- (2006) Volume 3, Issue 3
Editor, Diversity in Health and Social Care; Professor of Nursing, Faculty of Health and Community Care, University of Central England, Perry Barr, Birmingham, UK
Editor, Diversity in Health and Social Care; Professor of Diversity in Health and Social Care, Mary Seacole Research Centre, De Montfort University, Leicester, UK
‘In the country of the blind’, wrote Erasmus, ‘the oneeyed man is king’ because, to the ignorant, the half educated person appeared learned (Barker, 2001). He was wrong. In the country of the blind the one-eyed man must cut out his eye to become the same as everyone else because to differ in any way from societal norms is to invite censure, prejudice and hostility that lead to exclusion. Even today, there are parts of the world in which simply being able to read and write places one in danger of suffering and even death. Being different in other ways can be equally dangerous. To experience difference is to feel continually at odds with the world, never quite fitting in, never quite at ease. Discernable differences mark out an individual as deviating from carefully defined and guarded social norms, as being in some way abnormal, a state that attracts a host of negative reactions: unwanted pity, mockery, anger, rejection. Differences that are not obvious, and which in some instances may be nobody else’s business, are particularly prone to inciting hostility and thus create the additional fear of being found out. Either individuals are not believed when revealing their differences or they are rewarded with opprobrium, as though they have in some way wilfully deceived others about their true selves.
Sexual differences are a classic example. Who goes to bed with whom and what they do there is no concern of anyone else, providing those concerned are adults, in agreement about what they want and don’t harm others in the process. It sounds very simple but as a species we are obsessed with sex; how it should be done, why, with whom, when, where. Novels, films, TV, magazines, art and now internet chatrooms all deal with our endless preoccupations with who should put what into where.We have sex therapists for those who can’t do it and addiction services for those who do it too much; priests and lawyers to set boundaries on our behaviour, agony columnists to advise us and doctors to pick up the pieces when things go wrong. Nothing sets our tongues loose like the chance to talk about sex or more likely to encourage us into judging others from some assumed moral high ground. In The Line of Beauty Hollinghurst (2004) demonstrates this very accurately. Barry Groom is a sleazy ‘multiple adulterer and ex-bankrupt’ but his preference for bedding women allows him to moralise about Nick who has been publicly outed as gay. ‘Well I never trusted him. I can tell you that, unequivocally. I know the type ... They hate us you know, they can’t breed themselves ... they’re parasites’ (p. 477).
Being different is, therefore, a risky business though one might consider it a blessing if Barry Groom is the alternative. Human beings are far more than the sum of their sexual organs and preferences yet lesbian, gay, bisexual and transgender (LGBT) people are regarded as though these attributes are all encompassing, providing a lens through which every other action is noted and judged.Moreover, revelation is not a single event. As Cant (p. 161) points out in our guest editorial, coming out as an LGBT person is a never ending series of events. Coming out to oneself, parents, family, friends, doctors, each requires courage and carries the risk of rejection. The psychological effort is exhausting and the risks can be high particularly in those societies where homosexuality is a crime. It is small wonder if LGBT people choose to limit their engagement with the societal mainstream from which they are excluded. In the short term, limiting one’s engagement offsets the challenges of coming out but both LGBT and mainstream society lose out as a result. LGBT people have as much to offer as anyone else and in excluding them society lacks the contributions that they might otherwise provide. The experience of exclusion, of thinking of oneself as an outsider who cannot do the things that other, straight people do can lead to risky behaviour. The extension of the civil rights of LGBT people could go some way towards tackling this thinking by enabling them to take up opportunities in the same way as everyone else. Integration, however, can have a downside; the frisson of being an outsider is lost. As the writer Quentin Crisp remarked, when he was young, being gay was a full time occupation. Nowadays, it is brushed aside with the question ‘yes, yes, but what do you do?’
The experience of being an outsider has consequences in terms of health. As Fish (p. 163) makes clear in our first paper, health service provision is predicated upon the assumption that users will be heterosexual; this assumption is neither stated nor discussed but it is present all the same and consequently lesbian women are underservedwith regard to screening for cancers. In 2004, 1093 women died of cervical cancer in the UK alone and yet 12% of Fish’s sample had never attended for a smear test (Cancer Research UK https://info. cancerresearchuk.org). The most frequent reason for non-attendance was the women’s belief that theywere not at risk. Breast cancer accounts for 32% of cancers in women in the UK and 10 500 women in England died from the disease in 2003 (National Statistics on Line www.statistics.gov.uk) yet only 13% of Fish’s sample regularly examined their breasts.
Fish’s paper raises some important issues about how people view health and what constitutes illness. Fazil et al’s study (p. 171) presents an account of health beliefs among Pushtuun people living in the UK. In addressing the needs of minority groups there is a tendency to focus on those with large numbers but, as the publication Multicultural Matters makes clear, there are numerous smaller populations that are either, as in this case, assumed to be part of a much larger, but quite different group or ignored altogether. This paper highlights the distinct nature of Pushtuun culture and demonstrates Helman’s (2000) assertion that the majority of people attribute misfortune, including illness, to relationships between themselves and the supernatural, other people or both. Such beliefs about the causes of illness and other unpleasant events transcend cultural boundaries. It is only small step from the Pushtuun people stating that someone has put a curse on them to the middle aged Englishwoman who insisted to one of us that she got cancer because ‘I never made it up with my mother before she died’. In her mind her cancer was a punishment for misdeeds. Surgery and chemotherapy were all very well but what she also needed was some kind of spiritual reconciliation or reassurance and it is in this context that traditional healers can have much to offer. They often understand themindsets of their clients far more clearly than health and social care professionals, and can help people come to terms with events in ways that are meaningful to them and which give them some sort of peace (Nolan, 1989). Religious beliefs can also help which is why many health service providers employ chaplains (Sheikh et al, 2004) although they do not always represent the diversity of faith and belief.
We move on to papers that address issues which have received little attention elsewhere. There is ample evidence that black people do not receive the care and treatment they need from mental health services (see for example, Keating and Robertson, 2004; The Sainsbury Centre for Mental Health, 2002). However, there has been little attempt to consider the needs of those living in Wales. As Saltus’ paper (p. 183) points out, black people form a very small minority in a population of less than 3 million. Wales is historically, culturally and linguistically different to England (Madoc-Jones and Dubberley, 2005); health services and practices developed in England cannot automatically be considered suitable for another country. Black people in Wales are likely to have their own Black Welsh identities, their own views on what they require from mental health services and it is surprising to find that Saltus’ paper presents the first attempt since devolution to explore this matter and thus provides a new perspective on this subject.
Members of black and other minority groups are also the subject of our next paper. In the UK, health and social care services have relied heavily on staff recruited from these groups but have been tardy or even obstructive in facilitating career progression (see for example Beishon et al, 1995; Klem and Notter, 2001). The pioneering work of Nesslyn Watson-Druee (see the Leadership, Career and Personal Development Programme for Black and Minority Ethnic Managers at www.learnonline.nhs.uk) in encouraging the career development of black nurses, the promotion of Mary Seacole as an example of black nurses’ achievements and the contributions of high profile black nurses have gone some way towards opening doors for those who wish to develop further although there is still a considerable way to go. Employers have a responsibility to develop organisational systems and procedures that are transparently fair to everyone and which provide the right environment for individual capabilities to flourish irrespective of any other characteristics those people might possess (Cornelius, 2002). In this context we are pleased to present here a practical example of how this could be facilitated. Hafford-Letchfield and Chick (p. 191) outline a programme for aspiring social services managers to encourage the development of staff who might not otherwise have either the chance or the confidence required to put themselves forward for promotion. Fourteen members of staff completed the programme and eight were successful in obtaining managerial posts. All bar one of these was from a black or other minority ethnic group. Clearly there is still much to be done, particularly in facilitating further development, but social services will now benefit fromthe expertise of those eight people in ways that might previously never have occurred.
Our concluding paper in this section concerns black people, mental health and murder enquiries. Desai’s analysis of nine UK reports concerning black mentallydisorderedmenwho committedmurder raises a number of issues (p. 203). First, it appears that these reports are not easily accessible. They may have been produced by UKNHS organisations that have since been disbanded or reorganised as part of continuingUKNHS reforms. Most are not available via the internet or the usual library systems. We are not implying anything untoward here but merely observing that obtaining copies of these reports is not straightforward. Press coverage about reports such as the inquiry into the death of Christopher Clunis is easier to locate than the original documents themselves. This very lack of availability may militate against the development of a consistent approach and serves to perpetuate errors or omissions such as consideration of race and ethnicity. Desai’s paper makes it clear that these two factors were not addressed in any of the inquiries either in terms of the composition of the inquiry panels or examination of the events surrounding the murder. Given the uneasy relationship between black people with mental health problems and mental health service provision, Desai’s findings are both surprising and disturbing. It is to be hoped that, if the UK Department of Health does review the guidelines for murder inquiries, Desai’s findings will be taken into account.
Finally, in our debate section we present a paper on a topical issue: arranged and forced marriage. Readers will be familiar with the story of Romeo and Juliet, the two teenage lovers pulled apart and ultimately destroyed by the feud between their two families. To Shakespeare’s contemporaries the play may well have seemed shocking.At a time when children were expected to give their parents unquestioning obedience, here was a couple of very young people who defied everyone, aided and abetted by an ignorant servant and a priest from the outlawed Roman Church. In this context, their deaths can be seen as a just reward for their wilfulness but Shakespeare was far too subtle for such a moralistic stance. He counterpoints the romance with violence and in doing so reveals some very disturbing undercurrents. Juliet lives in a gilded prison, privileged and cosseted but allowed out only to go to church. Everything seems fine until she refuses her father’s choice of a husband. Forced marriage is, therefore, nothing new and has persisted over time. Western societies may regard it as an outlandish practice but until fairly recently parental consent was considered an essential pre-requisite to marriage in indigenous British cultures.
As Uddin’s paper (p. 211) points out, most parents love their children and want the best for them but some clearly lose the plot particularly when money, property or social status are at stake. In Juliet’s case the Count Paris is clearly wealthy and has everything required to support a wife; he is good husband material. Juliet’s sights are set elsewhere and the violence of her father’s reaction to her refusal is shocking. He proposes to drag her to church and force her to marry and if she still refuses he will throw his daughter out of the house, an act that will make her destitute.
The scene that Shakespeare presents is still acted out in homes where parents seek to force their children into marriages that they do not want. Every year, at least 100 British nationals alone find themselves in this situation (The Foreign and Commonwealth Office, 2000). The actual numbers are probably much higher. In August 2000 the UK Foreign and Commonwealth Office together with theHomeOffice published a Joint Action Plan on Forced Marriage (Foreign and Commonwealth Office, 2000) and, in October of the same year, they created the Community Liaison Unit which has since dealt with over 440 cases, 85% of which involve young women whose families, for the most part, wish to control the women’s sexuality or independent behaviour or to maintain family and honour (Samas and Eade, 2002).
Weak, ineffectual governmental or police responses compound the women’s situation particularly in countries where women have limited civil rights. The consequences for those who try to intervene in such situations can be devastating. For example, a social worker in India was gang-raped by her neighbours because she tried to prevent a family from marrying a baby (Huggler, 2006). Hers is one of the 58 310 rape cases currently awaiting trial with little hope of the successful conviction of her attackers. Governments, police forces and religious leaders need to stand together, making clear, through their actions, that forced marriages will not be tolerated
Forced marriage should not, however, be confused with arranging a marriage which is quite another matter. All societies have processes that allow men and women to meet and choose their partners. In most instances these are intended to lead to marriage in some form. In those societies in which social interaction between the sexes is severely curtailed, professional matchmakers and parents have a role in helping young people to find suitable partners. As Uddin points out, this is a feature of life in many African societies, in South Asian cultures and among orthodox Jews to name but a few. Western societies still show a need for matchmaking. Dating agencies may vary in their reputations but they point to a social need because, even in societies where men and women may mix freely, many have difficulties in finding the right person. Given that the ultimate decision about marriage must rest with the couple concerned, there is no reason to suppose that bringing people together in this way should be any more or less successful than any other.
There are, however, forms of arranged marriage. As Samas and Eade (2002, p. 4) point out, the emphasis in some types of arranged marriage may mean that they are ‘not contracted between individuals but between families and families invest in the stability and success of marriages because divorce and separation can result in inter-family feuding. There are various forms of arranged marriages and the social class and educational backgrounds of parents are closely linked to the degree of choice that is offered to children in the arrangement of marriages’. This is not the same as saying that there is no choice at all. The teachings of all the major religions, and modern secular concepts of human rights, make clear that marriages that do not have the full consent of both parties cannot be considered valid. As Uddin points out, more needs to be done in helping and supporting those who find themselves in situations over which they have no control. So much seems to depend not only on the victims having the courage to resist but also on them having opportunities to access help and the willingness of others to support them.
To conclude, our knowledge-share section contains many items of interest. These include a report on a conference about infertility among South Asians, book reviews and some useful internet resources about diabetes and about men’s health. We welcome contributions to this section. Please send these direct to Lorraine Culley at lac@dmu.ac.uk. However, we would like to make the point that, whilst we are happy to include items in this section, we take no responsibility for quality. We offer them only to draw to readers’ attention to what is available but we do not offer any endorsements.
We continue to welcome papers about all aspects of diversity in health and social care. We invite papers that:
. address social care issues including gender, sexuality, disability and social inclusion from the perspective of clients, service providers or managers
. debate papers that address key issues in diversity or that focus on under-researched topics
. research papers that address any aspect of diversity, including evaluative studies and methodological debates
. practice papers that provide examples of multiprofessional practice or which address the practicalities, policy or managerial aspects of delivering services to members of diverse groups
. knowledge-sharing reports that may include short papers about initiatives to improve practice, information about tools and resources for practitioners as well as book reviews.
We look forward to hearing from you.
Cancer Research UK. https://info.cancerresearchuk.org (accessed 19 September 2006).
Multicultural Matters is a monthly newsletter published by Building Bridges, 15 Eversleigh Road, London N3 1HY, UK. Tel: +44 (0)208 343 2371; fax: +44 (0)208 343 2385; email: info@multicultural-matters.com; website: www. multicultural-matters.com
National Statistics on Line. www.statistics.gov.uk (accessed 19 September 2006).
