Abstract
The paper is drawn from the lead author’s doctoral study: a qualitative exploration of the health and social care pathways of a marginalised population group in North East England, a region impacted by increased health inequities in comparison to the rest of the country. One of the study’s challenges was to find a methodological framework that could capture some of the complexities of human social experience both within and across cultures. The pairing of bounded relativism with descriptive phenomenology aimed to address this by blurring the assumed boundaries between realism and relativism, subjectivity and objectivity. Descriptive phenomenology in particular places a value on people’s lived experiences that can be attractive for the qualitative researcher. However, those initially drawn to phenomenology may be faced with a steep learning curve: a bank of often dense philosophical literature; new terminology and concepts; and an array of criticism aimed at descriptive phenomenology as a research method. This paper documents how, despite these initial hurdles, methodological exploration and immersion into the literature brought new analytical vocabulary and perspectives to the current study. The authors then present practical examples of how phenomenological concepts were applied to the analysis of study interviews. These practical applications not only supported a richer synthesis of the study data but also led to the creation of the unified visual framework of relationality that is presented here.
Background
This paper follows the methodological journey taken by the lead author (MA) during his doctoral study, supported by the co-authors: SS and AOD (PhD supervisors), and MY (methodological guidance). Adopting a qualitative, intersectional perspective, the study explored the health and social care pathways of LGBTQ+ people who had faced additional marginalisation as a result of, for example, domestic abuse, racism, homelessness, struggles with drug or alcohol use, or experience of the criminal justice or care systems (Adley, 2025). Seventy-two interviews were conducted: 39 with LGBTQ+ people with experience of additional marginalisation and 33 with professionals working within local health and care services. The study’s aim was to synthesise data from its qualitative interviews in order to identify barriers and facilitators within these health and social care pathways, and to use this knowledge to make recommendations for future service provision.
As a novice researcher, but one with over 30 years’ professional experience working in primary care, substance use, criminal justice, and homelessness service settings, MA faced what Sinfield et al. (2023, p. 1) referred to as the ‘the daunting dilemma of selecting a methodological route which best fits the purpose of [the novice researcher’s] study’. Creswell (2017) highlights that a researcher’s orientation towards the subject of their study is shaped by their ontological and epistemological positions, which in turn shape their approach to theory, methodology, and methods. From the outset, one of the main considerations was whether to face in the direction of the lived experiences of participants, or to turn towards the wider culture that impacted upon these experiences. Rather than treating this as a binary choice, we instead chose an ontology of bounded relativism and an epistemology of descriptive phenomenology: a methodological alignment that sought to reflect and acknowledge this tension rather than trying to resolve it.
The authors document how exploration of ontology and epistemology led to the discovery of new vocabulary and analytic perspectives that in turn brought a re-evaluation of the phenomenon under study. The paper aims to highlight the benefits that a novice researcher might draw from exploring methodology within its description of the health and social care pathways of a marginalised and under-represented population group. It also presents the visual framework of relationality that resulted from this exploration as a contribution to knowledge, and a starting point for further qualitative enquiry by future researchers.
Research Philosophy
Ontology: Bounded Relativism
The ontological question is about what we study: the object of investigation, how the world fits together and how we make sense of it (Denzin & Lincoln, 2008). From his experience working in primary healthcare settings, MA had observed distinct cultures and terminologies within primary care practices that were set only a few hundred metres apart. This resonated with his experience of LGBTQ+ communities which, although nominally grouped under the same acronym also consisted of distinct cultures and terminologies. Keen to explore people’s experiences within these discrete cultural groupings led to the selection of a bounded relativist ontology.
The seeds of this ontology can perhaps be traced back to the work of Mannheim (1924), whose position was that while a shared reality was possible within social phenomena this was transient: bound within social groups and within space and time. His idea of a ‘new form of relativization’ (1924, p. 144) addresses a key aspect of relativism: the tension between individual and collective realities. He argued that ‘We may relativize ideas… by demonstrating that they belong to a system’ (p. 144), and in a later work suggested that ‘every particular world appears as historically and socially situated, and continues to evolve within those confines’ (1933, p. 379).
It was not until 2006 however that the term bounded relativism was itself coined. Yolles (2006), within his exploration of social collectives as complex systems, put forward a bounded relativism of local realities. Each lifeworld locality constructs a form of shared knowledge, with every bounded locality cultivating a distinct knowledge pattern: a reality specific to itself. For Yolles, the knowledge held within these lifeworld localities is embedded in the particular realities of their members, thus bringing the ontology of bounded relativism into alignment with the study’s epistemological approach. For this doctoral study, bounded relativism reflected the lead author’s experiences working across multiple primary care settings whose varied cultures – even within buildings set a few metres from each other – shaped staff and patient experiences. Bounded relativism also aligned with the study’s intersectional lens by acknowledging that people’s health and social care pathways are context-dependent and moulded by cultural norms. This brought with it an enriched awareness and understanding of the influence of social determinants on service access and use.
Epistemology: Descriptive Phenomenology
If ontology is concerned with what we study and how we make sense of it, epistemology is about how we know things, what counts as acceptable knowledge, and the best ways to research the world (Creswell & Creswell, 2018). The study’s epistemological choice was initially inspired by the work of Ahmed (2006) who added a queer perspective to the phenomenological writings of Husserl and Merleau-Ponty. Among other things, Ahmed focused attention on the power of organisational collective directions in orienting professional practice. This issue resonated with MA, who a few years ago had transitioned from working in drug and alcohol services to primary care settings. After this move he began to realise how much his professional practice had – albeit unconsciously at the time – been shaped by broader cultural influences, with the substance use field positioned within a framework of risk management and the health sector within a salutogenic and more patient-centred model.
Life-World
Husserl (1913) developed the phenomenological approach in his quest to understand the foundations of philosophical inquiry. Phenomenology emerged as a philosophical movement in response to positivism’s view of reality as something that could be precisely measured and ordered. Husserl’s focus was on examining human experience in its most essential form: how people subjectively experience the world, interact with others, and their day-to-day knowledge and understanding. He argued that knowledge is grounded in the life-world: ‘a realm of original self-evidences’ (1936, p. 127). Distinguishing between the objective world of science and the world as directly experienced, the life-world is the world before scientific fact that provides the source of experiential qualities. For example, we might consider experiences of ‘stress’ that exist before any scientific measurement of blood pressure or cortisol levels. Spiegelberg (1960) referred to the life-world as the world of lived experience, and the phenomenological researcher seeks to arrive at the life-world via processes of reduction.
Reduction
The practice of reduction lies at the heart of phenomenological method. Husserl believed that it was via reduction that essences could be isolated from a range of experiences, and – famously – that ‘the things themselves’ could be revealed (1913, p. 79). Reduction involves multiple processes such as reflection, rumination, unbuilding, and abstracting from how the phenomenon appears in our consciousness. Husserl separated the processes of consciousness into noesis (the consciousness-of) and noema (the object of consciousness). Where noesis is an act of consciousness such as perception, memory, or imagination, noema is the something towards which we direct our consciousness (Gallagher, 2012). Husserl (1952) explained noema by asking us to turn our thoughts to consider the meaning, or sense, of a round rectangle. Later, Føllesdal (1969) noted that when we think of a fictional creature such as a centaur, the act of thinking itself has a noema ‘but it has no object; there exists no object of which we think’ (p. 681). Phenomenological essence is therefore reached through layered inquiry and reflection whose goal is to reveal the essence of an object, its ideal content or object-as-it-is-intended. While this might imply a belief in an objective reality behind phenomena, concepts such as life-world and essence all refer to meanings. The essence of a phenomenon (such as stress) is not a ‘truth’ within it, but rather its distinctive qualities. The descriptive phenomenological process is therefore epistemological in scope, as it privileges these meanings of subjective experiences.
Bracketing
Husserl believed that uncovering the essence of experience requires researchers to suspend their natural attitude and set aside or ‘bracket off’ their preconceived beliefs, judgements, and presuppositions. A mathematician by background, he adapted the concept of bracketing from the mathematical function ‘( )’. According to Husserl, bracketing – setting aside our preconceptions – is one of the core processes in the move towards a pure consciousness of lived experiences and perception of meaning.
Heidegger (1927a) fundamentally disagreed with the concept of bracketing (and other elements of descriptive phenomenology) and proposed an interpretive phenomenological philosophy. He challenged the idea of bracketing preconceptions, arguing instead that the practitioner’s pre-existing beliefs and suppositions, far from being something that would get in the way of understanding, were central to it. Heidegger believed that consciousness cannot be separated in this way from the world in which it exists. His approach was more existential and ontological in scope, focusing on the way we are rather than the way we know the world (1927a, 1927b). For Heidegger, humans are inherently interpretive beings who discover truth through their engagement with the world (Polkinghorne, 1989), and within interpretive approaches phenomenological reduction leads to interpretation of how we exist in the world (Hofstadter, 1982). This paper will not delve further into distinctions between descriptive and interpretative approaches and there is extensive literature on this topic. However, as Al-Sheikh Hassan (2025) suggests, it is important for researchers with an interest in phenomenology to consider at least which broad strand of phenomenological thought will best suit their study design.
For the current study, there were two main reasons behind the selection of descriptive over interpretive phenomenology. First, that an intersectional perspective on marginalised LGBTQ+ people is a relatively unexplored topic area within the field of population health research. As such this makes it well-suited for descriptive phenomenology, which can help to uncover the essences of phenomena that have not yet been conceptualised in previous research (Lopez & Willis, 2004). Secondly, given his positionality as both an insider and outsider of both the professional and marginalised LGBTQ+ study cohorts, the lead author was concerned about the extent of this previous experience. He was drawn towards bracketing as an approach that aimed not to erase these past experiences but instead to acknowledge them and set them aside. Bracketing was applied as an ongoing reflective and reflexive process that called for continued effort and a redirection of attention (Al-Sheikh Hassan, 2025), in which MA was observant of his own ‘inner dialogue’. He sought to focus on and notice instances of his bias and assumptions, and when his own normative views, perhaps shaped by professional experiences, might be encroaching on his ability to actively listen to participants’ voices. Framing bracketing as a continuous inner dialogue addresses issues around who brackets, how, and when raised by Tufford and Newman (2010). The application of bracketing within the current study also adds to the qualitative research literature by suggesting that bracketing can not only be carried out during data collection and analysis, but also when proposing and designing a study.
Key Phenomenological Concepts and Their Application
This section describes the authors’ understanding of four core phenomenological concepts: intentionality, orientation, field of vision, and horizon, and how these were applied within the current study. It is important to note that the descriptions of these concepts should not be taken as definitive, as they are interpreted differently across the phenomenological literature that spans different fields of study. What follows are only our interpretations.
We selected a case study approach to illustrate how these concepts were applied within the study. For the sake of clarity a single interview has been selected: an interview with Katy (not her real name), a professional participant who is female, cisgender, aged between 18 and 24, bisexual, who worked as a keyworker in a commissioned drug and alcohol treatment service outside of the region’s main urban centres.
Intentionality
A fundamental concept in Husserl’s descriptive phenomenology is intentionality, which describes how our experiences are always directed towards the world around us (Husserl, 1913). In this context intentionality does not mean purpose or deliberation, as it is used in everyday language. Instead, it returns to its Latin root in- ‘towards’ + tendere ‘stretch, tend’ (Heidegger, 1927a; OUP, 2023). Where ‘ex-tending’ reaches out from, in-tending reaches out into. This makes intentionality a two-way process that describes how experiences always involve being conscious of something, and how perception always involves the perceiving of something. This creates a mutual relationship between the person experiencing (the subject) and what they are experiencing (the object). Bloom (2020, p. 392) offers a practical example: ‘When I want to sit on a chair, the chair is the object of my intentionality for contact – its comfort attracts me’. Our consciousness doesn’t just reach out to objects; objects also draw our attention and shape our experience.
As applied to the current study, consideration of intentionality encouraged reflection on the bi-directional nature of health and social care service pathways. For LGBTQ+ participants, access to and use of services was not just a matter of needing support but also involved how attractive the service was. This drew in issues such as word-of-mouth recommendations or warnings from peers, service environments such as waiting rooms and engagement with reception staff, anticipation of stigma, and previous experiences of stigma enacted within similar services. On the other side of this coin was the issue of intentionality towards LGBTQ+ people for professionals working in frontline services. This is highlighted here by Katy: ‘So I have the statistics of everybody in service, their substances, their gender, etc. We actually only have male and female options… And gender identity and/or sexual orientation is not something that we ask. So we don’t have statistics on that’.
Later, Katy explained the service’s lack of focus on LGBTQ+ substance use: ‘The reason for that [not considering sexual orientation or gender identity] is because there’s… we don't have any data on LGBT communities and substance misuse… I have none of that data’.
At first glance this highlights a ‘Catch 22’ in which the service neither has the data nor collects it, however there are other issues to consider here. There is information available about LGBTQ+ substance use and treatment if one is looking for it: within clinical guidance (Clinical Guidelines on Drug Misuse and Dependence Independent Expert Working Group, 2017) and grey and peer-reviewed literature (e.g., Dimova et al., 2022; Hibbert et al., 2021; Hibbert et al., 2019; London, 2014). Katy’s quotes describe a service with a lack of intentionality towards LGBTQ+ people: a lack of interest in or consideration of issues specific to this group. This then raises questions about which groups do draw the service’s attention and interest, with the following section highlighting the turn taken by Katy’s service towards a specific cohort.
Orientation
How we orient ourselves in space, the directions we face, and how we turn towards or away from things, influences what becomes accessible or inaccessible to us. Merleau-Ponty (1945) explored in depth how our bodies relate to and orient themselves within space. Adding important social dimensions to this work, Ahmed (2006) noted how our particular orientations and the paths we follow depend on factors in our perceptual ‘rear-view mirrors’ that may not be immediately visible. She highlighted how organisations act as orientation devices: in belonging to a group or community we follow the path that others have trodden before us – the well-trodden path of collective direction.
In the following quote Katy describes the centring of a particular demographic (middle-aged White men, apparently cisgender and heterosexual) within her service: ‘Our key demographic is White men between the ages of 40 and 45… We have funding pressures which we have to respond to. We’re good at collecting data around risk and type of drug used, as this is what we receive funds for. This is why our client group is mostly cisgendered White males. We respond to nationwide agendas’.
While Katy acknowledges the influence of government policy and funding pressures on determining the service’s ‘key demographic’, there may be other influences that are not immediately visible. For example, the ‘type of drug used’ that Katy refers to are opiates and crack cocaine, and what may not have been immediately visible is the continued influence of previous government drug strategy (HM Government, 2010) on the provision of drug treatment. The focus on reducing crime and ‘offenders who use heroin, cocaine or crack cocaine [who] commit between a third and a half of all acquisitive crimes’ (National Treatment Agency for Substance Misuse, 2012) reified and prioritised a specific key demographic. This cohort were deemed most ‘in need’ of drug treatment, with commissioned services required to submit monthly person-level data reports at a national level to measure progress against key indicators (NHS Digital, 2024). In this way, Katy’s service was oriented towards this group and towards the provision of a service that specifically met their needs: in doing so sidelining or de-prioritising the treatment needs of ‘other’, minority groups.
Field of Vision
Objects always appear against a background that gives them context. For example, consider how the same book might be perceived differently when placed on a table as opposed to lying on a pavement, even though the object itself has not changed. Phenomenology also reflects on how objects continue to exist even when they are not directly in our line of sight, and in this way our field of vision is difficult to define. Merleau-Ponty (1945) describes field of vision as being in a constant state of flux, without clear boundaries, incorporating both what we currently see (impressions on our retina) and what we remember seeing (but can no longer directly observe). Within the current study, professional participants repeatedly described people’s sexual orientation and/or gender identity as not being relevant to their need for services. Here, Katy explains why LGBTQ+ issues are outside of her service’s field of vision: ‘But I also think that, truthfully, I think it’s not something that’s identified as a priority target in the area of substance misuse in the sense that, you know, when you’ve got somebody coming in, how relevant is it, their sexual orientation?… And I think that there’s still an issue with LGBT being viewed as a choice in some sort of way or as something that is, you know, as insignificant as what colour of your hair. Like, I think I think it comes to, to that, of does it, does it actually make an impact that we have to then support?’
Katy was not alone in framing LGBTQ+ issues in this way, and similar statements were shared in interviews by other professionals across service settings. Foucault (1980) posited that such institutional discourse functions as a mechanism that influences and produces knowledge, framing it as fact. For Katy, this discourse justifies why sexual orientation and/or gender identity is placed outside of the service’s field of vision and deemed irrelevant to treatment need. The perceived logic within the service is therefore that it is not necessary for professionals to discuss sexual orientation and/or gender identity with clients, to explore how these might connect to people’s need for treatment, or to develop any specialist awareness around these issues.
Horizon
The phenomenological horizon can be summarised as the perceptual limit: the framework or edge which borders the field of vision (Husserl, 1969; Ihde, 2012). Horizons define what we are able to perceive and what we value, for example whether we prioritise only what is immediately apparent, or perceive beyond the immediate.
The study’s horizon had initially been defined quite literally: by the study cohort, the types of services, and the geographical location. However, immersion into the philosophies of bounded relativism and descriptive phenomenology brought new perspectives and scope. Bounded relativism provides a framework for understanding that knowledge and reality are shaped by the specific contexts and perspectives of different groups. Each context, or ‘bounded locality’ has its own unique understanding of reality, influenced by factors such as language, culture, and social norms (Yolles, 2006). For example, an LGBTQ+ professional may have a number of bounded cultural contexts as a woman, a nurse practicing within primary care, or a lesbian who is both ‘out’ in certain localities and who hides her minoritised sexual orientation in others.
In this way, bounded localities are created with their own cultures and social norms that are shaped by their contexts. In the following conversation, Katy highlights how a heteronormative workplace culture contributes to rendering sexual orientation and/or gender identity invisible: MA: ‘Why is it that [sexual orientation and/or gender identity] is not recognised?’ Katy: ‘I’m not quite sure… I think these are a lot of questions that actually have never asked before… I think there’s a lack of conversation… it’s not generally a topic of conversation… even between colleagues, like we don’t have that discussion. I think the majority of my colleagues are in relationships with the opposite sex. So I, I think it’s a conversation that isn’t had. It’s just not had’.
At times the pairing of bounded relativism and descriptive phenomenology led to a tension in the study, and whether its focal point should be on participants’ lived experiences or on the influence of bounded localities. However, the authors’ ongoing discussions around this tension brought rewards. Their discussions led to a re-evaluation of the study’s horizon, and a perceptual shift in the phenomenon being studied that is documented in the following section.
Relationality, and Shifting Horizons
Re-evaluating the study from these new perspectives, the study’s horizon then shifted towards the relationship between services and those using them. However, as noted by Merleau-Ponty (1945), when we think about a relationship between a subject and an object these are often perceived as separate entities, whose connection exists mainly as ‘an idea’ rather than a lived experience. Reframing the phenomenon as ‘the relationships between local health and social care services and the people using them’ was an improvement, but it was still not quite right. There were interactions between people and services within the interviews that this did not quite capture, in terms of how they related to one another, the nature and quality of these relationships, and how these relationships and social positions fluctuated according to the influence of their bounded localities.
Relationality
It was the work of organisation theorist and self-defined social philosopher Robert Cooper, specifically Peripheral Vision: Relationality (2005), that provided this missing vocabulary. Cooper defined relationality as including the dual concepts of relationships and relativity. Relationality is the source point of relationships (which he described as transitive and mobile) and relativity (the densely intermeshed relationships between human and environment), and was part of a continuous process of movement and interaction between entities: ‘Relativity and relationship… both relate the human world as a generic condition of relationality where everything is relative to everything else’ (ibid., pp. 1692–1693).
Although the interaction between perceiver and perceived, the I and the Other, lies at the heart of phenomenological inquiry, the term ‘relationality’ is – as such – relatively new in its literature. However, versions of Cooper’s concept of relationality are interwoven throughout phenomenological philosophy. In his later work Husserl explored ‘relativity’ (1936, p. 63) and Merleau-Ponty ‘relational spatiality’ (1968, p. 216). The concept of relationality also runs through Heidegger’s work, especially in his notion of ‘being-with’ (Mitsein) (1927b). He saw this as a fundamental aspect of human existence, describing how we live ‘in a world saturated with others linked through shared social practices’ (Moran, 2021, p. 111). For Heidegger, human existence is inherently relational: ‘being-with’ others is not something we choose to do, but rather an essential part of how we exist as social beings, something that ‘is already’ present in our nature (1962, p. 162). Recently, Thonhauser (2023) also highlighted how we are inherently connected to and shaped by our environment and relationships in his reference to ‘the unavoidable relationality of our bodily being-in-the-world’ (p. 11). Relationality is primitive: we are shaped, we are who we are, by virtue of our intertwining and ongoing relationships with each other and our environments.
Within the current study it was the work of Yolles (2006) that connected this concept of relationality to the study’s research philosophy. Yolles identified overlapping areas and shared threads running through bounded relativism and descriptive phenomenology: ‘A system is bounded through a frame of reference that is defined for and within the context of a situation. The boundary will change according to the interest, purpose and worldview of a viewer. A system boundary may also be defined in terms of the degree of interaction between the parts that define it’ (p. 138).
Now armed with the vocabulary of relationality, previously abstract phenomenological concepts began to take shape and have greater meaning. An image of relationality started to form in the lead author’s mind: of shapes moving across a two-dimensional field, pointing towards, rotating around, turning away from, interacting with and positioning themselves relative to a central object.
A Visual Framework of Phenomenological Relationality
In Queer Phenomenology Ahmed explored queer orientations – with queer used as a spatial term referring to a twisted or oblique orientation in three-dimensional space. Consideration of the queer descriptions of relationality within the study’s interviews acted as a catalyst for the model of phenomenological relationality presented here (Figure 1). In this model the grid represents the field that situates subject and object, with the edge of the grid forming its limit: its phenomenological horizon. This new visual language supported a more comprehensive understanding and description of the phenomenon, now revised as: relationality within health and social care pathways. A visual framework of phenomenological relationality: concrete structures form from the spaces between subject and object (image: MA)
Spaces Between
While intentionality, field of vision, and orientation appear as foreground objects in Figure 1 there is also space between them, represented by the grid. Merleau-Ponty wrote in depth about those things that exist outside of our vision in Phenomenology of Perception (1945), and for Cooper (2005) too, this ‘missingness’ was embedded within relationality. Gadamer (1977), referring to a comment made by Heidegger about a pocket knife, also highlighted the empty space left by an absent object: ‘When one has lost a long familiar implement such as a pocket knife, it demonstrates its existence by the fact that one continually misses it’ (p. 235).
Applying Spaces Between to the Descriptions of Participants’ Experiences
Throughout the study, professionals and marginalised service users navigated the spaces between formal service pathways. Apparent gaps in service provision functioned as meaningful spaces in their own right. Being able to recognise these as concrete structures added richness and depth to the analysis of the meaning of participants’ descriptions of relationality.
Discussion
This paper describes how the application of phenomenological constructs – intentionality, orientation, field of vision, horizon – led to a perceptual shift in the phenomenon under study, namely the health and social care pathways of marginalised LGBTQ+ people in the North East of England. In speaking to both this marginalised population group and to the professionals who supported them, participants’ health and social care pathways could now be described in terms of relationality. With this new vocabulary, the two study cohorts could be considered not as separate entities but as an entwined, fluctuating system that varied across bounded localities.
Moreover, by focusing analysis on intentionality, this study helps to shift the discussion around service access for marginalised groups from being mainly a matter of need or availability to one also of attraction. Evidence suggests that LGBTQ+ people may be more inclined to take drugs such as MDMA, GHB, or methamphetamine (Hillyard, 2024; Roberts et al., 2025; Schuler et al., 2022), in contrast to the current UK policy focus on treatment provision for people using crack cocaine or opioids (Holland et al., 2023; Home Office, 2022). As such commissioned health and care services might not be drawn towards or have capacity to effectively support this specific substance-using group. Conversely these same treatment services may be deemed unattractive to LGBTQ+ people by way of anticipated stigma, reception spaces, or (lack of) word-of-mouth recommendations.
As the example of ‘Katy’s’ case presented in this paper shows, the intentionality, orientation, field of vision, and horizon of health and care services are not neutral, but are structured by political, cultural, and organisational priorities. This has public health implications. When the attention of health and social care services is sculpted by national agendas, some population groups become easier to ignore than others. This leads to a situation in which ‘the majority is the priority’ (Adley et al., 2025a) and minoritised groups are pushed further into the margins of care.
Recent policy analyses from the UK show that Integrated Care System strategies seldom include LGBTQ+ needs in a meaningful way; while this population group is included in around half of these strategies, only a quarter of those references provided the context shaping the specific needs of LGBTQ+ people or the health inequities they face (Braybrook et al., 2025). Evidence shows that accurate data on the health and care use, and outcomes of LGBTQ+ people is lacking; UK coroners do not routinely record sexual orientation or trans status, limiting the accuracy of LGBTQ+ drug-related mortality statistics (Fairbairn & McGuinness, 2021; Roberts et al., 2025). At the same time, capturing data does not equate to institutional intentionality. Thus, while some services might collect relevant data, research suggests that this rarely leads to inclusive practice or LGBTQ+-affirming care (Akre et al., 2025). For example, in the UK, drug and alcohol services are routinely asked to collect data around clients’ sexual orientation (NHS England, 2024). However as the findings of this study show, the significance of this data can be quashed or rendered invisible by discourse such as Katy’s, that compares the relevance of LGBTQ+ people’s treatment needs with something as superficial as hair colour.
The study’s turn towards relationality also led to awareness of ‘spaces between’: the gaps in service provision that might otherwise have remained unnoticed. Following Ahmed, treating spaces between as structures in their own right supported description of where, how, and when these gaps between services were navigated by study participants, and the impact of cultural norms on these alternative health and social care service pathways. This supports consideration of relational stigma (Addison et al., 2023), the use of structural stigma tools to track culture change in services (Eschliman et al., 2024; Yigit et al., 2025), and the reorientation of service design towards responding to emerging issues within local communities. For example, substance use services might turn towards younger and more diverse populations, and the increasing use of newer drugs such as ketamine (Office for Health Improvement & Disparities, 2025).
Within the current study, descriptive phenomenology was applied by centring the voice of lived experience in the research process, setting aside presuppositions, and focusing on intentionality within service pathways. This follows guidance and scoping reviews of descriptive phenomenology within applied healthcare research that highlight the importance of transparently justifying methodological choices, outlining processes for bracketing, and a coherence with phenomenological philosophy (Al-Sheikh Hassan, 2023; Rodriguez & Smith, 2018; Shorey & Ng, 2022). Our reflexive bracketing techniques such as journaling, peer debriefing, and iterative analytic memos are also aligned with recent methodological health research literature (Dörfler & Stierand, 2020; Squires, 2023; Thomas & Sohn, 2023). Particularly as a novice researcher, bracketing provided MA with a structured approach to putting participants’ subjective experiences at the heart of analysis and enhancing his awareness of his own bias and assumptions.
Limitations of the study include its sample size, which goes beyond what is traditionally considered within phenomenological research. While there are no exact guidelines around the number of interviews within phenomenological studies, Guest et al. (2006) cite recommendations of sample sizes ranging from between five and twenty-five. Additionally, generating a phenomenological essence from such a large sample might risk over-simplifying the study findings and minimising the influence of intersectionality, for example masking the discrete experiences of LGBTQ+ people of colour. The study’s focus on bounded localities within a specific region of the UK may also limit the transferability of its findings.
Within his decision-making process for selecting descriptive or interpretive phenomenology, Al-Sheikh Hassan (2025) suggests that descriptive phenomenology can provide a starting point for discovery, and that interpretative approaches may become more suitable once a substantial body of research has been developed. To the authors’ best knowledge, only a single grey literature report on this topic in the UK had been written at the time of this study, supporting their choice of descriptive phenomenology. Future studies might therefore consider further descriptive phenomenological research within a subset of this cohort such as LGBTQ+ people of colour. Alternatively, applying an interpretive phenomenological methodology and measures of structural stigma within a wider, comparative study across different commissioning areas could develop an explanation of the issues raised within the doctoral study's scoping review (Adley et al., 2025b). Indeed, without considering or seeking to explain the influence of relational and structural stigma on marginalised populations, current reviews such as the upcoming health evidence review by NHS England (2025) risk reproducing invisibility at the margins of care.
Conclusion
In its reframing of the phenomenon as relationality within health and social care pathways, this paper shines a light on the influence of political agendas and organisational cultures on the service experiences of a marginalised population group in the North East of England. Immersion into philosophical and methodological literature also led to consideration of spaces between services, and the creation of the unified visual framework of relationality that is presented here. While this model seeks to provide a more accessible way of describing the influence of relational and structural stigma on service pathways, there is also scope for it to be modified for different contexts. For example, the terminology within the model might be adapted for use with public contributors without an academic background. The two-dimensional model might also be elaborated to include structural vectors such as commissioning metrics, policy or data standards that flow around and across the grid, which could help to illustrate how macro-level structures colour micro-level relationality within health and social care pathways. As national initiatives progress, such as the LGBT+ Health Evidence Review by NHS England (2025) and the Advisory Council on the Misuse of Drugs’ open call for evidence on drug use in LGBT+ communities and chemsex (ACMD, 2025), the framework could inform submissions and recommendations, highlighting how organisational orientations and horizons shape service access. Future studies might test this framework in diverse settings, contributing to equitable policy and practice.
Footnotes
Acknowledgements
The authors would like to thank the journal’s editors and reviewers for their considered comments which greatly helped to improve this article.
Ethical Consideration
No ethical approval was required for this methodological paper that does not directly involve humans or animals, and uses completely anonymized data which does not contain personal information.
Author Contributions
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This is a component of a study that is funded by the National Institute of Health and Care Research (NIHR) Applied Research Collaboration (ARC) North East and North Cumbria (NIHR200173).
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Other Identifying Information
One of the co-authors (Prof. Yolles) is a proponent of the bounded relativist ontology discussed within the paper.
Disclaimer
The views expressed are those of the author(s) and not necessarily those of the NIHR or the Department of Health and Social Care.
Data Availability Statement
There are no datasets associated with this paper. Data sharing is therefore not applicable to this article as no new data were created or analysed in this study.