**1. Introduction**

Through history and across different social and cultural contexts, homosexuality was and still is presented as a sin, a disease, a crime, or a variation of sexual orientation. Following pressure from strong activist movements, the American Psychiatric Association removed homosexual‐ ity from its official diagnostic manual in 1973. In Slovenia, the Criminal Code treated homo‐ sexuality as a criminal act until 1976. WHO eliminated homosexuality from its list of diseases in 1991. Nevertheless, misinformation and prejudiced views strongly persist in certain areas, the most discussed currently being same-sex families and the right of gays and lesbians to adopt children. Common, general, and erroneous assumptions that get replicated in public discourse are, for example: homosexuality is not normal/natural; it is impossible to have two fathers or mothers; and it is for the good of the children to prevent their adoption by gay or lesbian couples, to name just a few [1]. These assumptions reflect the prevailing heteronor‐ mativity [2], which denormalizes and excludes all other variations of intimate practices and thus regulates our relationships, attitudes, expectations, and behaviour.

More than ever before, homosexuality today is understood in socio-political terms, as a question of social (in)equality. Attention is focused on socially excluding practices; that is, practices that deprive certain people of their basic rights, resources, and opportunities in a society. From the perspective of social psychology [3], these discriminatory practices are grounded in social categorization. The formation of stereotypes involves simplistic generalizations and neglects individual specifics. Stereotyping thereby uncritically over‐ states typical characteristics of a group at the expense of an individual's unique charac‐ ter. Stereotypes are, furthermore, value loaded. Stereotypical negative claims, usually formed even before coming into contact with the person or group talked about, are called prejudiced judgements. Since they are negative, they are related to behaviour excluding

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certain groups of people from the core of the society and relegating them to its margins. The core society, or "us", is considered normal, righteous, and just, while the margins, "them", are attributed a negative, abnormal, and endangering character [4]. Applied to sexuality, heterosexuality is considered a norm (hence the term heteronormativity), pushing homo, bi, and transsexuality to a marginal position. Marginalization is justified and naturalized (presented as natural) in several ways, but it is grounded in prejudiced presentation of certain social minorities as endangering the majority [2]. Although it seems to make little sense, dominant discourses employing different representational strategies to depict certain minorities in negative ways, persistently and powerfully persuade the majority to recognize these minorities as a threat and to act defensively.

From the sociological perspective, the relation between expressed attitudes and real life behaviour is not straightforwardly cause-consequential but rather complex [5,6]. LaPiere's famous study was carried out in 1934 in the United States of America when anti-Asian feelings prevailed. He travelled with a Chinese couple around the country and they were only turned down once out of 251 times, when they asked for a room in a hotel. Later, he sent mail survey to the same hotels and 92% of the respondents claimed that they would not serve Orientals. Prejudices attitudes, therefore, could not simply be taken as predic‐ tors of discriminatory behaviour. What had to be taken into account were wider situation‐ al social factors. In face-to-face contact, especially, less discrimination was detected. Generalization of the causal relation therefore proved problematic, and the importance of different intervening social and personal variables that were activated when an individu‐ al person encountered a unique social situation were stressed. Similarly, considerable problems with defining attitude as a concept appeared. It was established that attitudes were not underlying stable entities but rather varied according to circumstances. Further complexity regarding the distinction between verbally expressed attitudes and their latent constellation was pointed out. Also, presupposing that behaviour could change only if attitudes changed first, neglected the power of social structure to affect behaviour. The latter proved an even greater determinant of behaviour than attitude. Martin Luther King Jr. is often quoted in this respect: "Morals cannot be legislated, but behaviour can be regulat‐ ed. The law cannot make an employer love me, but it can keep him from refusing to hire me because of the colour of my skin" [6]. It is very important to pass laws prohibiting discrimination. It is of equal importance to then implement them systematically and persistently.

It may seem then that actions speak louder than words, but comparing the two would only be to engage in endless discussion about which is more powerful and influential — actions or words. Instead, we should change the perspective and focus on the interpretation that actions manifest through words. We shall adopt this view by observing the changing manifestations of discrimination. Researchers [7,8,3] distinguished between the old and new forms of racism. Slavery and apartheid, for example, were explained in terms of biological inferiority, brutally enacted in direct physical contact as explicit hatred and violence. People were physically segregated. In such forms, racism was condemned — transparent expressions of racism are now globally socially unacceptable. Racism itself, however, was not rooted out. It transformed into the new type, which presents itself in democratic lights and denies being discriminatory. It claims to be a defender of the majority's rights that are endangered by minorities claiming to be deprived and fighting for more privileges. New racists avoid direct contact; rather, they keep their distance from their targets. The new racism is symbolic and cultural. Instead of manifest aggression, it deploys a more indirect and covert strategies such as passive decline and ignoring the minorities. The transformation to more subtle and indirect manifestations established a much stronger relationship between attitude and behaviour. Symbolic racism is primarily a discursive racism. Discourse is a concept that helps us to understand language use within its social context, as a specific form of social interaction [9]. Within a social construc‐ tionist perspective we not only understand the world as we can describe it through language but we actively (re)create it by making different interpretations of it — texts and talks are, therefore, social practices [10]. Interpretations differ in descriptions and values. For example, there is a great difference between descriptions of a bruise as a consequence of a fall and a push. Contrary descriptions can be used to describe and value the same physical event, but which create two different interpretations with completely different judgemental values, and social and personal consequences — the event can be interpreted as an accident or an act of violence, respectively. Our reality is a discursive one and it is important, and far from coinci‐ dental, who possesses the power to interpret, whose version of the world is taken to be the correct and true one.

certain groups of people from the core of the society and relegating them to its margins. The core society, or "us", is considered normal, righteous, and just, while the margins, "them", are attributed a negative, abnormal, and endangering character [4]. Applied to sexuality, heterosexuality is considered a norm (hence the term heteronormativity), pushing homo, bi, and transsexuality to a marginal position. Marginalization is justified and naturalized (presented as natural) in several ways, but it is grounded in prejudiced presentation of certain social minorities as endangering the majority [2]. Although it seems to make little sense, dominant discourses employing different representational strategies to depict certain minorities in negative ways, persistently and powerfully persuade the

From the sociological perspective, the relation between expressed attitudes and real life behaviour is not straightforwardly cause-consequential but rather complex [5,6]. LaPiere's famous study was carried out in 1934 in the United States of America when anti-Asian feelings prevailed. He travelled with a Chinese couple around the country and they were only turned down once out of 251 times, when they asked for a room in a hotel. Later, he sent mail survey to the same hotels and 92% of the respondents claimed that they would not serve Orientals. Prejudices attitudes, therefore, could not simply be taken as predic‐ tors of discriminatory behaviour. What had to be taken into account were wider situation‐ al social factors. In face-to-face contact, especially, less discrimination was detected. Generalization of the causal relation therefore proved problematic, and the importance of different intervening social and personal variables that were activated when an individu‐ al person encountered a unique social situation were stressed. Similarly, considerable problems with defining attitude as a concept appeared. It was established that attitudes were not underlying stable entities but rather varied according to circumstances. Further complexity regarding the distinction between verbally expressed attitudes and their latent constellation was pointed out. Also, presupposing that behaviour could change only if attitudes changed first, neglected the power of social structure to affect behaviour. The latter proved an even greater determinant of behaviour than attitude. Martin Luther King Jr. is often quoted in this respect: "Morals cannot be legislated, but behaviour can be regulat‐ ed. The law cannot make an employer love me, but it can keep him from refusing to hire me because of the colour of my skin" [6]. It is very important to pass laws prohibiting discrimination. It is of equal importance to then implement them systematically and

It may seem then that actions speak louder than words, but comparing the two would only be to engage in endless discussion about which is more powerful and influential — actions or words. Instead, we should change the perspective and focus on the interpretation that actions manifest through words. We shall adopt this view by observing the changing manifestations of discrimination. Researchers [7,8,3] distinguished between the old and new forms of racism. Slavery and apartheid, for example, were explained in terms of biological inferiority, brutally enacted in direct physical contact as explicit hatred and violence. People were physically segregated. In such forms, racism was condemned — transparent expressions of racism are now globally socially unacceptable. Racism itself, however, was not rooted out. It transformed

majority to recognize these minorities as a threat and to act defensively.

persistently.

166 Sexology in Midwifery

The power of discourses is also enabled by structural conditions of dissemination. The basic means of disseminating information today is provided by media of mass communication. People learn more about what is happening around them and in the world from mass media than from their personal experience; their knowledge is therefore mediated through media discourse. As such, media should be the prime locus of our critical attention. Critical discourse analysis developed out of that understanding and need [9,11,12]. Critical discourse analysis of Slovenian mass media texts on homosexuality [2] reveals five basic homophobic strategies: stereotypization, medicalization, sexualization, normalization, and homosexuality as a secret. Discriminatory discourse nowadays is rarely straightforwardly aggressive and explicit, but the same exclusionary effects remain. Some scientists claim its effects are even stronger, because symbolic discriminatory discourses present themselves as democratic, normal, and common sense, something we need not doubt and be critical about. Hate speech nowadays avoids direct disregard; rather it subtly discredits, humiliates, disrespects, and deprives people of dignity. As such, it is no less discriminatory than the older method. Understanding language use as discourse helps us surpass the distinction between actions and words — it stresses doing (discriminating) by using words (interpreting certain people as less worthy). That is why modern activists fighting inequality also operate at the level of legislation, and strive to enforce laws on hate speech. In Slovenia, freedom of speech is written into the Constitution, yet its Article 63 also prohibits the encouragement of inequalities, spread of hatred, intolerance, violence, or war. The Criminal Code was enacted in 2008; article 297 regulates hate speech and article 141 prohibits discrimination on the grounds of sexual orientation.

Surveys on public opinion in Slovenia detected homophobia. The great majority of the respondents did not personally know any people that were homosexually oriented yet more than half of them would not want a gay or a lesbian to be their neighbour [13,14]. In another study [15] more than half of included gays and lesbians had experienced violence due to their homosexual orientation: 90% characterized it as psychological, 24% as physical, and 6% as sexual violence. It was mostly caused by strangers and enacted in public places (61%), but to a lesser extent also by parents (25.8%), relatives, friends, and school peers (25%). At work, 4% suspected they had been fired due to the disclosure of their sexual orientation. Regarding family planning, 42% of gay and lesbian respondents wished to have a child and 40% did not. It was interpreted as reflecting their understanding of an unfavourable social context and scarce chances they were given to realize this wish, which therefore mainly stayed repressed. These data also indicated the (large) extent of deliberation they invested in this question, given that their wish for a child is often considered to be selfish and without any consideration for that child.

Children of gay and lesbian couples are stigmatized and victimized: that is, attributed the role of the victim from the outside by the prejudiced wider society, not based on their own bad experience or objective data of poor living conditions. It is supposed to be for children's own good not to have same-sex parents, although in most cases one of the partners is a biological parent of a child, making such prejudice an instance of homophobia dressed in altruistic clothes. Namely, there is no evidence of lower quality parenting in gay or lesbian couples. Children do not report problems if the relations within the family are of good quality. Rather, the problems appear once they enter an institution or society at large, where others start telling them that they are different or less worthy. Only then do children become at risk of homo‐ phobia, discrimination, and violence. Compared to activist attitudes and the demonstrative silence of gay/lesbian parents and their children in Sweden and Germany, the Slovenian response is to hide — they were afraid of being abused. Homosexuals do have children, either from their previous heterosexual relationships, by in vitro fertilization, or some other kind of arrangement. Rainbow families already exist but they are excluded at the symbolic, legal, and social levels [16].

Social inequalities do not refer only to the economic, political, and cultural conditions of life, but also manifest in health. In the last two decades, WHO has been strongly promoting the awareness of the social determinants of health, especially in terms of the devastating effects of health inequalities [17]. The social determinants of health are defined as economic and social conditions that influence the health of people and communities, and are shaped by policy choices, power, money, and resources that people have. This also means that they could and should be decreased by appropriate socio-political action. Research showed that homophobia and discrimination — negative (pre)judgements, hatred, and practices that deny social participation or human rights — have negative effects on (mental and physical) health of the discriminated and the accessibility and quality of health care services provided to them [18]. Health problems of lesbian, gay, bisexual, and transgender (LGBT) people have only just recently begun to be surveyed [19]. They were found to have worse mental health than the general population, they were more likely to commit suicide, and they had a higher rate of alcohol consumption and misuse of substances/recreational drugs and related problems. They had higher rates of physical ill health, worse self-reported health status, more acute physical symptoms, and chronic conditions. It is important to understand that this morbidity is caused by psychosocial stress stemming from stigma and discrimination coming from the wider society but also occurring in healthcare settings. On the one hand, health professionals were reported to have denied homosexual people access to certain services, excluded them from decision making. or made inappropriate comments. On the other hand, health professionals were experienced as not being knowledgeable about homosexuals' lifestyle and specific health care needs [20]. Studies showed that homophobia amongst health professionals had negative consequences for the care of lesbian and gay clients [21,22]. This is also one of the reasons why LGBT people keep their sexuality a secret from health care professionals or even fail to engage with health services. A general ignorance of lesbian needs is not only present in the field of health care but also social services [21]. In Slovenia, such a deficit combined with homophobic standpoints was already detected in the field of social and consultant work related to mental health, where evidence was found that homosexuality was still considered to be a disorder [23].

### **2. Problem and aim**

than half of them would not want a gay or a lesbian to be their neighbour [13,14]. In another study [15] more than half of included gays and lesbians had experienced violence due to their homosexual orientation: 90% characterized it as psychological, 24% as physical, and 6% as sexual violence. It was mostly caused by strangers and enacted in public places (61%), but to a lesser extent also by parents (25.8%), relatives, friends, and school peers (25%). At work, 4% suspected they had been fired due to the disclosure of their sexual orientation. Regarding family planning, 42% of gay and lesbian respondents wished to have a child and 40% did not. It was interpreted as reflecting their understanding of an unfavourable social context and scarce chances they were given to realize this wish, which therefore mainly stayed repressed. These data also indicated the (large) extent of deliberation they invested in this question, given that their wish for a child is often considered to be selfish and without any consideration for

Children of gay and lesbian couples are stigmatized and victimized: that is, attributed the role of the victim from the outside by the prejudiced wider society, not based on their own bad experience or objective data of poor living conditions. It is supposed to be for children's own good not to have same-sex parents, although in most cases one of the partners is a biological parent of a child, making such prejudice an instance of homophobia dressed in altruistic clothes. Namely, there is no evidence of lower quality parenting in gay or lesbian couples. Children do not report problems if the relations within the family are of good quality. Rather, the problems appear once they enter an institution or society at large, where others start telling them that they are different or less worthy. Only then do children become at risk of homo‐ phobia, discrimination, and violence. Compared to activist attitudes and the demonstrative silence of gay/lesbian parents and their children in Sweden and Germany, the Slovenian response is to hide — they were afraid of being abused. Homosexuals do have children, either from their previous heterosexual relationships, by in vitro fertilization, or some other kind of arrangement. Rainbow families already exist but they are excluded at the symbolic, legal, and

Social inequalities do not refer only to the economic, political, and cultural conditions of life, but also manifest in health. In the last two decades, WHO has been strongly promoting the awareness of the social determinants of health, especially in terms of the devastating effects of health inequalities [17]. The social determinants of health are defined as economic and social conditions that influence the health of people and communities, and are shaped by policy choices, power, money, and resources that people have. This also means that they could and should be decreased by appropriate socio-political action. Research showed that homophobia and discrimination — negative (pre)judgements, hatred, and practices that deny social participation or human rights — have negative effects on (mental and physical) health of the discriminated and the accessibility and quality of health care services provided to them [18]. Health problems of lesbian, gay, bisexual, and transgender (LGBT) people have only just recently begun to be surveyed [19]. They were found to have worse mental health than the general population, they were more likely to commit suicide, and they had a higher rate of alcohol consumption and misuse of substances/recreational drugs and related problems. They had higher rates of physical ill health, worse self-reported health status, more acute physical

that child.

168 Sexology in Midwifery

social levels [16].

Health care professionals and their respective professional fields are a part of society and thereby prone to be affected by various public discourses and policies. It is a constitutive part of their supportive, therapeutic, and educational work to include and empower people in their endeavour to promote, preserve, or restore health. Their professional ethics require them to be knowledgeable, objective, and non-judgemental, and to provide equally accessible and high quality services to all. Midwives are among the health care professionals that deal most directly with different aspects of human sexuality. One of their important competences, therefore, is to gain knowledge and develop sensitivity towards different forms of (health) inequalities related to sexual orientation, starting by becoming aware of and overcoming their own prejudices.

The aim of the original study was to study attitudes of first year students of different health professions towards homosexuality and homosexual parenting. The focus of this chapter is placed on midwifery students. Right at the start of their studies, the students were not yet exposed to a faculty professional curriculum. The purpose was to get an idea of the extent and types of potential prejudices against gays/lesbians and homosexual parenting. On these grounds, it will be possible to revise and adjust the contents of existing study programmes to provide knowledge supporting equal midwifery care in the future. Another aim was to raise awareness of a special discourse pattern — the disclaimer — which in today's' society, especially, effectively supports the hidden persistence of all sorts of prejudices, while giving the illusion of tolerance in the speaker.

### **3. Methods**

A qualitative study was designed and carried out. It involved the first year students of different study programs at the Faculty of Health Studies (University of Ljubljana) at the beginning of the school year 2013/2014. The participation of students was voluntary, free from any pressure, and anonymous. They were informed of the aim of the study and given enough time to ask for additional information. They were asked to provide descriptive answers to eight open ended questions regarding their conceptualization of sexuality in general, sexology as a science and its relevance to their professional field, and their attitudes towards homosexuality and same-sex parenting. They wrote their answers on a piece of paper. Textual material was generated from 49 students of occupational therapy, 16 of orthotics and prosthetics, 39 of radiologic technology, 36 of sanitary engineering, 28 of nursing, and 29 of midwifery. Their answers were typed into an electronic format, and then coded and analysed using a critical discourse analytic framework [9,11]. Acknowledging the purpose and theme of this book, the primary analytic attention was attributed to the answers of midwifery students. In particular, the analysis focused on disclaimers.

In democratic societies, social norms prescribe tolerance and prohibit prejudice and discrim‐ ination among citizens. Speakers breaking this social norm by expressing negative opinions against certain individuals or social groups, therefore, need to apply denials or at least some form of mitigation strategy to maintain positive self-presentation in public. A disclaimer enables this impression management. According to van Dijk [7], a disclaimer (an apparent denial) is a specific structure of language use, the prototype being: "I have nothing against them, **but**...." In the first part of the structure, a generally tolerant attitude is stated while the second part continues with a specific negative opinion. This structure does not support inference from specific to general and as such presents a defensive strategy against potential accusations of socially unacceptable intolerance. On the other hand, the denial is only apparent, because the specific disregard is nevertheless inconsistent with the prevailing social norm. What is negatively stated is not really denied, at least not completely. Rather, the speaker wishes to deny the possible negative inferences about his social intolerance and to establish positive self-presentation. The tolerant attitude is left unsupported by evidence that the speaker really does not have anything against them. At its best, it therefore expresses limited social acceptance.

Billig [24] claimed that the social value of not being prejudiced is so general and deep-rooted that is also shared by the most extreme political agents. The disclaimer represents an advanced justification against the accusation of being prejudiced. It is not merely public impression management. Speakers also justify themselves to those who hold similar values and to themselves. It is therefore also a discursive strategy of self-justification: by the self to the self.

The analysis focused on disclaimers, through which prejudiced viewpoints against gays, lesbians, and same-sex parenting were identified. Results are presented by excerpts from direct writing collected from the midwifery students that participated in our study. Each excerpt is labelled with a code in brackets, where M stands for midwifery and the number for a random number attributed to the study participant. Excerpts are grouped under several sub-headlines according to themes that appeared to be most prominent.
