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REVIEW
2 Annals of Long-Term Care February 2008
Recognizing and responding to the needs of lesbian, gay, bisexual and transgender
elders will promote better services for ALL elders because it promotes sensitivity and
respect for diversity in all its aspects, as well as creating a space where sexuality and
aging in general can be explored and discussed.
—Quam (n.d.)
Introduction
Similar to other aging Americans who are constrained by ageist stereotyping
and misconceptions, older lesbians and gay men face such problems as loss of fam-
ily and friends, health concerns, increased isolation from community, fear of
dependency, and reduced income.1Older lesbians and gay men may experience
additional challenges as they approach mainstream health and social service agen-
cies and programs. As young and middle-aged adults, lesbians and gay men expe-
rienced structural and institutional homophobia, heterosexism, and anti-gay vio-
lence in healthcare, housing, employment ,and civil rights.2Nowas older adults,
they also experience inequality and disparity because of unequal coverage for same-
sex couples under policies regulating Social Security and private pension plans.3
When the caregiving needs of older lesbian and gay men can no longer be met
bytrusted partners, friends, and relatives, they may be reluctant to access tradi-
tional community-based and institutional long-term care(LTC) services.4
Unrecognized caregiving needs, concerns about affordable housing, and real or
anticipated homophobia and heterosexist attitudes byagency staff in LTC facili-
ties further marginalize older lesbians and gay men5and can compromise their
quality of care.
Demographics
Current demographic trends reveal that the U.S. population is aging. The gay
and lesbian population over 65 is also aging,6and by 2030, there will be 4-6 mil-
lion older lesbian, gay, and bisexual people.7This approximation is conservative
because neither the U.S. Census Bureau nor other population studies ask about
sexual orientation. Based on the commonly used estimate that 3-5% of the older
population utilizes nursing home care8by 2030, between 120,000 to 300,000
older lesbians and gay men will reside in nursing homes across the United States,
while others will reside in the community with the support and assistance of
friends, family, and utilization of health, social service, and community-based
LTC services.
Although there is a lack of information about specific demographic character-
istics of this population, what is known is that this older lesbian and gay popula-
tion is heterogeneous. In addition to cultural, ethnic, and racial diversity, older
lesbians and gay men differ in other factors such as education, income, abilities,
history of partnerships (including previous heterosexual marriage), length of cur-
Older Lesbians and Gay Men:
Long-Term Care Issues
Harriet L. Cohen, PhD, LCSW, Linda Cox Curry, PhD, RN, David Jenkins, PhD, LCSW,
Charles A. Walker, PhD, RN, and Mildred O. Hogstel, PhD, RN, BC
Dr. Cohen is Assistant Professor,
Dr. Curry is Professor, Dr. Jenkins is
Associate Professor, Dr. Walker
is Associate Professor, and Dr.
Hogstel is Professor Emeritus,
Harris College, Texas Christian
University, Fort Worth, TX.
Many health and social service
providers lack awareness of and
knowledge about the long-term
care (LTC) needs of the lesbian and
gay population, about how to provide
culturally-sensitive and affirming
services and programs, and about
ways to increase accessibility and
acceptability of LTC options for les-
bian and gay older adults. This arti-
cle reviews the history of oppression
experienced by lesbians and gay
men, what is known about them,
and issues for consideration by
staff in LTC facilities.Alifecourse
perspectiveprovides the conceptu-
al framework for understanding the
challenges and opportunities faced
byolder lesbians and gaymen in LTC.
Recommendations are provided to
combat heterosexist assumptions and
enhance culturally competent care.
(Annals of Long-Term Care: Clinical
Care and Aging 2008;16[2]:xx-xx)
Lesbians and Gay Men
rent or past same-sex relationships, children, age and
experience of coming out, and the degree of identification
as gay or lesbian.9The life course perspective emphasizes
the diversity of life paths of individuals and recognizes the
impact of historical events on age cohorts.10 Regardless of
their diversity, older lesbians and gay men share a com-
mon history of discrimination, such as rejection, oppres-
sion, invisibility, and threats of violence.11
History of Oppression
Older lesbians and gay men are sometimes referred to
as the “pre-liberation” generation who were labeled “sick
by doctors, immoral by clergy, unfit by the military, and
amenace by the police.”12 For them the “the heavy moral,
social and legal injunctions against homosexuality have
weighed heavily.”13 Hutchinson10 emphasizes that the life
course perspective links childhood and adolescent experi-
ences with later experiences in adulthood. Heterosexism
or homophobia created hostile environments for lesbians
and gays in the past, and these forms of oppression still
permeate our society and affect the quality of life of older
lesbians and gay men.
Heterosexism is a system of beliefs and attitudes “that
denies, denigrates, and stigmatizes any non-heterosexual
form of behavior, identity, relationship or community.”11
Homophobia is an irrational fear and hatred of people
because of their sexual orientation.14 Inaddition to expe-
riencing homophobia and heterosexism in the larger com-
munity,older lesbians and gay men often confront ageism
in the lesbian and gay community.15Although society is
moreopen and accepting of sexual diversity than before
the Gay Liberation Movement began in the early 1970s,
older lesbians and gay men may still carryscars from their
experience of discrimination and stigmatization.16
Marginalized in Healthcare and
Social Services
Many health and social service providers lack aware-
ness of and knowledge about long-term care needs of the
lesbian and gay population, about how to provide cultur-
ally sensitive and affirming services and programs, and
about ways to increase accessibility and acceptability of
long-term care options for lesbian and gay older adults.
The needs of older gay men who Berger17 referred to as
“gay and gray” and older lesbians who Kehoe18 called the
“triple invisible minority” (female, old, gay) have been
excluded from research and practice.1Anti-gay bias has
been recognized by the Gay & Lesbian Medical
Association since 1994, when medical professionals and
students reported hearing negative and disparaging com-
ment about lesbians, gay,bisexuals and transgender peo-
ple.19 As a result, older lesbian and gay adults may mis-
trust the health, social service, and aging services delivery
network, and may refuse or be reluctant to access them20
even when their health and safety is at risk.
Victimization of older adults, including elder abuse
(physical, emotional, sexual), financial exploitation, neg-
lect, and abandonment, is perpetrated by spouses, part-
ners, adult children and staff in LTC facilities, and it has
been documented in the gerontological literature.8What
has not been researched is “victimization based on sexual
orientation [as] an additional form of elder abuse that can
occur simultaneously with other types of elder abuse.”2
The fear of discrimination and disclosure, plus the risk of
victimization, may increase the vulnerability of older les-
bians and gay men.
Marginalized in Research
Agrowing, but limited, body of research on older les-
bians and gay men has begun to emerge; however,most
studies utilizesmall samples, are nonrepresentative, do
not reflect ethnic and racial diversity,and recruit from
gay-friendly religious and social organizations.16 The
research has been criticized for its attention to upper-
middle-class, white, well-educated gay men who are
active in the gay community.21 Other methodological
issues, such as inconsistency in defining age cohorts22 and
failure of researchers to employ strategies to ensure valid-
ity and reliability, have created additional challenges in
research with older lesbians and gay men.
Research findings for some diverse groups are avail-
able. For example, cancer rates differ for heterosexual
African-American and white women. Breast cancer is the
most commonly diagnosed cancer for all heterosexual
women in the United States; however, the second most
commonly diagnosed cancer for African-American
women is colon and rectum cancer, while white women
are more often diagnosed with lung cancer. Research is
desperately needed to ascertain the cancer diagnosis rate
and effectiveprevention strategies for lesbians, who may
have never given birth, used oral contraceptives, or even
had regular physician exams.7
Annals of Long-Term Care February 2008 3
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Lesbians and Gay Men
Research about lesbians and gay men has previously
lacked funding and recognition by the mainstream
research community.23 In March 2006, however, the
Department of Health and Human Services, through the
National Institute of Mental Health, released a Program
Announcement (RO1) inviting grant applications under
the category“Health Research with Diverse Populations,”
which included research affecting the health of lesbian
and gay men and related populations. Including lesbians
and gay men as a research population is an important step
forward by the federal government. Nonetheless, there are
many challenges in applying and receiving federal fund-
ing for what many gerontologists viewas a politically con-
troversial, special interest or fringe group.
What WeKnow About Older Lesbians
and Gay Men
As with older adults, myths and stereotypes about
older lesbians and gay men reflect negativecharacteristics,
such as loneliness, lack of companionship,dissatisfaction
with their lives, and absence of satisfying sexual relation-
ships.23 Current research indicates that older lesbians and
gays are less likely to be living with life partners or their
children and are more likely to live alone than their het-
erosexual counterparts.7Although they are more likely to
live alone, they do not necessarily report feeling lonely
and isolated. In contrast to the myth of loneliness, older
lesbians and gay men are no lonelier than their heterosex-
ual counterparts or younger lesbians and gay men. Social
networks, sometimes called “family of friends” or “fami-
lies of choice” that older lesbians and gay men have devel-
oped may provide a buffer during times of loss and need.14
Studies of older gay men17 and older lesbians24 show that
they desirecompanionship and involvement in satisfying
sexual relationships, as do heterosexual people.
Common Fears
Recent studies describe the health, social service, and
LTC needs of older lesbians and gay men in various geo-
graphic locations: Chicago,25 Canada,26 rural Maine,27
California,22 and mid-Atlantic states.28 The locality in
which these studies were conducted differed but two
themes emerged consistently: Fear of discrimination and
fear of disclosure prevented utilization of needed services.
Although no studies explore how older lesbians and gay
men negotiate their multiple identities when they transi-
tion from the community to LTC, fear of discrimination
and fear of disclosure might well apply to this population
as they access LTC and or move into LTC facilities. Studies
reveal that some older lesbians and gay men are willing to
access generic health and LTC services through mainstream
organizations when the aging service network is aware,
understands, and is prepared to meet their unique needs.29
Because culturally sensitive services are not consistent-
ly available, the importance of partners and friends is
underestimated or ignored, and older lesbians and gay
men do not seek or receive needed services. Some older
lesbians and gay men may chose to move to an exclusive
lesbian and gay retirement community; however, many
will havereasons to stay in their local communities
because of financial resources, straight friends or cowork-
ers, family members, or lack of desire to live in a segregat-
ed community.
Coping Strategies
Innegotiating between the heterosexual society and the
homosexual community,some older lesbians and gay men
havedeveloped “crisis competence”30 or “stigma manage-
ment”28as they havelearned to address the environmental
pressures in their lives. While many older gay men and les-
bians are“described as psychologically well adjusted,
vibrant, and growing older successfully,”1some struggle
with their aging. A lack of research about the health con-
cerns of lesbians and gay men contributes to these struggles.
In fact, except for HIV, healthcare issues among midlife and
older lesbians and gay men urgently need attention.
Despite the victimization, many lesbians and gay men
have learned ways to master the minority stress and
stigmatization imposed by the external environment. They
develop internal resources and external supports, leading
to resiliency.20 Yet some of their adaptive coping mecha-
nisms that served as protective factors when they were
younger—avoiding identification of themselves and their
partners to others, avoiding identification with the lesbian
and gay communities, and avoiding services—may not be
life-affirming as they get older.31 The decision to conceal
one’s sexual orientation, based on fear and anxiety, may
prevent them from receiving appropriate services.
Retreat to the Closet
Like older adults in general, older lesbians and gay
men may struggle with developmental tasks associated
4 Annals of Long-Term Care February 2008
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Lesbians and Gay Men
with successful aging, such as claiming pride with their
life’s accomplishments, finding meaning in their lives,
and engaging in social and productive activities.11Because
of the limitations on aging services that address the spe-
cialized needs of older lesbians and gays; however, many
hide their sexual orientation when they are faced with
dependency on agencies and services. The concern that
these experiences and threats of prejudice, marginaliza-
tion, and physical harm will persist and affect their qual-
ity of care is increased.
Older lesbians and gay men “often find themselves
having to [go] back into hiding,”26when they became ill,
vulnerable, and dependent on others.2The decision to
return or not to return to the closet demonstrates the
interplay between human lives and historical times,
human agency in decision making, the diversity of the life
experiences, and the impact of earlier events and transi-
tions on current and future transitions10,32,33,which are
themes reflected in the life course perspective.
It is particularly troubling when older lesbians and gay
men, who havepreviously lived fully or partially open lives,
decide they must hide a critical part of their identity, i.e.
their sexual orientation, in order to feel physically and
emotionally safe in nursing homes, assisted living facilities
or retirement communities.34,35 Concealing their sexual
identity limits lesbians and gay men’s ability to integrate
their life experiences across their lifespan and to make
meaning of their lives. This concealment creates a potential
tension because if previously open older lesbians and gay
men decide to retreat to the closet to feel safe, then cultur-
ally competent health and social service practitioners can-
not address the challenges and barriers facing them.
Although it is not clear whether the retreat to the clos-
et is internally or externally motivated,35 many older les-
bians and gay men fear homophobic attitudes from staff
and other residents, and as a result, their needs may go
unrecognized.4Even those “who had open relationships,
who were active in the community, and who were com-
fortable with their identity were often unwilling to open
themselves up to additional vulnerabilities that accompa-
ny coming out.”15 Examples of homophobia among nurs-
ing home staff include refusal to bath “the lesbian” and
workers threatening to reveal a resident’s lesbian identity
to other residents and to staff.3Alifelong relationship
may be negated during a medical crisis, when gay couples
are separated into different nursing homes, without
regard for their long term relationship.36
Other lesbians and gay men agonize about accessing
LTC services “because they worry that their integrity and
their life choices will not be honored …and their long
term partnerships may not be recognized or valued.”11
Same-sex partners are often denied visitation privileges in
hospitals and LTC facilities and chosen families are often
excluded from making decisions about an older lesbian or
gay man’s care in LTC facilities.29 In fact, “people have
been prepared to die at home without sufficient care,
rather than go back into the closet in order to enter an
otherwise appropriate nursing home setting.”37
Long-Term Care: Challenges and
Opportunities
While for many ethnic individuals and heterosexuals,
the family of origin serves as a protection against an
oppressive society, some lesbians and gay men have found
their home and nuclear family a place of rejection and
hostility.As a result, lesbians and gay men havelikely
developed a networkof close friends or chosen families of
choice to whom they can turn when in need,31 but “soci-
ety has not always acknowledged the importance of these
“chosen families.”38 Therefore, it is imperativefor health
carepractitioners to understand that a move to a nursing
home for an older lesbian and gay man may mean the loss
of a supportivecommunity,making it more difficult to
adjust to the new, and potentially hostile, environment.
In addition to social discrimination, this population
faces income discrimination in the form of unequal finan-
cial factors, such as retirement income, Social Security,
private pensions, and Medicaid. Older lesbians and gay
men are not eligible for the Social Security survivor ben-
efits when a loved one dies.39 Although some older les-
bians and gay men may be covered under domestic part-
ner benefits for health care, they are not eligible to receive
retirement benefits or Medicaid spousal impoverishment
protection.28
Ethical Mandates
Social workers, nurses, and LTC administrators have
an ethical responsibility to treat all people with respect
and dignity. In the state of Texas, LTC administrators are
governed by directives from the Department of Aging and
Disability Services (DADS). DADS mandates continuing
education for LTC administrators and requires annual
Annals of Long-Term Care February 2008 5
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Lesbians and Gay Men
continuing education content on business and manage-
ment practices, resident care, and ethics. Tolerance for
resident and family diversity is highlighted.
Social work’s core values of service, social justice, digni-
ty and worth of the person; importance of human relation-
ships; and integrity and competence mandate that social
workers adhere to ethical standards in practice, research,
and education. Through the more recent versions of the
Council on Social Work Education Educational Policy and
Accreditation Standards40 and the National Association of
Social Work Code of Ethics,41 the profession of social work
has reaffirmed its devotion to addressing issues of social
justice associated with sexual orientation.42
Both the American Nurses Association (ANA) and the
American Association of College of Nursing (AACN)
supportethical nursing practice. The first of nine revi-
sions in the ANA Code of Ethics emphasizes “compassion
and respect for the inherent dignity, worth, and unique-
ness of every individual” (Retrieved July 25, 2006,
www.nursingworld.org/ethics/chcode.htm). Core profes-
sional values cited in the AACN Essentials of
Baccalaureate Education include altruism, autonomy,
human dignity, integrity, and social justice. Core knowl-
edge required for professional nursing practice includes
human diversity and lifestyle variations in which the pro-
fessional nurse is a client advocate, sensitive to the needs
of individual patients or vulnerable populations.43
From the brief descriptions above, it is clear that LTC
administrators, social workers and nurses are required to
achieve similar ethical competencies related to marginal-
ized and vulnerable clients. However, some providers may
not be aware of the heterosexual assumptions and homo-
phobia that construct barriers to welcoming and inclusive
services and settings for older lesbians and gay men or
may not have thought about these issues previously.
Affirming Practices
An organizational approach for mainstream health and
social service agencies and LTC facilities to demonstrate
affirming practice is developing “statements of nondis-
crimination that include sexual orientation”44,which can
affect agency policy and practice. Healy14identifies four
guidelines for providing culturally sensitive services:
awareness, combat heterosexist assumptions, learn about
culturally competent practice, and utilizeinclusivelan-
guage and actions for culturally sensitiveaffirmativeprac-
tice. Anetzberger45 suggests initiating conversations with
staff and administrators about gay and lesbian issues that
may affect quality of careand providing a “mechanism for
hearing directly from older gays and lesbians regarding
what they perceiveas their needs, concerns, issues and
service preferences.43 Other recommendations can be
found in Table I.
Conclusion
While communities, policy makers, and health and
social service organizations struggle with how to prepare
for the increasing demands of an aging population, more
research is needed to better understand the challenges and
barriers experienced by of older lesbians and gays in
accessing and utilizing LTC. Because of the heterosexist
and hostile environment that existed for this population
when they were younger, and may still exist for many
older members of the lesbian and gay populations, it is
imperative that researchers and practitioners adhere to
their profession’s guidelines for cultural competency.
Most significant is the protection of these individuals
from exploitation and harm while participating in
research projects.
Cultural sensitivity training for LTC facility staff, resi-
dents and their families can assist LTC facilities to pro-
6 Annals of Long-Term Care February 2008
Table: Affirming Practice with
Older Lesbian and Gay Adults:
Recommendations for Aging, Health,
and Long-Term Care Practitioners
•Do not assume heterosexuality. Use “partner” rather
than “spouse” or “marital status” on the intake form.
Pay attention to the name or pronoun of the significant
others in the person’s life.
•Understand that lesbian and gay couples are not
covered by many legal rights and privileges available
to heterosexual couples. Encourage lesbians and gay
men to complete advance directives and other legal
documents recognized in their states.
•Challenge negative and derogatory comments.
•Avoid focusing solely on the client’s sexual orientation
or gender identity.
•Understand the person’s history of discrimination and
oppression, and how that has impacted beliefs,
attitudes, and behaviors.
•Be aware of your own internal prejudices, and ask
others to help you address your personal questions,
fears, and concerns.
•Acknowledge the diversity within the lesbian and gay
community.
•Develop a list of local resources for lesbian and gay
clients.
•Be aware that lesbians and gaymen mayhavecreated
“chosen families” who maynot be biologically or legally
related, but are veryimportant sources of supportand
assistance.
•Start with a strengths perspective, and recognize the
resiliency that older lesbians and gay men have
developed in response to a hostile environment.
•Become an advocate and confront people when they
makederogatory comments.
•Develop lesbian- and gay-affirming staff development
for all staff.
Lesbians and Gay Men
vide an environment where older lesbians and gay men do
not need to fear or to hide, but can experience the same
quality of life of older adults in general. More research
and practice strategies are necessary to insure the presence
of ethical policies and practices ending discrimination
against older lesbians and gay men and create welcoming
and affirming environments, positively affecting the dig-
nity of and respect for all older adults.
The authors report no relevant financial relationships.
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