research and how that variation builds and impacts our knowledge. She believes that opportunities such as Jaylyn’s REAP project are a great way for students to learn about research options and be exposed to topics that they may not have had the inspiration to investigate on their own.
Copyright 2022, Jaylyn Jewel