Hetero‐ and cisnormativity—UK pharmacy education as a queer opponent

Queer pedagogy is a lens through which the hegemonic discourses of curricula and the heterosexual assumptions within them can be made visible. Using this lens, sexuality and gender norms incorporated in undergraduate medical and health curricula can be located and the lived experience of a curriculum examined. This paper seeks to determine the extent of hetero/cisnormativity within UK pharmacy education with the aim of problematising the normalisation of heterosexuality; following this, strategies to disrupt structured hetero/cisnormativity are considered.


| INTRODUCTION
Heteronormativity 1 refers to a view of sexuality where 'heterosexuality is taken as normative within society'. 2 The concept of heteronormativity is grounded in post-structuralist feminist theory where heterosexual male dominance is critiqued as both a societal norm and social conditioning. This heterosexual male hierarchy binarises gender and sexual orientation and gives rise to homonegativity or the negative attitude towards sexual divergence. 3 Genderfication, the binarised view of gender, involves the standardisation of gender within the heteronormative construct of male/female, boy/girl.
Whereas sexual diversity has somewhat mainstream visibility and tolerance, gender diversity has not and continues to be policed, diminished and 'othered'. 4,5 Queer theory, emerging in the 1990s in response to widespread overt homophobia during the AIDS endemic, argues for a non-binary normality that allows for an 'open mesh of possibilities' 6 deconstructing an ideology of normal heterosexuality within social consciousness, cultural practices, institutions and politics, termed the heterosexual matrix. 7-10 Warner 11 argues that the construct of sexual normality is not only heterosexual but a defined type of prevailing heterosexuality that is masculine, occurs in monogamous, for life marriage, and forms the morality of many Western cultures. So, although the dominant heteronormative discourse rewards the perceived natural normality, non-conforming sexuality or gender is criminalised, medicalised, policed, punished and 'othered'. 12 In response to this prevailing heteronormative discourse, queer theory deconstructs essentialised heteronormativity and seeks to disrupt binary conceptualisations of sexuality and gender. 13 Queer pedagogy draws together queer theory and critical pedagogy to examine, ontologically, the normalisation and default of heterosexual ideology within teaching and learning. The hegemonic normality of heterosexuality persuasively infiltrates every aspect of society; in education, this creates an 'otherness' when considering LGBTQI+ identifying people. Queer pedagogy, then, challenges the dominance of heteronormativity within education and the antipathy associated with sexual/gender intolerance. 7,14 From this perspective, it is possible to identify the ways that curriculum design is arranged to incorporate heteronormative values and goals and to critique the face inclusivity and visibility of initiatives intended to disrupt heteronormative discourse, the invisibility of queer sexuality 10 and normalised heterosexual sexuality in higher education. 15,16 That transphobia is prevalent despite LGBTQI+ inclusivity having a platform supported by legislation within the United Kingdom (UK) suggests the experienced and hidden curriculum contradicts the inclusivity espoused by education providers. Reports [16][17][18][19] have highlighted inadequate representation of LGBT people and issues, exposing a normative hidden curriculum in medical, health science and STEM programmes. In health profession education, this can be seen in the ways that patients are presented as heterosexual and are treated as such [20][21][22][23][24] and so nonnormative people are invisible. The effect of this is to further instil heteronormativity in students' psyche and to reinforce implicit bias. [25][26][27] A national policy mechanism, the UK Government Equalities LGBT action plan, 28 recommended education and training to address this implicit heteronormative bias. In the context of pharmacy education, the General Pharmaceutical Council (GPhC), the regulatory body for pharmacists, 29 references a need for inclusivity in its standards for initial (undergraduate) education and training 29,30 although the LGBTQI+ pharmacist network group has called on the GPhC and Pharmacy Schools Council (a body that represents all 29 MPharm programmes in the United Kingdom) to revise the undergraduate (MPharm) degree to be LGBT+ inclusive. 31 Representation within undergraduate pharmacy education is important in order to prepare graduates to care for non-heteronormative people and in order to understand them both as people and as a structurally disassociated/ violated group. This is critically important because it is widely evidenced that LGBTQI+ people suffer health inequalities and the implicit or explicit biases of health care providers that reinforce structural, systemic inequalities. 32,33 It is not just pharmacy education that needs to include representation of LGBTQI+ people. There is evidence that medical and other health profession curricula exclude sociocultural information in case studies or clinical presentations 24,34 at the expense of the role that culture and identity play in health and well-being. Arguments that medical education fails to train doctors to address LGBTQI+ health inequalities, and ignores LGBTQI+ people and/or medicalises queer issues, persist as a product of a training gap. 35 This is unlikely to be addressed in the short term given that curricula are not mandated to be inclusive of specific LGBTQI+ competencies and that queer issues remain peripheral. 35  Where previous studies 20,33,34,[38][39][40] have sought to establish the extent of LGBTQI+ representation in undergraduate curricula, given medical and health professions curricula still struggle with designing inclusive programmes suggests that either educators are not acting on the findings of this research or that they are unsure of how to enact representation in their pedagogic practice. To this end, the research presented here adopts the lens of queer pedagogy to critique heteronormative hegemonic power. It seeks to interrupt heteronormativity and to uncover the implicit bias that works to create invisibility of LGBTQI+ in UK pharmacy education and agitate thinking in medical and health professions education.
Informed by a constructivist research paradigm that treats heteronormativity as socially constructed, and using UK pharmacy education as an exemplar, the aim of this paper is to deconstruct undergraduate pharmacy (MPharm) curricula as a discursive praxis. We seek to: Our intention is to then use the findings from our study and, by adopting a queer pedagogy lens, to expose and disrupt normativity.
We seek to provide medical and health professions educators with both a theory and a method for interrogating implicit bias structuring health professions curricula, so that they can then work with this theory to change their pedagogic practices.

| Research approach
We have approached this study from a critical realist standpoint 41 and use queer theory-in particular queer pedagogy-to deconstruct UK undergraduate pharmacy education, with a view to making visible the practices of normalisation within curricula. Our research approach combines a quantitative survey to capture descriptive data on pharmacy curricula (and in so doing, address the first aim of our study); we also collected qualitative data to deepen our understanding of pharmacy curricula and to allow us to hear the student voice regarding the hidden curriculum and their experiences of the enacted curriculum. We believe that using both quantitative and qualitative approaches is important in order to fully explore and understand curricula structures and practices as both observable and experienced.

| Setting and participants
Data were collected using an online cross-sectional survey design.  [42][43][44][45] Each stakeholder group was invited to complete an anonymous online questionnaire designed specifically for that respondent group.

| Measures and survey development
Course leads: Assessment of hetero and/or cisnormativity in pharmacy curriculum design was based on Tollemache et al. 38 and Obedin-Maliver et al. 39  Questionnaire responses were collected using Qualtrics ® following pilot work to establish face and content validity. Informed consent was obtained electronically prior to providing survey responses.
Ethical approval was sought and obtained from the home institution of the researcher: project ID 11543.

| Data analysis
To establish whether curricula design is hetero-and/or cisnormative, descriptive statistics were calculated using IBM SPSS Statistics version 25 ® . Responses from course leader and students were then compared to identify possible differences in the espoused/intended curriculum and the experienced/hidden curriculum. Qualitative data from free-text responses were analysed using a comparative method. 46 This is an iterative process of coding and thematic analysis that provided additional meaning to the descriptive statistics concerning how LGBTQI+ teaching is positioned and considered. The qualitative data further provide insight into how discursive strategies are used to other LGBTQI+ people. Following this, quantitative and qualitative datasets were interpreted through the lens of queer pedagogy.
AM constructed and distributed the surveys. AM and SW were both involved in data analysis and interpretation. This was particularly important for the qualitative data, where although our approach was primarily inductive, the quantitative data were used initially to frame coding deductively under broad categories for understanding the experienced and hidden curriculum. Following this, inductive analysis was undertaken by each of the authors independently, with us coming together to discuss coding and interpretation. Through reflexive discussions, we were able to generate understanding of codes and apply our conceptual, theoretical standpoint of queer pedagogy. 47

| RESULTS
After reviewing responses from course leads to ensure they reached a minimally acceptable level of completion, 19 valid cases were analysed, yielding a 65.5% response rate. Of these 19 responses, Analysis presented both describes, quantitatively, the current state of play reported to us in the survey, with qualitative data used to provide a narrative account of these numerical data. We deconstruct pharmacy curricula to identify the ways that curricula are enacted in a heteroÀ/cisnormative paradigm. As a consequence, we show the ways that this then creates a hidden curriculum where LGBTQI+ people are represented in a reductive, invisible and stereotyped way, which we argue results in producing graduates who are unprepared for practice within a diverse society. This deconstructive approach can be adopted across medical and health professions curricula. There is evidence that programmes use heterosexist devices to validate a normative construct whilst making LGBTQI+ themes peripheral. Thus because LGBTQI+ people are constructed as 'other', educators describe having to design 'special' content requiring a different approach when delivering:

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[We] advised students of the nature of the content in advance of sessions and set clear ground rules for sessions.
Othering was also apparent in normative discourses such as isn't care of people who identify as LGBTQI+ specialist?. When LGBTQI+ people were present in curricula, this tended to be marginalised:   25 (14) irritation when we bring this up … any teaching around safe sex is heteronormative, sexist and only relevant to straight monogamous relationships.
Pharmacy students need to be educated on issues specific to LGBT people because every piece of information taught assumes that they don't exist.
Some learners expressed concern with inclusion of LGBTQI+ themes within the MPharm, suggesting sexuality and gender policing by the student body. 5

| The curriculum as a tool to disrupt normativity
Although none of the student responses indicated sustained or positive LGBTQI+ teaching, some course leads were able to showcase positive steps in inclusive education particularly in partnership with LGBTQI+ charities and organisations. Teaching on LGBTQ+ identities, and the inequalities LGBTQ+ people face … teaching on gender-affirming care, particularly the pharmaceutical aspects of this.
How to be an ally.
The feeling of being unprepared was particularly prominent when considering the care of trans people with a strong expression that more knowledge and experience was needed in this area:   52 For example, gay marriage is widely acceptable but in itself is being fit within a hegemonic heteronormative structure as it preserves the institution of marriage, monogamy and two-person coupling that fits with normative models and assumptions. 53 An area where disrupting normativity can be achieved, particularly in repositioning the espoused and enacted curriculum, is through heterosexual allies who interrupt prevailing ideology with a cooperative approach to pedagogy and not, as this study finds, leaving LGBTQI+ education to queer staff or external agencies. 7 As outlined by Seal, 7 heteronormativity is best challenged by a whole team or programme approach where allies are fundamental to the disruption of hetero-hegemony within a curriculum. Another area of focus is the visibility of non-heterosexual and non-binary genders within teaching content as normal, that is, as usual examples and not solely used when teaching topics such as sexual health and mental health. Here, co-creation of curricula content with learners is a useful tool to achieve this. This has been termed LGBT competence. 49 Repositioning social education to enable learners to challenge political, structural and institutional hegemony and think critically about privilege and the heteronormative, cisnormative worldview.
The Ward-Gale Model for LGBTQ-inclusivity 17 may be useful for educators to consider the language, role models and content present in a curriculum.
Some respondents described positive practice in LGBTQI+ inclusivity, and this best practice should be disseminated across medical and health professions education. On a broader scale, the bodies representing the medical and health care professions and their respective education standards have a duty to disrupt heteronormativity and make visible efforts in queering the curriculum. Explicit curricula outcomes and standards regarding LGBTQI+ health should be incorporated in to education standards by curriculum regulators.
Respondents in this study were not clear whether the GPhC achieve this in their accreditation standards and this lack of explicit training standards also exists within medicine. 37 These results demonstrate disconnect between the espoused, enacted and experienced curriculum. The hidden curriculum is experienced by a student body that is frustrated and angered with LGBTQI + invisibility and found to be knowingly hetero-and cisnormative in design and culture producing graduates ill equipped to care for all patients within an inclusive society.
A limitation of this study may be the extent of knowledge the participant has about their curriculum particularly if and where LGBTQI+ content is taught, if at all. This could explain why some programmes espouse to enact an inclusive curriculum, but they actually cannot easily evidence the fact. The student survey may have attracted queer identifying participants and may not reflect the sentiment of the whole student body.
Whilst this study took a quantitative and descriptive approach to establish a national picture of LGBTQI+ teaching in pharmacy education, it acts as a conceptual lens for medical and health professions educators to interrogate, establish and dismantle their own hidden curriculum. Our work intends to move away from describing the volume and place of content and seeks to encourage educators to embed an inclusive ethos and culture in their curricula. The next steps for this work are to evaluate the attitudes and beliefs pharmacy educators hold towards hetero-and gender normativity to establish and disrupt homonegativity within the sector to move past the shortcomings within pharmacy education as established here.
Hetero-and cisnormativity does not discriminate and is present across the spectrum of medical and health professions education despite the issue being well accepted. This article concludes that once this phenomenon is acknowledged, educators can hold a critical queer lens to the espoused, enacted and the experienced curriculum, and through this uncover what is hidden. Through this practice, it is then possible to take a stance of continual, sustained and systematic disruption of hetero-and cisnormativity as a means to overcome it.

CONFLICT OF INTEREST
There are no competing interests.

ETHICS STATEMENT
Ethical approval was sought and obtained from the home institution of the researcher: project ID 11543-The University of Manchester.

AUTHOR CONTRIBUTIONS
Andrew Mawdsley designed and facilitated the survey, analysed the findings and wrote the manuscript. Sarah Willis analysed the findings and contributed to the manuscript. Both authors give approval to the submitted work.