Knowledge of Homosexuality and Attitudes Toward Lesbian and Gay Parenting Among Israeli Nurses in Mother-Child Health Clinics

Abstract

The growing number of lesbian and gay (LG) parent families in Israel, along with the increasing involvement of nurses in Mother-Child Health Clinics (MCHCs) in supporting them, served as the impetus for this study. The study aimed to examine (1) MCHC nurses’ knowledge of homosexuality and attitudes toward LG parenting; (2) the association between their knowledge and attitudes; and (3) their association with socio-demographic, professional, and LG-related characteristics. Findings from 65 MCHC nurses revealed moderate levels of knowledge about homosexuality, low levels of negative attitudes, and moderate levels of positive attitudes toward LG parenting. Nurses who were Jewish, secular, or living in a city had greater knowledge about homosexuality and fewer negative beliefs about LG parenting. Acquaintance with LG individuals was associated with fewer negative beliefs about LG parenting. Greater knowledge about homosexuality correlated with fewer negative beliefs and more positive perceptions of LG parenting, suggesting that enhanced knowledge fosters more positive attitudes toward LG parenting. The findings emphasize the need for tailored, knowledge-based training in nursing education for MCHC settings, considering nurses’ diverse cultural backgrounds, level of religiosity, and familiarity with LG individuals. Incorporating content on homosexuality and LG parenting may promote more inclusive and supportive care practices.

1. Introduction

In recent decades, most Western countries have witnessed the proliferation of new family forms alongside the once-dominant traditional model of a heterosexual married couple raising their biological children [1,2,3]. Despite this growing diversity, the culturally dominant view continues to privilege the heteronormative family [4] positioning it as the standard for comparison with other family forms [5], thereby devaluing family configurations that fall outside the traditional model [1]. This dominant ideal of the family plays an important role in shaping institutional practices, often reflected in hostile laws and policies toward individuals whose family choices deviate from the heteronormative model, including those of lesbian and gay (LG) parents [6]. Early research on LG-parent families reflected traditional perceptions of family by focusing on comparisons with heterosexual two-parent families in an effort to assess LG individuals’ parental suitability and their children’s adjustment [7,8]. However, these studies found that children raised by LG parents fare just as well as those raised by heterosexual [7,9,10,11]. More recent research have moved beyond using the traditional heterosexual two-parent family as a control, focusing instead on the unique features and diversity of new family forms. These studies highlight the central role of family processes, rather than family structure, in shaping outcomes for both parents and children [2,12,13].

The devaluation of LG families is also evident in the healthcare system, where providers often lack sensitivity to the specific needs of LG individuals and their families. Research indicates that healthcare professionals hold heterosexist attitudes that lead to flawed diagnoses and medical care assessments, resulting in flawed medical treatments of LG individuals [14,15]. Many LG individuals report negative experiences when accessing healthcare, due to homophobia and prejudice stemming from the lack of professional training in this area [16].

Regarding LG parenting, the main concern of LG parents when approaching healthcare services is the attitudes of providers towards their sexual orientation [16]. Chapman and colleagues found negative attitudes and beliefs, as well as a low level of knowledge regarding LGBT parenting among healthcare professionals [17]. This leads many LG parents to conceal their sexual identity from the staff for fear of discrimination, damage to their child due to prejudice, and negative judgment of LG parenting [18,19]. Research by Tzur–Peled and colleagues found that most nurses in women’s health centers in Israel had negative attitudes toward the treatment of lesbian women and only moderate levels of knowledge about homosexuality. Older age and a higher level of education were associated with more positive attitudes toward the treatment of lesbians [20]. A study by Klein and Elboim-Gabyzon revealed that heterosexual male therapists, particularly those who were religious, held more negative attitudes toward LG patients, while LG therapists expressed more positive attitudes [21].

Legal frameworks related to sexual minority rights vary widely across the globe and continue to evolve [22,23]. This includes substantial variation in the legal possibilities for same-sex couples to become parents, such as through adoption or assisted reproductive technologies. In some countries, same-sex couples have full access to parenthood, while in others, significant legal and policy barriers remain [23,24]. While many European and North American countries have witnessed notable advances in the legal recognition of same-sex parent families and in public attitudes toward them, equal rights have yet to be fully achieved across these regions [23]. Moreover, societal prejudices may persist even in countries with established legal protections for sexual minorities [22].

Within this broader global context, Israel represents a distinctive sociocultural setting for studying LG parent families. This distinctiveness stems from Israel’s strong pronatalist and familistic values, alongside legal barriers to marriage and parenthood for LG individuals [6]. The pronatalist and familistic values of Israeli society, attributed to the Biblical imperative to “be fruitful and multiply” and to the traumas of the Holocaust [25], are evident in the country’s high marital and birth rates [26,27], as well as in its fertility rate—the highest among OECD countries [28]. They are also evident in the state’s provision of child-related benefits [29] and unlimited state-funded in vitro fertilization (IVF) cycles for all women up to age 45, regardless of whether they already have children [30]. Indeed, parenthood in Israel is viewed as central to social acceptance [31].

Despite strong cultural and institutional support for parenthood, until recently, gay men in Israel, both couples and individuals, faced legal barriers to becoming parents. The Law Approving the Bearing of Fetuses, enacted in 1996, initially restricted surrogacy to heterosexual couples, which resulted in discrimination against gay men and prevented them from using this procedure [32]. However, in 2021, following a prolonged struggle against the legislature, a Supreme Court ruling led to a change in the law that, for the first time, allowed gay couples and individuals to access surrogacy in Israel.

In Israel, assisted reproductive technologies, including egg donation and surrogacy for gay men and sperm donation for lesbian women, are major pathways to lesbian and gay parenthood [6,33]. Additional pathways to parenthood for LG individuals include adoption and co-parenting arrangements [6,34]. All pregnant women and parents of children up to the age of six are referred to Mother and Child Health Clinics (MCHCs, or ‘Tipat Halav’) to receive free consultation services and preventive care, including immunizations, growth and developmental surveillance, anticipatory guidance, breastfeeding support, and screening for postpartum depression [35,36]. These clinics are located throughout the country, with public health nurses serving as the primary care providers, supported by pediatricians [37]. The increasing number of LG-parent families in Israel, along with the growing involvement of MCHCs in supporting these families, underscores the need for healthcare services that are both equitable and tailored to diverse family structures. This study focuses on the knowledge and attitudes toward lesbian and gay parenting among MCHC nurses, who play a key role in delivering healthcare to these families, aiming to promote the development of more inclusive healthcare practices.

To our knowledge, no previous study in Israel has examined MCHC nurses’ knowledge about homosexuality and their attitudes toward LG parenting. In the current study, we aimed to address this gap by examining: (1) MCHC nurses’ knowledge of homosexuality and attitudes toward LG parenting; (2) the association between their knowledge of homosexuality and attitudes toward LG parenting; and (3) the association between socio-demographic, professional, and LG-related characteristics and nurses’ knowledge and attitudes.

2. Materials and Methods

A cross-sectional research design was employed to address the study’s objectives.

2.1. Sample

The sample consisted of 65 female nurses employed in Mother and Child Health Clinics (MCHCs). The sole eligibility criterion for inclusion in the study was employment in an MCHC. Of the 104 nurses who initially began completing the study questionnaire, 39 (37.5%) were excluded from the sample due to missing responses to more than 20% of the questionnaire items.

Participants were recruited from MCHCs operated by the Ministry of Health in two districts in Israel. District Nurses were asked to distribute a link to the study’s online questionnaire to nurses in their district via organizational email.

Table 1. Socio-demographic, professional, and LG-related characteristics of the sample (N = 65).

Socio-Demographic	Range	M	SD
Age	27–68	47.91	10.35
	N	%
Religion
Jewish	45	69.2%
Muslim	10	15.4%
Christian	4	6.2%
Other	6	9.2%
Religiosity
Secular	23	35.4%
Traditional	30	46.2%
Religious	9	13.8%
Orthodox religious	1	1.5%
Other	1	1.5%
Place of residence
City	45	69.2%
Other	20	30.8%
Professional	Range	M	SD
Experience in nursing (years)	1–36	20.6	11.2
	N	%
Education
Practical nurse	4	6.2%
Academic nurse with a non-nursing bachelor’s degree	19	29.2%
Academic nurse with a bachelor’s degree	27	41.5%
Academic nurse with a master’s degree	12	18.5%
Advanced practice course
No	28	43.1%
Yes	37	56.9%
District of MCHC
Ashkelon	40	61.5%
North	25	38.5%
LG-related	N	%
Personal acquaintance with LG individuals
No	36	55.4%
Yes	29	44.6%
Sources of familiarity with LG individuals
Family member	9	13.8%
Friend	15	23.1%
Colleague	1	1.5%
Patient	3	4.6%

Note. Age was missing for 32 cases. LG = Lesbian and Gay; MCHC = Mother and Child Health Clinics.

presents the socio-demographic, professional, and LG-related characteristics of the sample.

As shown in Table 1, the participants’ average age was 47.91 years (SD = 10.35). Most were Jewish (69.2%, N = 45). Regarding religiosity, 46.2% (N = 30) identified as traditional, 35.4% (N = 23) as secular, and 13.8% (N = 9) as religious. The majority resided in cities (69.2%, N = 45). Participants’ average years of nursing experience was 20.63 years (SD = 11.22), ranging from 1 to 36 years. Most held a bachelor’s degree (41.5%, N = 27), with 29.2% (N = 19) being registered nurses with a non-nursing bachelor’s degree. Additionally, 56.9% (N = 37) had completed an advanced practice course. Only 44.6% (N = 29) reported having personal acquaintance with someone identifying as LG. Of these, 23.1% (N = 15) indicated the acquaintance was a friend, and only 4.6% (N = 3) reported acquaintance with an LG patient.

2.2. Measures

The study’s questionnaire included background information (e.g., socio-demographic, professional, and LG-related characteristics) as well as two established scales.

Socio-demographic characteristics consisted of age, place of birth, religion, religiosity level (was evaluated by the nurses according to three categories: (1) religious; (2) traditional; and (3) secular), and place of residence.

Professional characteristics consisted of years of experience in nursing, type of nursing degree, participation in an advanced practice course (yes/no), and the MCHC district.

LG-related characteristics included personal acquaintance with LG individuals (yes/no) and sources of their acquaintance.

Knowledge about Homosexuality was assessed by the Hebrew version [38] of the 20-item Knowledge about Homosexuality Questionnaire [39]. This 20-item questionnaire was designed to evaluate factual knowledge about homosexuality. Nurses were asked to indicate whether each statement is true or false (sample items: ‘According to the American Psychological Association, homosexuality is a mental disorder’). The summation of the answers forms a general score ranging from 0–20. A high score indicates a greater degree of factual knowledge about homosexuality and sexual orientation issues. The reliability obtained for the Hebrew version was α = 0.70.

Attitudes toward Lesbian and Gay Parenting were evaluated using the Hebrew version of the Attitudes Toward Gay and Lesbian Parenting Scale [40], which was translated and validated as part of our study. This scale includes 11 items that encompass two dimensions: (1) Negative Beliefs about gay and lesbian parenting (6 items; sample item: ‘Gay men and lesbians should not have children because it is a sin’) and (2) Perception of Benefits of gay and lesbian parenting (5 items; sample item: ‘Children of gay and lesbian parents are more tolerant’). Nurses were asked to indicate their level of agreement with each item on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree). Higher scores on the Negative Beliefs dimension indicate greater agreement with statements that suggest a negative perception of children and parents in LG-parent families, while higher scores on the Perception of Benefits dimension indicate greater agreement with statements that suggest a positive perception of children and parents in LG-parent families. High Cronbach’s alphas have been reported for the two dimensions of this scale, ranging from 0.82 to 0.87 for the Negative beliefs dimension, and from 0.79 to 0.84 for the Perception of benefits dimension [40,41].

2.3. Data Analysis

An EFA with principal component extraction and varimax rotation was conducted to determine the factor structure of the Attitudes toward LG Parenting questionnaire. The number of factors was based on parallel analysis, Velicer’s minimum average partial test [42], and the scree plot. Then, reliability analysis was examined via Cronbach’s α. Descriptive statistics were used to describe the levels of outcomes (knowledge about homosexuality and measures of attitudes toward LG parenting) among the nurses. Then, bivariate analyses tested the associations between socio-demographic, professional, and LG-related characteristics and outcomes. Zero-order correlations were performed for continuous variables and independent sample t-tests for dichotomous variables. Finally, a zero-order correlation was also conducted for the association between the outcomes. Data was analyzed using IBM SPSS Statistics version 29 with an alpha set at 0.05 for all statistical tests.

3. Results

3.1. Validation of the Attitudes Toward LG Parenting Questionnaire

EFA on the eleven items resulted in two factors, which explained about 57.5% of the variance. Item loadings ranged between 0.51 to 0.88 on the relevant factor suggested by Costa and colleagues [40]. Reliability analysis for the two factors yielded satisfactory results (see Appendix A). In addition, both factors were negatively intercorrelated, r(62) = −0.30, p = 0.017.

3.2. Levels of Knowledge About Homosexuality and Attitudes About LG

Table 2. Descriptive statistics of Knowledge About Homosexuality and measures of Attitudes About LG Parenting.

Variable	M	SD	Range
Knowledge about homosexuality	13.00	2.52	7–19
Negative beliefs about LG parenting	1.99	0.89	1.00–4.50
Perception of benefits of LG parenting	3.26	0.76	1.60–5.00

Note. N = 65, Perception of benefits of LG parenting was missing for one case. LG = Lesbian and Gay.

presents descriptive statistics for knowledge about homosexuality and measures of attitudes about LG parenting. As can be seen from this table, on a scale of 0–20, the mean score of knowledge about homosexuality was moderate. Namely, nurses showed moderate levels of knowledge about issues related to sexual orientation. Regarding attitudes about LG parenting, the mean scores of negative beliefs and perception of benefits of LG parenting, on a scale of 1–5, indicated generally low levels of negative attitudes and moderate levels of positive attitudes toward LG parenting, respectively.

3.3. Associations of Socio-Demographic, Professional, and LG-Related Characteristics with Knowledge About Homosexuality and Attitudes About LG

Table 3. Associations of socio-demographic, professional, and LG-related characteristics with Knowledge About Homosexuality and measures of Attitudes About LG Parenting.

	Knowledge About Homosexuality			Negative Beliefs About LG Parenting			Perception of Benefits of LG Parenting
	M	SD	t/r	M	SD	t/r	M	SD	t/r
Socio-demographic
Age	-	-	r(31) = −0.38, p = 0.006	-	-	r(31) = 0.10, p = 0.588	-	-	r(30) = −0.06, p = 0.711
Religion			t(63) = 2.94, p = 0.005, d = 0.79			t(23.29) = −5.13, p < 0.001, d = −1.76			t(62) = 0.96, p = 0.341, d = 0.26
Jewish	13.58	2.33		1.61	0.50		3.32	0.76
Muslim/Christian/Other	11.70	2.49		2.83	1.01		3.12	0.77
Religiosity			t(62) = 2.04, p = 0.045, d = 0.53			t(60.55) = −2.39, p = 0.020, d = −0.52			t(61) = 1.42, p = 0.162, d = 0.37
Secular	13.74	2.68		1.70	0.51		3.42	0.70
Other	12.46	2.23		2.16	1.02		3.14	0.78
Professional
Experience in nursing (years)	-	-	r(63) = −0.17, p = 0.164	-	-	r(63) = 0.10, p = 0.435	-	-	r(62) = −0.04, p = 0.771
Education			t(60) = 0.30, p = 0.769, d = 0.08			t(60) = −0.65, p = 0.520, d = −0.17			t(59) = 0.45, p = 0.656, d = 0.12
Practical nurse/academic nurse with non-nursing degree	13.17	2.99		1.89	0.84		3.35	0.71
Academic nurse with bachelor or master’s degree	12.97	2.29		2.04	0.95		3.26	0.78
Advanced practice course			t(63) = 0.40, p = 0.694, d = 0.10			t(63) = −1.23, p = 0.225, d = −0.31			t(62) = −0.18, p = 0.857, d = −0.05
No	13.14	2.45		1.83	0.79		3.24	0.74
Yes	12.89	2.60		2.11	0.96		3.27	0.79
LG people related
Personal acquaintance with LG individual			t(63) = −1.60, p = 0.114, d = −0.40			t(49.33) = 4.47, p < 0.001, d = 1.03			t(62) = −1.40, p = 0.167, d = −0.35
No	12.56	2.38		2.36	1.00		3.14	0.76
Yes	13.55	2.61		1.53	0.42		3.41	0.75

Note. N = 65. Age was missing for 32 cases. LG = Lesbian and Gay; MCHC = Mother and Child Health Clinics.

presents means and standard deviations of knowledge about homosexuality and measures of attitudes about LG parenting by categorical explanatory variables and associations between these variables and continuous explanatory variables. Age was negatively associated with knowledge about homosexuality. Regarding religion, religiosity level, and place of residence, results showed that nurses who are Jewish, secular, or living in a city scored higher on the knowledge about homosexuality measure and lower on the negative beliefs about LG parenting measure than other nurses. Differences by district of MCHC and personal acquaintance with LG were found for negative beliefs about LG parenting, with nurses from Ashkelon district or with acquaintance with LG individuals scoring lower than nurses from the north district or without personal acquaintance with LG individuals, respectively. Note that all analyses with the perception of benefits of LG parenting yielded non-significant results.

3.4. Association Between Knowledge About Homosexuality and Attitudes About LG Parenting

Results revealed that knowledge about homosexuality was negatively correlated with negative beliefs about LG parenting, r(63) = −0.37, p = 0.002, and positively correlated with perception of benefits of LG parenting, r(62) = 0.29, p = 0.019. As knowledge about homosexuality increased, negative beliefs about LG parenting decreased, and perceptions of the benefits of LG parenting measures increased.

4. Discussion

This the first study to explore levels of knowledge about homosexuality and attitudes toward LG parenting among nurses working in MCHCs in Israel. Our study revealed that regarding levels of knowledge about homosexuality, the nurses demonstrated a moderate level of knowledge. This finding is consistent with existing literature [38,43]. Insufficient knowledge is one of the most common barriers to providing quality care. It has been suggested that when nurses have a greater understanding of homosexuality and the unique health challenges faced by the LGBTQ+ community, they are better equipped to provide quality care. This, in turn, could lead to improved health outcomes for individuals in this community [44]. Our study also found a low level of negative attitudes toward LG parenting and a moderate level of perceived benefits of LG parenting were observed. These findings align with the research of Costa and Salinas-Quiroz [40], which reported similar results among nursing students.

Our findings suggest that lower levels of knowledge about homosexuality are associated with more negative attitudes toward LG parenting and a lower perception of the benefits of LG parenting. These findings, along with prior research showing that personal attitudes of medical staff toward marginalized groups influence the unequal provision of care and directly impact patient health outcomes [45], highlight the importance of implementing dedicated educational programs on LG health and their unique needs during nursing training. Such programs may increase nurses’ knowledge about this population, enhance their positive attitudes toward LG parents, and better prepare them to support LG parents [46,47,48].

Regarding nurses’ age, we found that age is negatively associated with their level of knowledge about homosexuality: the older the nurse, the lower their knowledge about homosexuality. This finding aligns with the study by Torrente-Jimenez and colleagues [49], which found that knowledge about LGBT individuals was negatively associated with older age among nursing students. It is also consistent with the findings of Wang et al. [43], who reported lower knowledge levels among nursing instructors compared to nurses and nursing students. That study suggested that nursing instructors, being older, may be less open to learning content about homosexuality due to a lack of education on the topic from a young age and stronger societal stigma compared to younger individuals. Additionally, older nurses may face challenges in learning about and understanding their personal beliefs regarding homosexuality. Therefore, age should be considered when developing tailored training programs, ensuring that content is adapted to the relevant age group [50]. In this context, it is also recommended to incorporate cultural and religious sensitivity training, in addition to age sensitivity, to ensure that this important subject is accessible in ways that align with cultural and religious values. Our study’s findings revealed higher levels of knowledge and more positive attitudes toward LG individuals among Jewish nurses compared to nurses of other religions, as well as among secular nurses compared to their religious counterparts. According to the literature, these differences are attributed to the influence of more conservative religious environments, which are often associated with negative attitudes toward LG individuals [51].

Interestingly, no significant correlation was found between the level and type of nursing education and the nurses’ knowledge about homosexuality or attitudes toward LG parenting. A possible explanation for this finding is that LGBTQ+ health and medicine are still in their early stages in Israel. Consequently, many doctors and nurses at all levels of education have not received training on the unique health needs of this community during their studies. Had training on the health needs and characteristics of LGBTQ+ individuals been provided differently across various degrees of nursing education, the study’s findings might have differed, further underscoring the importance of incorporating these topics into Israel’s official curriculum. This gap is not unique to Israel. A systematic review from 2024 found that most nursing programs do not offer dedicated courses on LGBTQ+ health, leading many nurses to seek this knowledge independently [52]. Researchers worldwide have emphasized the need for targeted nursing education on LGBTI health [53].

A major limitation of this study is the relatively small sample size, composed entirely of nurses from MCHCs located in two districts. Future studies involving a larger sample and including nurses from MCHCs across all districts in Israel may provide a more comprehensive understanding of the knowledge and attitudes of MCHC nurses toward LG parenting. Another limitation concerns potential survey-specific biases, such as self-selection bias, stemming from the voluntary nature of participation, possibly attracting individuals holding stronger positive or negative views on LG parenting, or a greater interest in the topic in general. Additionally, responses may have been influenced by social desirability bias, potentially leading participants to present more favorable attitudes toward LG parenting than they actually hold. To gain a more holistic picture, future research is recommended to explore MCHCs’ actual practice behaviors with LG parents, in addition to their attitudes toward LG parenting. This may assist health policymakers in the development of targeted training programs that address both knowledge and practice skills needed to support LG families in healthcare settings.

Despite the aforementioned limitation, this study extends prior research by shedding light on the interrelations between knowledge about homosexuality and attitudes toward LG parenting among MCHC nurses, as well as on the factors shaping their knowledge and attitudes. The findings stress the need for tailored, knowledge-based training in nursing education for MCHC settings, taking into account nurses’ diverse cultural backgrounds, level of religiosity, and familiarity with LG individuals. This need is further supported by prior international research demonstrating that LGBT parents often encounter negative attitudes, discrimination, and stigmatization in maternal and child healthcare settings, stemming from healthcare professionals’ lack of knowledge and training about LGBT-parent families [16,54]. Indeed, many health professionals view their limited knowledge of these families as a key barrier to providing them with inclusive care [55]. Our findings suggest that incorporating content on homosexuality and LG parenting in nursing education for MCHC settings could foster more positive attitudes toward LG parenting among MCHC nurses and promote more inclusive care practices, which may enhance the well-being of both LG parents and their children. Addressing the educational gaps observed may contribute to reducing broader societal prejudices and systemic barriers by creating better-informed professionals who can advocate for broader change within the healthcare system.