Professional Documents
Culture Documents
2016 Book HandbookOfLGBTElders
2016 Book HandbookOfLGBTElders
Harley
Pamela B. Teaster Editors
Handbook of
LGBT Elders
An Interdisciplinary Approach to
Principles, Practices, and Policies
Handbook of LGBT Elders
Debra A. Harley Pamela B. Teaster
•
Editors
Handbook of LGBT
Elders
An Interdisciplinary Approach
to Principles, Practices, and Policies
123
Editors
Debra A. Harley Pamela B. Teaster
University of Kentucky Virginia Tech
Lexington, KY Blacksburg, VA
USA USA
v
vi Foreword
The collection also takes very seriously the reality that in so many areas,
discrimination according to these categories is even firmly protected by
law—laws that not just allow, but actually promote, discrimination in
housing, employment, and public accommodation. And even if not formally
protected by law, customary exclusions on the basis of biases such as racism,
classism, ageism, homophobia, and transphobia continue to thrive as this
book goes to press in 2015, which is likely to be the year when, according to
the US Supreme Court, marriage equality (the legal recognition of same-sex
marriages) becomes the law of the land. The contributing authors of this
collection know well that if/when that happens, homophobia will not go
away. Indeed, as this decision by the US Supreme Court comes to seem
inevitable, there is a “frontlash” taking place as more and more US munic-
ipalities introduce laws that will allow frank exclusion of sexual and gender
minorities specifically on the basis of religious belief. So, even if marriage
equality comes into the legal light as this book goes to press, the need for this
unique collection will remain compelling.
By getting to the heart and effects of bias against sexual and gender
minorities and their multiple identities as aged persons, this book makes an
enormous and exquisitely timely contribution, not just to the empirical,
theoretical, and practical literatures for service professionals, but to the lit-
eratures on social justice, as well. We are all well served by it.
Joan Callahan
Professor Emerita
Department of Philosophy
Department of Gender and Women’s Studies
University of Kentucky
Preface
vii
viii Preface
Debra A. Harley
Pamela B. Teaster
Contents
ix
x Contents
Glossary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 685
Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 689
Editors and Contributors
Pamela B. Teaster is the associate director for Research at the Center for
Gerontology and a professor in the Department of Human Development at
Virginia Tech. She established the Kentucky Justice Center for Elders and
Vulnerable Adults and the Kentucky Guardianship Association and was its
first president. She is the secretary general of the International Network for
the Prevention of Elder Abuse. She served as director and chairperson of the
Graduate Center for Gerontology/Department of Gerontology as well as the
director of Doctoral Studies and associate dean for Research for College of
Public Health at the University of Kentucky. She serves on the editorial
board of the Journal of Elder Abuse and Neglect and Frontiers. Dr. Teaster is
xiii
xiv Editors and Contributors
Contributors
Loree Cook-Daniels has been working on LGBT aging issues for more than
four decades, focusing particularly on public policy and social change. She is
the founder of the Transgender Aging Network and currently serves as policy
and program director for FORGE, Inc.
Randy Thomas is a retired police officer having served for over 25 years in
the law enforcement profession (Tampa Police Department, Richland County
(SC) Sheriff’s Office and South Carolina Department of Public Safety). He was
a member of the South Carolina Adult Protection Coordinating Council and
was instrumental in the passage of South Carolina’s Omnibus Adult Protection
Act. He received his bachelor’s degree from Chaminade University (1971) and
his master’s degree in political science from the University of South Florida
(Tampa 1974).
Abstract
This chapter presents an overview of select theories of sexual orientation
and gender identity. Traditional theories of life span development offer a
general framework within which to understand issues and experiences
common to persons in later stages of life. The intent of this chapter is to
discuss theoretical constructs and models of sexual identity, counseling,
public health, gerontology, and social work that can be applied with aging
LGBT populations. These theories underscore the necessity of helping
present and future professionals who understand differences among LGBT
elders and the complex nature of identity, their psychosocial adjustment,
and ways in which stigma of sexual identity and gender identity affects
their well-being. Although the various theories and models in this chapter
are presented according to discipline, theories are not mutually exclusive
to disciplines.
Keywords
LGBT theories Sexual orientation identity development
Gender
identity development Life span development theories
gender identity are based on Eurocentric cultural 4. Identify the social work theories that work
models of sexuality. Traditional theories of life effectively with LGBT elders.
span development (e.g., Erikson 1950; Levinson 5. Explain how various practice models can be
1978, 1996) offer general frameworks within integrated in working with LGBT elders.
which to understand issues and experiences
common to persons in later stages of life (Hash
and Rogers 2013).
Although it is beyond the scope of this chapter
to include all theories, constructs, and applica- Introduction
tions in human services, our intent is to present
an overview of select theoretical constructs and Theory is a general statement, proposition, or
models of sexual identity, counseling, public hypothesis about a real situation that can be
health, gerontology, and social work that can be supported by evidence obtained through a sci-
applied with aging LGBT populations. These entific method. A theory explains in a proven
theories underscore the necessity of helping way why something happens and offers guidance
present and future professionals who understand in explaining and responding to forgoing prob-
differences among LGBT elders and the complex lems (Gratwick et al. 2014). A construct is an
nature of identity, their psychosocial adjustment, idea, often referred to as a theory, which contains
and ways in which the stigma of sexual identity conceptual elements or parts that are put together
and gender identity affects their well-being. in a logical order to explain something. Con-
Specific theories of late adulthood development structs are typically subjective and not based on
and functional capacity are presented in Chap. 3. empirical evidence. A model is a blueprint for
Also, it is not the intent of this chapter to present implementation. It describes what happens in
techniques for counseling LGBT elder in specific practice in a general way. Theory and models are
circumstances (e.g., couples or relationship, influenced by perspective, a value position
family, mental), nor to critique various theories. (Payne 1997). Every discipline has theories to
Although the various theories and models in this explain particular phenomena upon which it
chapter are presented according to discipline, operate to guide development of hypotheses,
theories are not mutually exclusive to disciplines. research, and recommendations for best practices
A theory may easily be applied by various dis- and policy. In fact, Payne suggests that theory
ciplines to investigate and explain behavior and succeeds best when it contains all three elements
phenomenon. —perspective, theory, and model/construct.
Theory serves the function of providing practi-
tioners a guide for behavior in very specific cir-
Learning Objectives cumstances and making decisions.
Although various disciplines study aging, the
By the end of the chapter, the reader should be study of older persons occurs primarily within
able to: the discipline of gerontology. Hooyman and
Kiyak (2008) suggest that because of the multi-
1. Understand the various theories of LGBT disciplinary nature of gerontology, examination
identity development. of aging on the societal, psychosocial, and bio-
2. Identify the counseling theories that can be logical levels. However, on all these levels, older
applied effectively for work with LGBT sexual minorities (lesbian, gay, bisexual, trans-
elders. gender [LBGT]) have been relatively ignored in
3. Identify the theories of public health and gerontological research (Grossman 2008; Orel
practice. 2004; Quam 2004). Similarly, very little content
1 Theories, Constructs, and Applications … 5
on specific care needs of LGBT persons exists in the additional impact of making a marginalized
the nursing literature, especially for older adults. and stigmatized group feel even more of a
This lack of focus is particularly troubling minority.
because nurses and other such caregivers are the
front line of care and are in a position to create
health care environments that will meet the needs Elderly LGBT Diversity, Identity,
of LGBT elders (Jablonski et al. 2013). In and Resilience
addition, many other disciplines omit LGBT
populations from curricula and research to the As an LGBT person and an older person, an
extent that it appears that sexual minorities do LGBT elder does not belong to one homogenous
not even exist (Hall and Fine 2005; Harley et al. group within the acronym. LGBT elders come
2014). The lack of focus on LGBT elders in from every race and ethnicity, nationality, gen-
research and training programs frequently results der, ability level, socioeconomic status, place,
in service providers who are inadequately to and space. Some LGBT elders have been married
meet the needs of this population. According to and have children, while other have either or
Gratwick et al. (2014), “even when providers of neither. Thus, LGBT elders cannot be grouped or
aging services express willingness to become treated as one cohesive category (Mabey 2011).
more responsive to the needs of LGBT older Older LGBT persons grew up during a time
adults there is evidence that they do not take when homosexuality and gender nonconformity
sufficient action” (p. 5). Hughes et al. (2011) were viewed as a mental illness, a sin, or a sexual
report that of service providers affiliated with the perversion. Open discussion about homosexual-
National Association of Area Agencies on ity, sexual identity, and gender identity was not
Aging, only 15 % provide services tailored to the done. Rather, secrecy about one’s sexual desires
need of older LGBT adults. Moreover, at the and behaviors was the norm; to reveal that one’s
organizational level, LGBT older adults are lit- sexual orientation was other than heterosexual or
erally not being seen, organizations are not one’s gender identity was other than conforming
directing resources to these populations, and it to social expectations was not only vocationally
appears that there is agency resistance to and socially devastating, but patently unsafe.
acknowledging the distinctiveness of LGBT Negative attitudes and perceptions about LGBT
aging issues. persons are not only historical. Today, hetero-
Considering the increase in the number of sexism, homophobia, transphobia, and biphobia
older persons in general and the projection for continue to be intertwined in social customs,
continued growth in numbers and anticipated cultural beliefs, institutional structures, and pol-
growth in the one to three million individuals in icy development. It is both the long-term and
the USA over age 65 who are already identified ongoing socially sanctioned discrimination, pre-
as LGBT, the lack of focus of multidisciplinary judice, and stereotypes that present unique chal-
research relegates older LGBT persons to a status lenges and, ironically, opportunities for LGBT
of invisibility. Mabey (2011) contends that the persons globally (e.g., Austria, Canada, England,
omission of LGBT elders in gerontological Ireland, USA). Because of the diversity among
research “leaves professional counselors without LGBT elders, some of the stereotypes encompass
a substantive bridge with which to connect the entire LGBT population such as its attempts
resources with treatment planning when working to covert heterosexuals that the population is
with sexual minorities” (p. 57). Moreover, age- composed of pedophiles or that it is a threat to
ism as experienced in LGBT communities has marriage and structure of the family. Other
6 D.A. Harley and P.B. Teaster
stereotypes are specific to subgroups of LGBT values youth, and rejection of old persons. In
persons such as the belief that a lesbian cannot addition, cultural barriers and being very
self-reliant further isolate Latinos LGBT elders. In
“get a man,” gay men are responsible for a needs assessment of older Hispanic LGBT
HIV/AIDS, or that older LGBT persons are not adults, participants expressed varied experiences of
attractive. aging as: (a) not different from that of the general
In a society that places an inordinate emphasis population, with more self-acceptance, particularly
if one is financially secure, (b) there is a great deal
on youth, older adults face stigma and discrimi- of rejection of older persons because they are
nation beyond that of their younger counterparts, persons in which people are not interested and,
especially ageism (Butler 1994) in addition to even why they do not have a support group even
lifelong negative attitudes and poor treatment among themselves, (c) social isolation within their
own families because of their identities as LGBT
related to their sexual orientation and gender people, and (d) dual discrimination as Latinos and
identity. Hash and Rogers (2013) acknowledge as members of the LGBT community (www.
“while these difficult experiences can create a gallup/poll/158066/special-report-adults-identity-
host of problems for LGBT individuals, they can lgbt.aspx).
also help them develop unique skill sets or
strengths that their non-LGBT counterparts do
not necessarily benefit from as they age” Case of Maria
(p. 249). Further, Hash and Rogers suggest that Maria is a Latina 73-year-old lesbian. She
despite difficulties associated with aging as and her partner of 40 years live in a small
LGBT persons, elders have successfully devel- third floor apartment in Los Angles. The
oped social networks, successfully developed a building is old and does not have an ele-
strong sense of identity through the coming-out vator. Maria has arthritis in her knees and
process, and have successfully responded to hands, hypertension, and glaucoma. Here
discrimination and stigma to develop a positive partner, Sophia, is in better health but has
sense of self and identity leading to stronger ego asthma. Neither Maria nor Sophia has
integrity. Despite the challenging and threatening children and both have been estranged
context often associated with LGBT elders’ ear- from their families for most of their adult
lier lives, most are now comfortable with their life. They consider themselves “closeted”
sexual orientation and gender identity and dis- and have identified themselves publically
play a marked resilience to the minority stress as sisters.
they experienced in their lives (Irish Association Maria worked for 55 years as a house-
of Social Workers 2011; Szymanski and Gupta keeper for a wealthy family. She does not
2009) (see especially Chaps. 6, 7, 8 and 10 in have retirement income and receives Social
this book on resilience among LGBT elders of Security of $540 per month, Medicare, and
color). food stamps. Sophia worked as a city bus
The process of aging for LGBT persons pre- driver for 30 years and receives retirement
sents the typical challenges and concerns related benefits, Social Security, and Medicare.
to health status, financial stability, loss of a The two of them are concerned about
spouse or partner, and so forth. We present the the feasibility of continuing to live in their
case of Maria, a Latina 73-year-old lesbian, to apartment, but know that it will be difficult
illustrate some of the challenges she faces. to find other affordable housing. In addi-
tion, their share of cost for health care
As a member of the Latino culture Maria believes continues to increase. Although neither
that the Latino community is less accepting of
homosexuality. Maria recognizes that living in Los
women have been diagnosed with depres-
Angeles she faces the challenges of being invisible sion, both express having feelings of
because of ageism, an LGBT community that depression.
1 Theories, Constructs, and Applications … 7
Table 1.1 Plummer’s stages of homosexual identity describes a process of six stages of gay and
Stage 1: Sensitization—thinks about one’s sexual lesbian development. Although these stages are
identity sequential, some persons revisit stages at differ-
Stage 2: Significance and disorientation—accepts the ent points in their life. Each stage is accompa-
deviant label with all the potential social consequences. nied by a task. Cass believes that coming-out is a
Social oppression creates disequilibrium where the lifelong process of exploring one’s sexual ori-
homosexual person becomes stalled, perhaps for life, in
this stage entation and lesbian or gay identity and sharing it
Step 3: Coming-out—goes public with one’s rebuilt
with others. Table 1.3 contains Cass’s model of
sexual identity. Disclosure is linked to the person’s identity formation.
willingness and ability to join the homosexual Bisexual Identity Formation. Though limited
community research as been conducted on development of
Stage 4: Stabilization—no longer questions one’s bisexual identity formation, probably the most
homosexual identity important research on bisexuality was that of
Adapted from Plummer (1973) Alfred Kinsey with the publication of Sexual
Behavior in the Human Male (Kinsey et al.
that self-disclosure of one’s homosexuality was 1948) and Sexual Behavior in the Human
beneficial because coming-out meant dealing Female (Kinsey et al. 1953) (as cited by Burle-
with the socially learned “internalization of son 2005). Kinsey developed the Kinsey scale, in
oppression,” which is liberating. Plummer’s which individuals can fall anywhere along a
approach was one of individuals adopting a continuum of 0 (exclusively heterosexual) and 6
“homosexual way of life” or a “career type” of (exclusively homosexual). Burleson contends
sexuality. Recognizing homosexuality as a social that Kinsey had created the present model of
construct developed by the majority to restrict bisexuality without ever once using the word
and pathologize a sexual minority, Plummer bisexual. In addition, Kinsey scale clarified two
argued that all forms of deviancy need to be issues: (a) There is great variability of sexual
viewed within a historical and cultural context. orientation, and (b) an implication that perhaps
He regarded current social hostility to homo- all human beings on this continuum are ranked
sexuality as responsible for many of what he the same way (i.e., heterosexuality is not primary
labeled “pathologies.” Plummer was one of the or held above other sexual orientations). Kin-
first theorists to present identifiable stages of sey’s work, while groundbreaking, was rudi-
“homosexual identity” (see Table 1.1) (Eliason mentary and did not address the complexities of
and Schope). behavior and attraction and past behavior and
Subsequent to Altman (1971) and Plummer’s future predictions. In response to questions of
(1973) theories, an abundance of stage models on complexity, Fritz (1993) expanded on Kinsey’s
sexual identity formation evolved, the majority continuum model to measure a person’s past and
of which moved away from the deviance model future sexual attraction, behavior, fantasies,
to a focus on healthy consequences of accepting emotional preference, social preference, lifestyle,
one’s sexuality (see Table 1.2). Eliason and and self-identification.
Schope (2007) identify two assumptions about Stroms (1978) offers yet different model of
stage model theorists. First, most assumed that sexual attraction, a multiple-variable model, in
one is or is not gay or lesbian and embraced the which sexual attraction to different genders is
argument from an Essentialists’ perspective. examined independently of each other. In this
Second, most models are based on a review of model, Stroms’ scale has one end representing no
the literature and are not empirically tested or are attraction to one gender and the other end pre-
based on single case or small sample size. senting high attraction to that gender. The con-
Probably, one of the most influential and tinuum offers great variation within this model.
frequently cited theories of gay and lesbian Although this model did not include transgender
identity development is that of Cass (1979). Cass persons, a scale could be created for them. In
1 Theories, Constructs, and Applications … 9
addition, Strom’s model includes people who sexual orientation identity development with the
tend toward asexuality. The model describes emergence of theoretical state stage models. The
attraction to women and men as two separate primary focus of these models was on the resolu-
variables (Burleson 2005). tion of internal conflict related to identification as
Theoretical State Stage Models. In the USA, lesbian or gay and informed the “coming-out”
the 1970s ushered in a new era of research about process. Bilodeau and Renn (2005) describe these
1 Theories, Constructs, and Applications … 11
models as having the following characteristics: of sexual minority identity development for older
(a) begin with a stage, (b) describe individuals LGBT adults and the impact of sociocultural
using multiple defense strategies to deny recog- issues on their lives. Based on this model, indi-
nition of personal homosexual feelings, viduals in minority groups experience additional
(c) include a gradual recognition and tentative minority-related stressors that individuals who
acceptance, (d) have a period of emotional and are part of the majority do not have to contend.
behavioral experimentation with homosexuality, The minority stress model is a consolidation of
(e) involve a time of identity crisis, and (f) marked several theories and models that propose that
by the coming-out process. Although difference minority persons experience chronic stressors
exists among the stage models, which illustrate the and these stressors can lead to negative psycho-
difficulty of using one model to understand the social adjustment outcomes. According to Meyer
complex psychosocial process of the development (2010), the minority stress model does not
of sexual orientation identity, their predominance attempt to imply that sexual minorities have
and persistence in the research literature and in higher rates of psychosocial issues because of
current educational practice suggest that they their sexual orientation and gender identity;
represent with some accuracy the developmental rather, the model identifies the pathogenic con-
process (Bilodeau and Renn 2005). ditions that stigmatize LGBT persons and treat
The minority stress model (Brooks 1981; them as inferior to heterosexual individuals.
Meyer 1995) is useful in understanding aspects Minority stressors for LGBT persons include
12 D.A. Harley and P.B. Teaster
experiences of discrimination, concealment or Table 1.4 D’Augelli life span model of sexual orienta-
disclosure of sexual orientation/gender identity, tion development
expectations of prejudice and discrimination, and Exiting homosexuality
internalized homonegativity (Cox et al. 2011; Developing a personal LGB identity
Meyer 2003). Unlike ethnic and racial minority Developing an LGB social identity
groups who experience minority stress, LGBT Becoming an LGB offspring
persons who experience sexual minority stress
Developing an LGB intimacy status
often do not receive support and understanding
Entering an LGB community
from their families of origin (Dziengel 2008).
Minority stress in LGBT persons has been linked D’Augelli (1994)
to higher levels of depression and negative health
outcomes (Cox et al. 2009; Huebner and Davis model suggests that sexual orientation may be
2007). fluid at certain times and more fixed at others and
McCarn-Fassinger (1996) developed the les- that human growth is intimately connected to and
bian identity development model, and Fassinger influenced by both biological and environmental
and Miller (1996) later validated the applicability factors. D’Augelli’s model has six “identity
of the theory with gay men (subsequently refer- processes” that function more or less indepen-
enced in the literature as Fassinger’s gay and dently and are not sequenced in stages (see
lesbian identity development model), which Table 1.4). An individual may experience
examines identity development from a personal development in one process to a greater extent
and a group perspective. The lesbian identity than another, and, depending on context and
development model includes four phases: timing, he or she may be at different points of
awareness, exploration, deepening/commitment, development in a given process (Bilodeau and
and internalization/synthesis. The use of “pha- Reen 2005).
ses” is intentional to explicitly indicate flexibility Renn and Bilodeau (2005) extended D’Aug-
that individuals revisit earlier phases in new or elli’s (1994) model and applied it to under-
different contexts. The model explores attitudes standing corresponding processes in the
of lesbians and gay men toward self, other sexual formation of transgender identity development.
minorities and gender identity, and heterosexu- Bilodeau (2005) found that transgender persons
als. A distinguishing aspect of Fassinger’s model describe their gender identities in ways that
is that lesbians, gays, or bisexuals are not reflect the six processes of D’Augelli’s model.
required to “come out” or to be actively involved Since the inclusion of gender identity disorder
in the lesbian, gay, or bisexual community. (GID) for the first time in the diagnostic and
A life span approach to sexual orientation statistical manual of mental disorders (DSM) in
development has been introduced an alternative 1980 as a mental illness, other theories on
to stage models. D’Augelli (1994) offers a “life transgender identity formation have been pro-
span” model of sexual orientation development. posed by Nutterbrock et al. (2002) and Devor
This model takes social contexts into account in (2004), bisexual identity formation by Fox
different ways than stage models. In addition, (1995), and multiple identity formation by Rey-
D’Augelli’s model has the potential to represent nolds and Pope (1991) (Table 1.2); however,
a wider range of experiences than do the theories none of these models have been empirically
relating to specific racial, ethnic, or gender validated. In the fifth edition of the DSM, GID
groups and addresses issues often ignored in was deleted and replaced with gender dysphoria
other models. D’Augelli presents human devel- (GD), indicating that it is not a mental illness,
opment as unfolding in concurring and multiple rather a lifestyle with which individuals may
paths, including the development of a person’s need assistance in making adjustments. Feminist,
self-concept, relationships with family, and con- postmodern, and queer theoretical theorists (e.g.,
nections to peer groups and community. This Butler 1990, 1993; Creed 1995; Feinberg 1996,
1 Theories, Constructs, and Applications … 13
1998; Halberstam 1998; Wilchins 2002) have determining what is possible to know. Lev’s
introduced alternatives to medical and psychiat- approach is to consider the ecosystem (i.e.,
ric perspectives on gender identity. These theo- influence of environment on perception and
rists suggest that gender is not necessarily linked behavior) in working with transgender persons.
to biological sex assignment at birth, but is cre- According to Lev, “gender variance does not
ated through complex social inequities, and simply live within individuals but exists ‘within’
gender identity is more fluid. These theorists a larger matrix of relationships, families, and
propose transgender identities and gender fluidity communities” (p. xx).
as normative as oppose to the binary, two-gender Lev offers three goals for therapists working
system and the influence of themes reflecting with transgendered persons and their families. The
fluidity of gender that have emerged in the dis- first goal is “to accept that transgenderism is a
cipline of human development (Bilodeau and normal expression of human potentiality.” The
Renn 2005). second goal is “to place transgenderism within a
As an extension of sexual minority identity, in larger social context that includes an overview of
2004 Lev introduced the transgender emergence the existence of gender variance throughout his-
model, a stage model that examines at how tory.” The third goal is “to outline various etiolog-
transgender people come to understand their ical theories that impact assessment and diagnosis,
identity. Lev’s model comes from the perspective as well as innovative, possibly iconoclastic treat-
of a counseling or therapeutic point of view and ment strategies to work with gender-dysphoric,
focuses on what the individual is experiencing gender-variant, transgendered, third-sexed, trans-
and the responsibility of the counselor or inter- sexual, and intersexed people as members of
ventionist. As with other stage theories, Lev’s extended family systems” (pp. xx–xxi).
model begins with the first stage as awareness.
(see Table 1.5 for Lev’s stages). Lev’s clinical
and philosophical ideology is based on the belief Counseling Theories and Practice
that transgenderism is a normal and potentially for Older Adults
healthy variation of human expression. As pos-
tulated by Goldner (1988), gender dichotomies A commonly held view of older persons is that
are not only restrictive, but also constitutive, with they are mentally incompetent. Although there is
the gendering of social spheres constraining some cognitive decline associated with normal
personal freedom and gender categories aging, the majority of older adults do not
14 D.A. Harley and P.B. Teaster
demonstrate significant mental decline. approach should be based on the individual and
For LGBT elders, psychosocial issues arise from his or her needs. Counselors tend to adapt their
ongoing discrimination on the basis of their approaches to working with a client based on the
sexual orientation and gender identity, lack of person’s developmental changes in life, the par-
acceptance from the heterosexual community and ticular cohort to which the person belongs, and
family members, and isolation and exclusion the social context in which the person lives
from LGBT communities because of ageism. The (Blando 2011). Older persons fit into a contex-
general lack of support in many political, edu- tual, cohort-based, maturity-specific change
cational, and religious institutions and the dis- model (Knight 1996) that suggests they face
tinctively oppressive social climate for sexual particular challenges that are unique in later life.
minorities in which older LGBT generations live Older LGBT persons belong to a particular
creates personal conflict that can manifest itself cohort with a collection of experiences and
through internalized disorders (e.g., depression, norms that differ from those of the present and
homophobia) or externalized disorders (e.g., from heterosexual elders (Blando). In the
suicidal behavior) (Mabey 2007). Counseling or remainder of this section, we will present select
therapeutic intervention can help LGBT elders counseling approaches that may be effective with
who experience multiple discrimination to come older LGBT populations. These counseling
to terms with factors associated with ageism (Sue approaches are not intended to be either inclusive
and Sue 2013) and how the historically negative or suggestive; rather, they are a starting point or
climate of discrimination and oppression shapes serve as guidelines.
their experiences with, and impressions of, their One of the most common forms of therapy
own sexual identity (Heaphy 2007; Porter et al. with the general population and with older adults
2004). However, it is important for counselors is cognitive-behavioral therapy (CBT). CBT may
not to view identity as necessarily problematic be particularly efficacious with older adults
(Berger 1982; Mabey 2011). In fact, researchers because of its focus on the present, strict struc-
have introduced the concept of “crisis compe- ture, emphasis on self-monitoring, psychoedu-
tence” or “stigma competence” (Almvig 1982; cational orientation, and goal oriented.
Balsam and D’Augelli 2006; Vaughan and Wa- Adjustment may need to be made for older adults
ehler 2010), in which coming-out by LGBT who have developmental changes such as speed
persons allows them to develop a competency for of processing in intellectual configuration (e.g.,
dealing with other crises or stigma in the life later life of crystalized over fluid intelligence),
span, including difficulties associated with aging emotional changes (i.e., emotions are more
(Heaphy 2007; Kimmel et al. 2006; Schope nuanced and complex and may include
2005). Stigma competence was first developed co-experience of discrepant emotions such as
with regard to persons from racial and ethnic being both happy and sad), and the person’s
minority groups who have multiple minority worldview (Blando 2011). CBT examines the
statuses, including sexual minority identity. In a role thoughts play in maintaining a problem,
study testing the theory of stigma competence stress, or concern. Emphasis is on changing
with lesbian, gay, and bisexual adults over age dysfunctional thoughts that influence behavior.
60, Lawson-Ross (2013) found that older sexual The application of CBT with LGBT elders may
minority adults who were more accepting of their be effective in addressing behaviors stemming
sexual minority identities had lower levels of from past experiences of discrimination with
internalized ageism and had higher levels of life institutions and service providers, fear of
satisfaction and happiness than their peers who homophobia-based victimization, and also from
were less accepting of their sexual minority fear or anticipation of discrimination. In addition,
identities. Satterfield and Crabb (2010) demonstrated the
Counseling Approaches. In working with effectiveness of CBT for depression in an older
LGBT elders, the selection of the counseling gay man.
1 Theories, Constructs, and Applications … 15
behavior to adopt or discontinue. The authors concerns undertaking some steps toward a change,
contend that an elder’s beliefs and attitudes shape such as talking to a doctor about a health condition
his or her intent to take an action and that social or visiting another health professional to seek
influences or norms on LGBT elders also affect advice. The stage of action concerns undertaking
behavioral intent. For example, if an LGBT elder an identifiable activity (e.g., walking, eating
believes that stopping smoking is a goal but healthy foods, wearing a condom). Finally, the
that society would offer little help for him or her maintenance stage is when the change is adopted
to do so because of a pervasive attitude that the and the effort to continue the change diminishes
elder’s sexual orientation is causing the problem, from the action phase. Recidivism is possible, but
then he or she is unlikely to attempt the change continued progress decreases the chances of
because the cost of doing so is too high or returning to the former and undesired behavior
difficult. (Schneider 2013). High self-efficacy is critical to
Another type of theory or perspective is those reach the maintenance stage (Bandura 1986).
concerning a perceived threat. Perhaps the most
well known is the health belief model, which has
been used by public health practitioners and Social Work Theories and Approaches
researchers for over 50 years. The health belief
model has similarities to the value-expectancy One of the unique concepts of social work prac-
model above, but it is also a departure, due to the tice is an understanding of the constant state of
insertion of a threat or fear that drives changes in change of the contextual arena in which social
health behavior as well as a person’s perception workers operate. With the continuous change in
of health severity and his or her perception of environments and populations, social workers
health susceptibility (Salazar et al. 2013), and, need to rethink how they deliver services in
added to the model in the late 1980s, the concept response to distinct alterations in family struc-
of self-efficacy (Bandura 1977) or an older tures and functions, medical advances and aging,
adult’s conception of his or her own power or economic shifts, and shifting evolving profes-
self-determination (Rosenstock et al. 1988). The sional and political ideologies (Allen 2005).
cost-benefit valuation determines the course of Gratwick et al. (2014) contend that theoretically
action, as it also does with the theory of reasoned driven service models are crucial to effective
action described above. A fear appeal might be service provision. Similar to the other disciplines
used to promote a health behavior change, such mentioned previously, various theories and model
as the threat of susceptibility to HIV in older are used in social work practice. Social work
adult populations. practice employs the developmental theories of
A fourth and well-known stage is the trans- moral reasoning (Kohlberg 1973; Gilligan 1982),
theoretical model of change, a model explaining cognition (Piaget 1932), stage theories (Erikson
how persons may change their health behavior and 1950), and transpersonal theories of human
derived from more than 300 theories of psycho- development (going beyond identity rooted in the
therapy (Prochaska 1979; Prochaska and Di- individual body or ego to include higher levels of
Clemente 1986). Five stages, in which persons can consciousness). Developmental theories focus on
facilitate, comprise the model: precontemplation, the changes and stability of behavior across the
contemplation, preparation, action, and mainte- life span. The remainder of this section concerns a
nance. Precontemplation is the stage when a per- presentation of these theories, the primary per-
son is not ready to attempt a change at all. In the spectives, and current social work practice mod-
contemplation stage, an elder is thinking of els. Infused throughout is discussion on social
embarking on a change, and the impetus to act or work practice with LGBT elders.
not is the fulcrum of decisional balance. The scale The major theories used in social work prac-
must tip in favor of attempting the change rather tice are systems theory, psychodynamic, social
than impediments to doing so. Preparation learning, and conflict theory. Systems theory
1 Theories, Constructs, and Applications … 17
Conflict theory, introduced by Karl Marx the helping relationship. Although resilience has
(cited in Dobb 1979) as the name implies, various definitions, at times it is “defined as a
involves conflict, dominance, and oppression in psychological process developed in response to
social life. Basically, groups and individuals intense life stressors that facilitate healthy func-
attempt to advance their own interests over those tioning” (Ballenger-Browing and Johnson 2010).
of others. However, because power is unequally Resilience has four prerequisites: (a) risk or
divided, social order is based on manipulation predisposition to biopsychosocial or environ-
and control of non-dominant groups by dominant mental conditions, (b) exposure to a high-
groups. In the case of LGBT elders, heterosex- magnitude stressor, (c) stress response, and
uals and younger groups exert domination (d) return to baseline functioning and symptom
through heterosexism and homophobia. levels (Ballenger-Browning and Johnson 2010,
Depending on other group affiliations of LGBT p. 1). The feminist perspective takes into account
persons (e.g., race/ethnicity, socioeconomic sta- the role of gender and the historical lack of
tus), they may be further dominated. Conflict power experienced by women in society. Social
theory is further characterized by a lack of open workers using this perspective emphasize equal-
conflict as a sign of exploitation. Social change is ity and empowerment of women in society.
driven by conflict, with periods of change inter- Application of the feminist approach with LGBT
rupting long periods of stability. Social workers elders would place emphasis on equality with
use conflict theory to understand those experi- regard to sexual orientation, gender identity, age,
encing oppression in some form or another in and other characteristics of the populations.
society. Research indicates that LGBT elders Finally, the ecosystem (Germain 1973) is the
experience oppression (e.g., political, religious, person-to-environment concept presented earlier
economic, cultural) and marginalization (e.g., in this chapter. According to Mattaini and Meyer
sexual orientation, gender identity, age) from (2002), the ecological system has been almost
numerous sources. For example, in a study of the universally accepted in social work practice
prevalence of mental disorders in LGBT persons, because of its framework for understanding net-
Meyer (2003) found a higher prevalence of work complexities.
mental disorders than in heterosexual persons. Social work practice model provides
He attributed this to minority stress, explaining step-by-step guides for client sessions. The
that stigma, prejudice, and discrimination create current social work practice models include
a hostile and stressful social environment that problem-solving, task-centered, solution-
causes mental health problems. Application of focused, narrative, cognitive-behavioral, and
conflict theory helps LGBT elders to deal with a crisis. In the problem-solving approach, one must
history of homophobia and discrimination, first understand the presenting problem or issue
experiences of antigay gay violence and hate and then brainstorm possible solutions. It is
crimes, addressing public opposition to gay incumbent upon the person or client to select a
marriage, expectations of rejection, internalized solution, implement it, and evaluate its effec-
homophobia, hiding and concealing identity, and tiveness. The task-centered model focuses on
ameliorative coping processes. breaking down the problem into small manage-
Perspective in social work practice represents able tasks, thus facilitating accomplishment. The
the specific aspects of a session that are empha- solution-focused model takes the approach of
sized. The primary perspectives used in social identifying the solution first and having the per-
work practice include strengths (Saleeby 1996) son establish the process that will lead to the
or resilience, feminist, and ecosystem. The social solution. Finally, the narrative model uses a
worker believes that a person has multiple variety of method for the person to express his or
strengths that are assessed and incorporated into her thoughts.
20 D.A. Harley and P.B. Teaster
Integration of Practice Models elders need, CDT offers a way of looking at the
in Working with LGBT Elders interconnectedness of services and activities
from an operational level intended to improve
Understanding how models work can work outcomes. Moreover, CDT values and principles
effectively in support of LGBT elders is neces- potentially empower LGBT elder to be involved
sary to improving service outcomes. When in their community to have input on decisions
drawing from theories from the disciplines rep- that may influence them.
resented in this chapter, it is efficacious to con- Several practice models have been developed
sider bringing them together from an to assist in older LGBT adults, ranging from
interdisciplinary perspective (some cross one or guidelines for practice to specialized support
more disciplines anyway). Tan (2009) suggests groups and approaches to individual therapy
that many in the field of social work remain too (Hash and Rogers 2013). The American Psycho-
focused on individual therapy and clinical prac- logical Association (APA) developed the Guide-
tice when there is a need to shift more globally lines for Psychological Practice with Lesbian,
and holistically. Furthermore, progressive social Gay, and Bisexual Clients (www.apa.org/pi/lgbt/
work place more emphasizes on the need for the resources/guidelines.aspx) (APA 2012), the
individual to be part of his or her own change Association for Lesbian, Gay, Bisexual, and
(Mullaly 2002). Tan suggests that community Transgender Issues in Counseling (ALGBTIC
development theory (CDT) is a practical frame- 2009) developed competencies for counseling
work. Community development theory is defined LGBT clients, and ALGBTIC in conjunction with
as “the employment of community structures to the American Counseling Association (ACA
address social needs and empower groups of 2010) approved competencies for counseling
people” (Mendes 2008, p. 3). CDT is rooted in transgender clients. The code of ethics of the
sociology. Its primary functions are to provide National Association of Social Work (NASW
norms for the practitioner’s actions and a model 2008) (http://www.socialworkers.org/pubs/code.
of practical help to communities. CDT depends asp) emphasizes the importance of cultural com-
heavily on general systems and on the conceptual petency and social diversity, including sexual
frameworks of social systems, thus treating orientation and gender identity, as does the Code
communities as systems (Cook 1994). Tan pur- for Professional Ethics for Rehabilitation Coun-
ports that the principles of CDT have implica- selors (www.crccertification.com/filrbin/pdf/
tions for the ways clinicians view and engage crcCodeOfEthics.prf) (CRCC 2010). The Cen-
with clients and ways social workers seek to ters for Disease Control (http://www.cdc.gov/
make large-scale changes within the community. lgbthealth/) emphasize the importance of
A key to application of CDT to LGBT elders addressing disease in the LGBT community
is the notion that people involved in a system across the life course, particularly as it concerns
have a sense and recognition of the relationships HIV and other sexually transmitted diseases as
and areas of common concerns with other well as violence prevention and intervention
members. For LGBT elders, the community may (CDC 2014). The Council on Social Work Edu-
be their immediate surroundings as well as cation (CSWE) has incorporated issues relevant to
regional, national, or international organizations sexual orientation (www.cswc.org/File.aspx?id=
with which they have affiliation or that provide 25501) (CSWE 2008). Through an examination of
services and advocacy on their behalf. Because the unique strengths and challenges faced by older
many theories are used in community develop- LGBT adults, Crisp et al. (2008) constructed a
ment, the holistic approach of CDT consciously profile and suggested an age-competent and gay
attempts to emphasize on the functional rela- affirmative model for practice, including cultur-
tionship among the parts and the whole. Given ally competent knowledge, attitudes, and skills for
the variety and degree of services that LGBT work with older LGBT adults in the USA.
1 Theories, Constructs, and Applications … 21
(b) Attempts to imply that sexual minorities 9. Which theory hypothesizes that human
have higher rates of psychosocial issues behavior is learned through observing oth-
because of their sexual orientation and er’s behaviors and through modeling?
gender identity (a) Ecological theory
(c) Confirms LGBT sexual identity as a (b) Systems theory
mental illness (c) Social learning theory
(d) Supports the notion that gender is (d) Solution-focused theory
socially defined 10. Which theory is defined as the use of com-
4. Which of the following developed the munity structures to address social needs and
transgender emergence model? empower groups of people?
(a) McCarn-Fassinger (a) Community action theory
(b) Lev (b) Community development theory
(c) D’Augelli (c) Family systems theory
(d) Devor (d) Action development theory
5. Which therapy may be particularly effective
with older adults because of its focus on the
Key
present, emphasis on self-monitoring, psy-
choeducational orientation, and goal
1-c
orientation?
2-d
(a) Person-centered therapy
3-a
(b) Psychoanalytic therapy
4-b
(c) Cognitive-behavioral therapy
5-c
(d) Existential therapy
6-b
6. Which of the following is of primary concern
7-a
for public health?
8-d
(a) Health of individuals
9-c
(b) Population health
10-b
(c) Immigrant populations
(d) Underserved groups
7. Which theory emphasizes that people have
control over their lives and can consequently Resources
make a decision about a behavior to adopt or
discontinue? American Counseling Association: www.
(a) Theory of reasoned action counseling.org.
(b) Centrality theory Association for Adult Development and Aging:
(c) Snowball theory www.aadaweb.org.
(d) Gestalt theory Association for Lesbian, Gay, Bisexual, &
8. Which theory has as it basic tenet that the Transgender Issues in Counseling: www.algbtic.
perception of time affects how people regu- org.
late their social environment and that those Association of Lesbian, Gay, Bisexual, &
who perceive time as finite spend their time Transgender Issues in Counseling. (2009).
optimizing relationships that are emotionally Competencies for counseling with transgender
fulfilling? clients. Alexandria, VA: Author.
(a) Reality theory Bockting, W., Knudson, G., & Goldberg, J. M.
(b) Feminist theory (2006). Counseling and mental health care of
(c) Behavior theory transgender adults and loved ones. Available at
(d) Socioemotional selective theory www.vch.ca/transhealth.
1 Theories, Constructs, and Applications … 23
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Sexual Minority Status and Aging
2
Pamela B. Teaster, John T. White and Sujee Kim
Abstract
There are estimated to be between 1.4 and 3.8 million LGBT Americans
over the age of 65. This population is expected to increase between 3.6
and 7.2 million due to the Baby Boom generation. The older adult
population is the most rapidly growing age group in the United States and
experiences normal age-related changes in cognition as well as in internal
and external physical health. Although differences exist within and among
groups, more minority elders live in more poverty and with lower incomes
than their white counterparts. Emerging scholarship reveals that social
isolation and discrimination experienced by many LGBT elders hinder
them from aging well. Increasing diversity of the LGBT elder population
has important implications for bolstering individual autonomy in the care
environments.
Keywords
LGBT Demographic characteristics Theories of aging Population
Overview
this chapter delineates an understanding of LGBT orientation and gender identify, education,
elders by providing information on a general aging income, and physical and mental health mea-
population as well as on those elders who identify sures. The population of elders who identify as
as being in a minority status, particularly those lesbian, gay, bisexual, and transgender has come
with a sexual minority status. We consider basic to the forefront as our understanding of the aging
age-related changes as well as what they may population becomes more nuanced than in pre-
mean for elders who are LGBT, and we consider vious generations and as individuals who are
current trends and future issues (e.g., health dis- aging are coming out more than in previous
parities and person-centered care). generations. Legislative landmarks, such as the
Defense of Marriage Act (DOMO 1996) and the
ensuing state by state legislative and legal battles,
Learning Objectives heighten the overall awareness and need to
understand both how individuals in the general
By the end of the chapter, the reader should be population age as well as how those who are of
able to: sexual minority status age.
The purpose of this chapter is to help the
1. Identify basic terms, including sexual orien- reader understand the nexus of sexual minority
tation and gender identity, LGBT, unisex, status and aging. First, we provide definitions
queer, questioning, ally, sex, gender role, and germane to those who identify as being members
gender expressing. in the population with sexual minority status.
2. Understand relevant characteristics of Second, we characterize the population of elders,
African-American, Hispanic, and Asian elders with a minority status, and the population
elders. of LGBT elders. Third, we explain age-related
3. Identify age-related changes. changes for the general population. Next, we
4. Explain the nexus between aging and LGBT discuss issues of aging for those in a sexual
older adults. minority status. We explain theories of aging that
5. Describe basic theories of aging salient for are salient for the aging population and conclude
LGBT older adults. with a discussion of future considerations for
those who are aging and identify as LGBT.
Definitions
Introduction
The nomenclature surrounding sexual orientation
That older adults are living to longer ages are and gender identity, across the life span, is
now culturally and historically accepted, but ever-expanding and increasingly complex. The
thinking beyond the fact that older adults com- decade between the Stonewall Riots in New
prise approximately a fifth of the US population York in 1969 and the Castro Riots in San Fran-
still seem enigmatic to many. Though many cisco in 1979 saw an emergence of the term
policies and services dating back from the 1960s “gay” to replace the largely derogatory term,
have evolved to reflect a more nuanced view of “homosexual.” Both terms served as an umbrella
the population of adults who are age 65 and over, for “gay” men and women. At the same time, as
others have lagged behind, still regarding older gay women forged more public identities in
adults as a homogenous group. In fact, nothing conjunction with the second feminist movement
could be further from the truth. Our under- for equal rights in the 1970s, the terms “gay
standing of the current population of older adults and lesbian” emerged (Faderman 1991). The
tends to reveal great differences in race and eth- terms “bisexual” and “transgender” subsequently
nicity, which is further revealed in sexual emerged also, as new and unique communities
2 Sexual Minority Status and Aging 29
struggled for voice and identity from the mac- sexual orientation or gender identity. Further,
rostructural and overly inclusive “homosexual” there are those whom the LGBT umbrella does
umbrella. not cover, such as persons who identify as unisex,
Toward the latter part of the 1980s, the initials intersex, and asexual. In addition, the Human
LGBT and GLBT evolved as inclusive of the Rights Campaign believes that the data based on
lesbian, gay, bisexual, and transgender commu- the 2010 US Census do not represent a compre-
nity in place of “gay” or “gay and lesbian.” It is, hensive picture, as the Census only counts indi-
however, important to note that significant strains viduals from gay- and lesbian-identified
of resistance to the inclusivity were present and households (Gendron et al. 2013). Much of the
remain, particularly among bisexual and trans- data on LGBT individuals are aggregated from
gender communities (Alexander and Yescavage national, urban studies, many of which do not
2004). These strains of resistance continue as the include older adults; individuals from rural com-
LGBT initials expand to include queer, ques- munities; and those who do not, or have not as
tioning, unisex, intersex, asexual, and ally. yet, identified as LGBT. This representation is
To enjoy a comprehensive understanding of only one component, however, of those individ-
the totality of the sexual orientation and gender uals who are considered to be older adults.
identity umbrella of terms requires a nuanced
understanding when engaging in a true
person-centered approach to care for elders. For Understanding the Older Adult
the purposes of this and the following chapters, it Population
is important to understand that sexual orientation
(LGB) and gender identity (T) are unique. Sexual The very description of an older adult calls into
orientation refers to one’s sexual or romantic question at what age one becomes an older adult.
attraction and, in the case of LGB, refers to a Historians have long recognized that persons as
sexual or romantic attraction to members of the young as age 40 could be characterized as old as
same gender. Gender identity refers to someone’s late as the early 1900s; the Age Discrimination in
innate, psychological (not necessarily physical) Employment Act (1967) covered discrimination
identification as male, female, or other gender of employees aged 40 and over. What does seem
(see definitions for LGBTQUIA in Fig. 2.1). to be clear is that most people think of them-
selves as being “younger than” another person
rather than “older than.” This statement illus-
Describing the Population trates that being older is somewhat subjective as
well as dependent on the population under
According to the National Gay and Lesbian Task examination. For example, the age at which a
Force (2011), there are currently between 1.4 and farmer is considered old is 50 (Amshoff and
3.8 million LGBT Americans over the age of 65. Reed 2005), which is also the age that HIV/AIDS
By 2030, this number is expected to increase to researchers place research participants in the
between 3.6 and 7.2 million LGBT Americans, older adult category (Goodroad 2003). Despite
as the Baby Boom population, those born numerous subgroups within the population,
between 1946 and 1964, ages. Although there is many of whom age differently, the age at which
no definitive measure to determine the percent- recipients qualified for full Social Security ben-
age of LGBT individuals in the USA, national efits was set at age 65 in 1935. In the 1960s, the
organizations such as the Human Rights Cam- US government again de facto established old
paign and the National Gay and Lesbian Task age as being 65 years old or the age when most
Force use 3.5 % as a measure. persons qualify for Older Americans Act,
Certainly, numerous limitations impact the Medicare, and Medicaid dollars and services.
LGBT census, not the least of which are indi- These rough age delineations do little to encap-
viduals who do not recognize and report their sulate what it means to be an older adult who is
30 P.B. Teaster et al.
Lesbian- A woman who is attracted physically, romantically, emotionally and/or spiritually to other
women.
Gay- Commonly used to describe a man who is attracted physically, romantically, emotionally and/or
spiritually to other men. Some women prefer the term “gay” over “lesbian.” Gay can also be an
umbrella term for many people who identify within the LGBTQUIA realm.
Bisexual- A person who is attracted sexually and emotionally to members of both sexes. (Assumes a
binary understanding of gender)
Transgender- A person whose gender identity and/or gender expression differs from the sex they
were assigned at birth. A person who feels that the binary gender system (male/female) is an
incomplete description of who they are. An umbrella term for people whose anatomies and/or
appearance do not conform to predominant gender roles.
Unisex: a term referring to individuals who ascribe to both a male and female gender or have an
outward expression of both the male and female gender.
Queer- A blanket term that some LGBTQUIA individuals use to describe themselves. It is preferred
by some because it is inclusive of the entire LGBTQUIA community. Most often used as a self-
identification by an LGBTQIA individual.
Questioning- A person who is in the process of determining sexual orientation or gender identity.
Intersex- A term to describe a person whose biological sex is ambiguous. There are many genetic,
hormonal, and/or anatomical variations which cause someone to be intersex. The term intersex is
preferred to “hermaphrodite,” which is now considered a derogatory term.
Asexual- A person who does not experience sexual attraction towards anyone. Asexual individuals
view their asexuality in different ways and are extremely diverse.
Ally- A member of the majority/dominant group who works to support and advocate for the
LGBTQUIA population.
Sex- Classification of a person as male or female, assigned at birth based on external genitalia. Most
often sex is based on chromosomes that an individual is born with. Please notice that sex and gender
are not interchangeable terms.
Gender Role- Set of roles and behaviors assigned to females and males by society.
Gender Identity- An individual’s internal, personal sense of their gender.
Gender Expression- Refers to the ways in which people externally communicate their gender identity
to others through behavior, clothing, haircut, voice, and emphasizing, de-emphasizing, or changing
their bodies’ characteristics.
Fig. 2.1 LGBTQUIA alphabet soup (adapted from St. Mary’s College Intercultural Lounge)
not a member of the majority group of older experience. The population of older adults rep-
adults (at this point, Caucasian), the face of resents the most rapidly growing age group in the
which is rapidly changing (see, especially, US. For example, in 1990, older adults composed
Chaps. 6–10). The focus of this chapter is to 13 % of the total population. By 2020, that
consider older persons with a minority status, and number is estimated to increase to 18 % and to
in many cases, more than one. 25 % in 2050 (McKinney and Young 1985). In
In order to understand what it means to be a 2012, persons aged 65+ numbered 43.1 million,
person in a minority status as well as a person in a for an increase of 21 % since 2002, a number is
sexual minority status, we characterize the older projected to grow to 79.7 million by 2040.
adult population and older adult LGBT popula- Moreover, the 85+ population, the most rapidly
tion and then present a brief discussion of normal growing age cohort, is projected to increase from
age-related changes that many, but not all persons 5.9 million in 2012 to 14.1 million in 2040.
2 Sexual Minority Status and Aging 31
Consequently, approximately one in every seven adults worry about becoming more forgetful and
persons in the USA is an older adult: people aged worry that it is the first sign of Alzheimer’s
65+ represented 12.4 % of the population in the Disease (AD), according to NIH Medline Plus
year 2000, a percentage projected to increase to (2007), scientists now know that people can
19 % by 2030 (West et al. 2014). remain both alert and able as they age, although
Persons who reach age 65 are projected to it may take them longer to process their memo-
have an average life expectancy of an additional ries. The cognitive functions that aging affects
19.2 years (20.4 years for females and 17.8 years most are attention and memory, which are not
for males). Because of their ability to live to simultaneously affected—some aspects are rela-
longer, older women outnumber older men (24.3 tively unaffected, while others may decline pre-
to 18.8 million). Another reflection of that phe- cipitously. Though the results of studies of
nomenon is that in 2013, 36 % of older women psychometric testing of persons of older ages
were widows (Administration on Aging 2010). seem to paint a picture of overall cognitive
Also, older men are married far more frequently decline, enormous variability exists across aging
than are older women (i.e., 71 % of men vs. 45 % individuals. Many older people out-perform
of women). About 28 % (12.1 million) of older young people, at least on some cognitive tasks,
persons live alone (8.4 million women and and others of the same age do at least as well as
3.7 million men); 45 % of women age 75+ live their younger counterparts (Glisky 2007).
alone. In 2012, approximately 518,000 grand- Internal Age-Related Changes. Internal
parents aged 65 or older assumed primary changes occur as adults age. Although many
responsibility for their grandchildren who were changes occur gradually across an individual’s
living with them. In 2012, the median income of lifetime, the rate is dependent on heredity as well
older persons was $27,612 for males and as environment (Rowe and Kahn 1998). Many
$16,040 for females, approximately 9.1 % of changes are inter-related; however, the body has
those persons were living below the poverty level a remarkable variety of compensatory abilities
(Administration on Aging 2010). that adjust to insults experienced over time.
Within the older adult population are older Stressed in previous sections, high variability
adults who are LGBT. Mentioned in Chap. 1 and exists as to when these age-related changes
throughout this book, no accurate percentages of present.
LGBT people in the US exist; however, most Heart. Age-related changes in heart muscle
researchers estimate that approximately 3–7 % of cells help explain alterations in the heart as a
the aging population are LGBT, most of whom whole. As the heart ages, it thickens, becomes
identify as lesbians and gay men. Thus, between less elastic, and may become enlarged. An older
one and 3.5 million older lesbians and gay men, heart is less able to relax completely between
this number is expected to double by 2030 beats, and its pumping chambers stiffen. Because
(Jackson et al. 2009). Individuals who are aging, the heart is unable to pump as vigorously as it
those who are heterosexual and those who are once did, it is less able to supply adequate blood
LGBT, can expect to experience some and oxygen to muscles during exercise (Young
age-related changes, typically starting around the 2002).
fourth decade. Lungs. Age-related changes to the pulmonary
system are associated with structural changes
leading to a decline in function. The reduction in
Age-Related Changes that May Affect the diameter of small airways and their tendency
Older Adults for closing early contributes to air trapping and
ventilation problems. With age, the lungs stiffen,
Cognitive Changes. Changes in our under- making it harder for them expand and contract.
standing of the aging brain are among the most The chest wall becomes more rigid, and the dia-
exciting in all of aging science. Though many phragm and other muscles of respiration become
32 P.B. Teaster et al.
weaker. A decreased cough reflex and a reduction examinations can help older adults protect them-
in the number of cilia that sweep mucous up and selves from developing severe eye problems that
out of the lungs results in increased likelihood of may occur for some, but not all older adults. Pre-
infection (Medline Plus 2010). ventive measures (e.g., proper nutrition, wearing
sunglasses, and physical activity) can help mollify
eye problems that some older adults experience.
External Physical Changes Hearing. About one-third of Americans
between the ages of 65 and 74 have age-related
Generally accepted physical changes that occur as hearing problems, and about half of adults aged
persons age include a reduction in physical 85 and older have hearing loss (National Institute
height, usually more pronounced in women than on Deafness and Other Communication Disor-
in men (Currey et al. 1996), a decline in total ders 2010). Another common problem that some
body weight due to a loss of lean body mass, a older adults encounter is ringing, roaring, or
decrease in bone strength, wrinkling and dryer other noises inside the ears. This problem, known
skin (often exacerbated by exposure to UV rays), as tinnitus, may be diminished when certain
and changes in hair color. As with the above, medicines or other health problems (e.g., aller-
physical changes that older adults experience are gies or atherosclerosis) are addressed.
subject to great variability. One of the most sig- The central message about age-related chan-
nificant factors thought to slow such changes is ges is that variability exists among older adults.
physical activity, which is now recommended for Some adults experience age-related changes so
in all ages, and in sharp contrast to the prevailing small as to be barely noticeable. Others, how-
wisdom of the early 1900s, when elder adults ever, experience such difficulties that their health
were encouraged to rest frequently and preserve and quality of life are greatly diminished.
their (remaining) strength (Buchner 1997; Roig Although some age-related changes do occur
et al. 2010). Below, we discuss a few examples of over time, there are many opportunities and
common age-related sensory changes. strategies to mitigate their affects.
Sensory Changes. Starting roughly around
the fourth decade, eyesight weakens; around the
sixth decade, cataracts and macular degeneration Aging and Minority Status
may develop for some individuals. Hearing may
also decline with age. Mentioned earlier, vari- Along with the general trends for America’s
ability exists within the population of older aging population and the age-related changes
adults. described earlier, many minority populations are
Eyesight. Around age 40, most individuals living to older ages. In this section, we charac-
encounter weakened eyesight, and some experi- terize the population of older adults living in a
ence cataracts and glaucoma. Certain adults may minority status. Below, we focus on older
be less able to see objects at close distances or African-Americans, Hispanics, and Asians.
read fine print than in earlier years. For most,
reading glasses or contact lens address the
problem. Other adults are less able to see objects African-American Elders
at far distances, and eyeglasses or contact lenses In 2008, the African-American older population
are helpful. Some individuals develop cataracts, was 3.2 million in 2008 and is projected to grow
which affects nearly 22 million Americans age 40 to over 9.9 million by 2050, when African
and older; by age 80, more than half of all American elders will compose 11 % of the older
Americans have cataracts (National Eye Institute population. In 2008, 50 % of black elderly peo-
2008). Corrective surgery is now one of the most ple lived in eight states: New York (9.1 %),
common surgeries done in the US. Annual eye Florida (7.1 %), California (6.5 %), Texas
2 Sexual Minority Status and Aging 33
Fig. 2.2 Population and projections for black elders. Retrieved from http://www.aoa.acl.gov/Aging_Statistics/
Source Administration for Community Living (2010). minority_aging/Facts-on-Black-Elderly-plain_format.
A statistical profile of black older Americans aged 65+. aspx
34 P.B. Teaster et al.
Fig. 2.3 Population and projections for Hispanic elders. Retrieved from http://www.aoa.acl.gov/Aging_Statistics/
Source Administration for Community Living (2010). minority_aging/Facts-on-Hispanic-Elderly.aspx
A statistical profile of Hispanic older Americans aged 65+.
households, 16 % had an income of less than bachelor’s degree or higher (40 %) is almost
$15,000 (compared to 5.4 % for non-Hispanic 50 % higher than for the overall older population
Whites family households) and 45 % had (27 %) (Administration for Community Living
incomes of $35,000 or more (compared to 62 % 2010) (Fig. 2.4).
for non-Hispanic Whites). The poverty rate in In 2008, 84 % of older Asian men lived with
2007 for Hispanic older persons (65 and older) their spouses, 6 % lived with other relatives, 2 %
was 17.1 %. This was more than twice the per- lived with non-relatives, and 8 % lived alone. For
cent for non-Hispanic Whites (7.4 %) (Admin- older Asian women, 47 % lived with their
istration for Community Living 2010) (see spouses, 30 % lived with other relatives, 3 %
Chap. 10 for a discussion of Hispanic and LGBT lived with non-relatives, and 20 % lived alone.
elders). Households containing families headed by Asian
persons aged 65+ reported a median income in
2008 of $48,859. The comparable figure for all
Asian Elders older households was $44,188. The median per-
Older members of the older adult population who sonal income for Asian men was $18,518 and
identified as Asian, Hawaiian, and Pacific Islan- $11,501 for Asian women. The comparable fig-
der numbered over 1.3 million in 2008 (3.4 % of ures for all elderly were $25,503 for men and
the older population) and is projected to grow to $14,559 for women. In 2008, the poverty rate in
over 7.6 million by 2050, at that time accounting for Asian elders was 12.1 %; the rate for all
for 8.6 % of the older population. In 2008, almost elders was 9.7 %. The rate for Asian men was
60 % of Asian, Hawaiian, and Pacific Island 11.1 %, and the rate for Asian women was
elders lived in just three states: California 12.8 % (Administration for Community Living
(40.5 %), Hawaii (9.6 %), and New York 2010) (see Chap. 8 for a discussion of Hispanic
(9.2 %). In 2008, 74 % of the older Asian pop- and LGBT elders).
ulation aged 65 and older had finished high The data above posted by the Administration
school. Also in 2008, almost 32 % of Asian older for Community Living and distilled from the
persons had a bachelor’s degree or higher. The information reflected by the US Census indicate
percent of high school graduates among older that there are both differences and similarities
Asians is almost as high as the percent among all between and among older adults with a minority
older persons (77 %). However, the percent of status and those who are Caucasian. In the main,
older Asians in 2008 who had a bachelor’s minority status for elders means that they live in
degree or higher (32 %) was over 50 % higher greater poverty and with lower incomes that do
than for the overall older population. Further- those with majority status. For older
more, the percent of male Asians who had a Asian-Americans, the educational level attained
2 Sexual Minority Status and Aging 35
Fig. 2.4 Population and projections for Asian, Hawaiian, older Americans aged 65+. Retrieved from http://www.
and Pacific Island elders. Source Administration for aoa.acl.gov/Aging_Statistics/minority_aging/Facts-on-
Community Living (2010). A statistical profile of Asian API-Elderly2008-plain_format.aspx
is actually higher than that of the general popu- to increase to approximately 3.5 million by 2030.
lation. All older adults of minority status live Among these elders, social isolation has been
with their spouses more so than those of the identified as affecting a disproportionate numbers
general population. Also, the older adult popu- as they continue to deal with stigma, discrimi-
lation as a whole, whether or not they are nation ageism, homophobia, and transphobia (see
members of minority groups, are living longer Table 2.1).
than were previous generations, a trend contin-
uing until at least 2050. Statistics are but one way
to understand what it is like to be a member of a LGBT Optimal Aging: Barriers
minority population. Another are stressors, and Opportunities
affecting both physical and mental health—much
has been written on early and persistent stressors Older reports and other supporting data indicate
over the life course and will not be discussed rates of smoking, alcohol use, and obesity higher
here. However, one important stressor that will for the LGBT population than their heterosexual
be discussed below are implications for being a peers (Hughes and Evans 2003). Also, older data
member of a minority status and a member of a tend to support other antiquated stereotypes of
sexual minority. the LGBT population: immersed in a culture of
alcoholism, depression, and poor health habits.
Examples of real evidence-based qualitative and
Aging and Sexual Minority Status quantitative studies on LGBT elders began to
emerge in the 1990s and 2000s when member-
In recent years, new scholarship has emerged on ship from national organizations including the
the barriers to positive aging faced by members of Human Rights Campaign, National Gay and
the LGBT population (e.g., Fredriksen-Goldsen Lesbian Task Force, and Services and Advocacy
et al. 2011). It has taken decades for this infor- for GLBT Elders (SAGE) were queried.
mation to “come out” simply because it has been Although an improvement, the data were col-
difficult to acquire data from this largely unseen lected from members of the LGBT population
and fragmented population. In a 2010 study, the who are active, enfranchised, engaged, and more
National Resource Center on LGBT Aging likely to participate in “out and proud” organi-
reported that there are approximately 1.5 million zations. Many of the previous studies lack sta-
lesbian, gay, bisexual, and transgender elders tistical power due to small sample size and a high
currently residing in the USA. Given the increase potential for participant bias. Therefore, it is
in the number of Baby Boomers, those born unwise to unilaterally rely on research that is still
between 1946 and 1964, this number is expected emerging and calibrating. Although excellent,
36 P.B. Teaster et al.
Table 2.1 Support systems of LGBT elders and the general elderly population
Support system LGBT elders (%) General elder population (%)
Live alone 75 33
No children 90 20
Single 80 40
(Adapted from the Web site of services & advocacy for GLBT elders on social isolation. Retrieved from http://www.
sageusa.org/issues/isolation.cfm)
rich, and statistically significant studies have from administration, direct care professionals,
recently been completed (Fredriksen-Goldsen and other residents (Johnson et al. 2005). These
et al. 2011), further research that supports a responses varied widely with regard to the vari-
person-centered model of care and inquiry is ables of age, income, gender, community size,
needed. and education level of the respondents but are
Emerging scholarship tells us that elders who concurrent with the notion, even among health-
are isolated are at increased risk for abuse and care professionals and, arguably, younger mem-
premature death (Acierno et al. 2010; Pantell bers of the LGBT community, that LGBT elders
et al. 2013). Compounding this, according to are “homogeneous, isolated, lonely and without
SAGE, LGBT elders are at increased risk for hope.” (Johnson et al. p. 86).
isolation: LGBT elders are over twice as likely to According to the National Gay and Lesbian
live alone with thinner support networks, three to Task Force, the fear of isolation is real among
four times less likely to have children, and twice LGBT elders. For many elders who have expe-
as likely to be single as compared to the heter- rienced marginalization and disenfranchisement
osexual population. LGBT elders have higher over the life span, with advancing age comes an
disability rates, struggle with economic insecu- increasing reliance on public programs and social
rity, and have increased mental health concerns services. LGBT elders have less independence or
manifest from a lifetime of discrimination ability to retreat from discrimination, conse-
(SAGE 2010). quently reinforcing isolative behaviors and
The Caring and Aging with Pride Study leading to the negative health outcomes outlined
(2011) gives additional information on why the above.
barriers to inclusion and “othering” of LGBT Further, as of this writing, housing discrimi-
elders are so real and profound. The study found nation based on sexual orientation and gender
that 82 % reported having been victimized at identity is prohibited in only 15 states and the
least once, with 64 % reporting experiencing District of Columbia: California, Colorado,
victimization at least three times in their lives. Connecticut, the District of Columbia, Illinois,
The report notes: “The most common type of Iowa, Hawaii, Maine, Minnesota, New Jersey,
victimization is verbal insults (68 %), followed Nevada, New Mexico, Oregon, Rhode Island,
by threats of physical violence (43 %), and being Vermont, and Washington. There are also six
hassled by the police (27 %). Nearly one in four states that prohibit housing discrimination based
(23 %) have had an object thrown at them, and on sexual orientation (but not gender identity):
one-fifth (20 %) have had their property damaged Delaware, Maryland, Massachusetts, New
or destroyed. Nearly one in five (19 %) have Hampshire, New York, and Wisconsin. In addi-
been physically assaulted (i.e., punched, kicked, tion, many cities prohibit discrimination on the
or beaten), 14 % threatened with a weapon, and basis of sexual orientation, including Atlanta,
11 % have been sexually assaulted.” Chicago, Detroit, Miami, New York, Pittsburgh,
This discrimination continues into later life. and Seattle. While the status of the LGBT pop-
According to a 2005 study of LGBT long-term ulation is changing, anti-discrimination is by no
care residents, LGBT elders fear discrimination means universal.
2 Sexual Minority Status and Aging 37
When reviewed in its sum, there are few circumstances. Continuity is thus a grand adap-
“usual and normal” phenomenon facing LGBT tive strategy that is promoted by both individual
elders. Social isolation is a common occurance. preference and social approval. In other words,
Fear of healthcare professionals is a theme that is what makes elders unique earlier in life will only
worthy of note. The lack of family caregivers is be enhanced in later life, particularly true for
also a barrier for positive aging. But when LGBT elders?
evaluating sexual orientation, gender identity, Another salient theory for aging persons who
and aging, there is much more to the story. While are LGBT and that draws upon Continuity The-
discrimination and fear are pervasive in these ory is Carstensen et al. (2003) Socioemotional
communities, there are examples of positive Selectivity Theory, which suggests that, with age
aging. In particular, studies by Frederiksen- and the realization of mortality, individuals focus
Golden et al. (2011) and others are revealing on more personally relevant and meaningful
the emergence of stronger scaffolding, with sto- pursuits and passions. As persons age, items that
ries of resilience in the face of adversity (see comprise individuality and uniqueness become
Table 2.2). more pronounced with age. As individuals age,
regardless of race, ethnicity, and sexual orienta-
tion of gender identity, they tend to focus their
Theories of Aging as Applied to LGBT attention on a more refined series of activities,
Elders experiences, emotions, and memories. Increasing
the focus on “things” that make us unique that
Data discussed above demonstrate that diversity supports the inherent diversity of the aging
among elders is on the rise from racial, ethnic, population.
sexual orientation, and gender identity perspec- Though most research on LGBT elders
tives. This is not only true from basic demo- examines those in community settings, the
graphic data, but it is also true from increasing diversity of the aging population also
gerontological theories that have applicability for has profound implications for the long-term care
the older adult LGBT population. continuum (Fig. 2.5).
The Continuity Theory of Aging (Atchley One challenge is that the long-term care
1989) suggests that, in making adaptive choices, continuum, from independent living through
middle-aged and older adults attempt to preserve skilled nursing facilities, has been developed in a
and maintain existing internal and external medical model. The medical model suggests a
structures. They prefer to accomplish this top-down approach to direct care that supports
objective by using strategies tied to past experi- uniformity and lack of participation in medical
ences of themselves and their social world. treatment, a model better suited to the general-
Change is linked to the perceived past, producing izations alluded to in the previous section. The
continuity in inner psychological characteristics medical model ascribes to the philosophy that the
as well as in social behavior and in social dispensation of medication, the creation of
activities, the development of menus, and, really, 1996) are far from universally acknowledged and
the physical structure of the long-term care integrated into regulations, organizational mis-
environment can be created on an assembly line. sion statements, care plans, and direct care
Person-centered care is a holistic approach to practices. The push and pull of profitability ver-
care that recognizes and empowers the unique- sus person-centered care and culture change, to
ness of each individual. It supports individual say the least of more historically conservative
autonomy throughout the long-term care contin- values and norms, should be considered when
uum while creating environments conducive to evaluating the following chapters.
independence, engagement, social confidence,
respect, and diversity. (Barsness and White
2011). Scholars, educators, and employees who
work in the long-term care continuum are seeing Summary
a culture-change movement that supports the
redirection of care to a person-centered model. The letters LGBT represent an initialism that
This approach is extremely important for mem- indicates lesbian, gay, bisexual, and transgender
bers of the LGBT community because it creates community. National Gay and Lesbian Task
an environment where apathy and even dis- Force (2011) reported that there are currently
crimination is unacceptable and where unique- between 1.4 and 3.8 million LGBT Americans
ness is actually embraced. over the age of 65, and this population is
The person-centered care movement to inform expected to increase to between 3.6 and 7.2 mil-
culture change in long-term care is by no means lion due to the Baby Boom generation.
fully accepted by owners of long-term care We have discussed the characteristics of the
communities, administrators, direct care profes- older adult population in order to aid readers’
sionals and regulators or inspectors. Efforts by understanding of elders with a sexual minority
organizations such as the Pioneer Network and status. The older adult population is the most
initiatives such as the Eden Alternative (Thomas rapidly growing age group in the USA with
Fig. 2.5 Barriers to health care for LGBT elders. Source LGBT—health disparities impacting long-term care.
Retrieved from http://longtermcare.gov/the-basics/lgbt/lgbt-health-disparities-impacting-ltc/
2 Sexual Minority Status and Aging 39
that can help you get those documents Fortunately, such attitudes are chang-
prepared.) ing. A recent survey of aging services
3. Financial Insecurity providers shows that a growing number of
LGBT older people are less financially respondents would welcome LGBT elders,
secure than American elders as a but lack the proper training. Resources
whole. For example, poverty rates such as the federally funded National
among elder lesbian and gay couples Resource Center on LGBT Aging have
are 9.1 and 4.9 %, respectively, com- been created to provide training and tools
pared with 4.6 % among elder hetero- to aging providers, LGBT organizations
sexual couples. Several factors and LGBT older people themselves,
contribute to higher poverty rates, ensuring that our community increasingly
including employment discrimination will be able to age with the dignity and
and barriers in Social Security, Medic- respect we all deserve.”
aid, and pension and retirement plans Discussion Questions:
that deny same-sex couples key retire-
ment benefits afforded to the broader 1. What are the five unique challenges
population. In addition, state laws can faced by LGBT community?
shut LGBT partners out of an inheri- 2. Do you agree that those five challenges
tance, or can require them to pay steep are prevalent in our society? Give spe-
taxes on an estate that a surviving het- cific examples.
erosexual spouse would inherit tax-free. 3. What challenge do you think most
4. Social Isolation problematic as a barrier to optimal
Despite creating families of choice and aging for LGBT elders?
other support networks, many LGBT 4. Think about how LGBT elders and
older people still experience high rates heterosexual elders differently experi-
of social isolation. They are twice as ence and deal with aging.
likely to be single and to live alone, and
three to four times as likely to be child- Discussion Box 2.2: Age-related Phys-
less. They are also less likely to feel ical Changes
welcome in the places where many older Visit the link, Columbia University’s
people socialize, such as senior centers, Brave Old World Web site (http://news21.
volunteer centers and places of wor- com/columbia/2011/2010/growing-old/
ship. Research and SAGE’s experience index.html) and watch the four videos on
show that the harmful effects of this age-related changes in vision, hearing,
include depression, delayed care-seek- mobility, and thinking. After watching
ing, poor nutrition and premature each video, answer the following
mortality. questions.
5. Access to Aging Services
LGBT older people often do not access 1. Describe the changes you see taking
aging services out of fear of harassment place with aging.
or hostility. Few aging services pro- 2. When, approximately at what age, do
viders plan for, or reach out to, the you expect to undergo each of these
LGBT community—and few are pre- changes? Why you chose that age?
pared to address insensitivity or dis- 3. What strategies and/ or information do
crimination aimed at LGBT elders by you know to slow the rate of these
staff or other older people. changes? Give examples for each
condition.
2 Sexual Minority Status and Aging 41
Questions to Consider
References
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nih.gov/health/hearing/older.asp. care-module-03.
Family Relationships of Older LGBT
Adults 3
Katherine R. Allen and Karen A. Roberto
Abstract
The study of older lesbian, gay, bisexual, and transgender (LGBT) adults
and their families is a growing area of research and practice. This field
addresses intersections of social structure and personal experience,
beginning with the interaction of family and sexual minority status, and
complicated by gender, race, social class, ability status, and other social
locations. Older LGBT adults experience families in normative and
non-normative ways. They have families of origin (i.e., the family one is
born into), families of procreation (i.e., the family one creates, typically,
through a committed union and the children they rear), and families of
choice (i.e., the family one creates through converting friends into kin).
Yet, there are unique aspects of what it means to be an aging LGBT
individual that affect the emotional dynamics of family relationships,
including the historical treatment of LGBT individuals, the increasing
social climate of self-affirmation and public acceptance, and the policies
that impact their lives.
Keywords
LGBT families Family of origin
Family of procreation Family of
choice Chosen kin
Overview
individuals who identify as lesbian, gay, bisex- 6. Locate national and international resources
ual, or transgender, as shifting social norms have for working with older LGBT individuals and
challenged conventional definitions of families their families.
and have helped produce greater diversity across
and within families (Bianchi 2014). We examine
LGBT family dynamics, including reliance on
families of choice and the use of formal services
and networks to meet older adults’ care needs. Introduction
We incorporate research and practice from pri-
marily modern Western societies in North The study of older LGBT adults and their families
America and Northern Europe (e.g., the USA, is a growing area of research and practice. This
Canada, and United Kingdom), and where it field addresses numerous intersections of social
exists, include what is currently known regarding structure and personal experience, beginning with
other LGBT families in countries on other con- the ways in which aging, sexual orientation, and
tinents. We acknowledge that cultural differences family experience interact, and is further compli-
influence the perceptions, behaviors, and inter- cated by gender, race, ethnicity, social class,
actions of family members; however, it is not ability status, among many other social locations.
feasible to include representation of all cultures Given the lack of comprehensive data collected on
in this chapter. Finally, we provide an assessment the experiences of LGBT individuals and families,
of directions for expanding the research on older it is difficult to estimate the precise number of
LGBT family relationships and address the future LGBT aging individuals and even more difficult to
of service delivery and public policies affecting estimate their distribution by family structure
this ever-increasing population. (e.g., LGBT-parent families; older couples; aging
parent–adult child relationships). Estimates,
however, do suggest that approximately one to
Learning Objectives four million Americans aged 65 and older identify
as LGBT (see Cahill et al. 2000; NGLTF 2015;
After reading this chapter, the reader should be Orel 2014). With the aging of the population and
able to: the increasing visibility of LGBT individuals,
these numbers will nearly double by 2030.
1. Identify the similarities and differences Turning to the family relationships of older
between the family relationships of older LGBT adults, it is clear that older LGBT adults
LGBT individuals and the family relation- experience families in both normative and
ships of older heterosexual individuals. non-normative ways. Structurally, older LGBT
2. Explain the distinctions among families of adults are not unlike non-LGBT adults: they have
origin and families of choice in the LGBT families of origin (i.e., the family one is born
community. into), families of procreation (i.e., the family one
3. Understand the history of research and creates, typically, through a committed union and
activism regarding LGBT aging individuals the children they rear), and families of choice
and their families. (i.e., the family one also creates through con-
4. Identify the major issues and future directions verting friends into kin). At the same time, there
for research on older LGBT individuals and are some unique aspects of what it means to be
their families. an aging LGBT individual; thus, the emotional
5. Explain the service models and intervention dynamics of family relationships may also vary
strategies that are effective in addressing the from normative expectations, and for a variety of
practical and policy issues for LGBT elders reasons. These reasons are associated with all
and their families. aspects of life, including the historical treatment
3 Family Relationships of Older LGBT Adults 45
of LGBT individuals, the increasing social cli- For example, in 1973, the American Psychiatric
mate of self-affirmation and public acceptance, Association reversed its stance on homosexuality
and the policies that impact their lives. as a mental illness, setting the stage for more
openly identifiable research and theorizing about
the experience of LGBT aging individuals, cou-
ples, and their families. Also in the activist realm,
Historical Perspectives on the Family Senior Action in a Gay Environment (SAGE;
Relationships of Older LGBT Adults now Services and Advocacy for Gay, Lesbian,
Bisexual, and Transgender Elders) was founded
Research on sexual orientation and aging began in 1978 in New York City in order to create a
to appear in the late 1970s and 1980s. As with support network for older gay individuals. This
many new areas of research in the study of pioneering group, co-founded by gerontologist
LGBT individuals and families (Allen and Demo Douglas Kimmel, has evolved into one of the
1995), the original papers that appeared in largest member-led organizations in both the
scholarly journals and books were primarily LBGT community and the aging community
personal narratives and included a call to (SAGE 2015).
acknowledge and accept the study of aging of
LGBT families as a legitimate area of investi-
gation (Cohler and Hostetler 2002; Cooper 1997; Case Study: Douglas Kimmel
Kimmel 1978, 1992). Douglas C. Kimmel is one of the pioneers
In part, the attempt by scholars to address in LGBT aging. His research on adulthood
sexual orientation and aging was spurred by the and aging, in general, and aging gay and
political activism that was initiated with the lesbian couples and families, in particular,
Stonewall Riot on Friday, June 27, 1969. The has broken new ground and inspired young
moment that sparked a new era of activism for and old scholars alike. In addition to his
civil and legal rights was the death of Judy research and scholarship, Dr. Kimmel is
Garland, a beloved icon for the gay community. one of the founders of SAGE: Services and
In the wake of mourning, gay men who dressed Advocacy for GLBT Elders. He is a
in drag and other patrons rebelled against Man- champion of all of the values described in
hattan police raids of the popular bar (The this chapter: aging well, valuing family,
Stonewall Inn) in Greenwich Village (Allen and working for social justice.
2005; D’Emilio and Freedman 1997; Editors of Dr. Kimmel was born in Denver in
the Harvard Law Review 1990). The uprising 1943. He received his PhD in Clinical
was the lighting rod that led to the emergence of Psychology from the University of Chi-
the Gay Liberation Front, an activist movement cago in 1970. For many years, he was a
that challenged heteronormativity and sought professor in the Department of Psychol-
self-affirmation for lesbian and gay men in pri- ogy, at City College of the City University
vate and public realms (Engel 2002). The gay of New York. He has also served as a
liberation movement mirrored other social visiting scholar in universities around the
movements in privileging men, but lesbians, too, world, particularly in Japan. He has
fought back against the oppression that both received many prestigious awards for his
condemned them and outlawed their sexual research and service, including several
behavior and social relationships (Faderman from the American Psychological Associ-
1991). ation: the Distinguished Elder Award, the
This gay-affirmative social activism led to Distinguished Service Award, and the
increasing visibility of lesbian and gay individ- Distinguished Educational Contribution
uals, with reverberations throughout society. Award.
46 K.R. Allen and K.A. Roberto
relationships and families (for example, see constraints. Now that same-sex marriage is legal
Blieszner and Bedford 2012; Brock and Jennings in most of the USA as well as many other
2007). countries (e.g., Argentina, Canada, France, New
Despite these publications in scholarly ven- Zealand, Norway, South Africa, and Spain)
ues, the lack of integration of the research on (HRC 2015), the research will uncover more
aging families and sexual orientation is an trends and issues facing older LGBT couples and
ongoing concern. For example, in a review of families. Next, we address theory, research, and
research in the last decade (2000–2010) on aging policy linked to variations in aging LGBT family
families, sexual orientation was only mentioned relationships, in terms of coming out and devel-
as an area that lacks attention (Silverstein and oping intergenerational, intragenerational, and
Giarrusso 2010). Similarly, in a review of chosen kin relationships.
research about LGBT families, older LGBT
adults and their family relationships were not
mentioned (Biblarz and Savci 2010). Sullivan Theoretical Perspectives
(2014) and Witten and Eyler (2012), as well,
identifies the dearth of research on aging in the Most of the research on older LGBT families was
LGBT community. Yet, we also see a great deal spurred by the articulation of the life course
of promise in the emerging literature that perspective, which provides a model for under-
addressing aging, sexuality, and family (see standing individual, family, and social historical
Kimmel et al. 2006). Perhaps now, gerontolo- processes and change over time (Allen et al.
gists, family scholars, and LGBT scholars are 2000; Bengtson and Allen 1993; Bengtson et al.
discovering the importance of investigating lived 2005). There are several key concepts from the
experience at these intersections. life course perspective that are particularly rele-
vant to the study of LGBT aging individuals and
their families. The concept of linked lives refers
to the ways that individual lives are connected
Theory, Research, and Policy Related “across the generations by bonds of kinship”
to LGBT Aging and Families (Bengtson et al. 2005, p. 494). A second key
concept refers to the major life transitions that
Family relationships are typically defined by a individuals and families experience, as well as
legal or biological tie, as in legal marriage, in-law their timing in each person’s life (Bengtson and
relationships, biological parenthood, or adoptive Allen 1993). For example, the first time one
and step parenthood. Family relationships can comes out to family members is an event that
also be matters of choice. In situations where signals a major life transition. From that point
LGBT individuals have been rejected by bio- forward, an individual is no longer seen as het-
logical family members, they have turned to erosexual, or as fitting into a normative model of
LGBT community members and converted them development. A third key concept refers to the
to kin-like relationships. Indeed, as Maupin historical time, place, and context in which
(2015), author of the iconic novels, Tales of the individuals experience major social changes. For
City, is credited as saying, friends are the “logi- example, as we describe later in this chapter, the
cal” (compared to the biological) family for issue of “same-sex marriage” is likely experi-
LGBT people. Families incorporate both struc- enced very differently for persons who are cur-
tural (i.e., household) units and emotional ties. rently age 65, compared to adults who are
Older LGBT individuals, particularly those who currently age 25. Older LGBT individuals part-
came out before a new wave of significant social nered and established their families at a time
change began in the 1990s, have had to be cre- when same-sex marriage was legally and socially
ative in their family ties, given legal and social prohibited. This social historical reality is a likely
48 K.R. Allen and K.A. Roberto
contribution to so many older LGBT individuals social environment that causes mental health
first marrying heterosexually, particularly in problems” (p. 674). Minority stress for LGBT
order to become a parent. In contrast, young individuals is linked to alienation and problems
LGBT adults are much more free to come out as with self-acceptance (that is, internalized homo-
a sexual minority and to have the opportunity to phobia). Aging-related stress is linked to con-
legally marry their same-sex partner, as well as to cerns about the ability to maintain health and
establish their own LGBT-parent family (Tasker independence into old age, as well as fiscal
2013). concerns, such as outliving their income and
In an application of the life course perspec- having a place to live (MetLife Mature Market
tive, Fredriksen-Goldsen and Muraco (2010) Institute 2010). Minority stress theory has been
reviewed 58 empirical articles published between used to examine whether same-sex marriage is a
1984 and 2008 that focused on the lives of LGB protective factor against the combined effects of
adults aged 50 and older. They found that much sexual minority stress and aging-related stress.
of the research addressed two themes central to For example, an analysis by Wight et al. (2012)
the life course perspective: (a) the interplay of of a subsample of gay men (age range of 44–
lives and historical times and (b) linked and 75 years, with a mean age of 57 years) from the
interdependent lives. Early studies on LGB aging Multicenter AIDS Cohort Study, examined the
focused on stereotypes about the mental health impact of minority stress and aging-related stress
status of these populations. Contrary to popular on their lives. They found that legal marriage
belief that older gay men and lesbians were among HIV-negative and HIV-positive older gay
depressed, felt sexually undesirable, and strug- men is indeed a protective factor that may offset
gled with the normative aging process, the the mental health issues associated with being
majority of the early articles describe positive gay and growing old.
psychosocial functioning among older gay men
and lesbians (Berger 1984; Berger and Kelly
1986; Gray and Dressel 1985), with favorable Research Perspectives
feelings about aging (Whitford 1997), appear-
ance (Gray and Dressel 1985), and sexuality LGBT families are varied. There is no “typical”
(Pope and Schulz 1990). In fact, studies showed LGBT family form any more than there is a
that older gay and lesbian adults typically rated typical heterosexual family form. In addition,
their mental health as good or excellent cultural norms dictate additional family interac-
(D’Augelli et al. 2001) and reported no more tions for racial and ethnic minority LGBT per-
depressive symptoms than their heterosexual sons (see Chaps. 6, 7, 8, and 10).
counterparts (Dorfman et al. 1995). With respect Families of origin. Family of origin rela-
to social relationships, the research suggested tionships refers to biological or genetic ties
that older gay male and lesbian women were not within the context of marriage and parenthood.
isolated but were actively engaged in supportive Family of origin relationships include, then, the
relationships with partners, friends, members of relationships that LGBT adults have with their
their families of origin, and the larger LGB aging parents and adult siblings, as well as the
communities (Brown et al. 2001; Grossman et al. relationships they have with their same-sex
2000; Nystrom and Jones 2003; Whitford 1997). partners, same- or different-sex partners, chil-
Another major theoretical framework relevant dren, and grandchildren. As we note throughout
to the study of LGBT aging and families is this chapter, it is very common for LGBT indi-
Minority Stress Theory. Developed by Meyer viduals to substitute chosen family relationships
(2003), minority stress theory is a conceptual for biological ones, given the lack of acceptance
framework that explains how “stigma, prejudice, and legal protection that has been the legacy of
and discrimination create a hostile and stressful being gay, at least until very recently (Cohen and
3 Family Relationships of Older LGBT Adults 49
Murray 2006). We discuss chosen family rela- Although aging baby boomers are among the
tionships in a subsequent section below and first to experience a more positive social and
focus on the traditional understanding of “family legal climate in which to grow old, the literature
of origin” in this section. on LGBT elders has documented more chal-
Considering a wide age span (65+) for older lenges to their well being, compared to hetero-
adulthood, elders who are 65 years old in 2015 sexually identified elders (e.g.,
were born in 1950; elders who are 85 years old in Fredriksen-Goldsen et al. 2013; Gabrielson and
2015 were born in 1930. Representatives of these Holston 2014; Quam and Whitford 1992; Shenk
two eras were thus born into the baby boom and Fullmer 1996). A history of strained rela-
generation (1950s) and the children of the Great tionships with family of origin members can add
Depression generation (1930s). All of these additional stresses to aging-related concerns.
individuals came of age when sexual minority Naples’ (2001) autoethnography of coping with
status was illegal, prosecuted, and considered her father’s funeral in the face of disapproving
morally and mentally depraved. Being a sexual adult siblings is a powerful illustration of strained
minority was a truly isolating and underground family ties. The good news is that because pri-
experience. Individuals hid their sexual orienta- vate life is inextricably linked to broader social
tion from their family members and employers in and political trends, LGBT aging family rela-
order to survive persecution and rejection. Thus, tionships are likely to be less stressful as public
coming of age as an LGBT individual before the acceptance increases.
end of the twentieth century was a time when Reczek (2014) examined the intergenerational
openness was dangerous to one’s social standing relationships of 22 lesbian women and 28 gay
and familial relationships. men aged 40 and older who were in an intimate
As a result of the severely restricted social relationship for at least seven years. The partic-
climate for LGBT individuals until the very late ipants’ relationships with both their parents and
twentieth century, one of the most significant parents-in-law included dimensions of support,
family of origin issues was “coming out” as conflict, and ambivalence. Supportive parents
lesbian or gay to parents and siblings (Cohen and integrated the couple into their everyday lives
Murray 2006; Jacobson and Grossman 1996; and special family events (i.e., holidays, funer-
Orel 2014). als), used inclusive language seen as evidence of
Until recently, LGBT individuals did not tend acceptance of the relationships regardless of legal
to come out until well into adulthood, after they status, relied on the couple for instrumental and
had already experienced heterosexual marriage, emotional support, and affirmed their gay or
and possibly parenthood. Although mothers and lesbian identity. Evidence of conflict in their
siblings were reported to be more accepting than relationship with at least one of their parents
fathers (a trend that continues to this day), many manifested as rejection in everyday life (e.g.,
LGBT individuals lost their family of origin ties unpleasant or absent interactions), rejection
(Friend 1990). As they grew older, this lack of around traumatic events (e.g., changing will with
sustained biological family ties contributed to a the occurrence of a severe illness), and the threat
need for chosen kin relationships, particularly the of being usurped (e.g., not respecting wishes at
development of friendship ties as a substitute for illness or death). Some respondents acknowl-
family ties (Muraco and Fredriksen-Goldsen edged that their parents and parents-in-law
2011). However, Connidis (2010) explains that experienced both support and strain simulta-
coming out and experiencing rejection is not a neously (e.g., acts of acceptance but words of
lifelong legacy for LGBT adults; as time passes, disapproval). Identification of these dimensions
“many gay and lesbian persons with families in the families of aging LGBT individuals pro-
work out good relations with both their parents vides the groundwork for future research on
and siblings” (p. 239). parent–child relationships and the consequences
50 K.R. Allen and K.A. Roberto
for the well-being of aging LGBT adult children Murray in which lesbian caregivers described
and their older adult parents. strained interpersonal family relationships
Another life course issue that is complicated because of a lack of acceptance of their sexual
by sexual orientation diversity is the likelihood orientation or choice of partner. The following
that older LGBT individuals, especially lesbians, quote by two study participants illustrates the
are more likely called upon to care for aging tension LGBT caregivers may face.
parents. Although 43.5 million individuals in the
Robin, single, age 46: As long as my Dad is alive,
USA provide care for a family member 50 years I cannot openly live as a lesbian. He has threatened
of age or older (Family Caregiver Alliance to leave his estate to one of my male cousins if I
2012), to date, there has been little empirical act ‘queer.’ I thought that getting married would
research on family of origin caregiving by LGBT get him off my case about women, but it didn’t. At
this point in my life, it’s just easier to have female
adults. Based on available qualitative data and friends rather than lovers (p. 293)
anecdotal accounts, LGBT caregivers’ reasons Anne, partnered for 16 years, age 42: Although
for providing care (e.g., need; filial responsibil- I’m the only one who has taken responsibility for
ity), types of caregiving tasks in which they Mom and Dad, they have cut me out of their will.
Dad said that he wouldn’t leave any money to his
engage (e.g., emotional and instrumental sup- queer daughter. (Cohen and Murray, p. 293)
port), and concerns they have about caregiving
(e.g., where to turn for help, how to access ser- From a life course perspective, with its
vices, and what services are available) are very emphasis on linked lives, transitions, and trajec-
similar to heterosexual family caregivers. For tories over time, when a person comes out, there
example, Cantor et al. (2004) study of gay and is also an impact on their siblings’ lives. Thus,
lesbian adults caring for a relative from their one person’s coming out is likely to be a family
family of origin identified three primary reasons event for heterosexual and LGBT individuals
their family member needed care: physical ill- alike (Connidis 2010). One of the most exciting
ness, frailty, and Alzheimer’s disease. The types areas of new research is how sibling relationships
of care included providing emotional support and are impacted by LGBT identity among family
hands-on care, helping with decision making and members throughout the life course. For exam-
financial management, serving as liaison with ple, Rothblum et al. (2004), in a study of 1254
other family members, and arranging for medical LGB adults and their siblings, found that, in
care and support services. About half of the general, LGB adults were more highly educated,
caregivers were women and about two-thirds of geographically mobile, less religious, and less
lesbian caregivers said that they were either the likely to have or live with children than hetero-
sole provider or provided most of the care. As sexual siblings. Thus, understanding the nature
with the general population of family caregivers, of sibling ties among older adults, particularly in
gay and lesbian caregivers reported significant terms of companionship and caregiving, is an
burden and stress as a result of their caregiver important issue for future study (Goldberg 2007;
role (e.g., juggling the demand of being Gottlieb 2004; Grossman et al. 2000).
employed and caregiving, limited time for self Intergenerational relationships with chil-
and other relationships, and conflicts or dis- dren and grandchildren. Although about
agreements with other family members about the one-half of lesbian and gay older adults have
care of the older person). biological or adoptive children from previous
While family caregivers often experience both heterosexual relationships (Heaphy 2009), little
positive and negative aspects of caregiving, is known about older LGBT persons’ relation-
LGBT caregivers may face additional challenges ships with their adult children. Coming out to
when their family has a negative view of their children after years of hiding their sexual identity
sexual orientation. Cohen and Murray (2006) often happens indirectly and can be emotionally
cited findings from an unpublished study by challenging for older adults (Hunter 2007). Yet,
3 Family Relationships of Older LGBT Adults 51
Goldberg (2007) found that most of the 42 adult For example, Kerry explained that he recently
children with LGB parents in her study reported reunited with his estranged son and had since
positive relationships with their parents. become “more of a grandfather” to his
The small, but growing literature on the five-year-old grandson. Conversely, Kerry’s
experiences of gay and lesbian grandparents son-in-law does not accept Kerry’s sexuality,
suggests that adult children are the key in which has influenced his relationship with his
determining the nature of the relationship older grandsons with whom he does not have a
between grandparents and their grandchildren close relationship.
(Orel 2014). Because adult children typically act With the increase in the number of LGBT
as family gatekeepers, their acceptance and atti- adults who are parents and the aging of the
tudes toward non-heterosexual identities and population, “doing family” will require an
relationships often determine the amount of openness to complex family structures and rela-
access grandparents have to their grandchildren tionships (Perlesz et al. 2006). In their study of
(Orel and Fruhauf 2013). When adult children multi-generational family interviews with 20
hold negative beliefs about homosexuality, many lesbian-parented families living in Victoria,
grandparents are reluctant to disclose their sexual Australia, Perlesz et al. (2006) revealed that
identity to their children because they fear they being a grandparent in a lesbian-parented family
may lose contact with their grandchildren. Con- was not always comfortable and challenged the
versely, supportive adult children often facilitate dominant discourse around the definition family.
the process of coming out to grandchildren, In one family, the non-biological grandfather
which many gay and lesbian grandparents initially made heterosexist jokes about his
believe is important because it promotes toler- daughter “playing daddy” in her prospective
ance and honesty. lesbian co-parenting role. Yet, upon the birth of
In a qualitative study of 11 gay grandfathers, his grandchild, he adopted the title of “Pop” and
aged 40–79, Fruhauf et al. (2009) found that embraced a grandparent role in relation to his
adult children played an active role in the men’s non-biological granddaughter. The biological
coming-out process to grandchildren, with most grandmother in this family initially also was
adult children involved in explaining their negative about her daughter’s decision to parent
fathers’ relationship to their children. For exam- in a lesbian relationship, but after the child was
ple, Bruce relayed the following story. born she embraced her role as a grandmother.
The lesbian couple, while recognizing the exis-
The family was over for dinner and my grand-
daughter turned to Eric, my life partner, who is tence of their parents’ homophobia, was pleased
Japanese-American. (So, hardly, you know, a that their parents engaged in positive relation-
match in terms of an obvious brother or some- ships with their child (Perlesz et al. 2006,
thing.) She said, “Why do you live here?” and I p. 193):
went like that, and my daughter said, “No, no, no,
no, I’ll deal with this.” So, they left the table, came Fiona: … you do think about your own parents,
back about 15 min later, and everybody, you how you were parented when you have a child and
know, is terribly silent waiting to see what will like Jacqui’s family, as much as they are a pain in
happen. My granddaughter sits there, and she said the butt sometimes, they’re actually, it’s nice
after a few minutes, “Mommy says that Eric is having them around you know. Like your mum,
daddy’s special friend. When I’m older, Jessica Imogen has a great time with your mum. Your
will be my special friend.” (p. 111) mum is bloody atrocious sometimes with some of
the stuff that she says but her relationship with
The roles grandfathers played in the lives of Imogen is really good.
their grandchildren also depended on their rela- Jacqui: Yeah it is good.
tionship with the grandchildren’s parents (Fru- Fiona: And it is great, it’s fabulous seeing
that….
hauf et al. 2009). Some grandfathers have no or
limited contact with their adult children because LGBT intimate relationships in later life.
they are unaccepting of their father’s sexuality. About 60 % of older lesbian and bisexual women
52 K.R. Allen and K.A. Roberto
to find other lesbians to interact with” (p. 281). themselves, perceiving improvement in their
Finally, considering the theme of frustration of self-esteem, and engaging in typical friend
relentless battles, which are a constant stream of activities (Muraco and Fredriksen-Goldsen
battles—with one’s own emotions, with family 2014). Conversely, caregiving can create con-
and the partner’s family, and with other indi- flict between friends due to misunderstandings
viduals in the broader social system, a woman and short tempers. Depending on the nature of
stated, “None of my family attended the funeral the conflict, it may negate the beneficial feelings
…. I have loads of anger about how I was treated that caregiving friends gain from providing care
by others over her passing” (p. 282). The authors and ultimately threaten the duration of the care-
concluded that until the legal status of same-sex giving relationship, leaving the care recipient
marriage is widespread, it is important for service vulnerable.
providers to develop appropriate means of help- The federal Family Caregivers Support Pro-
ing lesbian women (as well as GBT individuals) gram, created with the 2000 reauthorization of
deal with the issues surrounding the death of a the Older Americans Act, and amended in 2006,
partner. expanded its definition of family caregivers so
Families of choice. The concept of “families that extended LGBT family members qualify
of choice”, which we have described throughout (Administration on Aging 2012). Eligibility for
this chapter, was first articulated by Weston the program is no longer limited to a married
(1991). It is linked to fictive kin concepts, which partner or blood relative. As a consequence,
have strong roots in the field of family geron- LGBT people caring for partners or other mem-
tology (See Allen et al. 2011; Johnson 1999). bers of their chosen families can benefit from
Families of choice of older LGBT adults are services provided under the program, including
characterized as ones comprised of a deep sense individual counseling, support groups, caregiver
of belonging and feelings of safety, common training, respite care, and other supplemental
values, and mutual trust (Gabrielson and Holston assistance. Research has shown that these ser-
2014). They provide many of the same support- vices can reduce caregiver depression, anxiety,
ive and care functions as family of origin. In fact, and stress and enable them to provide care
research suggests that older gay and lesbian longer, thereby avoiding or delaying the need for
individuals prefer to receive care from their institutional care (Wacker and Roberto 2014).
chosen family instead of their biological family
members (Fredriksen-Goldsen et al. 2011; Hea-
phy 2009). When receiving care from other
LGBT people, older adults do not have to Service Delivery and Interdisciplinary
“de-sexualize” or eliminate evidence of their Approaches
sexual orientation from their homes or the stories
to appease or hide their identity from a hetero- One of the major issues affecting older LGBT
sexual caregiver (Cronin et al. 2011). families is the invisibility and marginalization
Older LGBT care recipients rely upon their they face with respect to health care and sup-
friends as a safety net that stands between them portive social services. Reports of discrimination,
and an unmet need for care (Muraco and homophobia, hostility, bias, and general lack of
Fredriksen-Goldsen 2014). For example, an older understanding of lifestyle choices are common.
gay man in this study explained that when he was Older LGBT adults often report anxiety around
hospitalized, none of his family members came the prospect of requiring health or supportive
to visit and, “all the things that they should have care (Cohen and Murray 2006; Davies et al.
done, could have done, ought to have done—[my 2006; Heaphy and Yip 2006; Price 2005) and
friend] did that” (p. 262). Caregiving friends fear having to come out to service providers or
acknowledged the benefits they received from having to forcibly return to the closet (Brotman
providing care including feeling good about et al. 2007). They may be reluctant to seek
3 Family Relationships of Older LGBT Adults 55
mental health services, for fear of being invisible decision to disclose was mediated by three in-
as LGBT, or if out, stigmatized (Blando 2001; terlinked factors: experiences of negative reac-
Greene 2002). tions to and misunderstanding of their sexuality,
Brotman et al. (2003) conducted four quali- their perceived feelings of discrimination, and
tative focus groups in three Canadian provinces their anticipation of negative responses. For
(Quebec, Nova Scotia, and British Columbia) to example, a passive discloser who was a gay
assess their perceptions of health and social ser- caregiver of a female friend that he and his
vice providers. Participants included 21 gay and partner took into their home so they could pro-
lesbian elders, and 11 familial and informal vide her care relayed the following experience.
caregivers or service providers. All participants This excerpt reveals how the service provider’s
identified a profound marginalization and invis- misconceptions and lack of understanding
ibility of gay and lesbian elders. Those who were undermined the caregiver’s efforts to ensure his
gay and lesbian themselves described their lack friend’s dignity:
of trust for health care services and professionals
We were talking about getting her dressed and
saying that issues of sexuality and the nature of everything…and I was saying Yeah, ‘cos we
gay and lesbian chosen family relationships were bought all her clothes, so we kind of erm, and, in a
unacknowledged or denied. Similarly, responses way, we made sure she was fantastic, you know
to a survey completed by 569 LGBT adults what I mean, she wasn’t just like, you know a lot of
people who are like cared for, they just wear easy to
attending the 2007 Palm Springs Pride weekend wear clothes with elasticated things and t-shirts and
events revealed that older gay men and lesbians stuff, but we liked, because she always did look
maintain some fear of openly disclosing their fantastic, so we tried to keep that up as much as we
sexual orientation and some discomfort in their could. …And somebody said to us, ‘So, when
you’re getting her dressed then, do you love it? So,
use of older adult social services (Gardner et al. do you sometimes think, hey, I could wear that and
2014). The majority of respondents reported that I could put that on?’ And I’m just like, ‘No, no we
they would feel more comfortable accessing don’t think like that actually!’ (p. 163–164)
LGBT friendly identified services and programs.
Women reported being somewhat more likely to The above example and others like it found in
use those services publicly identified as LGBT the literature reinforce the need for education and
friendly than respondents who were men. training for health and human service providers to
For older LGBT families dealing with eliminate discriminatory and oppressive practices
dementia, the entry of service providers into their and implement appropriate responses and care.
lives is a pivotal point at which they need to Service providers must consider the extensive
decide whether or not to come out to profes- invisibility of older LGBT families and practice
sionals. Price (2010) conducted qualitative in a manner that is culturally sensitive and com-
interviews in England with 21 gay and lesbian petent (Healy 2002). Culturally sensitive prac-
adults aged 20–69 who cared for a parent, part- tices are affirming to LGBT families and include
ner, or friend with dementia. Participants used a the use of language and behavior that validates,
mix of strategies for disclosure of their sexuality acknowledges, and accepts LGBT families. Cul-
to care providers including: (a) active disclosure, turally competent practice requires that service
where service providers were directly informed providers acquire knowledge about the diversity
that the family caregiver was not heterosexual; within the LGBT population, learn the resources
(b) passive disclosure, where caregivers’ sexual available to LBGT families, gain an understand-
identity was suggested by way of clues given that ing of the unique challenges faced by LGBT
relate to their sexuality; and (c) passive nondis- families due to the laws and policies that dis-
closure, where caregivers purposefully concealed criminate against them, and be sensitive to the
aspects of their sexuality or actively avoided general impact of heterosexual assumptions in the
questions related to sexuality. The caregivers’ health and social service system (Healy 2002).
56 K.R. Allen and K.A. Roberto
3. Educate LGBT individuals about the impor- LGBT adults bring their accumulated wisdom
tance of planning ahead for future long-term and adaptability into their later years in order to
care needs. (Meyer 2011, p. 25) maintain emotional, physical, and relationship
health is a promising pathway to deepen under-
Establishing the National Resource Center for standing about aging differently, and aging well.
LGBT Aging was an integral first step in
addressing the needs of LGBT elders and their
families. While the education and training pro-
cesses have shown initial signs of success, fed- Summary
eral, state, and local agencies must continue to
invest in this work in order to implement the Families are the most important institution for the
necessary systemic changes to the aging service care and nurturance of human beings; attention to
delivery system (Meyer 2011). family ties is crucial for professionals in all areas
working with elders. Historically, the family
experiences of LGBT aging individuals have
been largely ignored and stigmatized given the
Issues to Be Resolved Through social and legal prohibitions against sexual ori-
Research and Practice entation minority status. Currently, however, this
situation of exclusion is being rectified and now
Although promising strides have been made, older LGBT family life is beginning to receive
much more research is needed about the various the theoretical, empirical, and practical attention
biological and chosen family relationships of it deserves.
aging LGBT individuals. As we have noted Aging LGBT individuals have faced many
throughout this chapter, these relationships stresses associated with the overlap between
include those with same-sex and different-sex aging and being members of a sexual minority.
partners, with children and grandchildren, with As a result, these elders have developed very
aging parents and adult siblings, and with friends resilient strategies for constructing long-term
and informal relationships that are converted into kinship bonds, even when societal customs and
family relationships. With the changing social laws have disallowed them. One of the strengths
and political context, as well as the aging of the of this population is the activist spirit in the
LGBT population, conducting the research on LGBT community. The desire to live an
LGBT families is increasingly possible. Social authentic life, despite prejudice and hardship has
changes in marriage equality, legalized second led older LGBT individuals to create a rich array
parent adoption, and recognition of friends as of legal, biological, and fictive kin ties. Indeed,
informal caregivers are likely to contribute to some “family” ties of older LGBT individuals are
new research and thinking about aging, sexual actually with their friends. Blurring the bound-
minority status, and families. With all of these aries across biological and chosen kin ties is a
changes, there will be an expansion of resources legacy and a contribution of the LGBT aging
for LGBT older adults and their families, beyond community.
the pioneering efforts that currently exist (e.g., As the aging LGBT population increases, it is
Lambda Legal Defense 2015; SAGE 2015). even more imperative that health care and social
The challenges facing older LGBT individuals services professionals have up-to-date knowl-
as members of families of origin, families of edge about similarities and differences in families
procreation, and families of choice are well where members are LGBT. They also need to be
documented. What is needed now are more informed about the changing legal climate that
studies about LGBT resilience over the life impacts the family relationships of these elders
course (e.g., Oswald 2002) and successful aging so that they can ensure their access to the ser-
(van Wagenen et al. 2013). Research on how vices that will improve their quality of life.
58 K.R. Allen and K.A. Roberto
tools for planning, and support group informa- oldest LGBT rights organizations in the world. It
tion. In addition, this organization has several works to serve the needs of LGBT individuals
international branches in more than 40 countries. and their relatives and friends. The organization
(http://www.ageuk.org.uk/health-wellbeing/ carries out advocacy work, educational courses,
relationships-and-family/older-lesbian-gay-and- and support groups. Here readers can find
bisexual/). information on projects, health, and older adult
Equal Aging (Seta—LGBTI Rights in Fin- and family support groups. (http://rfslstockholm.
land). Founded in 1974, Seta is a national human com/).
rights non-governmental organization (NGO) SPN (Senior Pride Network): The Senior
with local and national branches in Finland. Pride Network is a two-pronged service provider
Equal Aging is a three-year project run by Seta in to LGBTQ Canadians aged 50+. This
cooperation with Fin-Bears and Mummolaasko. network-based organization is comprised of
Here Finnish caregivers and students can find individuals, organizations, and community
information on LGBTI care needs. In addition, groups that serve or are committed to serving the
this web site also includes a care for the elderly needs of LGBT older adults. In addition, this
knowledge library. (http://seta.fi/yhdenvertainen- Senior Pride Network also includes a six-person
vanhuus/in-english/; http://seta.fi/ advisory committee that sets the network’s pri-
yhdenvertainen-vanhuus/vanhustyon- orities, strategic direction, and future initiatives.
tietokirjasto/). Here readers can access information on programs
National LGBTI Health Alliance. (National and services, training, and research. (http://www.
Lesbian, Gay, Bisexual, Transgender, and Inter- seniorpridenetwork.com/home.htm).
sex Health Alliance—Australia): The
National LGBTI Health Alliance advocates for Acknowledgment We thank Erin Lavender-Stott and
Emma Potter for their research assistance.
the improved health and well-being of LGBTI
individuals across Australia. This coalition group
is made up of individuals and organizations and
was created in response to the expected increase Learning Exercises
in the demand for services for LGBTI older
adults in Australia. The Alliance Web site pro- Self-Check Questions
vides information on the organization, their
training initiatives, strategic documents, and a 1. In what ways did the scholarship on LGBT
review of progress made in the previous calendar elders and their families emerge out of the
year. (http://lgbtihealth.org.au/ageing). social activism on behalf of LGBT civil
ODL (Opening Doors London): Opening rights?
Door London is one of the largest sources of 2. What are families of choice? How are they
support and information for older LGBT adults significant in the LGBT aging community?
in the United Kingdom. Opening Doors London 3. What impact will the legalization of same-sex
was created as a response to the high rates of marriage have for current generations of
isolation experienced by older LGBT adults. The LGBT individuals as they age?
program is aimed at LGBT men and women over 4. What are the unique circumstances that older
the age of 50 and includes regular social activi- LGBT individuals and their family members
ties, referral services, and information and guid- must prepare for, due to their sexual minority
ance to service providers. (http://opening status?
doorslondon.org.uk/). 5. What knowledge do health care professionals
RFSL Stockholm (Swedish Federation for and social service providers need to be able to
Lesbian, Gay, Bisexual, Transgender, and Queer ensure quality of care to aging LGBT indi-
Rights): Founded in 1950, the RFSL is one of the viduals and their families?
60 K.R. Allen and K.A. Roberto
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Deconstructing Multiple Oppressions
Among LGBT Older Adults 4
Tracy Robinson-Wood and Amanda Weber
Abstract
The purpose of this chapter is to interrogate oppression through an
analysis of discourses related to lesbian, gay, bisexual, and transgender
(LGBT) older adults. As part of our reflexive posture, we attend to the
social constructions of meaning about age, ability, gender, race, and sex
and their colossal impacts on LGBT older adults. We are mindful of the
weight of oppression for LGBT older adults in general but in particular
overlooked subgroups of this diverse population (e.g., people who are
with low income, people of color, and people who are transgender and do
not fit into the binary of woman or man, gay or straight). We confront
multiple layers of discrimination by deconstructing cultural assumptions
of normalcy (e.g., heteronormativity within the LGBT community)
presented in visual form, verbal text, and within discourses.
Keywords
LGBT elders Ageism Racism Homophobia Transphobia Multiple
oppressions
perpetuate silence about race and transgender major cultural shift pertains to people with
among LGBT older adults. 65 years of age and older. Older adults are living
As authors, we bring our lens, biases, and and working longer than ever before. Although
positions to the writing of this chapter. We the actual numbers are inaccurate, millions of
acknowledge our subjectivity informed by our older adults are LGBT. In not being young and
location within multiple identities. We are het- not being heterosexual, LGBT older adults are
erosexual and lesbian, faculty member and distinguished by multiple identities that run
graduate student in counseling psychology, black counter to the dominant culture’s fascination
and white, married and single, and baby boomer with and insistence on youth, beauty, and tradi-
and millennial. Despite our differences, our tional gender roles (Robinson-Wood 2013).
similarities are greater and galvanize us to speak Ageism or age discrimination is fueled by a
truth to power. We monitor our proximity to a cultural belief that people who are middle-aged
multitude of live discourses in our interactions and older are past their prime, disabled and
with LGBT people and clients. We have queried unproductive that denies the vast diversity
ourselves and one another about the unconscious among old LGBT adults. Although successful
and/or unspoken discourses that lie beneath aging refers to the physical and emotional ability
socially constructed categories of difference rel- to thrive, cope, socialize, and learn (Van Wage-
ative to LGBT older adults. nen et al. 2013), the USA culture places con-
siderable emphasis on anti-aging, youth, and the
body beautiful (Robinson-Wood 2013). Ageism
Learning Objectives and ableism intersect and are codependent on one
another for their existence.
Upon completion of this chapter, the reader Gender prescriptions normalized by hetero-
should be able to: sexuals extend to LGBT populations. Moreover,
the social construction of race is evident within
1. Understand the role of discourses in the lives the LGBT community. LGBT individuals of
of LGBT individuals in general and for color experience more psychological distress,
LGBT elders, in particular. financial instability, limited access to culturally
2. Understand the multiple impacts of racism, competent care, and housing inequality than their
sexism, homophobia, transphobia, and bi- white counterparts.
phobia on the LGBT older adult population. Discrimination occurs among most LGBT
3. Understand the roles of policies and laws on older adults; however, vast intragroup differences
older LGBT individuals. exist and are related to disability, age, gender
status, race, income, the quality of aging, and
identity development. An LGBT older adult, who
is transgender, single, working class, a person of
color, and resides with friends in an apartment,
Introduction lives in a society where his or her gender, sexual-
ity, and marital status are inconsistent with cultural
Within the last few years, the United States of values such as patriarchy, heterosexual marriage,
America (USA) has witnessed dramatic changes home ownership, economic success, and repro-
regarding who can legally marry. As of the duction. Conversely, the middle-class gay male,
writing of this book, nineteen states now sanction who is married to and living with his husband, has
marriage between two women or two men. The children, and owns a home, occupies identity sta-
heterosexist discourse is being challenged that tuses that are culturally privileged and valued.
dictates that marriage between a normal XY male The purpose of this chapter is to interrogate
and a normal XX female is the only acceptable oppression through an analysis of discourses
union that warrants legal protection. Another related to LGBT older adults. As part of our
4 Deconstructing Multiple Oppressions Among LGBT Older Adults 67
reflexive posture, we attend to the social con- Falling outside of this cultural swath has signif-
structions of meaning about age, ability, gender, icant implications for financial stability,
race, and sex and their colossal impacts on LGBT employment, dating, marriage, access to and
older adults. We are mindful of the weight of quality of health care, and social capital.
oppression for LGBT older adults in general but in
particular overlooked subgroups of this diverse
Discussion Box: Can you think of any
population (e.g., people who are with low income,
movies (non-musicals) where LGBT elders
people of color, and people who are transgender
have been depicted? What were their lives
and do not fit into the binary of woman or man,
like? What race were they? How similar
gay or straight). We confront multiple layers of
were their lives to cultural values? How do
discrimination by deconstructing cultural
movies reinforce dominant cultural values
assumptions of normalcy (e.g., heteronormativity
and often perpetuate race, gender, and
within the LGBT community) presented in visual
sexuality stereotypes?
form, verbal text, and within discourses.
expectations for persons with the same label. viewed as unattractive as they age. The hetero-
Deviation from prescribed gender roles attracts normative standard of beauty has been critiqued
notice and comment from a scrutinizing public. by many older lesbians who refuse to be bound
At the center of cultural and gender normativity by body image ideals that harass heterosexual
is patriarchy through which gender oppression is women (Kimmel et al. 2013). Although older
maintained. Among older people, gender is lesbians are likely to be welcomed, respected,
eclipsed by age unless it is nestled within and even “treasured” by younger lesbians
youthfulness or age defiance. Among people of (Schope 2005), the challenge with this endear-
color, gender tends to be obscured by race, in ment is the perception of being patronized
that race vies for more attention as the salient (Macdonald and Rich 1983).
identity construct (Robinson-Wood 2013). Unlike the majority of lesbian, gay, and
Social constructions of gender and sexual bisexual (LGB) individuals, many trans* indi-
identity impact one’s lived experience. The vis- viduals decide to transition later in life after
ible signs of aging that mark a person as unde- retirement and after adult children have moved
sirable or unappealing are a phenomenon in the out of the house (Kimmel et al. 2013). The
LGBT community (Sargeant 2009). Ageism in economic means to live one’s gendered and
the gay community is rampant with gay men sexual identity exists for many older trans*
being particularly vulnerable to becoming “too individuals; nonetheless, problems remain with
old” for relationships if over the age of 35 dating, finding culturally competent healthcare
(Sargeant 2009). Gay and bisexual men are twice providers, and coexisting within a marginalizing
as likely to live alone as heterosexual men. Gay society. Little research is available on trans*
and bisexual men tend to have a harder time individuals and how they live in older adulthood.
successfully aging, and they seemed to be over-
whelmed and even depressed, in comparison
with lesbian and bisexual women (Macdonald
and Rich 1983; Schope 2005). Feminism has Privileged Queerness
exerted a tremendous impact on the formation of
lesbian and bisexual women’s communities, thus Queer theorists have excluded LGBT older
inspiring resistance to and confrontation of age- adults from their research in much the same way
ism (Grant et al. 2010a). that LGBT older adults have been excluded from
Gay and bisexual men appear to have had health care, policy, and mental health research.
little connection to dialogues in which queer Brown (2009) argued that the producers of queer
women have participated (Grant et al. 2010a). and gerontological theory communicate from a
The youth orientation of gay culture has helped position of power that both silences and ignores
to cultivate internalized ageism among some gay the realities of LGBT older adults. She argues
and bisexual men who feel rejected and isolated that homophobia, heterosexism in gerontology,
from the mainstream gay community. Schope and ageism in queer theory drive this production.
(2005) took a different position and argues that Halberstam (2005) identified two new terms
gay men are actually better able to cope with in queer theory that have direct implications for
aging than are heterosexual men. LGBT older adults. Queer time and queer space
Although lesbian and bisexual women are is a model for minimizing the heteronormative
more likely to live alone than heterosexual gaze of aging. A new queer version centers on
women (Grant et al. 2010a), lesbians seem to fare the present and is not focused on biological
better than their gay counterparts and have reproduction and the traditional family. Queer
broader social support networks and community time and queer space questions the mainstream
involvement. Many lesbians enjoy intimate and definition of healthy development and identity
sexual relationships well into older adulthood politics. Brown (2009) proposed that this per-
(Kimmel et al. 2013) and are less likely to be spective of living for today may have emanated
4 Deconstructing Multiple Oppressions Among LGBT Older Adults 71
from the AIDS epidemic during the 1980s, which Internalized homophobia can cause serious
had a profound and lasting impact on the LGBT mental health effects and is fairly prevalent in the
community. Brown (2009) also postulates that LGBT older adult population. Although many
queer theory has historically focused on the LGBT older adults are typically well adjusted and
young, creating a power differential and a dis- mentally healthy (Graham 2011), the Aging
missal of LGBT older adults’ voices, bodies, Health Report (Fredriksen-Goldsen et al. 2011)
desires, and perspectives. stated that 26 % of the 2500 LGBT older adults in
Research and media on LGBT individuals the project tried at one time or another to not be
ignores stratification and diversity within the lesbian, gay, bisexual, or transgender. On a scale
LGBT community. Television shows such as The of 1–4 with 4 representing higher levels of
L Word and Will and Grace made a valiant stigma, the average level of stigma on a nine-item
attempt to empower and give voice to LGBT measure adapted from the Homosexuality-
individuals. LGBT portrayals were overwhelm- Related Stigma Scale was 1.5 for LGBT older
ingly problematic because they presented people adult participants; 1.3 for lesbians; 1.5 for
in stereotypical and sensationalized fashion bisexual women; 1.5 for bisexual men; and 1.8
(Akita et al. 2013). Far too often, a preferred type for transgender older adults.
of LGBT person blankets the media. Despite the
number of prime time television shows that give
voice to the LGBT experience, such as Orange is
the New Black and Gray’s Anatomy, more often Multiple Oppressions Among
than not, media reflect dominant discourses and Between LGBT Older Adults
concerning which LGBT individuals are worthy
of watching. People who are young, attractive, Defining systems of oppression is critical to a
white, wealthy, promiscuous, dramatic, gender- thoughtful analysis of the history of LGBT people
conforming, and physically fit are iconic. during the twentieth and twenty-first centuries.
Most LGBT individuals and heterosexuals do not Pre- and post-WWII era policies banned LGBT
resemble these unrealistic television images. individuals from serving in the military. In 1952,
A bifurcated and binary system of gender and the Diagnostic and Statistical Manual of Mental
gender expression is still imposed at this point in Disorders (DSM-I) published by the American
the twenty-first century. Within this system Psychiatry Association referred to homosexual-
some, albeit not all, LGBT individuals are posi- ity, pedophilia, and sexual sadism (e.g., rape and
tioned at the periphery of mainstream society, mutilation) as sexual deviation. WWII and the
which can increase one’s susceptibility to DSM were watershed events that perpetuated a
oppression, prejudice, and stereotyping. Adher- cultural belief about homosexuality—that it was
ence to a binary gender and sexuality system pathological, immoral, deviant, and unpatriotic.
contributes to discrimination against bisexuals LGBT individuals were banned from mainstream
within the LGBT community. Men and women society; however, wartime accelerated social
who identify as bisexual experience biphobia and changes, providing recruits who joined the mili-
may not be considered as serious romantic part- tary with an opportunity to escape to large cities.
ners or are perceived to be in transition or Such an exodus served to jump-start the forma-
experimenting sexually, similar to adolescence. tion of large LGBT communities.
Bisexuals and trans* individuals have historically Senator McCarthy was intent on excising
been silenced and excluded with many regarding identifiable LGBT individuals from government
them as part of the “out group” within LGBT positions through arrests, blackmail, and coer-
organizations and movements (Graham 2011). cion. Many private businesses followed suit.
Little research is available on internalized trans- LGBT individuals living through pre- and
phobia and ageism within the trans* older adult post-WWII were largely closeted. Exorbitant
population. amounts of energy were spent cloaking the
72 T. Robinson-Wood and A. Weber
experience victimization than white LGBT older including many of color, a lifetime of employ-
adults. She also reported that both Hispanic and ment discrimination translates into earning dis-
Native American LGBT older adult participants parities, reduced lifelong earnings, smaller social
report lower levels of general mental health, security payments, and fewer opportunities to
higher rates of depression, and more stress than accumulate large pensions and retirement pack-
do whites. The likelihood of neglect for Hispanic ages (Auldridge and Espinoza 2013).
and black LGBT older adults is also greater. Patriarchy and racism have contributed to the
Compared to whites, Native Americans are more institutionalization of privilege for some and to
likely to experience anxiety, suicidal ideation, disadvantage for others. Although context and
and loneliness. Asian/Pacific Islanders do not situation are relevant, race occupies grand master
differ on mental health indicators from whites status in that race has enormous power to eclipse
with one exception; Asian/Pacific Islanders have other identities, such as socioeconomic class,
lower rates of suicidal ideation. The Center for professional dress, and title/position (Robinson-
Black Equity has hosted black LGBT Prides for Wood 2013). LGBT older adults of color occupy
years in an effort to grant LGBT people of color a multiple marginalized identities within a system
separate voice outside of the mainstream LGBT where the grand master status of race is active
community. Please visit the Center for Black with respect to one’s position in society, expe-
Equity (http://centerforblackequity.org/) for more riences with discrimination, and overall treat-
information on how this organization promotes ment. Irrespective of gender and sexuality,
social justice for black LGBT communities. elderly African Americans are more than three
Some people of color understand the LGBT times as likely as elderly Caucasians to live in
movement as complicit with an imperialistic poverty, while elderly Hispanics are more likely
culture in support of white superiority. A history than the older population to be poor and in need
of excluding some sexual, gender, and racial of long-term care. Elderly women also are highly
minorities influenced some people of color not to vulnerable. Nearly three out of four older
identify as LGBT but rather endorse other iden- Americans who fall below the poverty line are
tifiers (e.g., third gender, down low, MSM, women, and retirement incomes for older women
WSW, same gender-loving). Previous studies average about 55 % of those for comparable men
found that black men having sex with men (SAGE 2010).
(MSM) are generally less likely to self-identify Internalized homophobia and transphobia
as being “gay” when compared to white men, exist among some LGBT people of color. Black
even when they are open about their sexuality men experience higher levels of internalized
(Han et al. 2014). Han et al. (2014) also found homophobia and are less likely to disclose their
that black MSM do not identify as gay because homosexual orientation. They are also more
of their marginalization in the larger gay com- likely to perceive their friends and neighbors as
munity. Some black MSM men have come to disapproving of homosexuality (Graham 2011).
reject what they perceive to be a narrow and In both the Latino and Asian American com-
non-inclusive definition of sexual relations with munities, cultural expectations surrounding
other men. Very little research has been con- family role obligations encourage the mainte-
ducted on marginalization among LGBT people nance of strong ties to families of origin.
of color in general and the trans* community of
color in particular.
Racism is undeniable in the marginalization of Discussion Box: Concerns about individ-
far too many LGBT older adults of color. ual behavior that is outside of cultural
Research suggests that black and Latino elders dictates and subsequent implications for a
experience poverty at twice the rate of the gen- family’s honor or social standing can
eral US elder population. For LGBT elders, weigh heavily on groups characterized by a
74 T. Robinson-Wood and A. Weber
their partners. Because, in most cases, LGBT estimates of discrimination, which reflect the
couples are not legally recognized, hospital vis- extent to which heterosexual couples were con-
itation policies may exclude same-sex partners or sistently favored over gay male or lesbian cou-
other family members, which can impede or ples, are 15.9 and 15.6 %, respectively. Sexual
complicate critical health decision-making pro- orientation and gender identity are not federally
cesses (Grant et al. 2010a). Although President protected classes. In efforts to end housing dis-
Obama issued a memorandum (House 2010) crimination against LGBT individuals, on Feb-
allowing for LGBT couples to make decisions ruary 3, 2012, HUD published its Final Rule,
for each other, many hospitals and long-term care “Equal Access to Housing in HUD Programs
agencies refuse to follow suit. regardless of Sexual Orientation or Gender
Another challenge for LGBT older adults is Identity.” This ruling prohibits HUD-assisted
financial insecurity as they enter retirement. organizations from discriminating on the basis of
Overall, 42 % of all LGBT elders indicated that sexuality or gender identity. There is very little
“financial problems” are a big concern in their recourse for LGBT individuals when other
lives (SAGE 2010). Many LGBT individuals organizations continue to discriminate, particu-
have faced historical employment discrimination larly with laws written as they are.
that has resulted in lower levels of financial Contending with financial insecurities, hous-
security throughout life and that directly affects ing, and other types of chronic discrimination is a
retirement income and social security payouts. breeding ground for social isolation and depres-
A recent article by New York Times economists sion. LGBT older adults may be denied housing,
Tara Siegel Bernard and Ron Lieber estimated the including residency in mainstream retirement
added costs incurred by a hypothetical same-sex communities, based on their sexual orientation,
couple between $41,196 and $467,562 (Grant gender identity, and expression. This discrimi-
et al. 2010a). The poverty rate for senior gay nation may separate LGBT older adults from
couples is 5 and 9 % for lesbian couples (SAGE beloved friends or partners or push them into
2010). Trans* individuals are more likely to live homelessness (SAGE 2010). In response to sys-
in extreme poverty and are nearly four times more temic housing discrimination, some LGBT older
likely to have a household income of less than adults have created non-mainstream retirement
$10,000/year as compared to the general popu- communities that honor diversity. LGBT older
lation (Grant et al. 2010b). Employment dis- adults have even been able to erect small retire-
crimination against trans* individuals is rampant; ment communities and assisted living commu-
90 % of those surveyed reported harassment, nities. For resources and advocacy groups, please
mistreatment, or discrimination (Grant et al. visit theses Web sites for more information
2010b) with no legal protection because the (Legal Resources: http://www.lambdalegal.org/
Employment Non-Discrimination Act (ENDA) and http://www.hrc.org/resources/entry/maps-of-
has not passed through Congress yet. With the state-laws-policies.
repeal of the Defense of Marriage Act (DOMA),
LGBT older adults are able to receive retirement
benefits, social security, benefits for military Research Box: Research shows that the rate
action, and Medicaid after their spouse is of homelessness among elders has
deceased. This important legislation does not increased in the last decade with about
alleviate the lost financial opportunities for LGBT 2,960,000 elder adults who are homeless.
older adults whose partners died prior to DOMA. Rates for LGBT older adults homelessness
Recently, the US Department of Housing and are currently not recorded, but 30 % of LGB
Development (HUD) (Friedman et al. 2013) older adult couples faced housing discrim-
released a study about housing discrimination ination and 19 % of trans* older adults
toward individuals who identify as LGBT. HUD being denied a home or an apartment.
(Friedman et al. 2013) concluded that gross
76 T. Robinson-Wood and A. Weber
Policy Impact and Mental Health individuals access to healthcare plans targeted for
for LGBT Older Adults same-sex families and trans* individuals.
Unfortunately, homophobia and multicultural
As individuals transition into older adulthood, incompetence from healthcare professionals have
multiple challenges arise, such as disability and contributed to primary care underutilization for
loss of loved ones. Compared to their hetero- many LGBT individuals (Grant et al. 2010a).
sexual counterparts, lesbian, gay, and bisexual The Federal Family Caregivers Support Pro-
older adults are at an elevated risk of disability gram, which was created with the 2000 reau-
and psychological distress (Hudson 2011). thorization of the Older Americans Act and
A 2006 study reported evidence of higher levels amended in 2006, expanded its definition of
of depression and psychological distress among family caregivers to include extended LGBT
midlife and older lesbians and gay men, which family members (Grant et al. 2010a). This pro-
the researchers attribute to the accumulated effect gram provides LGBT individuals who are care-
of a lifetime of stigma (SAGE 2010). givers to partners or family members by choice
Defined as chronic stress related to stigmati- with the ability to utilize respite care, counseling,
zation and actual experiences of discrimination support groups, and training groups. This bill is
and violence, minority stress has been found to significant for many reasons. First, it reflects
increase loneliness in LGBT older adults (SAGE social justice and basic human rights. Second,
2010). An alarming 41 % (out of 6450 individ- when the data are examined, it is evident that
uals) of trans* older respondents reported LGBT individuals are more likely than are het-
attempting suicide compared to 1.6 % in the erosexuals to report a disability: 41 % aged 50
general population (Grant et al. 2010a). In an and older report a disability (Hudson 2011).
effort to address disparities, former Secretary The Family Caregivers Support Program
Kathleen Sebelius of the US Department of broadened the definition of families in 2006. In
Health and Humans Services (HHS) announced 2013, with the repeal of the Defense of Marriage
on June 29, 2011, that HHS would begin col- Act (DOMA), individuals were protected by the
lecting data through population health surveys to Family Medical Leave Act (FMLA). FMLA
facilitate identification of health issues (National allows people to take extended periods of paid
Resource Center on LGBT Aging 2013). leave to care for their partners (United States
In light of the mental health disparities Department of Labor 2013). Family of choice is
between heterosexual and LGBT older adults, critical for caregiving given the substantial
there is a distinction between health policies that numbers of LGBT older adults receiving support
perpetuate marginalization and policies that from families of choice or partners; 27 % provide
protect human rights. Policy differences between assistance to someone close to them with a health
state and federal governments are a hindrance to issue. A national survey of LGBT baby boomers
having full protection under federal mandates. by the MetLife Mature Market Institute found
Medicaid now offers benefits to legally married that 42 % of LGBT caregivers reported assisting
same-sex couples. Prior to 2014, this was not the partners, friends, neighbors, or others outside of
case. Thousands of people have access to their families of origin. Another recent study
healthcare providers. The Institute of Medicine found 32 % of gay men and lesbians providing
(IOM) defines access to health care as the “timely some sort of informal caregiving; 61 % of their
use of personal health services to achieve the best care recipients were friends, and 13 % were
possible outcomes.” With the passage of the partners (Grant et al. 2010a). There is a limited
Affordable Care Act (ACA), LGBT older adults research on trans* individuals with respect to
will have health insurance previously unavail- family of choice and caregiving. The National
able. Moreover, the ACA has created an Center for Transgender Equality (Grant et al.
insurance-based system that allows LGBT 2010b) stated that 55 % of respondents
4 Deconstructing Multiple Oppressions Among LGBT Older Adults 77
experienced family rejection; 45 % of respon- deception, and shame. Therapy also helped Gin-
dents reported that their family is as strong today ger think about what it means to be an older
as it was before coming out. transsexual woman of color. Throughout her life,
Ginger battled not only heterosexism but also
racism, sexism, internalized self-hatred, and age-
ism. She also struggled with alcoholism but has
Case Study been sober for eight years with the help of Alco-
holics Anonymous. Therapy provided a space for
In the case study of Ginger, we see a common Ginger to declare that she was a transfemale who
story that is told among transwomen veterans. has always been and is currently attracted to men.
Pay close attention to the intersections of gender, Her decision to undergo surgery was not attached
race, age, religion, employment, and substance to the presence of a life partner, although finding a
use in Ginger’s life. loving relationship with a man is something that
Ginger was born male. For as long as Ginger Ginger desires. She has found dating to be chal-
could remember, being male felt like a mistake. lenging, especially as she ages. Once Ginger came
Ginger had a military career for over three dec- out as a transgender, Ginger’s parents ceased
ades. Once Ginger left the military, she went to communication, claiming that Manuel (Ginger’s
culinary school and worked as a chef for ten years. birth name) is dead to them.
Ginger is now retired. For the last two years,
Ginger’s outward appearance has been feminine
with respect to appearance, hairstyle, makeup, Self-Check Exercise: Pair and share with
dress, and mannerism. Ginger identified as a male another student in the classroom. Discuss
for 60 years but did not identify as gay in her your feelings about Ginger. How do you
attraction to men. For her 65 birthday, Ginger’s feel about her decision to marry when she
gift to herself is gender-confirming/reassignment knew she was queer? What are your feel-
surgery. Ginger’s youngest sister is present to ings about Ginger’s surgery at age 60?
support Ginger before and after the surgery. How do socially constructed notions of
Raised in a very devout Catholic, Puerto Rican beauty, age, and sexuality collide for Gin-
family that vehemently denounced Ginger’s ger and/or impact your feelings about her
interest in girls’ toys and clothes, Ginger could not life choices?
reconcile being openly transgender with her
family. Out of respect for her parents’ feelings and
reputation, her plan was to come out after both her
parents died. At the age of 60, Ginger decided the
wait was over. Both her parents are in their late Discussion of Case Study
80s and enjoy good health. Ginger is determined
to live the remaining years of her life as authen- Trans* individuals may be less likely to disclose
tically and honestly as possible. Married to a their sexuality than their heterosexual counter-
woman for 16 years, Ginger fathered three chil- parts. Ginger resisted the asexualization of her
dren who are now adults in their 40s. Her children sexuality by disclosing her sexuality and step-
have limited contact largely due to Ginger’s ping into her life as the female that she knew she
emotional unavailability to them and her history was. Disclosure of sexual and gender identity can
of addiction. Ginger credits her sanity to a good lead to an array of social and community support
therapist whom she has seen for three years. In in the LGBT community (Fredriksen-Goldsen
therapy, Ginger learned that she was dying as she et al. 2011). Mental healthcare providers are
waited for her parents to die. She also came to encouraged to be familiar with community
realize that respect was not driving her decision to resources. Knowledge of sexual identity devel-
come out after her parents’ deaths but fear, opment models (e.g., Cass 1979 and Troiden
78 T. Robinson-Wood and A. Weber
1989) can assist the clinician in understanding gay man quoted in The Aging Health Report
phases and junctures of development, from (Fredriksen-Goldsen et al. 2011) said, “The
fragmentation to affirmation (Robinson-Wood LGBT community has stepped up in the past to
2013). Ginger’s therapist needs knowledge of address coming out, AIDS, and civil rights. The
the historical implications of homophobia and next wave has to be aging.” LGBT older adults
transphobia on transgender individuals, medical have a distinct experience of aging stemming
care concerns, particularly given Ginger’s recent from shared experiences in relation to the LGBT
surgery and continued hormone use, and aspects community, the lifelong process of coming out,
of LGBT culture for older transwomen. the experience of sexual and gender minority
Hardacker et al. (2013) and the Howard stress, marginalization inside and outside LGBT
Brown Health Center (HBHC) developed the communities, and LGBT pride and resilience
nurses’ Health Education About LGBT Elders (Van Wagenen et al. 2013).
(HEALE) curriculum, a 6-h cultural competency LGBT older adults have created families of
curriculum that focuses on providing training for choice when biological family is physically
nurses and other direct caregivers (for more removed or emotionally detached. Family of
information, visit http://www.nursesheale.org/ choice is one way that older LGBT adults thrive
curriculum/). Individuals who have been trained and alleviate isolation and depression. In many
using the HEALE modules have shown increase ways, the LGBT older adult community shows
in health care providers’ confidence in adminis- resilience (Fredriksen-Goldsen et al. 2011) and
tering culturally sensitive care to older LGBT the ability to handle adversity and challenges
individuals. There are six modules that would be successfully, which are important keys to main-
helpful for Ginger’s medical team to review: taining good physical, social, and mental health.
(1) introduction to the LGBT elder community; Meyer et al. (2011) found that participants spoke
(2) barriers to health care and health disparity; of the positive aspects of exposure to stigmatiz-
(3) sex and sexuality of LGBT elders; (4) legal ing experiences. Some who identify as a LGBT
concerns for LGBT elders; (5) an introduction to individual, and for some, persons of color and
transgender community; and (6) human immu- women, felt like they were better people for
nodeficiency virus (HIV) and aging (Hardacker surviving and thriving in the midst of oppression.
et al. 2013). It is possible that some LGBT older adults may
Interprofessional collaborations are needed to be in a better position to age successfully com-
provide the best care for Ginger. A multipronged pared to their heterosexual counterparts because
approach would encompass nursing, geriatric some older LGBT adults have acquired strengths,
medicine, and psychosocial education. Ginger’s including adaptability, self-reliance, advocacy
multiculturally competent therapist needs the skills, crisis competencies, and gender role flex-
ability to create a holding environment for Gin- ibility (Hash and Rogers 2013).
ger’s excitement, fear, anger, and shame while
facilitating the acquisition of skills needed to be
healthy and whole as a transwoman of color in a
society that struggles with extending justice and Discussion Box
decency for Ginger and others like her.
1. What are issues experienced by trans*
individuals that may differ from those
experienced by gay men or lesbians?
Summary 2. Is there a relationship between cumu-
lative and multiple oppressions (racism,
LGBT older adults have faced a lifetime of dis- heterosexism, transphobia, ageism) and
crimination yet continue to fight for equality and Ginger’s addiction to alcohol?
resist homophobia and ageism. A 63-year-old
4 Deconstructing Multiple Oppressions Among LGBT Older Adults 79
Abstract
This chapter focuses on the complexity of human identity by considering
the multifaceted and intertwined relationships between sexuality, gender,
race, ethnicity, socioeconomic status, and age, as well as other aspects of
one’s social and personal identity. To assist in illuminating our
understanding of these relationships, the structural, political, and social
factors that contribute to social inequality experienced by LGBT elders
situated at the multidimensional intersections of different races, ethnicities,
socioeconomic status (SES), sexes, and sexualities are explored. By
simultaneously considering the multiplicity and fluidity of identity and
exposing the diversity of experiences of LGBT elders, we are able to
underscore some of the many reasons for extant research involving sexual
minorities which must be carefully and critically evaluated.
Keywords
Intersection of identities Multiple identities Race Age Sexuality
Care network
when the predominant subjects of that research 3. Understand the diversity of relationships in
seem to mirror the longstanding stereotypical the LGBT community.
profile of young, white, gay, well-educated, 4. Understand the complexities of families of
middle-class, and urban dwelling (Albelda et al. choice as impacting intersectionality.
2009). To be fair, while this profile describes a 5. Summarize the convergence of race, age,
segment of the population, it is most notable for the sexuality, and service provision.
many LGBT persons it excludes—and for the fact
that its persistence as a presumably adequate proxy
for the population of sexual minorities as a whole
is based on a tacit acceptance of the study partic-
ipants as representative (Institute of medicine Introduction
[IOM] 2011). Building on this platform, we
explore the ways that racism, sexism, ageism, and A common theme and driving force behind this
heterosexism impact the processes through which book is an acknowledgment that the elder LGBT
individuals develop, experience, and manage their community/population is made up of a complex
multifaceted social identities (Kertzner et al. 2009; and diverse collection of human beings about
Purdie-Vaughns and Eibach 2008; Settles 2006). whom we know relatively little. Yet, if we are to
With a clearer understanding of the diversity rep- effectively address the needs of such a diverse
resented among elder LGBT persons, the chapter aging population, we must develop care networks,
will consider the relevance of these factors for the services, and programs that acknowledge and
development of informal support and caregiver affirm the multiplicity of social identities that
networks, as well as their implications for the converge to create the unique human beings with
creation and maintenance of formal care networks whom we will work (Abes et al. 2007; Jones and
that are responsive to the needs of the multidi- McEwen 2000). In a very real sense, one can look
mensional population of elder LGBT persons with to this book as a call to action for human service
whom we will engage (Van Der Bergh and Crisp professionals—seeking to simultaneously educate
2004). Finally, having established a foundation and inspire them to become the very best practi-
upon which we might build, suggestions for the tioner possible while moving forward on their
development of models of culturally competent career paths. Throughout our careers, we are
practice (Leyva et al. 2014), training of human called upon to act as culturally competent pro-
service professionals (Hardacker et al. 2014; fessionals in a variety of practice settings. In an
Hillman and Hinrichsen 2014), creation of effec- effort to rise to that challenge, we will turn to the
tive and responsive communities of care and ser- scholarly professional literature to seek guidance
vice organizations (Meyer and Johnston 2014), on best practices and insights into the lived
and the development of inclusive policies will be experiences of aging sexual minorities from
delineated (Auldridge and Espinoza 2013). diverse backgrounds. In the process, we are con-
stantly confronted by the reality that our knowl-
edge of this heterogeneous population of
Learning Objectives individuals who identify as lesbian, gay, bisexual,
or transgender is based largely on a fairly mono-
By the end of the chapter, the reader should be chromatic and unidimensional body of research
able to: (Huang et al. 2010; IOM 2011). In short, we know
very little about the full spectrum of LGBT lives.
1. Understand the multiple dimensions of iden- Until recently, the relative dearth of research
tities and their intersections. focusing on diversity within the LGBT popula-
2. Identify the stigmatization of “isms” with tion drew little attention. Whether this was the
regard to race, age, and sexuality in informal result of a failure to acknowledge the actual
and formal care networks. diversity of the LGBT population, a level of
5 The Intersection of Identities of LGBT Elders … 85
satisfaction with the fact that there was finally an et al. 2012; Fredriksen-Goldsen and Muraco
evolving body of LGBT-focused scholarship in 2010; Siverskog 2014).
general, a combination of the two, or something Against this less than satisfying backdrop, this
else entirely, LGBT-focused research tended to chapter focuses on one of the more challenging
ignore the roles of potentially relevant issues aspects of understanding the lives of human
such as race, ethnicity, social class, age, and beings—confronting the reality that each of us is
among others, in the lives of sexual minorities much more than the sum of our parts, and amidst
(IOM 2011; Van Sluytman and Torres 2014; this complexity, we each experience our identi-
Young and Meyer 2005). Over the last twenty ties as simultaneously fluid, contextual, and in
years, a growing number of studies have inclu- some ways, concrete (Diamond 2005; Fish 2008;
ded more diverse samples, yet recent systematic Hancock 2007). If that description seems to
reviews of the literature reveal that extant suggest inherent contradictions, in reality, it only
scholarship still offers only a limited look a more offers the tip of the iceberg of what makes the
diverse LGBT population (Eliason et al. 2010; process of developing a meaningful understand-
Fredriksen-Goldsen and Muraco 2010; Huang ing of human beings and the human condition so
et al. 2010). When researchers do give consid- challenging. Of particular relevance to the cur-
eration to differences related to race, ethnicity, rent focus of inquiry, this task is made all the
age, sexual minority identity, gender identity, more difficult by the fact that sexual minorities
geographic location, and/or SES, this acknowl- confront stigma, prejudice, and discrimination on
edgment comes primarily in the form of a sample a daily basis and thus have often been justifiably
description that rarely translates into a more reticent about participating in research (Bowleg
in-depth analysis (IOM 2011). Generally, when 2008; DeBlaere et al. 2010; Moradi et al. 2009).
acknowledged, the absence of such analysis is a Despite this reality, social scientists must con-
limitation that is attributed to having insufficient tinue to acknowledge the complex combination
numbers of individuals representing specific of factors that contribute to individual experi-
demographic characteristics (IOM 2011). Among ences, seek ways to measure these factors, and
the very limited number of studies that seek to subsequently configure this newly acquired
specifically address some aspect of the diversity knowledge into a narrative that can guide human
within the LGBT population, we find research service professionals in areas of practice, pro-
that is typically characterized by small sample gram development, and policy to positively
sizes and a reliance on qualitative research impact the lives of aging LGBT persons (Eliason
methods (e.g., case studies, focus groups, inter- et al. 2010; Van Der Bergh and Crisp 2004).
views). While these studies provide us with
valuable and useful information, the reality is
that our knowledge of significant portions of the The Limitations of LGBT Scholarship
LGBT community is based on the experiences of Related to Diversity
a very small number of people whose experi-
ences may or may not share commonalities with As efforts are underway to increase the diversity
others who have a similar, much less different, of questions explored in research involving elder
demographic profile. Thus, we remain fairly LGBT persons, certain identity-related assump-
uninformed about the lives of LGBT persons of tions that have influenced past scholarship have
color or elderly LGBT persons of any race/eth- been exposed. First, the centrality of
nicity and/or socioeconomic background, with problem-focused inquiry in the literature
scholars recently noting that amidst this limited involving LGBT persons has been well estab-
scope of available research, transgender persons lished (IOM 2011). Although this work has
remain all but invisible in the vast majority of all provided the basis for seeking funding for
sexual minority-focused scholarship (Averett much-needed LGBT-focused services and
86 M.D. Otis and D.A. Harley
programming, it has also been used to support of color), their relationship status (particularly
politically and culturally charged arguments, among single men in the study), and their phys-
suggesting that sexual minorities as a group are ical appearance (i.e., being overweight). Simi-
physically and mentally less healthy than heter- larly, in a qualitative study of older lesbians,
osexual men and women (Bowleg et al. 2003; Averett et al. (2012) found that the women
Purdie-Vaughns and Eibach 2008), and as such viewed their sexuality as less central to their
must be precluded from certain environments identity as they aged and instead emphasized on
and/or activities (i.e., teaching young children, establishing stability and a sense of security.
adoption/having children, serving in the mili-
tary). Amidst this body of work sits a significant
number of studies that focus on the centrality of Multiple Dimensions of Identity
the role of coming out as being either highly and Intersectionality
problematic, essential to well-being, and/or the
indisputable foundation of a sexual minority Identity is a central organizing tool for under-
person’s identity (Hunter 2007). Conceptually, standing how human beings create and maintain
this work suggests that for persons who identify a sense of self (Howard 2000). Social scientists
as lesbian, gay, bisexual, or transgender, one’s (primarily in the fields of sociology and psy-
sexuality is/should be the primary dimension chology) have been studying identity for many
defining one’s identity. Given that some research decades. In general, the field of inquiry has been
suggests that elder LGBT persons who came out guided by three fundamental assumptions:
prior to the beginning of the gay rights move-
ment (generally considered to be the day of the 1. Identities are not innate qualities, rather they
Stonewall riots—June 28, 1969) may not view are socially constructed;
publically acknowledging their sexuality (in any 2. Identities are fluid; and
way) as necessary or appropriate, this assumption 3. Identities are created/recreated over and over
about the primacy of one’s identification as a again through processes of social interaction
sexual minority may be highly problematic. and meaning-making.
There can be little argument that each of these
paths of inquiry has produced some important Utilizing these three basic building blocks, we
information that has enhanced our understanding can acknowledge that at the heart of our discus-
of the lives of LGBT persons and that could (and sion about multiple dimensions of identity and
does) assist in creating some form of positive intersectionality sits a fairly simplistic premise—
change, for direct practice, programming, policy each of us possesses a number of characteristics
development, or community change (IOM 2011). that coalesce and sometimes conflict to create the
Yet, beyond the debate about whether coming out unique individuals that we become (Jones and
is critical to the development of one’s identity as a McEwen 2000; McCall 2005). We self-identify
sexual minority, research demonstrates both the and we are identified and labeled by others based
significance and fluidity of the prioritization of on multiple dimensions, including our
multiple identities among sexual minorities— race/ethnicity, age, sexuality, sex, and social
including shifts in the centrality of one’s identity class (Hancock 2007; Roccas and Brewer 2002).
as a sexual minority (Diamond 2005; Kertzner While all of these characteristics constitute parts
2001). For instance, in a study of gay men in of us as unique human beings, a number of
midlife, Kertzner (2001) found that many of the influences we encounter across time and space
men viewed their sexual minority identity as less contribute to the salience of particular identities
important to them as they aged, with greater at any given point in time (Abes et al. 2007). By
significance being shifted to aspects of their framing our understanding of the lived experi-
non-sexual identity associated with race (for men ences of elder LGBT persons around the
5 The Intersection of Identities of LGBT Elders … 87
construct of multiple dimensions of identity/ decades. Moore (2010) examined strategies black
multiple identities, we acknowledge and embrace LGBT persons use in black environments to
this reality (Abes et al. 2007; Jones and McEwen proclaim a sexual minority identity that is
2000; Omi and Winant 1994; Tornstam 2005; co-occuring with a black identity. The belief is
Weber 1998). that increasing their visibility in black spaces will
Because our focus is on understanding and promote a greater understanding of minority
appreciating the lives of elder lesbians, gay men, sexuality as an identity status that can coexist
bisexual men and women, and transgender per- rather than compete with race. One of the foci of
sons, the fluidity of multiple identities experi- the study was to examine the particular health
enced across the life course figures prominently and social support concerns faced by older and
in our discussion (Kertzner et al. 2009; Omi and aging segments of this population (see Research
Winant 1994). Although our own developmental Box 5.1).
trajectories and associated expectations and roles
(i.e., becoming older, becoming a parent, part-
Research Box 5.1 See Moore (2010).
nering) certainly play a critical role in the pro-
Purpose: To analyze the ways black
cess, the impact of embracing or being ascribed a
gay people who feel a sense of solidarity
particular identity is bigger than just knowing
with the racial group experience the cross
which predetermined box we are expected to
cutting issue of openly expressing a gay
check on a survey. In fact, given the fluidity of
sexuality in black community contexts.
identity, how we self-identify may be both his-
Method: The data for this study come
torically and situationally influenced (Cronin and
from a larger project, Black Los Angeles
King 2010; Deaux and Martin 2003; Howard
Project, a research study examining
2000; Stirratt et al. 2007). For instance, in one’s
neighborhoods, religious life, political
place of employment, our sexuality may seem of
participation, cultural production, and
little relevance to us while highly relevant in
social justice in South Los Angeles, Cali-
others. A situation may be compounded by the
fornia. Approximately 30 months of qual-
fact that those around us may be prioritizing, and
itative data collection were used. This
thus responding to, aspects of identity that we
study was designed to examine the rela-
may or may not see as pertinent or primary in the
tionship that black LGBT persons have
moment. Or we may become a parent and come
with their racial communities, the types of
to centralize that aspect of our identity, regardless
kin arrangements they participate in, the
of what other aspects of our identity may remain
role religion plays in their lives, and the
more or less prominent as a result of our shifting
particular health and social support con-
priorities. In summary, as we move through
cerns faced by the older and aging seg-
various activities, interactions, and cognitive
ments of this population. In-depth,
processes over the course of a given day, a
semi-structured interviews were con-
month, or year(s), different aspects of our identity
ducted with self-identified LGBT
may be more or less salient—some of these shifts
African-Americans who live and/or work
may be fleeting, while others may mark a
in predominately Black or Black and
long-term or permanent shift in our identity
Latino neighbors. The researcher gathered
process (Abes et al. 2007; Fuss 1989; Kertzner
data at churches, art exhibits, backyard
2001; McCall 2005; Roccas and Brewer 2002).
barbeques, public forums, and other private
The question of which identity is primary has
activities.
long been a subject of debate for many ethnic
Results: Black lesbians and gay men in
minority LGBT persons (see Chap. 6–8, 10). The
LA born before 1954 tend to conceptualize
politics of multiple identities, especially sexual
black group membership as an identity
minority status inclusion in ethnic minority
status that must remain primary for the
communities, has become more fluid in recent
88 M.D. Otis and D.A. Harley
identities, questions arise about whether one combination of race and couple status revealed
aspect of one’s identity should be considered as that being a same-sex couple versus a
primary in relation to another. If we attempt to different-sex couple meant significantly higher
position this discourse at the intersections of rates of poverty for African-Americans, and
identity components, we are confronted with an same-sex African-American couples had poverty
array of questions: Is it more challenging to be a rates three times that of white same-sex couples
white gay man, a black heterosexual man? an (Albelda et al. 2009). It is worth noting that
Hispanic lesbian? or an Asian transgender per- limitations in the US Census Bureau’s data col-
son? Moreover, what are the challenges of being lection process preclude examination of these
multiracial, a sexual minority, and elderly? And, relationships for single sexual minorities or those
perhaps most critical for our consideration at this who may be part of a non-cohabiting couple. The
juncture, are these even the questions we should expansion of data collection categories to include
be asking? a more direct indicator of sexual minority status
As noted at the outset of this chapter, data would offer an unprecedented opportunity to
addressing the lives of the diverse spectrum of capture a meaningful picture of the number of
individuals who identify as sexual minorities are self-identified sexual minorities living in the
limited. Despite this, research conducted in USA (Gates 2006). To date, while scholars and
recent years offers some opportunities for advocates have called for a change in census data
glimpses into the lives of a growing number of collection practices as they relate to sexual
LGBT persons from a diversity of backgrounds, minorities (Auldridge and Espinoza 2013; Brown
and encompassing a broadening spectrum of and Grossman 2014; IOM 2011), there is no
identities (Albelda et al. 2009; Diaz et al. 2008). indication that the Census Bureau has plans to
As a result, an examination of secondary data make this adjustment.
from three population-based studies, including Research in the health and mental health fields
the US Census, the National Survey of Family has also exposed physical and mental well-being
Growth (NSFG), and the California Health disparities between sexual minorities and the
Interview Survey (CHIS), offers insight into a heterosexual majority and among LGBT persons
few of the ways the lives of sexual minorities (Auldridge and Espinoza 2013; Banks 2012;
converge and diverge in relation to some basic, Kertzner et al. 2009), with some of these differ-
yet influential, demographic characteristics (Al- ences being linked to economic inequalities
belda et al. 2009). Collectively, the information captured in the studies described above
offers evidence of some of the ways that race, (Fredriksen-Goldsen et al. 2011; IOM 2011). In
sex, age, and geography combine to impact the their study of LGBT persons age 50 and older,
economic well-being of self-identified LGB Fredriksen-Goldsen et al. (2011) found that,
persons. For instance, the NSFG identified higher compared to white respondents, LGBT persons
rates of poverty for women of sexual minority of color were more likely to experience higher
status as compared to heterosexual women, yet rates of a number of physical and mental health
lower rates for gay men as compared to bisexual problems, including HIV/AIDS, hypertension,
or heterosexual men (Albelda et al. 2009). Data heart disease, and diabetes, among others. These
from the 2000 US Census revealed that lesbian scholars go on to note that despite these elevated
couples over age 65 had a poverty rate that was risks, little to no discussion focusing on
twice that of heterosexual married couples. When addressing the specific needs of aging LGBT
the analysis took into consideration the possible persons of color has occurred
influence of race and geographic location (more (Fredriksen-Goldsen et al. 2011).
precisely, population density), the findings were Assumptions of Hierarchical Socialization.
even more compelling. Specifically, same-sex While basic demographic characteristics such as
couples living in rural areas were twice as likely one’s sex, age, race, ethnicity, and sexual orien-
to live in poverty as those in urban areas. The tation may be viewed simply as benign
90 M.D. Otis and D.A. Harley
descriptive information, the way these qualities In a study examining factors that serve as
are experienced as a part of one’s identity is social determinants of women’s health, McGib-
greatly influenced by the social construction of bon and McPherson (2011) argue that “the
meanings attached to those characteristics (Abes oppressions of sexism, racism, heterosexism, and
et al. 2007) and the context in which those ageism, to name a few, can and do happen
meanings are constructed and reinforced (Jenkins together to produce a complex synergy of
2014). Thus, the existence of prejudicial beliefs material and social disadvantage” (p. 61). As
that characterize racism, sexism, ageism, and both a challenge and a reminder to social scien-
heterosexism plays a significant role in the social tists and helping professionals, the authors go on
processes associated with identity development to assert that this conglomerate cannot be dis-
and identity management (Jackson III 2012; sected into separate parts that conveniently
Jones 1997). As we navigate daily life, we must address the influence of one ism in isolation from
manage both internalized beliefs and external another (McGibbon and McPherson 2011). Their
forces related to the socially constructed meaning assertions offer important tools to utilize when
assigned to various facets of our identities, and critically examining extant research, with its
we are often challenged to do so in different minimally diverse samples, and define the limits
environments and groups that hold varying per- of what it may or may not be able to tell us about
spectives on the “appropriate” hierarchy associ- the lives of elderly LGBT persons.
ated with our particular demographic profile Proceeding with this cautionary note in mind,
(Raetz and Lease 2002). research offers a number of insights into ways
that multiple oppressions impact our lives. While
stigma and discrimination often make it difficult
Examining Multiple Oppressions to access study participants who are representa-
tive of the diverse population of sexual minority
Along with multiple identities come opportunities persons (Fish 2008; Moradi et al. 2009), a
to experience multiple oppressions (and privileges growing, albeit small, body of work exists. This
—depending on one’s status location in the hier- research underscores the ways that members of
archy). In her research examining the lives of black already marginalized groups may be particularly
lesbians, Greene (1995) referred to this as “triple disadvantaged as they age. For instance, in gen-
jeopardy,” arguing that being part of three eral, Black and Latino persons are dispropor-
oppressed groups (i.e., women, lesbians, and tionately concentrated in low wage jobs that offer
blacks) resulted in the potential for black lesbians limited, if any, access to opportunities for
to experience a disproportionate share of the neg- advancement, health insurance, and retirement
ative consequences of oppression. Following security (National Hispanic Council on Aging
Greene’s argument, we argue that elder black les- [NHCOA] 2014; Services and Advocacy for
bians experience quadruple jeopardy. Similar LGBT Elders [SAGE] 2013; Social Security
arguments have been made by other scholars who Administration 2011). Limited work opportunity
have utilized intersectionality as a model to explore increases the likelihood that these individuals
the multiplicity of identity components in will experience greater health-related challenges
LGBT-focused research (Szymanski and Gupta as they age and that they will encounter these
2009). As suggested by the limited research challenges with a limited spectrum of resources.
available on LGBT persons, framing the potential While the available information is certainly lim-
consequences associated with possessing more ited, research suggests that this scenario may be
than one stigmatized minority status is supported similar, if not more problematic, for elder Black
by much of our available evidence (Purdie-Vaugns and Latino sexual minorities (Auldridge and
and Eibach 2008; Robinson-Wood 2009). Espinoza 2013). See Chaps. 6 and 10 for
5 The Intersection of Identities of LGBT Elders … 91
additional information on African-American/ which focused on LGB persons of color. Like the
Black and Latino LGBT elders. Against this bulk of LGB research in general, their analysis
backdrop, it is important to acknowledge that found the typical profile of study participants to
those experiencing the impact of multiple forms be young- to middle-aged living in an urban area,
of oppression may be highly dependent on and relationship status is either not addressed or
support from their informal care/support peripheral to the analysis.
networks. In an effort to gain insights into the ways race,
ethnicity, and age may impact the intimate rela-
tionships of LGBT persons, research focusing on
Diversity in Relationships heterosexual couples may prove useful. A case in
point can be gleaned from the research that has
To this point, this chapter has focused on the been guided by the increasingly popular minority
significance of multiple identities and intersec- stress model for LGBT research (Balsam et al.
tionality in the lives of individual LGBT persons. 2011; Meyer 1995). Initial research using the
However, given the increasing importance of minority stress model focused on understanding
social relationships as source of support as one the impact of racism in the lives of
ages, consideration of the ways sexual minority African-American men and women. As Pinder-
couples are impacted by intersectionality is also hughes (2002) discussed in her review of the
important. Although research on intimate rela- literature examining African-American marital
tionships of sexual minorities is somewhat lim- relationships, both economic conditions and sex
ited, there is an evolving body of work that role expectations serve to impact the stability and
speaks to the unique challenges faced by LGBT quality of these unions. While other factors that
couples (Brown and Grossman 2014; Gates are unique to opposite-sex relationships were
2006; Jeong and Horne 2009; Kurdek 2001; also found to be relevant in these studies, the
Long 2008). Numerous studies of same-sex influence of racism on economic well-being and
couple relationships have documented similari- how that intersection manifests itself as a stressor
ties in relationship quality and relationship in intimate relationships is likely to traverse
dynamics for both same-sex and different-sex relationship types (NHCOA 2014; SAGE 2013).
couples (e.g., Blumstein and Schwartz 1983; Similarly, given that members of same-sex cou-
Kurdek 2004; Malouff et al. 2010), yet the neg- ples are raised within the same environment as
ative consequences of minority stress in their heterosexual peers, expectations and
same-sex couples have also been a frequent assumptions (both positive and negative) asso-
themes. This work is guided by minority stress ciated with being a person of color are also
perspective (Meyer 1995), whereby experiences potentially influential in the lives of the sexual
of stigmatization and discrimination, as well as minority couples (SAGE 2013).
differences in degree of “outness” are examined
as contributing factors in relationship well-being
(Green and Mitchell 2008; Otis et al. 2006). Families of Choice
A limited body of scholarship examines the lives
of older sexual minorities of color or LGBT While the previously described complexity of the
persons who are identified in some way (e.g., lives of LGBT persons offers a daunting array of
race, ethnicity, SES, geographic location) that challenges to consider when attempting to
goes beyond sexuality or gender identity (L, G, understand and appreciate the social identities of
B, or T) and/or sex. This dearth of information sexual minorities, the concept of “families of
about older LGBT racial and ethnic minorities choice” offers yet another important element.
living outside urban areas was captured in Huang Families of choice is a construct originally
et al.’s (2010) content analysis of the literature, attributed to Weston (1991), who sought to
92 M.D. Otis and D.A. Harley
understand ways that sexual minorities cope with Kentlyn 2011). Thus, to better understand these
the loss of family ties and relationships associ- relationships, below, we consider relevant
ated with rejection by their families of origin. In aspects of informal and formal care networks
her qualitative study of lesbians and gay men, separately, and then in relation to one another.
Weston found that many described a process of
recreating many of the dynamics typically asso-
ciated with traditional family models in their
relationships with intimate partners and networks Preparing to Address the Needs
of friends (many of whom also identified as of Elder LGBT Persons
sexual minorities). Because Weston completed
her study more than two decades ago, the role of In light of multiple sources of evidence indicat-
families of choice (similar to the social anthro- ing that sexual minorities experience myriad
pology concept of fictive kin) in the lives of forms of prejudice, discrimination, and even
LGBT persons holds a significant place in the victimization in healthcare settings, aging and
sexual minority-focused literature (Cronin 2004; LGBT advocates championed a call for action
Grossman et al. 2000; Hughes 2007). While the (Fredriksen-Goldsen et al. 2011). Other studies
development of families of choice offers both addressing the preparedness of communities of
positives and negatives in the lives of elderly care to meet the needs of elderly LGBT persons
sexual minorities (Croghan et al. 2014), in the found that only about one-third of the agencies
current context, we are particularly interested in contacted had provided their employees with any
how this socially constructed model of family form of training related to working with LGBT
relates to the multiplicity of LGBT identities and persons (Knochel et al. 2011), despite indications
the lived experiences of elderly persons. The that trainings addressing culturally competent
reader will find further discussion on the func- practice with sexual minorities have been shown
tions of families of choice in many chapters in to be effective (Crisp et al. 2008; Porter and
this book. Krinsky 2014). An examination of the content of
those trainings provides little evidence that those
who are developing and/or implementing these
The Convergence of Race, Gender, trainings have done so with any awareness of the
Sexuality, Age, and Care Networks relevance of the intersectionality of multiple
identities. Thus, despite some recognition of the
As we age, the quality and quantity of sources of needs of elder sexual minorities as a monolithic
emotional and instrumental support become entity, any particular needs that might be asso-
increasingly relevant in our lives. This is true, ciated with other aspects of elder LGBT persons’
regardless of one’s sexuality. Despite the uni- identities are treated as invisible or irrelevant.
versality of the development of aging-related An examination of the responses of
needs and concerns, for elder LGBT individuals LGBT-related educational practice in the helping
securing access to stable supportive and affirming professions offers a number of efforts (e.g.,
care networks offers unique challenges and identification of key competencies and content,
opportunities for concern (Addis et al. 2009; constructing comprehensive assessment, under-
Brennan-Ing et al. 2014). Care networks are stand and articulate ways in which agency, pro-
constructed of both formal and informal care- gram, and service policies marginalize and
givers and resources. Understanding the signifi- discriminate against LGBT older adults) to
cance of the multiplicity of identities both within increase the cultural competence of future human
and between formal and informal care networks service professionals (Fredriksen-Goldsen et al.
is highly relevant to efforts to secure positive 2014; Hardacker et al. 2014). In the process,
outcomes for aging LGBT persons (Hughes and students are learning about the unique challenges
5 The Intersection of Identities of LGBT Elders … 93
faced by sexual minorities, the essential role of elders may be particularly disadvantaged because
families of choice, and the ways that practitioners challenges that they face may be quite similar to
and agencies can create a more welcoming and those experienced by members of their family of
supportive environment and reduce barriers to choice—a network likely to constitute their circle
access (Van Der Bergh and Crisp 2004). And, of informal caregivers (Brennan-Ing et al. 2014;
while training in being a culturally competent Gabrielson 2011). Unlike their heterosexual
human service professional also challenges stu- counterparts, LGBT elders are likely to share
dents to think about other marginalized and commonalities with their informal caregivers, not
stigmatized groups (e.g., the elderly, persons of the least of which may be that they are of similar
color, immigrants), similar to the bulk of extant ages. Whereas many heterosexuals may be more
research, this training is generally constructed likely to have caregivers across multiple genera-
based on compartmentalized identity components tions (e.g., children, nieces/nephews), LGBT
rather than the intersectionality of multiple elders’ informal care networks often consist of
identities (Eliason et al. 2010). generational peers (Brotman et al. 2007; Fitzgerald
Clearly, formal communities of care are con- 2013; Shippy 2007).
fronted with substantial challenges in terms of Similarities in age may increase the likelihood
being responsive to the needs and well-being of a that LGBT elders and their families of choice
diverse population of elder LGBT persons. With may experience concurrent increases in support
this as a foundation, we can begin to consider and resource needs, and so additional strains may
ways we can develop practices, programs, and be experienced by elder LGBT persons of color
policies that are actually responsive to the needs (Glass and Few-Demo 2013; Lehavot et al.
of this heterogeneous population (Knochel et al. 2009), and sexual minorities who identify as
2011; Leyva et al. 2014; Portz et al. 2014). transgender (Fredriksen-Goldsen et al. 2011;
A number of recent studies in various fields of Siverskog 2014). For instance, research suggests
the helping professions offer insight into ways to that sexual minorities of color may be more
transfer this knowledge about the complexity of likely to experience isolation in old age due to
elder LGBT population into effective practice lower levels of integration into the LGBT com-
(Leyva et al. 2014; Porter and Krinsky 2014; munity throughout their lives (Lehavot et al.
Portz et al. 2014). For example, recent studies in 2009; Szymanski and Gupta 2009; Woody
community nursing practice have demonstrated 2014). This situation may be compounded by the
the effectiveness of developing new programs or greater likelihood that elder LGBT persons of
refining existing programs within the community color are living in poverty, lacking
through a process of active engagement with healthcare-related resources, and experiencing
future/current program participants and service higher rates of disease (Fitzgerald 2013;
users (Fredriksen-Goldsen et al. 2014; Orel Fredriksen-Goldsen et al. 2011). These chal-
2004). In other arenas, community-based lenges may be particularly salient for lesbians,
research has given way to models of cultural bisexual women, and transgender persons who
competence that offer some useful techniques for may often have lived much of their lives with
increasing availability and accessibility of very limited formal and informal support net-
resources (Boulder County Aging Services 2004; works (Fredriksen-Goldsen et al. 2011). Simi-
Moone et al. 2014; Rainbow Train 2003). larly, aging LGBT persons who are living with
Informal care networks. The preceding pages HIV/AIDS often have informal support networks
of this chapter offer a sampling of supportive evi- that are largely constituted by peers who are also
dence related to the relevance of various social living with HIV/AIDS (Cantor et al. 2009).
identity factors as influences on mental and phys- Notably, among LGBT elders living with
ical health and access to life-enhancing opportu- HIV/AIDS, persons of color are disproportion-
nities. When we consider the relevance of these ately represented (Auldridge and Espinoza
factors on families of choice, we realize that LGBT 2013).
94 M.D. Otis and D.A. Harley
(2005) identified practical suggestions to that end teams, Bowleg (2008) argues that we will garner
(see Table 5.1). the benefits of creative approaches to conceptu-
alization, measurement and analyses that better
capture the complex and fluid model of social
identity that is more representative LGBT lives.
Summary For example, while research is constrained by
our ability to develop measures that are reliable
People throughout the world have multiple and and valid indicators of the aspects of identity we
intersection identities. Other attributes include wish to consider, increasingly sophisticated sta-
racial and gender identities, sexual orientation or tistical methods offer techniques for simulta-
gender identity, belief systems, and aging. In this neously considering these factors in complex
chapter, we highlighted a seemingly obvious, yet ways more closely aligned with human experi-
often ignored, reality; elderly lesbians, gay men, ence (Stirratt et al. 2007). As we increase our
bisexuals, and transgender persons are made up ability to capture evidence of the intersectionality
of a complex and fluid combination of social of identity, sophisticated research will offer
identities that have been influenced by their life greater insight into how we might best develop
experiences, which continue to reconfigure as programs that avoid the compartmentalization of
they age (Abes et al. 2007; Azmitia 2014; identity components in favor of programs that
McCall 2005). The presence of ageism, sexism, holistically embrace the complexity of LGBT
racism, ethnocentrism, classism, and heterosex- elders’ identities (Bowleg 2008; Weber and
ism, among other sources of discrimination, has Parra-Medina 2003). Notably, Stirratt et al.
contributed to myriad inequities in the lives of (2007) acknowledge that while statistical analy-
LGBT elders. The consequences of those past sis allows us to model a multidimensional view
experiences, as well as current ones, are mani- of the intersectionality of identities, we are still
fested on a daily basis (Meyer 1995). As has challenged to capture the contextual variation
already been documented in a number of studies, that contributes to the fluidity of identities
we anticipate that these consequences will con- (Deaux and Martin 2003; Stirratt et al. 2007).
tinue to be manifested in differences in disease Environments that construct and nurture norms
rates, life chances and opportunities, and overall and values that support hierarchical views of
quality of life across the life course. Although we race, ethnicity, age, sex, and sexuality, among
are unlikely to eliminate these sources of inequity other targets for differential treatment, contribute
any time soon, our awareness of them should be to the development and maintenance of social
a catalyst for change (Crisp et al. 2008; Van Den identity. Consequently, we have further evidence
Bergh and Crisp 2004). of the critical role that advocacy for social
Intersectionality as a conceptual framework change can play in the elder LGBT persons lives.
for understanding the complex identities of
LGBT elders offers a useful heuristic tool with
which to build a bridge between the processes of
conceptualization and program development in Learning Activities
the helping professions. Intersectionality invites
us to consider not only the categories associated Self-Check Questions
with different aspects of identity but also the
impact associated with privileges and oppres- 1. Why is it important to understand why and
sions that correspond with those categories how people are more than the sum of their
(Garry 2011). As a body of knowledge, extant parts?
scholarship on intersectionality reflects the 2. What are some of the limitations of research
influence of many disciplines. As research moves on the LGBT population related to identity
forward with the guidance of multidisciplinary intersectionality within this population?
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Part II
Multicultural, International, and Select
Populations of LGBT Elders
African-American and Black LGBT
Elders 6
Debra A. Harley
Abstract
This chapter discusses issues relevant to African-American and
Black LGBT elders, including historical influences that frame these
issues, demographic and cultural contexts, and sociopolitical consider-
ations that impact policy and service delivery. This chapter describes the
cultural capital of the African-American community and examines Black
homo–bi–transphobia, the intersection of identities is presented along with
multiple oppressions and gay racism, and the ways in which historical
hostilities influence help-seeking by older African-American LGBT
persons are presented. Information is presented on health disparities and
services. The ways in which service models nationally, cross-culturally,
and multidisciplinarily work to promote effective interventions are
discussed. Finally, the impact of policy on African-American LGBT
elders is presented within the context in which by this population
perceives services.
Keywords
African-American Aging Black Health disparities Intersectionality
LGBT
is more inclusive and is comprised of diverse are further marginalized. In fact, Dworkin (2006)
groups of ethnicities and cultures, including refers to bisexual LGBT elders as the “invisible
those who immigrated from Africa and the of the invisible minority” because as they enter
Caribbean (Welch 2003) and may include mul- into romantic relationships, they sometimes
tiple heritage individuals with Black ancestry begin to identify as lesbian, gay, or heterosexual
(e.g., biracial, multiracial) who experience life and thus become invisible as a bisexual aging
and development differently from monoracial person (p. 36).
minority and majority individuals (Henriksen and
Paladino 2009). Persons of African descent may
identify as African-American, Afro-American,
Black Hispanic, Black Caribbean, Black Ameri- Characteristics of Older
can, and Black African (Lewis and Marshall African-American/Black Adults
2012). It is not uncommon for older
African-Americans to refer to themselves as African-American and Black older adults are
Colored, Negro (both terms were used deroga- heterogeneous, multidimensional, and diverse in
torily), or Black, which are terms that were their cultural identities and social affiliations. They
commonly used to refer to them for a substantial represent various levels of educational attainment,
portion of their lives. These terms emphasize socioeconomic statuses and financial stability,
skin color, not cultural heritage (Paniagua 2014). beliefs and values, marital status, sexual orienta-
In addition, while it is acceptable to use lesbian, tion and gender identity, and so forth. However,
gay, bisexual, and transgender or LGBT when older Black adults share commonalities. Overall,
referring to African-American and Black sexual older African-Americans are more highly edu-
minorities, it is an error to assume that all people cated than previous older generations. In 2013,
use these terms to describe themselves. The 71 % of African-Americans age 65 and older had
Communities of African Descent Resource Kit finished high school and 15 % had a bachelor’s
(2014, http://www.glaad.org/publications.coadkit degree or higher compared to the fact that only
) indicates that many individuals have adopted 44 % were high school graduates and 7 % had a
the term “Same Gender Loving” (SGL) or other bachelor’s degree or higher in 1998 (Administra-
terms that are more inclusive of both sexual tion for Community Living 2012). In employment,
orientation and race, and others may not identify many were overrepresented in low-wage posi-
with any terms at all. tions, resulting in economic insecurity in retire-
Elderly (age 65 and over) African-American ment. Social security benefits constitute the largest
and Black LGBT persons represent multiple share of income of older African-Americans, but
classifications of minority statuses, and each of are modest in size. Many Black elders grew up in
their identities dictates certain social positions in southern states during a time of legal segregation
society and further relegates them to positions of and overt discrimination, which imposed limits on
marginality. For many African-American and their earnings, educational attainment, poor living
Black LGBT elders, addressing issues of racism conditions, and health outcomes (Social Security
in general and within the LGBT community Administration 2011). A residential shift has
specifically, heterosexism and homophobia both occurred as to where the majority of older
internal and external to their ethnic group, emo- African-Americans currently live. The largest
tional isolation (Kuyper and Fokkema 2010), and percentage of Black residents per total population
internalized oppression (Szymanski and Gupta in 2012 was in the District of Columbia (51.6 %)
2009) have been the hallmark of their experi- and Mississippi (28 %), with the largest total
ences. Even with the distinction of being a number of Black residents in New York (3.7 mil-
minority (ethnic) within a minority (sexual ori- lion) (Centers for Disease Control 2010). Table 6.1
entation), transgender (see Chap. 14 in this text) lists the states with the largest percent of older
and bisexual (see Chap. 15 in this text) persons African-Americans.
108 D.A. Harley
Table 6.1 States with highest percent of older Table 6.2 Frequently occurring health conditions of
African-Americans older African-Americans
New York 320,127 African-Americans All older persons (%)
Florida 271,554 Hypertension (85 %) 72
Texas 241,356 Diagnosed arthritis (52 %) 50
California 237,924 Heart disease (26 %) 30
Georgia 236,463 Diagnosed diabetes (40 %) 20
North Carolina 210,772 Cancer (17 %) 24
Illinois 190,521 Adapted from Administration for Community Living
(2012)
Maryland 166,186
Administration for Community Living (2012)
Table 6.3 Leading causes of death for
African-Americans
In a study of self-rated health status in 2010– Heart disease
2012, 62 % of older African-American men and Cancer
61 % of women reported “good,” “very good,” or Stroke
“excellent” health status compared to 78 % for
Diabetes
White older men and 80 % for women. Positive
Unintentional injuries
health evaluations decline with age, with 67 % of
African-American men ages 65–74 reporting Nephritis, nephrotic syndrome and nephrosis
“good,” “very good,” or “excellent” health com- Chronic lower respiratory disease
pared with 52 % among those aged 85 or older. Homicide
Similarly, 65 % of African-American women ages Septicemia
65–74 reported “good” to “excellent” health, with Alzheimer’s disease
58 % at ages 85 or older (Administration for Adapted from Centers for Disease Control (2010)
Community Living 2012). African-Americans
have a disproportionately higher rate of chronic
illnesses and lower survival rates. The most fre- a 65-year-old African-American male was expec-
quently occurring health issues among ted to live another 15.9 years, compared with 17.7
African-Americans include AIDS/HIV, asthma, for White males, and a Black female at age 65 was
cancer, diabetes, heart disease, hypertension, expected to live another 19.3 years, a full year less
obesity, and stroke (Centers for Disease Control than a White woman. Comparatively, Latino males
2013). In addition, African-Americans have higher (additional 18.8 years) and Latina females (addi-
rates of HIV and AIDS, many of whom were tional 22 years) are expected to liver longer than
infected at a younger age and who are now living Black or White males and females (National
longer (Baker and Krehely 2012). A combination Center for Health Statistics 2013). Interestingly,
of health inequities and financial and cultural bar- these data do not disaggregate outcomes for LGBT
riers to receiving health care in later life negatively persons. The leading causes of death for all
affects the health of African-American older African-Americans are in Table 6.3.
adults. Table 6.2 compares the most frequently African-American LGBT elders face chal-
occurring conditions among older African- lenges similar to those in both the
Americans compared to all other older persons. African-American and the older adult populations
In comparison to White elders, Black elders have as a whole. Collectively, more than 68 % of
severe limitations in daily tasks requiring assis- African-American elders are poor, marginally
tance with housework, personal care, and prepar- poor, or economically vulnerable, are more than
ing meals. The life expectancy for Blacks, at any one and a half times as likely as White elders to live
age, tends to be lower than that for Whites. In 2010, below the poverty line, and more than one in four
6 African-American and Black LGBT Elders 109
identity development, internalized binegativity, sexual orientation and gender identity. Moreover,
and access to social and psychological resources most studies on sexual minorities do not include
(Isarel 2007). While LGBT people of color sufficient numbers of African-American or Black
experience the worst outcomes and receive the participants to perform adequate or sophisticated
least institutional attention, the aging concerns of statistical analyses. In addition, research on
LGBT of color are virtually absent in national LGBT African-Americans focuses on urban
policy discussions on aging health and economic populations and ignores those in rural setting or
security (Auldridge and Espinoza 2013). Because smaller cities (Deblaere et al. 2010). For addi-
of the limited research on LGBT elders of color, tional information on LGBT persons in rural
there is reliance on the literature concerning settings, the reader is referred to Chap. 25 in this
LGBT elders in general, from which information text. LGBT persons in urban areas have the
is glean about African-American LGBT elders. privilege of anonymity, access to more services
However, additive research for and supports, and the opportunity to belong to an
African-American LGBT should be avoided LGBT community. The language used in many
because it does not equal research applicable to research studies present another barrier to
this group (Bowleg 2008). As author of this instrumentation design. Much of the terminology
chapter, I suggest that additive research may offer that is used is characteristics of the White LGBT
some comparative insight; however, should at community (e.g., “out”), which involves identi-
least approached with caution. fication by labels, whereas in Black culture, the
In advancing the research of LGBT persons of approach is more a use of descriptions.
African descent, Lewis and Marshall (2012) offer Researchers will need to develop measures that
several considerations. First, research on are consistent with indigenous structures in the
Black LGBT populations should not attempt to Black community. Finally, limited research
separate the various aspects of the individual’s exists that examines African-American LGBT
identities into mutually exclusive categories and issues and concerns across the life span (Harley
expect to understand their experiences. Second, et al. 2013).
research must incorporate questions of the par-
ticipants that do not force them to respond to
items as to which identity is more important,
which identity causes more stress, or rank iden- Cultural Capital
tities in order of concern on a daily basis.
Questions such as these assume an additive value The African-American community is known as a
to the multiple identities, and further marginal- collective society that provides support and ref-
izing as opposed to an intersecting relationship uge to its people. The cultural characteristics of
among the identities (Bowleg 2008; Lewis and the community consist of strong kinship bonds,
Marshall). According to Wheeler (2003), valuing education, strong religious orientation,
researchers must realize that the intersecting high achievement orientation, strong work ethic,
identities of sexual orientation, gender, race, and self-reliance, and adaptability of family roles
ethnicity are more likely to be geometric rather (Brown Wright and Fernander 2005). Table 6.4
than additive. Finally, Afrocentric theorizing, consists of value characteristics of the
which has “secured its own identity among African-American community. Homosexuality
dominant Eurocentric thought” (p. 13), must stop and nonconforming sexual identity are largely
being neglectful of prevalent sexual realities in considered incompatible with values in the Black
African-American culture. community. Lewis and Marshall (2012) suggest
All too often, research methodologies on factors that may influence the attitudes and per-
African-Americans and Black LGBT populations ceptions among Black people about LGBT per-
involve a comparison to White LGBT groups, sons of African descent, including racism and
with whom they share few similarities beyond ancestral baggage (i.e., rejection by some in their
112 D.A. Harley
through involvement in the Civil Rights Move- within the Black community about attitudes and
ment. On April 1, 1998, in the Chicago Tribune, behaviors toward their elders. For example,
Coretta Scott King acknowledged the role of elders in the Black community are increasingly
sexual minorities stating, “gay and lesbians stood targets of violence and crime, mistreatment, and
up for civil rights in Montgomery, Selma, in assault. This shift in attitudes toward
Albany, Georgia and St. Augustine, FL., and African-American elders must be placed within a
many other campaigns of the Civil Rights culturally sensitive context and considered
Movement. Many of these courageous men and alongside culturally specific risk factors (Teaster
women were fighting for my freedom at a time et al. 2014). For example, in the
when they could find few voices for their own, and African-American community, a single incidence
I salute their contributions.” Although the rate of of yelling or hitting an elder is not viewed as
homophobia and heterosexism is high in the Black elder abuse, whereas physical abuse is extreme
community, especially in the Black Church abusive behavior. Extreme abusive behavior
(which is discussed later in this chapter), most toward elders is considered as unacceptable in
African-American LGBT persons indicate that the Black community (Tauriac and Scruggs
they still find more support and refuge in the Black 2006).
community, especially against the tyranny of African-American elders hold the distinction
racism in the White gay community (Boykin of being the family historian. The elders continue
1996; Green 1994; Savage and Harley 2005). For the oral tradition of passing on cultural meaning,
African-American LGBT people, there is “a per- legacy, and knowledge. Within the Black com-
ceived link that connects its members regardless munity, elders are not referred to as old, but as
of other differences that might also exist” (Moore wise, illustrating that they have reached the “age
2010, p. 17). In fact, some researchers suggest that of wisdom.” Although aging is associated with
African-American lesbians, having learned to lived experience, chronological age is not the
handle their ethnic minority status, have devel- only criterion for ascension into the “age of wis-
oped a great deal of resilience and personal dom.” The experience that one has accumulated
strength and may be better equipped to also handle allows one, especially women to gain this wis-
their status as a sexual minority (Cooper-Lewter dom. Experience may include emotional and
2007; Dibble et al. 2012; Hall and Fine 2005). Yet, spiritual support, information, advice, and ser-
gender discrimination is not equal for LGBT vice. Old age for Black women is a matter of the
persons in the Black community. Lesbians often functions they carry out (e.g., teaching values,
face disproportionately more ridicule in the Black convening the family on certain occasions, reli-
community, and based on their multiple gious role model). Thus, wise women gain pres-
subordinate-group identities, Black lesbians have tige and power, and important matters are brought
“intersectional invisibility: as targets of sexism, to them (Brown Wright and Fernander 2005;
heterosexism, homophobia, and racism within the Peterson 1990). Peterson summarized the
dominant culture and the Black community” important role of older Black women in the
(Purdie-Vaugns and Eibach 2008, p. 377). family and church, “they move beyond the
Views Held About Elders. From a cultural potential constraints of class, money and blood
perspective, elderly African-Americans are rev- relationships to reinforce cultural values of the
ered and entitled to respect within the importance of children, the significance of fictive
African-American community, and a position of kin, the problem of clinging to possessions and
age carries with it a high level of cultural capital the wisdom derived from lived experience”
(Harley et al. 2014). Ageism is not a prevalent (p. 227). Given that the family and church are
characteristic in the Black community; however, considered to be the two most important institu-
it is in the gay community, especially with regard tions in the Black community and a high degree
to physical attractiveness. However, the reader of respect for elders, the question is raised, what is
should be aware of some generational changes the role of LGBT elders within these institutions?
114 D.A. Harley
Deutsch (2006) suggests that through civilized that of other non-white groups because of the
oppression (the experience of repeated, wide- existence of a large African-American population
spread, systematic injustice), Black LGBT per- and the complexities of race relations” (p. 428).
sons receive unequal treatment, are relegated to Black immigrants may conform more to seg-
invisibility, and are silenced, condemned, mented assimilation (Portes and Zhou 1993) in
shamed, and forbidden from participation in which they take three paths of adaptation: (1) the
activities afforded to heterosexual couples. White middle class, (2) identify with the Black
Acculturation and Assimilation Issues. underclass, and (3) carve out a path by deliber-
Numerous definitions of acculturation exist to ately retaining the culture and values of their
explain the multifaceted ways in which changes immigrant community. Frequently, older Black
occur at the group and individual level. Riva immigrants and subsequently generations take
(2010) offers the definition of acculturation as “a the third path, relying on their ethnic communi-
dynamic process of change that individuals ties for social capital, employment leads, and
undergo as they interact with and adapt to a new relief from discrimination. Segmented assimila-
or different cultural environment; it is an inter- tion allows the individual to maintain an ethnic
active process that occurs along different life identity as an invaluable resource (Lacy).
domains at different rates of change” (p. 331). The question of whether Black LGBT elders
Inherent in the practice of acculturation is the more acculturated because of their sexual orien-
concept of inequality and the lack of mutual tation and gender identity is not known. The
respect that the dominant culture tends to project, extent to which Black LGBT elders are accul-
consciously or unconsciously, on racial minori- turated or assimilated has not been studied, and,
ties (Wilson 2005). Assimilation is viewed more at best, one can glean from the research on
as voluntary aspiration to identify and integrate acculturation of African-Americans in general.
with and adapt to the ways of the dominant, Furthermore, the reality may be that neither
Anglo-Saxon mainstream. The intent of present- acculturation nor assimilation is the issue, but
ing information on acculturation and assimilation more one of cultural immersion in which indi-
is not to debate if Black LGBT elders are one or viduals reject mainstream culture and their
the other, but rather to illustrate that acculturation emotional needs are met exclusively in their
and assimilation involve changes in both values ethnic or in the gay community. Where one lives
and behaviors related to identity (Schwartz et al. may be a major determinant of cultural immer-
2007). Cultural identity is the sense of belonging sion. For example, LGBT persons who live in
that one derives from membership in groups that urban areas may immerse themselves in LGBT
provide knowledge, beliefs, values, traditions, communities; however, this is not an option
attitudes, and ways of life (Jameson 2007). available to most LGBT people who must live in
Although acculturation and cultural identity are many worlds/cultures and communities.
not totally uncorrelated, an individual who is
highly acculturated can have a high level of ethnic
identity or a low level of ethnic identify (Moore
et al. 2010). It is important to point out that race Black Homophobia, Biphobia,
and culture are not synonymous. Transphobia, and Heterosexism
For Black people in America, the assimilation
model is most useful for understanding voluntary African-American LGBT elders often face social
immigrants, not native-born Black who entered stigma in the Black community. Historically, the
the USA involuntarily who were selectively Black community view homosexuality as a
incorporated through enslavement, coercion, and characteristic of European culture, and they deny,
Jim Crow laws (Lacy 2004). Wamwara-Mbugua or at least overlook its existence in their own
et al. (2006) contend “the experience of Black community. Many in the Black community
immigrants in the United States is different from believe that homosexuality and any form of
6 African-American and Black LGBT Elders 115
alternative sexual identity is a strategy to destroy heterosexual marriage. The result of this assimi-
Black people and the Black family, is a moral lation is that Black people have to live with the
sin, and goes against the values of the Black contradictions of this restricted sexual system by
community. The Black community values pri- repressing or closeting any other sexual or erotic
vacy, which is in contrast to the White LGBT feelings or desires. However, the whole
community’s value of “coming out.” Strong African-American community is not homophobic
family and kinship ties stress that marriage and or heterosexist, and the “accusation of homo-
family always come first, and the family may phobia” directed toward the whole Black com-
present a united front against the LGBT member munity is inaccurate (Boykin 1996, p. 185), and
or disown him or her, resulting in a loss of the studies on the African-American community’s
sense of unity that helps the LGBT member form attitudes and perceptions of sexual minorities
cultural and/or race identity (Savage and Harley continue to unfold. Nevertheless, it cannot be
2005). The National Black Justice Coalition denied that the existence of homophobia has
(2009) found that while statistically always been a reality in Black life (Hooks 2001).
African-Americans are more disapproving of Today, the invisibility of homosexuality in the
marriage equality for sexual minorities, these Black community remains prevalent and is syn-
attitudes do not arise from simple homophobia; onymous with its own form of “don’t ask,”
rather, they come from their diverse experiences, “don’t tell.” Despite the sometime disapproving
opinions, and beliefs and are influenced by fac- attitudes and religious condemnation, the
tors such as geographic location, age, class, and majority of Black LGBT individuals remain in
other markers of differences. Often, this moral predominantly Black communities and social
disapprobation is linked to the pulpit and rhetoric contexts and negotiate daily with family and
of the conservative right that suggests that the community. They remain because they trust in
gay rights movement has appropriated the civil racial solidarity and racial group membership
rights philosophy and incorrectly equated racial (Moore 2010), which often provide protection
oppression with oppression based on sexual ori- from racial discrimination in the larger society.
entation and gender identity (National Black Religion and Spirituality in the Lives of Black
Justice Coalition). As a historically oppressed Elders. The Black Church is recognized as the
group, African-Americans have placed great oldest and one of the most influential institutions
importance on reproductive sexuality to ensure of the Black community. Both religion and
continue existence of the group in face of racist, spirituality are vital components of
genocidal practices by the dominant White group African-American racial and cultural activities
(Greene and Boyd-Franklin 1996). Thus, Black (Harley 2005a). Laderman and Leon (2003)
LGBT individuals are seen as a threat to the suggest that religion supplies perhaps the best
social structure of the family (Battle and Bennett vantage point from which to describe the devel-
2000; Boykin 1996; National Black Justice opment of African-Americans in relationship to
Coalition 2009). themselves, others, and the larger universe.
Research suggests that homophobia is greater National research data indicate that approxi-
in the African-American community than in the mately 97 % of African-Americans identify some
European American community (National Black religious affiliation (Pew Center 2006). The
Justice Coalition2009; Savage and Harley 2005; church is more than a place of worship and fel-
Stanford 2013). The existence of homophobia lowship; it is a place of advocacy, empowerment,
among Black people in America is largely personal and psychological support, socializa-
reflective of the homophobic culture in which we tion, emotional outlet, social status, political
live (Clarke 1999). According to Clark, Black action, cultural affirmation, and connection to the
Americans assimilated the Puritan value that sex community (Evans and George 2008; Loue
is for procreation, occurs only between men and 2014) and is essentially impossible to separate
women, and is only valid within the confines of from Black life for most African-American
116 D.A. Harley
more frequently than Whites and are less sup- condemnation from churches, they often esteem
portive of gay rights (Pew Center 2006). personal faith in a higher power other than their
According to Douglas (2006), “the Black Church religious institutions, and spirituality maintains
community, even with all of their diversity, the their formal connections to religious establish-
Black Church people are regarded as strikingly ments (Ward 2005). While homonegativity is not
similar in their attitudes toward non-heterosexual unique to Black Churches, it has dire psychoso-
sexualities. Black Church people are viewed as cial consequences for Black LGBT persons
not simply homophobic but more homophobic (Jeffries et al. 2008).
than other populations of society” (p. 12). The presence of homophobia and heterosex-
Although the majority of Black people in ism are persistent in the Black Church and Black
America regard themselves as Christians, grow- community as a whole, but not in all Black
ing numbers are counted among Islamists, Bud- Churches or all of the Black community. Clark
dhists, Jews, and agnostics (Robinson-Wood (1983, 1999) warned that the “accusation of
2009). homophobia” should not be directed toward the
In a study of Black lesbian spirituality, Betts whole African-American community. Neverthe-
(2012) found that African-American lesbians less, the continual stance of many Black Chur-
continually strive for a sense of spiritual whole- ches to both condemn homosexuality and to deny
ness. While the lesbians in Betts’ study had no fellowship to LGBT African-Americans appears
difficulty connecting to Black culture, they did to be in direct opposition to the mission of reli-
report difficulty connecting with their initial gion to be accepting of all people. Moreover,
religious roots within the churches of their such opposition contradicts beliefs and values of
childhood and actively sought alternative spiri- the Black community as collective and commu-
tual outlets. Other studies suggest that for certain nal (Harley et al. 2014). According to Greene
populations of Blacks, perceived religiosity is (2000), because of the importance of family,
related to faith healing (Harley 2005b; Mitchem community, and church as buffers against racism
2002; Lawson and Thomas 2007), and elderly and as sources of tangible support, homophobia
Black women have higher religiosity (e.g., in the Black community often leaves LGBT
prayer, giving thanks to God, reading the Bible, persons feeling vulnerable and less likely to
going to church) than Black men (Taylor et al. reveal their sexual orientation or gender identity.
2004). Black people who may not go to church
or even have a church home may still pray to the
Lord when confronted with difficult times
(Boyd-Franklin 2003). Even Black persons who Intersection of Racial/Ethnic
denounce religiosity often note religious ideol- and LGBT Identities
ogy as important to their moral beliefs and
practices (Dyson 2003; Ward 2005). With the Frequently, Black LGBT persons are challenged
importance placed on religion and spirituality by to choose between their sexual and racial iden-
African-Americans and their disapproval of tities. Black LGBT persons are confronted with a
homosexuality, transgender, and nonconforming dichotomy of allegiances. Meyer (2010) argues
gender persons, Black LGBT persons may be that the intersection of racial/ethnic and LGBT
denied the sense of community and support identities contain several basic truths. First,
afforded to others within the community when Blacks and other racial/ethnic minorities in the
the church denies them fellowship. Many LGBT USA do not form a different culture; they are
African-Americans often face the same ignorance surrounded, contribute to, shape, and are affected
within the very institution that has for so many by mainstream American culture; thus, the notion
been the centerpiece of their community as they of a gay community is not alien to them. Second,
face from the larger society (Harley et al. 2014). many LGBT of color in the USA were raised in
Because many LGBT persons have encountered the same culture as their White counterparts.
118 D.A. Harley
Third, among immigrants to the USA, many tend result of their sexual minority status, (b) Black
to acculturate and adopt local sociocultural sexual minorities who see their self-interests
norms. Finally, the gay liberation movement has linked to those of other Blacks use cultural ref-
had a great impact globally on cultures. Although erences to connect their struggles to historical
Meyer acknowledges that local cultures matter in efforts for Black equality and draw from
the analysis of LGBT populations and that sub- nationalist symbols and language to frame their
culture differences and clashes with White political work, and (c) they believe that increas-
American culture exist, a fundamental challenge ing their visibility in Black spaces will promote a
to these truths is that they fail to account for greater understanding of gay sexuality as an
social and historical contexts in which a myriad identity status that can exist alongside, rather
of cultural variables affect the lives of elderly than in competition with race. Conversely, Bates
African-American LGBT persons. However, this (2010) found African-American lesbians who
is not to say that elderly Black LGBT persons were once married and bisexual women expres-
cannot have several, even seemingly, conflicting sed difficulty assimilating into the
identities while maintaining a coherent sense of African-American community since coming out.
themselves (Meyer 2010; Singer 2004). In fact, Each of these studies focused on young to
Purdue-Vaughns and Eibach (2008) use the term middle-aged LGBT.
intersectional invisibility to refer to the failure to As is the case for any individual or group, the
fully recognize people with intersecting identities intermingling of identities for older Black LGBT
as members of their constituent groups. Because persons represents a degree of integration. Iden-
Black LGBT persons do not fit the prototype of tity models conclude with integration of sexual
their constitute group, they are likely to experi- identity into the personality as a seamless whole,
ence social invisibility (Lewis and Marshall when in reality one’s social circumstances
2012). change constantly and dictate priority of aware-
Gibson (2009) explored the behavioral and ness and identity importance (Eliason and
psychological strategies used by lesbians of Schope 2007). For example, depending on what
African descent to negotiate relationships within is occurring in society, for Black lesbians, the
their families of origin while simultaneously race may be the priority in the face of discrimi-
developing and maintaining an affirmative les- nation. Yet, in another situation, the murder of
bian identity. The results showed that lesbians of sexual minorities may pose greater importance
African descent negotiated multiple identities of than race. And still, ageism may be the salient
race, sexual orientation, disability, and gender factor. The point that Eliason and Schope make
through application of several identity manage- is that all people have multiple intersecting
ment strategies (e.g., cultivate LGBT community identities, and while people seek validation of all
and support systems, educate others about les- parts of their identity and not just one facet, full
bian identity, maintain visibility, and engage in integration all the time is unrealistic.
LGBT activism), including ways to manage Multiple Oppressions. African-American
conflicting loyalties between the community and LGBT elders, unlike their younger counterparts
Black community without any loss of significant who experience their young adult development
relationships and cultural ties. within a dual identity or bicultural framework,
In a similar study, Moore (2010) examined experience their development through three dis-
strategies that Black LGBT people used in Black tinct cultural perspectives: race/racism,
environments to proclaim a gay identity that is homo-prejudice, and aging. African-American
simultaneous with a Black identity. Moore found LGBT persons tend to construct their experi-
three distinct features: (a) Black gay protest takes ences in two distinct minority environments: (a) a
on a particular form when individuals are also racial minority within the dominant White cul-
trying to maintain solidarity with the racial group ture and (b) a sexual minority within the main-
despite the treat of distancing that occurs as a stream heterosexual culture (Burlew and Serface
6 African-American and Black LGBT Elders 119
2006). Racial minority status appears to be a marginalized populations (Sanders 2010). The
significant variable in determining the quality of exposure to the tri-vector of racial and sexual
life of people of color in the USA (Wilson et al. orientation microaggressions, and ageism are
2001). It is through the intersection oppressions likely to manifest as health-related problems and
of race and sexual identity that African-American mental health issues.
and LGBT persons experience multiple oppres- In a review of the intersections of sexual
sions. On the one hand, they are subjected to orientation, race, religion, ethnicity, and heritage
racism and oppression from mainstream society, languages, Van der Meide (2002) found a com-
and on the other hand, they face prejudice mon theme; the assumption by developed Wes-
because of their sexual orientation from main- tern nations that non-Western/non-White
stream heterosexual society of all races (Burlew communities and cultures are more homophobic
and Serface). In addition, African-Americans/ than the dominant Western/White communities.
Blacks are subjected to “colorism,” a differential The basis of this assumption is not one of
treatment based on skin hue, in which individuals research, but rather one of simplistic racist and
with lighter skin color are seen as more intelli- ethnophobic assumptions about the lack of
gent or attractive (Kelly and Greene 2010). sophistication or the cultural and religious
A lifetime of discrimination (e.g., racial backwardness of non-Western/White cultures. In
inequality, anti-LGBT policies) has adversely this review, Van der Meide (2002, p.9) incor-
affected African-American LGBT elders (Francis porates an observation by Gunnings that:
and Acey 2013).
Too often White folk in the lesbian and gay
Gay Racism. Experiences of racism by ethnic community want to latch on to statements or inti-
minority LGBT people in the White LGBT mations that the Black community is more
community are well documented in the USA and homophobic maybe because it releases them from
internationally (Asanti 1999; Boykin 1996; some of the hard and painful work of dealing with
their racism, personally as well as organizationally.
Brown 2008; Harley et al. 2013; Loiacano 1989; Perhaps, it allows them to avoid becoming multi-
Plummer 2007; Stansbury et al. 2010). Smith cultural and multiperspectival.
(1999) asserts that the racism that has pervaded
the mainstream gay movement only intensifies The descriptive (tell how people in a group
the perceived divisions between Blacks and supposedly behave) and prescriptive (tells how
LGBT persons. The majority of African- certain groups should think, feel, and behave)
American LGBT persons are exposed to racist beliefs (Fiske 1993) continue to shape the part-
and heterosexist messages in their daily lives, nership between discrimination and prejudice,
and they frequently internalize these negative allowing them to maintain a constant course in
subordinating the minority race status and pre-
messages about being both a Black person and a
sexual minority person (Szymanski and Gupta serving the majority race privileges.
2009). According to Parham et al. (1999), “irre-
spective of how one comes to understand the
concept of racism, there is little doubt that its World View and Historical Hostilities’
origins, promotion, and continuation are Influence on Help-Seeking
anchored in the context of how Whites relate to
African-descent people and other people of color African-American elders and their LGBT coun-
on individual, institutional, and cultural levels” terparts tend to have a high degree of suspicion
(p. 134). It has and remains necessary to dehu- of institutions and healthcare institutions because
manize African ancestral people and to cast them of becoming of age in the 1930s, 1940s, 1950s,
as inferior beings to enforce White, heterosexual and 1960s when institutional bigotry, hatred, and
superiority (Gibson 2009). In Cuba’s LGBT stigma were commonplace. They lived during an
community, lesbians, especially Black lesbians, era of “forced segregation and enforced Jim
continue to be one of Cuba’s most socially Crow etiquette” (Cooper-Lewter 2007, p. 214).
120 D.A. Harley
Elderly Black LGBT persons may exhibit a dis- phenomenon, dependent on context” (Eliason and
proportionate rate of historical hostility (Vontress Schope 2007, p. 21). The impact of dual or mul-
and Epp 1997) relating to past dealings with tiple identities of race, age, class, gender, gender
Whites and systems of oppression and discrimi- identity, and sexual orientation intersects in
nation. For example, the Tuskegee Syphilis diverse ways, which depending on rigidity of
experiments in which Black men were infected labels allows adaptations to changes in one’s
with and untreated for syphilis and allowed to die cultural and sexual landscape (Rust 1996).
during the 40-year study remain fresh in the Frequently, African-American LGBT elders
minds of many African-American elders. The are cautious about where they seek services
United States Public Health Service (USPHS) whereas to avoid discrimination (Redman and
designed the Tuskegee Syphilis Study, and dur- Woody 2012). Table 6.5 identifies some con-
ing its existence, the men in the study were not cerns LGBT elders have about healthcare envi-
provided with treatment and, in some instances, ronments, which are magnified twofold for
were prevented from obtaining treatment (Loue African-American and other ethnic minority
2014). The Tuskegee study is a reminder that of LGBT persons. African-Americans across the
how Black people may be at risk from the age spectrum tend to underuse mental health
medical community and it serves to increase services to the exclusion of needed mental health
distrust of health professionals and researchers, specialist for the following reasons: (a) reliance
as well as decrease participation of Blacks in on personal connections such as family members,
clinical trials. The historical devaluation of Black friends, and other community members, (b) reli-
bodies (Lemelle 2003) continues to produce ance on primary care providers or other
significant negative health outcomes of non-specialists, (c) dependence on emergency
African-Americans. Even with social transfor- departments for diagnosis and treatment of
mation, African-American LGBT elders continue mental health concerns, and (d) use of folk
to possess vivid memories of institutional and remedies, faith leaders, herbalists, and other
structural discrimination associated with race, nonstandard modes of care (Primm and Lawson
gender, gender identity, socioeconomic status, 2010). Regardless of race, studies consistently
and sexual orientation (Francis and Acey 2013). find that LGBT persons have negative interac-
Like for all LGBT elders, Black LGBT elders tions with their healthcare providers and are less
had the additional experience of coming of age at likely to disclose their sexual identity and
a time of acute homophobia at every level of behavior (Bernstein et al. 2008;
society (Funders for Lesbian and Gay Issues Fredriksen-Goldsen et al. 2011; Funders for
2004) and being medically classified with a Lesbian and Gay Issues 2004; Mayer et al. 2008;
psychiatric disorder and being subject to criminal Somjen 2009). Discrimination related to
charges because of their sexual orientation race/ethnicity and sexual orientation or gender
(Woody 2012). Until 1973, the American Psy- identity can be considered a social risk for Black
chological Association (APA) considered elderly LGBT persons’ health and well-being
homosexuality to be a mental illness. Research suggests that older LGBT persons
The reaction of individuals with distrust toward are generally well adjusted (Graham 2011);
an individual or group who have acted in a dis- however, compared to the general population,
criminatory way toward them is commonplace. In gay and bisexual men are twice as likely to have
general, LGBT persons mistrust heterosexuals; mental health concerns, and lesbian and bisexual
LGBT persons of color may distrust White LGBT women are three times as likely (Grant et al.
individuals; transgender and bisexual persons 2009). However, the number of Black LGBT
may distrust gays and lesbians; lesbians may participants in theses studies is low. Although
distrust gay men; older LGBT persons may dis- Black older adults have lower rates of psychiatric
trust young LGBT individuals; and so on. “The illness, including depression, than older White
oppressor and the oppressed are changing social adults (Jimenez et al. 2010), substantial
6 African-American and Black LGBT Elders 121
ethnic/racial disparities exist in the care given to Mayo explains that for people who are situated at
Black older adults with depression (Shellman the social margins do not necessarily internalize
2011). In comparison with other groups, Black their exclusion or devaluation, but instead
older adults are less likely to seek help from embrace differences as a source of strength and
mental health providers, are less likely to be sometimes as a source of empowerment. The
identified as depressed, and often delay or fail to application of positive marginality to Black
seek treatment until their symptoms are severe LGBT elders and their tri-vector of microag-
(McGuire and Miranda 2008; Neighbors et al. gressions, one can deduce that they may dem-
2007). Nevertheless, a lower number of onstrate more positive psychosocial adjustment
African-Americans in general seek mental health than their younger, heterosexual, and White
services. There are several explanations for lower counterparts. In fact, Hall and Fine (2005) assert
rates of service participation, including that positive marginality is the cornerstone of the
culture-specific beliefs about the causes of men- Black experience that provides psychological
tal illness, lack of awareness of mental health and political tools that teach survival skills for
services, poverty, stigma, inadequate insurance successive generations.
coverage, lack of access to transportation, lack of
culturally relevant approaches, and mistrust of
service providers (Bailey et al. 2009; Connor
et al. 2010; McGuire and Miranda 2008; Morrell Healthcare and Service Disparities
et al. 2008). Even after entering the mental
healthcare system, older Black adults are less Older LGBT adults in general are an at-risk
likely to receive quality care. population experiencing significant health dis-
Another potential explanation for underutili- parities (Fredriksen-Goldsen 2011), which is
zation of mental health services by older Black further exacerbated for ethnic minorities. Older
adults is the notion of “positive marginality” adults in the general population and among
(Mayo 1982), which suggests that for those who LGBT groups tend to be the most frequent users
exist and live in the margins of social arrange- of healthcare services in the USA. For older
ments result in strength, resilience, and vibrancy. LGBT adults, health concomitants of aging may
122 D.A. Harley
be exacerbated by factors associated with gender to place attention on the special health needs of
and sexual orientation (Institute of Medicine LGBT persons. Moreover, work has been done
Committee on Lesbian, Gay, Bisexual, and to increase the importance of understanding and
Transgender Health Issues 2011). Historically, eliminating health disparities across race cate-
disadvantaged groups (e.g., ethnic minorities, gories, and little work has focused specifically on
LGBT adults) within the older adult population the healthcare needs of ethnic minority LGBT
continue to have higher levels of illness, dis- persons (Wilson and Yoshikawa 2007).
ability, and premature death (Fredriksen-Goldsen According to Wilson and Yoshikawa, “most
and Muraco 2010). LGBT people of all ages are attention to health disparities has been placed
much more likely than heterosexual adults to either on the needs of ethnic minorities or
delay or not seek medical care (Institute of LGBTs, but not the needs of persons who belong
Medicine Committee on Lesbian, Gay, Bisexual, to both groups” (p. 609) an, certainly not on
and Transgender Health Issues 2011) because those belonging to both groups who are elderly.
they usually encounter two unique obstacles in For all adults, later life is known as a period of
navigating healthcare, social, and human service: both growth and decline, with studies over-
homophobia and heterosexism. Fear of discrim- whelmingly focused on the latter (Institute of
ination causes LGBT elders five times less likely Medicine Committee on Lesbian, Gay, Bisexual,
than non-LGBT seniors to access services and Transgender Health Issues and Research
(Funders for Lesbian and Gay Issues 2004). In 2011), yet we know very little about the health-
addition, LGBT seniors of color and transgen- care needs of African-American LGBT elders
dered elders feel unwelcome even among other and health issues specific to aging, disability,
LGBT elders, and many view LGBT elder pro- health, and sexuality (Comerford et al. 2004;
grams as hostile to their participation (Plumb and Dibble et al. 2012). Given the projected growth
Associates 2003/2004). Navigating those ser- in the number of older African-Americans,
vices can be further complicated by the degree to numerous questions are raised about the health
which LGBT elders self-disclose to others status, quality of life, and service delivery for
(Maccio and Doueck 2002). Racial and ethnic Black LGBT elders. Some of the most urgent
disparities in health care exist in the broader questions are as follows: Why are ethnic minor-
historic and contemporary social and economic ity LGBT populations at heightened risk for poor
inequality and in evidence of persistent racial and health outcomes compared to other populations?
ethnic discrimination in numerous sectors of Why are ethnic minority LGBT persons less
American society (Institute of Medicine of the likely than White LGBT persons to receive
National Academies 2003). African-Americans high-quality health care (Wilson and Yoshikawa
receive necessary health care and mental health 2007)? What are the long-term effects of dis-
intervention at half the rate of their White crimination, oppression, and homophobia on the
counterparts (Neighbors et al. 2007). These lives of ethnic minorities?
inequities create additional barriers that do not Ethically, only culturally appropriate testing
exist for most White heterosexual older adults. instruments and procedures should be used in the
African-American and Black LGBT persons assessment of people of color. In addition, mea-
are at risk for a variety of poor physical health sure and scale used must be psychometrically
outcomes. Over the years, data collected have reliable and valid and culturally sensitive within
consistently demonstrated significant health dis- the LGBT communities. Disparities in service
parities between minority and non-minority delivery for African-American LGBT elders may
groups in the USA. With the passage of the also be as a result of cultural bias or culturally
Health Disparities Act, increased visibility and insensitive assessment instrument and measures.
funding went to interventions created to address Clinicians serving Black LGBT persons should
health disparities between persons of different be familiar with instruments or scales recom-
racial/ethnic groups; however, the act neglected mended to assess racial/ethnic identity,
6 African-American and Black LGBT Elders 123
acculturation, acculturative stress, sexual meet the needs of LGBT elders of color; thus, an
identity/orientation, and internalized homophobia ethno-specific system appears to be more
(Chung 2007). When assessing and treating older appropriate. Mainstream services are not always
Black LGBT persons, circumstances that are welcoming to Black LGBT persons. It is
unique to them should be part of the protocol. important to recognize that treating people in the
Consideration should be given to the impact of same way does not account for difference and in
ageism, lifelong discrimination, and racism. In treating people equally may tantamount to dis-
addition, the role of sexism becomes more per- criminatory treatment. In essence, treating
tinent as a covariant of ageism and racism for everyone in a uniform way ignores differences.
African-American/Black LGBT elders because The aim should be to treat every individual with
of cultural gender role expectations, as well as the same level of dignity and respect (Social Care
the value (lack of) that society places on women Institute for Excellence [SCIE] 2011).
of color. Ethno-specific programs and services do not
imply an acceptance of the need for separate
services for all ethnic elderly LGBT. Neverthe-
less, moving beyond the controversy over the
Models for Service pluralistic versus assimilative nature of American
society, a pluralistic or multicultural model
The provision of services to African-American allows for inclusiveness. In the post-separate but
and Black LGBT elders is based on theories, equal era, one of the primary objections to sep-
concepts, and methods, which have emanated arate programing is that if all ethnic groups
largely from Western countries and with pri- subscribe to a common core of American values,
marily White populations, despite the fact that it should be possible for ethnic groups to benefit
Afrocentric and culturally specific interventions from mainstream programming (Gelfand 2003).
have been recommended. Scholars from various Unfortunately, this oversimplification often
health and human services disciplines, including ignores the long-standing historical hostilities
psychology, counseling, gerontology, social (Gelfand 2003) that have existed among LGBT
work, medicine, public health, and others, have Black elders, as well as mistrust and justified
developed and advocated for alternate paradigms paranoia toward discrimination and microag-
and models to understand the realities in the gressions (Sue and Sue 2013) of which they are
contexts of people of African descent. In a study subjected.
of LGBT health and human services needs in According to Social Care Institute for Excel-
New York State, one reason that high rates of lence (SCIE), LGBT persons do not necessarily
barriers to care were reported is attributed to feel they need special treatment, but they do not
current LGBT-specific and general services that want to have to explain or justify their lives or
do not provide culturally sensitive services to the relationships; instead, they want to be in an
full range of people of color. environment in which service providers under-
Great emphasis has been placed on service stand issues related to LGBT persons and are
models being inclusive of all people. However, competent to work in an inclusive,
for LGBT populations, especially in mental anti-discriminatory way. For African-American
health services, substantial barriers exist because and Black LGBT elders, this sentiment becomes
of a care system that is completely unprepared to magnified with the addition of race and age.
deal with their needs. In addition, LGBT persons Thus, person-centered approaches are recom-
face harassment in general and participate mini- mended as a means of service delivery. The
mally in mental health programs, and they go off multiple and intersecting identities of
their medication, spiral down, and in a few Black LGBT elders can come into play when
months are back in the hospital. For these rea- designing person-centered services because they
sons, a specialized system of care is needed to have usually experienced homophobia,
124 D.A. Harley
transphobia, and racial discrimination in their from family members and fear of facing stigma
lives and have concerns of losing choice and and discrimination in the health and legal sys-
control over their care. For LGBT elders to have tems (Muraco and Fredriksen-Goldsen 2011). In
choice and control over their care and support, a study of African-Americans and White older
“they need to have accessible, sensitive main- Americans, Troxel et al. (2010) found that
stream services as well as the opportunity to get African-Americans were the most isolated.
support from specialist services” (SCIE, p. 3). Among older African-Americans, Black women
Another emphasis of service model is on are most likely to be socially isolated and to
cultural competency of service providers. Too possess the lowest amount of social support and
often, Black LGBT elders enter a system in capital, to not to have a source of reliable trans-
which they experience the tri-vector barrier to portation, to being limited in life space, to lim-
race and ethnicity, age, and sexual orientation iting activities for fear of an attack, and to not
and gender identity. In the USA, the Affordable being married (Locher et al. 2005). As a mar-
Care Act (ACA) may benefit LGBT populations ginalized group, social isolation might be inten-
in a variety of ways since it requires the devel- sified for African-American LGBT elders, who
opment of a culturally competent and diverse may be isolated from their racial community as
healthcare workforce that has expertise providing LGBT older persons and isolated from the
care to underserved populations such as the mainstream LGBT community as people of color
LGBT communities. The ACA prohibits insur- (Fredriksen-Goldsen et al. 2011). In response to
ance companies from denying coverage based on social isolation among LGBT elders of color,
pre-existing conditions, which would be benefi- GRIOT Circle developed an intervention pro-
cial to Black LGBT elders, of whom have many gram called Buddy-2-Buddy. The program pairs
chronic conditions (Fredriksen-Goldsen et al. elders who are homebound or in facilities with
2011). The ACA affords access to healthcare more active elders for visits and invites them to
services, which for older Black LGBT popula- join in activities. The objective is to promote
tions may provide consistency of care (e.g., a independence and self-reliance among LGBT
routine annual checkup) and health outcomes elders by countering isolation and restricted
(e.g., early detection, providers who are familiar mobility. Buddy-2-Buddy distinguishes itself in
with medical histories), remove barriers, and work with elders of color who are often reticent
foster trust in healthcare settings (American about discussing personal problems with strang-
Medical Association 2009). The reader is refer- ers or outsiders (http://www.asaging.org/blog/
red to Chap. 19 for additional information on the reducing-isolation-community-engagement-
impact of ACA on LGBT elders. service-model.pdf). In general,
Older adults disproportionately experience African-American populations, especially elders,
isolation. A complex set of circumstances and do not share their problems with outsiders
factors that exist at the individual, social net- because of a high degree of distrust and privacy.
work, community, and societal levels contribute Because of multiple medical and psychosocial
to isolation (Elder and Retrum 2012). Elder and issues among Black LGBT elders, a team
Retrum suggest that many disciplines, including approach or collaborative model in the treatment
sociology, psychology, social work, nursing, of persons from this age, race/ethnic, and sexual
public health, gerontology, medicine, social orientation/gender identity group should always
neuroscience, public policy, and urban planning, be used (Paniagua (2014). In addition to the cli-
have recognized isolation and offer approaches to nician, physician, or mental health professional,
isolation in older adults. There is extensive Vazquez et al. (2010) recommend the inclusion of
overlap across disciplines in how isolation social workers, cultural healer, at least a family
among older adults is conceptualized (see Elder member, nursing home of care facility adminis-
and Retrum 2012). LGBT elders have risk factors trator, and the religious leader (if requested by the
for isolation that are compounded by less support person and/or family as members of a
6 African-American and Black LGBT Elders 125
multidisciplinary team. Conversely, a continuum model as the core of the consolidated approach
of care is frequently used to classify services for offers Black LGBT elders an informal response
the elder in the USA (Gelfand 2003). This con- and referral system that they may trust. The more
tinuum entails moving from placing no restrictions service models that are available to deliver pro-
to becoming more restrictive. Gelfand explains gramming to African-American LGBT elders
that serious problems underlie the concept of the might increase their options to get assistance.
continuum of care because it does not represent the Community-based programs have proven to be
reality of American programs and services for effective with in the Black community.
elders. The continuum of care model is based on
the faulty assumption that elderly persons have
only one need at any one point-in-time. As men-
tioned previous in this chapter, elderly persons Policy Issues
have multifaceted needs, and these needs may be
extensive. Older persons in general and The role of gender and sexuality is increasingly
African-American LGBT elders specifically need critical to policy development and implementa-
a combination of services, and the components of tion. The Black Racial Congress has incorporated
these services may vary over time. gay rights issues as part of its agenda. One of
Finally, the Black community has a helping their principles, “Gender and sexuality can no
tradition and “being part of a unique community loner be viewed as a personal issue but must be a
has long dominated the social consciousness of basic part of our analyses, politics, and strug-
African-Americans,” which emerged from a gles,” underscores the importance and urgency to
commonality of experience related to racism and integrate gay rights into broader issues affecting
oppression (Rasheed and Rasheed 2004, p. 142). the African-American community (National
Although the Black community is considered to Black Justice Coalition 2009). Leaders in the
be more homophobic than the general population, Black community support the rights of LGBT
African-American LGBT persons contend to persons as civil rights and as public policy issues.
have always had more of a sense of belonging to In 2005, Julian Bond as chairman of the NAACP
the Black community than LGBT communities. emphasized that gay rights are civil rights, and
Therefore, a consolidated approach of the Rev. Al Sharpton, founder of the
community-based, outreach, gatekeeper, and Harlem-based National Action Network, stated,
case-find model might offer a practical approach “unless you are prepared to say gays and lesbians
to identification of LGBT elders in need of ser- are not human beings, they should have the same
vices and service delivery. In fact, the Gatekeeper constitutional right of any other human beings”
Model of Case Finding was created in 1978 by (National Black Justice Coalition 2009, p. 4).
Raymond Raschko, a social worker in Spokane, Health disparities among African-American
Washington, as a community-wide system of elders and their LGBT counterparts are alarming,
proactive case finding to identify at-risk older and these populations remain largely invisible in
adult who remain invisible to the service delivery services, policies, and research (Fredriksen-
systems created to serve them. Gatekeepers are Goldsen and Muraco 2010; Metlife 2010).
people in the community (e.g., postal service Research suggests that knowledge of health and
worker, apartment manager, meter reader, code health disparities is crucial to inform the devel-
enforcement workers, emergency response teams, opment and implementation of effective services
business owners) who come into contact with and public policies (Auldridge and Espinoza
older persons through their everyday activities. 2013; Comberford et al. 2004;
They are trained to look for signs and symptoms Fredrikson-Goldsen et al. 2011; MetLife 2010;
that might indicate that an older person needs Wilson and Yoshikawa 2007). Fredriksen-
assistance (http://Spokane.wsu.edu/researchout- Goldsen et al. (2011) assert that in order to
reach/wimhrt/A7.pdf). Using the gatekeeper develop policies and effective interventions to
126 D.A. Harley
Table 6.6 SAGE recommendations for policy and practice for older LGBT of color
Include specific provisions for LGBT elders in the Older Americans Act (OAA), ensuring that vulnerable LGBT
elders of color are able to age in good health and with broad community support
Ensure that community services and supports in the OAA are offered in a culturally and linguistically competent
manner, better reaching LGBT elders of color
Increase federal funding for organizations and programmatic interventions targeting LGBT elders of color
Ensure that implementation of the Affordable Care Act engages LGBT elders of color as advocates, so that new health
reform effectively reach communities of color and LGBT communities that are dealing with aging challenges
Strengthen Social Security and increase access for LGBT elders and elders of color who experience diminished
economic security in their retirement years. A stronger, more inclusive Social Security will enhance the lives of
millions of LGBT people of color
Improve data collection on sexual orientation and gender identity to better identify and address health disparities
among LGBT elders of color
Decrease elder abuse among more vulnerable and socially isolated elders by strengthening outreach and community
support to LGBT elders of color
Increase federal funding for safe and affordable senior housing and housing supports, while expanding the
development of culturally and linguistically competent senior housing communities
Strengthen the federal response to HIV and aging, which includes public awareness about the issue, equipping aging,
and healthcare providers with the skills to effectively serve older adults with HIV, and specifically addressing the
impact of the epidemic on LGBT elders of color
Eliminate discriminatory exclusion of medically necessary transition-related care from federally funded health
programs impacting LGBT older people of color
Adapted from Auldridge and Espinoza (2013)
address the needs of LGBT elders, we must first consideration of the relative needs of
understand the conditions and factors that result Black LGBT elders. For example, elderly Black
in health disparities and lack of access to aging persons have a shorter life expectancy than
and health services. Formation of policy will White or Latino elderly. The equity argument has
continue to be compromised until we have a been put forth that because of this shorter life
thorough understanding of the needs of expectancy, African-Americans should qualify
Black LGBT elders. for programs and services at an earlier age
Questions on sexual orientation and gender (Gelfand 2003).
identity are rarely asked in Federal surveys or by In the UK, the Equality Act of 2010 provides
state and local aging service providers, resulting protection against discrimination for protected
in limited ability to understand the nature of classes, including sexual orientation and gender
health disparities among older Black LGBT identity. Comparable legislation in the USA
persons. Auldridge and Espinoza (2013) recom- includes Title VII of The Civil Rights Act, the
mend the federal agencies (e.g., AOA, Centers Protection of Freedom Act (2012), and the
on Medicare & Medical Services) should include Employment Nondiscrimination Act (ENDA).
uniform questions on sexual orientation and Some individuals will argue that the Constitution
gender identity in their national survey instru- of the USA is the ultimate legislation that
ments and encourage state and local agencies to includes rights and protections for all persons,
follow suit through their aging systems. Other including LGBT persons and African-Americans.
recommendations by Auldridge and Espinoza on Other legislation varies state-by-state.
policy and practice for older LGBT persons of Barriers to effective and appropriate services
color are presented in Table 6.6. Equitable dis- for African-American LGBT elders can be
tribution of program resources requires eliminated through policy reform at institutional,
6 African-American and Black LGBT Elders 127
community, and system levels. Thus, to improve 2002). The need and advocacy for equity in
healthcare access and health outcomes across the services for LGBT elders are well documented
population of Black LGBT elders, we must (e.g., American Society on Aging; Auldridge and
implement policy that can reach entire commu- Espinoza 2013; Fredriksen-Goldsen et al. 2011,
nities (Wilson and Yoshikawa 2007). Policy 2013; Movement Advancement Project [MAP];
makers should explore best practices and MetLife 2010; Services & Advocacy for Gay,
evidence-based practices to develop policy for Lesbian, Bisexual & Transgender Elders; Wilson
African-American LGBT elders. Cost of imple- and Yoshikawa 2007), and with the rapid
mentation should not be the only or primary expansion of both aging and ethnic minority
determining factor in policy development and populations, the time is now to increase the
implementation. quality and quantity of services for those among
them who are LGBT.
Summary
Learning Exercises
African-American and Black LGBT elders in the
USA have been victims of a dualistic and bias Self-Check Questions
system of health care and service delivery. These
individuals have come to distrust service pro- 1. What types of challenges do
viders and the system of care that are designated African-American LGBT elders face that
for their care. Research suggests that these mis- differ from those of their White counterparts?
trusts, cautions, and suspicions continue to have 2. How do historical hostilities influence
credence. In fact, Sue and Sue (2013) refer to this help-seeking behavior of older
mistrust as a “healthy cultural paranoia” by African-American LGBT persons?
African-Americans that can serve as a coping 3. What type of income constitutes the largest
strategy with respect to racism (p. 375). While share of income of older African-Americans?
various disciplines have begun to study the cul- 4. Who was one of the first documented cases of
tural, psychological, wellness, and resilience of an African-American transgender person?
elderly African-American and other LGBT per- 5. Explain how the long-term financial stability
sons of color, more understanding of their cir- of many LGBT elders of color is shaped by
cumstances, life experiences, and needs is employment discrimination.
needed. Just as African-American and Black
LGBT populations have differences and distinc-
tions from White LGBT communities, there are Experiential Exercises
numerous commonalities and convergences
(Meyer 2010). However, recommendations for 1. Identify a Black Church that is accepting of
inclusion of African-American and Black LGBT LGBT persons and volunteer to help to
elders in policy must move beyond an additive establish a senior program and resources that
approach in which race and ethnicity are incor- is inclusive of LGBT elders.
porated as the “other.” 2. Develop an anthology or documentary of
Healthcare and human services providers have older LGBT African-Americans.
the responsibility to make available appropriate 3. Identify one way in which you can change the
and effective services to all consumers, regard- life of an LGBT African-American elder and
less of minority status (Maccio and Doueck work with him or her to implement it.
128 D.A. Harley
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American Indian, Alaska Native,
and Canadian Aboriginal 7
Two-Spirit/LGBT Elderly
Abstract
The purpose of this chapter is to discuss the status of older two-spirit
American Indian, Alaska Native, and Canadian Aboriginal two-spirit
LGBT elders. Information is presented on traditional values and
behaviors, two-spirit tradition and roles of elders in tribal communities,
service utilization by two-spirit elders, systems of service delivery, and
policy implications. The authors acknowledge the heterogeneity of these
groups and do not presume uniformity across groups. Similarity, the term
LGBT is used as the modern roughly equivalent of the Native term
two-spirit. A brief background of two-spirit is included to provide the
reader with an understanding of the history and significance of
self-identity that is implicit in how two-spirit persons refer to themselves.
Keywords
American Indian Alaska Native Canadian Aboriginal two-spirit
LGBT elderly
mobility (i.e., regular travel between urban set- 1. Identify the role of historical oppression of
tings and reservations (Rhoades et al. 2005). AIAN and AP populations.
Weaver (2012) suggests that cyclical migration is 2. Understand the traditions of two-spirit person
problematic, “particularly at times of illness, [it] in North American Indian culture.
can complicate accurate epidemiological infor- 3. Identify traditions and roles of elders in North
mation” (p. 477). Similar to many ethnic minority American Indian culture.
groups, AIANs and First Nations are typically 4. Understand barriers to health care of North
overrepresented in the lower socioeconomic sta- American Indians.
tus; however, the reader is cautioned not to assume 5. Identify health practices and disparities of
that all AIANs and First Nations are poor or des- North American two-spirit elders.
titute. As with any group of people, there diversity 6. Identify policy issues and concerns affecting
exists across demographic characteristics. North American Indian two-spirit elders.
The purpose of this chapter is to discuss the
status of older two-spirit AIANs and APs of
Canada. Information is presented on the status of
AIANs and APs, traditional values and behav- Introduction
iors, traditions and roles of two-spirit elders in
tribal communities, service utilization by American Indians represent a diverse population
two-spirit elders, and systems of service delivery. consisting of 565 tribes, including indigenous
Discussion of policy and implications for future peoples of Alaska and Hawaii and more than 300
directions are also presented. The authors reservations that serve as indigenous homelands
acknowledge the heterogeneity of AIANs and and seats of tribal governments (Ogunwold
APs in North America and do not presume to 2006). American Indians and Alaska Natives
refer to the diversity of the people of tribal (AIAN) maintain a unique status as sovereign
nations or indigenous peoples of Canada in a nations. As indigenous cultures, American Indi-
collectivist way. However, space prohibits dis- ans reside primarily in the West, with approxi-
cussion of each tribal nation or indigenous peo- mately 34 % living on-reservations and 57 %
ples, and so general information is presented, living in metropolitan areas. Urban American
with specific reference to select groups. Although Indians experience significant social, health, and
the term LGBT is used throughout this book to economic problems while having access to sub-
reference lesbian, gay, bisexual, and transgender stantially fewer Native-specific resources than
persons, the term two-spirit is the preferred term their reservation-based counterparts (Weaver
of traditional American Indians and Aborigi- 2012). American Indians (AI) comprise less than
nal LGBT persons. LGBT is the modern equiv- one percent of the US population, a figure the
alent of the Native term two-spirit (Fieland et al. same for persons age 65 and over (Administra-
2007). Therefore, throughout this chapter, these tion on Aging [AOA] 2012). The low numbers of
two terms will be used interchangeably. A brief AIs result in a relatively invisible status, which
discussion of the background of two-spirit is make them highly susceptible to stereotypes
included to explain the history and significance (Bureau of Indian Affairs 2011). The history of
of self-identity implicit in how AIAN and AP American Indians is complex and one of disen-
two-spirit persons refer to themselves. franchisement and distrust of European Ameri-
cans and the government. According to Walters
et al. (2001), over the past century “American
Learning Objectives Indians have endured a succession of traumatic
assaults on their cultural and physical well-being,
By the end of the chapter, the reader should be and continue to disproportionately experience
able to: violence and trauma” (p. 134).
7 American Indian, Alaska Native, and Canadian … 137
Declaration”), which is a framework of rights for contrary to that of gender variance. Canadian
indigenous peoples for states. Each Nation that two-spirit persons who thought in more circular
adopts the Declaration is independently respon- ways resulted in outlawing and discrediting of
sible for enacting domestic legislation and polices any processes that that could not easily be
that comply with Declaration standards (Rowland co-opted to advance a larger agenda of profit by
2013), though the Declaration is not legally Europeans (Meyer-Cook and Labelle 2003). In
binding for Nations that adopt it. fact, for two-spirit persons, enculturation (the
Cultural determinants of AIAN resistance and process by which individuals learn or re-immerse
resilience include identity, spirituality, and tra- themselves in their cultural heritage, norms, and
ditional health practices, the very aspects of behaviors within a contemporary context) in the
Native culture targeted by colonial persecution form of “retraditionalization” may be a powerful
(Walters and Simoni 2002). For two-spirit per- process because of the denigration of their for-
sons in Canada, the binary concept of gender mally elevated status in many tribal communities
conformity that prevailed in colonial days was (Fieland et al. 2007). Meyer-Cook and Labelle
7 American Indian, Alaska Native, and Canadian … 139
(2003) suggest that for two-spirit persons to Table 7.3 Priority health needs identified by Alaska
achieve a sound identity, they need to simulta- Native elders
neously follow two tracks of identity formation: Personal care services
first as Native people or people of a minority Comprehensive care and tracking of chronic illnesses
group and second as people who are differently Medication issues
gendered. Elder abuse
As a population, health statistics for American
Housing
Indians reveal significant adverse outcomes
Alzheimer’s Disease and related disorders
(Roubideaux et al. 2004). As compared to the
general US population, American Indians have Unintentional injuries (causes and prevention of falls)
alcoholism mortality rates that are more than Telemedicine
twice as high, significantly higher obesity and Elder and youth activities (sharing traditions and
diabetes rates, injury-related deaths (e.g., homi- participating in intergenerational activities to support
youth and community)
cides, motor vehicle crashes, suicides), dispro-
portionate rates of depression, and deaths from Palliative care
injuries and violence account for 75 % of all Traditional healing
deaths (Centers for Disease Control [CDC] 2007; Urban/rural differences (understand why elders are
U.S. Department of Health and Human Services moving to town and the implications this has on service
availability in urban and rural areas)
2007), lower earnings, lower educational level,
Adapted from Branch (2005)
and higher poverty rates, violence, and depres-
sion (CDC 2011). These factors are co-occurring,
which means that AIANs are simultaneously at contribute to the vulnerability of older AIANs:
risk for all of them, creating a potentially severe lower educational attainment, lower household
network of social and psychological risks that income, greater poverty, less insurance coverage,
affect their mental well-being (Native Vision and higher limited English proficiency. Further-
Project 2012). Rates for older AIAN or two-spirit more, vulnerability might be affected by multiple
elders are not disaggregated among the data. The contributing factors, not by a single factor (Kim
Alaska Department of Labor estimates that et al. 2012). AIANs aged 62 and older
Alaska Natives (AN) account for about 7135 self-reports of health status reveals that almost
ANs over age 65 and 8040 between the ages of 46 % are in fair to poor health, compared with
55 and 64, with the most rapid increase in elders 33.6 % of the general population. AIANs have
between 70 and 74, followed by those 85 and higher rates of work limitations at 34.3 %,
older. There is a higher prevalence of chronic compared to 15.2 for the general population
illnesses such as cancer and heart and lung dis- (Dunaway-Knight et al. 2012). In addition, the
eases, which can lead to a higher incidence of percent of AIANs who will receive Social
functional disability, and a corresponding need Security disability benefits at some point in their
for long-term care (Branch 2005). Table 7.3 lives is higher than the general population
provides priority health needs as identified by (16.0 % vs. 10.8 %) (Social Security Adminis-
Alaska Native elders. tration 2011). Typically, the age at which a per-
Currently, older single-race AIAN adults son is considered elderly in American society is
account for 0.87 % of the total US population 65; however, there is no such consensus among
and multiple-race AIAN for 1.53 % of the US tribal nations. The Older Americans Act gives
population (Ogunwole 2006). Compared to the discretion to individual tribes to make this
general population, older AIANs are less edu- determination. The health status of AP of Can-
cated, have a higher divorce rate (24.0 % vs. ada, especially elders, is similar to that of AIANs
19.9 %), and a higher percentage has never and is substantially lower than that of average
married (11 % compared to 6.5 % of the general Canadians. Moreover, compared to other Cana-
population) (Tamborini 2007). Several factors dians, AP have poorer social and economic
140 D.A. Harley and R.J. Alston
indicators, face critical housing shortages, higher non-Aboriginal elders, and Aboriginal elders are
rates of unemployment, lack of access to basic often less able to pay for private or co-funded
health services, and lower levels of education services. Economic differences are more pro-
attainment (Lafontaine 2006). nounced among First Nations who come from
First Nations elders, including Aboriginal, reservations and cannot fulfill the residency
Metis, and Inuit seniors, have received limited requirements and are placed at the end of long
attention by researchers because as a population, waiting lists. With the increase in the number of
Aboriginals are younger than the non-Aboriginal people receiving homecare among those without
population (Beatty and Berdahl 2011), and a lack alternative income to supplement higher costs,
of epidemiological data results in pan-Aboriginal health care beyond post-acute care is unafford-
(i.e., between assimilation and traditional) evi- able and inaccessible to Aboriginal elders.
dence and approximations (Lafontaine 2006). A related issue is the underutilization of services
The dire straits of Aboriginal elders is summed by Aboriginal elders in cities and
up thusly: they “are among the most neglected on-reservations. Barriers to service utilization
social class because of their increasing multiple include culture, language, affordability, jurisdic-
physical and mental health problems and tion, and problems navigating the health services
increasingly poor socioeconomic supports have system, barriers exacerbated by limited knowl-
forced them into even more challenging and edge of and access to policymakers and service
dependent situations at an age when they should providers. Although some policies have helped
expect to be well treated and taken care of improve competency skills and communications
properly by both their families and governments” between service providers and minority elders,
(Beatty and Berdahl 2011, p. 1). Metis report limited efforts have been made to address insti-
poorer health status than the non-Aboriginal tutional structures, racism in gerontological set-
population (Janz et al. 2009; Wilson et al. 2011) tings, and access to care facilities for Aboriginal
and are more likely than First Nations elders to elders (Beatty and Berdahl 2011). Table 7.4
report fair to poor health (Wilson et al. 2010, identifies health and service needs of First
2011). One in five Metis has arthritis or rheu- Nations Canadian elders.
matism compared to one in ten in the general Among other problems, Aboriginal elders
Canadian population. In addition, Metis have encounter educational and literacy barriers, poor
higher rates of high blood pressure, asthma, housing conditions, homelessness in urban areas,
diabetes (30 % of men vs. 14 % of and elder abuse. In Canada, housing on reser-
non-Aboriginal men; 32 % of women vs. 11 % of vations is among the poorest in the country,
non-Aboriginal women), and heart problems. which means that many elders with disabilities
First Nation elders have higher rates of disability
due to injury and/or chronic disease, with 58.5 %
Table 7.4 Priority health needs of first nation elders
over age 60 compared to 46.5 % of Canadian
seniors (Lafontaine 2006). Aboriginal elders are Culturally responsive programming and employment in
healthcare systems
more likely than non-Aboriginal elders to report
daily smoking and heavy drinking; however, one Coordinated elderly care funding initiative for
Aboriginal caregivers
in two reports not drinking at all, with the
majority either never smoking or having quit Aboriginal long-term care facilities in the major prairie
cities
smoking (Turcotte and Schellenberg 2007).
An integrated, coordinated, and holistic healthcare
Similar to research findings in minority
system
groups in the USA, Beatty and Berdahl (2011)
First Nations long-term care facilities on reservations
identify social and economic status as the two
Palliative, respite and after hour care services
most important determinants of health among
Aboriginal elders. The prevalence of low income Access to all health benefits
is higher among Aboriginal elders than Adapted from Beatty and Berdahl (2011)
7 American Indian, Alaska Native, and Canadian … 141
and chronic conditions live in overcrowded and remainder of this section are generalizations and
deficient homes (Health Canada 2009). Cur- their applicability should be assessed for partic-
rently, federal funding policies do not allow for ular clients or patients and their families. The
building of long-term care facilities on reserva- authors acknowledge distinctiveness within and
tions (Beatty and Berdhal 2011). As a vulnerable between indigenous persons in the USA and
population, medically compromised and depen- Canada, and the intent is not to obscure such
dent Aboriginal elders are often targets of abuse distinctiveness.
(Podneik 2008). Elder abuse occurs most fre- Native Peoples traditionally have respected
quently as physical, psychological/emotional, the unique individual differences (personal dif-
financial abuse, and neglect whether the elder is ferences) among people. This respect is demon-
at home or in semi-private and public institu- strated through staying out of the affairs of others
tions. Often, elders’ and families’ preferences for and expressing personal opinions only when
self-determination of care are disregarded. asked. An expectation is that this courtesy will be
Aboriginal elders living in Toronto identified returned. Another traditional behavior is quiet-
major issues facing them including, social iso- ness. The act of silence serves multiple purposes
lation, lack of transportation services, lack of in Native life. Historically, silence contributed to
assisted living services, lack of family peer sup- survival. When angry or uncomfortable, many
port, lack of senior housing, poor proximity to Native Peoples remain silent. Silence is a deeply
housing services, lack of activities programming, embedded form of Native interpersonal etiquette,
lack of physical fitness resources, and lack of and Patience is a closely related value to silence.
alcohol and drug abuse counseling (McCaskill Patience is based on the belief that all things
et al. 2011). unfold in time. The practice of patience demon-
strates respect for individuals, facilitates group
consensus, and permits “the second thought”
(deliberation) (http://www.nwindian.evergreen.
Traditional Values and Behaviors edu/cirriculum/ValuesBehaviors.prf). In tradi-
tional Native Peoples’ life, work is always
Indigenous peoples have an identity that is rooted directed toward a distinct purpose and is taken on
in a particular land of origin. Cultural identity is when it needs to be done. Work is linked to
intimately connected with and defined by tradi- accumulating only that which is needed, which
tional territories. Indigenous cultural beliefs and reflects the nonmaterialistic orientation of many
values (e.g., harmony, respect, generosity, cour- Native Peoples. Mutualism, as a value, attitude,
age, wisdom, humility, honesty) and spiritual and behavior, permeates everything in the tradi-
practices (e.g., natural world) are inextricably tional Native social fabric. It promotes a sense of
linked to the land. Even when Native Peoples are belonging and solidarity with group members
displaced from their territories, with ethnic mix- cooperating to gain group security and consen-
ing, and sporadic contact with tribal homelands, sus. The traditional manner in which most Native
the tie to core indigenous values persists (Hendry Peoples prefer to communicate is affective
2003; Weaver 2012). For AIAN and First (nonverbal orientation) rather than verbal. That
Nations, family or tribe is of fundamental is, they prefer listening rather than speaking.
importance because it provides a sense of Talk, like work, must have a purpose, and talking
belonging and security, an extension of the tribe for talking’s sake is rarely practiced. Words have
(Sue and Sue 2013). This sense demonstrates the a primordial power, and when there is a reason
persistence and resilience of the community for their expression, it is generally done care-
despite change (Weaver 2012). Different families fully. Closely linked to nonverbal orientation are
and tribes have their own cultural assets. The the highly developed and valued skills of seeing
cultural values and behaviors presented in the and listening. Hearing, observing, and
142 D.A. Harley and R.J. Alston
Canada, in 1990 during the third annual Inter- terms regarding gender-variant people, indicating
tribal Native American First Nation Gay and that two-spirit is different from sexual orientation
Lesbian conference. Two-spirit was originally because such words did not exist in Native lan-
chosen to distance Native First Nations people guages. As terminology referring to LGBT per-
from non-Native as well as from the words sons has evolved over time, gender, which “is an
“berdache” and “gay” (http://www. obligatory grammatical category in the
rainbowresourcecentre.org). In 1991, the term English/French and Latin languages”… and as a
berdache was replaced with the word two-spirit linguistic term “… has no connection with bio-
because of various negative connotations (e.g., logical sex or social identity of an individual”
male slaves or prostitutes) (see Williams 1986 for (p. 2). The relevance of the issue is where gender
additional information). According to Laframbo- intersects with the Native Peoples of North
ise and Anhorn (2008), the term two-spirit is America because two-spirit does not refer to
preferred because it emerged from Native people with homosexual tendencies; rather, on
American people, whereas the term berdache was different genders being manifested and not on
imposed upon Native People by the colonial sexual preferences or practices (Lafranmoise and
explorers. Table 7.5 contains various terms that Anhorn). See Discussion Box 7.1 for ways in
have been used to describe two-spirit American which two-spirits are honored.
Indians. One of the reasons that two-spirits It is important to point out that the term
received respect was out of fear because they two-spirited has multiple meanings within sev-
were considered to be touched by the spirits and eral different contexts. For example, Aboriginal
to have powers on the level of a shaman. people who identify as gay or lesbian use the
Two-spirits were highly regarded as artisans, term because it is more culturally relevant to their
craftspeople, child-rearers, couples counselors, identities. Aboriginal people who are transgender
and tribal arbiters. might also use the term two-spirit, an umbrella
Two-spirits are considered to be a “third term for Aboriginal persons who live between
gender,” and female two-spirits are considered to socially defined male and female gender roles
be a “fourth gender” (similar to the way that both (Balsam et al. 2004), or they may use terms of
female and male homosexuals are considered to their own Aboriginal languages (Scheim et al.
be gay, while females are also considered to be 2013). Elders within Aboriginal culture teach
lesbian) (http://androgyne.0catch.com/2spiritx. that two-spirited people have a special place in
htm). Rather than emphasizing the homosexual- their communities. Aboriginal culture is recog-
ity of two-spirits, American Indian focuses on nized for balance and harmony, and no one ele-
their spiritual gifts (Williams 1986). Laframboise ment or force dominates the others. The term
and Anhorn (2008) make a key distinction about two-spirit originates from the First Nations’
Table 7.5 Two-spirit American Indian gender role and sexuality terms
Tribe Term Meaning
Crow bote Two-spirit
Kamia warharmi Hermaphrodite spirit
Lakota Sioux winkte Two-soul persons
Mohave hwame Female-bodied person who lives as a man
Navajo nadleehe “The change”
Omaha mexoga Homosexuality
Shoshoni tainna wa’ippe Man–woman/woman–man
Zuni Ihamana Man–woman
144 D.A. Harley and R.J. Alston
most moved from First Nations communities AIANs experience greater emotional and/or
and/or small or rural towns to metropolitan mental health problems compared to their peers
areas because doing so allowed them to find a of other racial and ethnic groups (Kim et al.
personal identity either with their sexuality 2011; Satter et al. 2010). Arguably, the impact of
and/or gender identity and/or Aboriginal iden- structural oppression including homophobia,
tity. Other reasons for the move were to explore heterosexism, and racism is likely to play a role
the anonymity that a big city can offer when it in the physical and mental health of Aboriginal
comes to exploring the “gay lifestyle,” finding two-spirit/LGBT persons (Canadian Rainbow
others like them, for gender reassignment, and Health Coalition 2004; Taylor and Ristock 2011;
to begin a healing journey from incest and Ristock et al. 2011). In response to the limited
violence, they may have encountered as chil- research on healthcare access and service, Kim
dren. Those not actively involved in the LGBT et al. (2012) examined older AIANs’ physical
community felt an affirmation of their identity and mental health status and related healthcare
just knowing that a large LGBT community in use in comparison with NHWs and found that
the city existed. Some distinction was made by older AIANs reported poorer physical and men-
two-spirit persons about the importance of tal health than NHWs, were less likely to see a
having their own space because of the domi- medical doctor and to have a usual source of
nation in the LGBT community by White medical care, and were more likely to delay
people. A culturally specific space also allowed getting needed medical care and report difficulty
a place to have ceremonies. understanding the doctor at their last visit.
However, this study did not indicate if any of the
participants were two-spirit persons.
Two-spirit persons do not have more pro-
AIAN, Aboriginal Peoples of Canada, pensity or pathology of mental illness than the
and Two-Spirit Elders Physical general population. However, their prolonged
and Mental Health exposure to hostile or intolerant environments
can cause significant stress on LGBT persons,
Individually and collectively, AIANs and AP and having to manage stigma has far-reaching
have worse health outcomes than other ethnic effects on their health status (Brotman et al.
minority groups and non-Hispanic Whites 2003). Although information in this section is
(NHWs). Health disparities and chronic health presented on the health status of AIANs and AP
conditions exist with marked variation across with reference to two-spirit elders as applicable,
Indian Health Service (IHS) areas and within the authors agree with the position of Scheim
tribes in the USA (Wright 2009) and likewise for et al. (2013) that AIAN and “Aboriginal
indigenous elders in Canada (Beatty and Berdahl gender-diverse peoples’ experiences and health
2011). The disparities are especially problematic statuses cannot be understood by simply sum-
for low-income elders in indigenous communi- ming together what is known from research on
ties. Older AIANs and AP have greater numbers broader (AIAN), Aboriginal, or gender-diverse
of chronic conditions, higher rates of disease populations. Nevertheless, health inequities doc-
comorbidity, and higher rates of disability than umented in studies using one or the other of these
do other populations of elders (Beatty and Ber- identity categories provide an important context
dahl 2011; Satter et al. 2010). Although research for understanding the well-being of (AIAN) and
has focused on the physical health status of older Aboriginal gender-diverse peoples” (p. 109).
AIANs and AP, studies pertaining to their access Scheim et al. (2013) conducted a study to
to healthcare service are sparse, and their mental describe barriers to well-being in a sample of
health status has been less often documented Aboriginal gender-diverse peoples in Ontario,
(Kim et al. 2012). Research suggests that older Canada (see Research Box 7.1).
146 D.A. Harley and R.J. Alston
Results: The participants were almost Cancer is the leading cause of death for AIAN
evenly split between male-to-female and females (breast) and the third leading cause of
female-to-male gender spectra. The death for males (prostate) (Paltoo and Chu 2004).
majority was under age 35, almost half Of all races, AIAN women have the lowest rates
were living in poverty, live in metropolitan of mammogram screening (Ward et al. 2004), the
Toronto, and none were living on a reser- youngest mean age (age 54) for breast cancer
vation. Many were homeless or unstably diagnosis of all racial groups (age 56–62) (Li
housed, most had experienced some form et al. 2003) and the lowest survival rates. Ward
of violence due to transphobia, including et al. (2004) found that for all cancers combined,
physical and/or sexual violence, and life- AIANs have lower mortality rates than the gen-
time suicidality was high. Most had a eral US population, but have disproportionately
regular family doctor but had unmet lower 5-year survival rates than Whites. Of all
healthcare needs. Many were unable to ethnic minority groups in the USA, AIAN men
obtain services including shelters, hormone have the highest rates of chronic disease (e.g.,
therapy, trans-related surgery, trans-related obesity, cardiovascular disease, hypertension,
mental health, sexual health, and addic- high cholesterol, diabetes, and smoking), and
tions. However, needs were met for general women have the highest rates of obesity, car-
health services, emergency care, and HIV diovascular disease, smoking, and diabetes, and
or sexually transmitted infections testing. the second highest rates of hypertension and high
Some had seen an Elder for mental health cholesterol after African American women
7 American Indian, Alaska Native, and Canadian … 147
(Centers for Disease Control [CDC] 2003). conditions for off- and on-reservation First
Again, it is supposition that older two-spirit Nations populations. For example, high blood
persons are counted among these numbers. pressure for off-reservation AP is 12 % versus
Overall, AP has poorer health than other 20.4 % for on-reservation, diabetes is 8.3 % for
Canadians. The long-term health conditions that off- and 19.7 % for on-reservation, asthma is
affect First Nations adults living on-reservations 12.5 % for off- and 9.7 % for on-reservation, and
tend to be the same as those affecting other heart problem is 10.3 % for off- and 7.6 % for
Canadians except for diabetes, which is more on-reservation. The higher rates of asthma and
prevalent among First Nations population. heart problems among off-reservation Aboriginal
Approximately, 60 % of the Aboriginal popula- populations may suggest a function of lifestyle
tion living off-reservations has chronic conditions and environmental circumstances.
compared to 49.6 % of the non-Aboriginal pop- Aboriginal adults living off-reservations are
ulation (Tjepkema 2002). AP living almost twice as likely to experience a major
off-reservations tend to have lower prevalence of depressive disorder compared to other Canadians
long-term conditions than those living (Canada Mortgage and Housing Corporation
on-reservations, with the exception for diabetes, 2004). In fact, it is suspected that the rate of
but these rates are still typically higher than they depression may be underdiagnosed within the
are for other Canadian adults except for the Inuit Aboriginal population. Mental health conse-
(Galabuzi 2004). Furthermore, Aboriginal adults quences among AP are linked to “persistent
living off-reservations are much more likely to be socioeconomic inequities, intergenerational
obese than non-Aboriginal adults in Canada, but trauma, and colonial and neo-colonial processes
those living on-reservations have even higher including racialization and discrimination have
obesity levels (Reading and Wien 2009; Tjepk- taken a serious toll on the mental health of AP as
ema 2002). In each geographic region (urban, reflected in alarming rates of suicide, depres-
rural, territories) (see Table 7.6 for a list of Canada sions, substance abuse, and violence” (Browne
provinces and territories), the Aboriginal popula- et al. 2009, p. 19). Although research on
tion living off-reservations reported higher levels Aboriginal Peoples’ mental health is sparse, the
of fair to poor health than their non-Aboriginal First Nations Centre (2007) indicates that some
counterpart in that region and percentage did not evidence exists that mental health is better for
vary significantly between regions (Tjepkema Aboriginal populations living off-reservation
2002). The First Nations Centre (2007) indicates a than their on-reservation counterparts. This
significant difference in morbidity and chronic more favorable outcome may be credited to
off-reservation AP having access to a relatively
Table 7.6 Canada provinces and territories greater number of mental health services avail-
Alberta able in urban areas (Place 2012).
British Columbia Rosenberg et al. (2009) report that in every
age cohort, AP are more likely than
Manitoba
non-Aboriginal people to indicate “poor/fair”
New Brunswick
health. Although chronic conditions increase
Newfoundland and Labrador with age, AP are more likely to report more
Northwest Territory chronic conditions than the comparable
Nova Scotia non-Aboriginal population. The prevalence rates
Nunavut of specific chronic conditions for elderly AP
Ontario exceed that of non-Aboriginal people with the
Prince Edward Island only exception being cancer. One possible
explanation for this exception is that the lumping
Quebec
together of all cancers more than likely masks a
Yukon Territory
number of critical differences between AP and
148 D.A. Harley and R.J. Alston
their non-Aboriginal counterparts. See Table 7.7 assault. The attitudes of service providers toward
for prevalence of specific conditions. Presum- AIAN were more positive than in the general
ably, elderly two-sprit Nations are included in population. Service providers indicated a high
these data. Ristock et al. (2011) found that the level of comfort working with American Indian
health concerns of Aboriginal two-spirit/LGBT two-spirit persons, and over 90 % of service
persons included HIV, hepatitis C, weight issues, providers indicated that they had LGBT friends
cancer, and diabetes. Unfortunately, no distinc- and LGBT friends who are American Indian. The
tion of these concerns was reported based on age. attitudes of service providers were consistently
positive for specific subgroups of LGBT persons.
However, service providers indicated a limited
understanding of terminology associated with
Service Utilization by Two-Spirited transgender, followed by homo-negativity and
Elders concepts of “passing,” heterosexism, gender
identity, homophobia, and sexual orientation.
In a study of sexual orientation bias experiences Research on service utilization by Aboriginal
and service needs of LGBT two-spirited Ameri- two-spirit persons in Canada is limited to
can Indians, Walters et al. (2001) found that high nonexistent.
rates of American Indians had experienced bias The problems identified facing American
from the general public, ranging from 43 to Indian LGBT or two-spirited ranged from
79 %. Types of biases they experienced include HIV/AIDS epidemic to problems raising children
verbal insults, threat of attack, chased or fol- (Walters et al. 2001) (see Table 7.8). Similar to
lowed, spat upon, object thrown, physical other LGBT persons, AIAN two-spirit persons
assault, assaulted with a weapon, and sexual face many barriers to service utilization. Of the
7 American Indian, Alaska Native, and Canadian … 149
Table 7.8 Problems facing American Indian two-spirit the non-American Indian imagination that makes
community it difficult for two-spirit persons to identify each
HIV/AIDS epidemic other for social support. In the American Indian
Substance abuse community, invisibility is manifest as the failure
Homophobia in the American Indian community to consider being LGBT as a possibility or
Shunned by American Indian community “Native reality,” which fuels homophobia within
the heterosexual American Indian community.
Homelessness
Furthermore, disclosure of one’s identity as part
Trauma
of visibility is determined by cultural values, in
Conflict with kin network/elders which elders dictates the parameters regarding
Racism from non-American Indian LGBT acceptable behavior. That is, it is not that the
Conflict with religion person is gay that the elder is responding to but it
Suicide is how the person is behaving (Walters et al.
Anti-gay violence 2001). Discrimination refers to dealing with
Conflict with Native traditions racism in the LGBT community and homophobia
in the American Indian community. A point of
Problems of raising children
distinction was made between two-spirit persons
Adapted from Walters et al. (2001)
on-reservations versus urban-born LGBT Indi-
ans. For those on-reservations who are required
thirteen barriers identified by Walters et al. and to leave because of publicly disclosing their
rated as moderate or great, nine were ranked sexual orientation, it is harder to do because of a
above 50 % as a barrier (see Table 7.9). The lack of transportation, whereas urban-born
results of the focus group study identified five two-spirit persons are able to be more open
main barriers for American Indian LGBT persons with their identity because they might be able to
in accessing services: invisibility, discrimination, blend in some ways. Dealing with historical and
trauma, identity, and program planning. Walters cumulative trauma, including anti-gay violence,
et al. suggest that invisibility in the LGBT domestic violence, and mental and emotional
community stems forms the colonization process abuse are the serious concerns of two-spirit per-
and the entrenched stereotypes that exist within sons. In addition, they fear being re-traumatized
by insensitive or “homo-ignorant” service pro-
viders, including American Indians.
Table 7.9 Barriers to services utilization by two-spirit
persons A critical issue for AIAN two-spirit persons is
identity, or the task of integrating a healthy,
Financial resources
positive identity both as an AIAN and as a
Specialized programming for Native two-spirit persons two-spirited person. Many AIANs have lost the
Fear of what Native community members might think social and spiritual context of whom they are and
Fear of being “outed” are always in crisis mode in trying to hold onto
Stigma related being LGBT traditions while dealing with the LGBT identity.
Professionals’ knowledge of Native two = spirit issues Service providers find it difficult to assist
Attitudes of Native two-spirit clients/family toward two-spirit persons when struggling to develop an
services integrated identity because of the historical
Staff support by non-Native LGBT agencies diversity in terms of tribal acceptance of
Two-spirits’ ability to locate services two-spirit persons and the LGBT person’s search
for a place and identity in relation to his or her
Staff attitudes toward Native two-spirit persons
own specific tribal nation. In addition, tribal
Transportation
acceptance is the conflict between AIAN Chris-
Physical accessibility/location of services tian belief systems and acceptance of
Adapted from Walters et al. (2001) two-spirit/LGBT (Pope 2012; Walters et al.
150 D.A. Harley and R.J. Alston
2001). Two-spirit persons declare that spirituality Aboriginal Peoples Survey (APS) asked three
is extremely important in their lives and may questions related to health utilization about
respond to spiritual conflict with adoption of an whether in the past 12 months individuals visited
inclusive approach to their spirituality that com- a (a) physician, (b) eye doctor, and (c) nurse. The
prises traditional tribal, pan-Indian, and Christian most notable difference in healthcare utilization
influences (Balsam et al. 2004; Fieland et al. by Aboriginal elders was a higher rate of nurse
2007). visits than non-Aboriginals, which may be due to
A final theme from the focus groups was the increased likelihood that rural and health
program planning, which identified four key centers on reservations are staffed by full-time
areas. The first is the need for community-based nurses than physicians.
discussion to identify culturally relevant and Aboriginal elders face a variety of unique
meaningful ways to discuss sex, sexuality, gen- issues and obstacles in the provision of health-
der identity, and LGBT issues. Second was the care services. Higher rates of Aboriginal elders
importance of contextualizing anti-gay violence are monolingual Aboriginal language-speaking,
and more general two-spirited experience within which complicates the interface between them
the context of AIAN experience of the coloni- and their largely non-Aboriginal healthcare pro-
zation, the historical trauma, and the cumulative viders. Other issues include cultural differences
effect of anti-gay victimization and resulting related to aging, medical treatment, traditional
trauma. The third area is in-service training for care-giving roles, the power structure inherent in
all staff regardless of sexual orientation. Finally, Western medicine, exclusion of Aboriginal
there is a need to develop programs that focus on worldviews, and end-of-life (Rosenberg et al.
health and mental health issues and to create safe 2009). According to Rosenberg et al., “Western
space for two-spirit persons, especially youths. medical practices are often viewed by AP as
Another possible explanation of underutiliza- dehumanizing as they separate older AP from
tion of services by AIAN elders is that the their communities and involve an
location of services may be a barrier. A quote individual-style decision making that can run
from Rose Jerue in 1989, an Alaska Native elder, contrary to traditional Aboriginal belief systems”
provides insight about the importance of elders (p. 17). These anxieties are particularly amplified
wanting to be close to home. According to Jerue, for those who are monolingual and hold strongly
“elders need to be near the river where they were to traditional views of health and healing. The
raised” (cited in Branch 2005, p. 1). AIANs and informal caregiving is important in Aboriginal
First Nations elders do not have long-term care communities. Similar to AIANs and other ethnic
facilities in their communities and when requir- minority groups in the USA, traditional care
ing institutional care are often placed in facilities within Aboriginal communities is gender
located great distances away. The detrimental dependent, with women family members typi-
effects of being removed from their communities cally being the primary caregivers. In fact,
may include culturally inappropriate care, lan- Aboriginal households tend to have stronger
guage barriers, isolation from family and friends, gender parity in residential family size and
loss of community affiliation, and loss of their structure, fewer women living alone, and fewer
social role as an elder (Lafontaine 2006). Aboriginal elders living with only their partner
A key issue for elderly AP is gaining access to (Rosenberg et al. 2009).
services because generally, more services, more AP, regardless of age, who move to urban
specialized services, and better access to them is areas in order to access medical services often
in urban areas than in rural areas. However, face additional barriers, including a lack of
access to services in urban areas does not imply financial and transportation support, suitable
more culturally sensitivity to the needs of elderly housing near medical services, type of services
AP (Rosenberg et al. 2009). The Canadian available, and isolation from their social support
Community Health Survey (CCHS) and network in their home communities. The urban
7 American Indian, Alaska Native, and Canadian … 151
Aboriginal population is fairly mobile and system, are more likely to have low incomes, and
movement occurs both between rural and urban may have been victims of violence, which is a
areas, and within urban settings (Place 2012). major determinant of health and requires its own
Access to services is only part of the equation for treatment (Browne et al. 2009; Native Women’s
better health outcomes. Others are appropriate- Association of Canada 2007).
ness of services and being culturally safe, to
which merely living in urban areas does not
overcome barriers (Adelson 2005). AP, espe-
cially Inuit and First Nations desire access to Systems of Service Delivery
traditional healing practices, and as age and for Two-Spirited Elders
strength of Aboriginal identity increases, so does
the perceived importance of access to this kind of In healthcare and mental health programming,
healthcare. In fact, the Urban Aboriginal Peoples there is a need provide a cultural network that
Survey (UAP) reveals that 72 % of Aboriginal integrates the AIANs’ indigenous community
residents in urban areas consider access to tra- into treatment plans along with prevention and
ditional healing practices to be more important early intervention services (Native Vision Project
than mainstream health, only 30 % have “very 2012). Many AIANs ascribe to traditional health
easy” access to them (Environics Institute 2010, practices that are grounded in an indigenous
p. 116). Just over half of AP in urban areas uti- worldview, which emphasizes harmony and
lizes city-based Aboriginal services and organi- balance. Traditional Native health practices (e.g.,
zations. Of those, Inuit (71 %) are most likely to sweat lodge, pipe ceremony, Sun Dance, Native
use city-based Aboriginal services and organi- American Church) are ways of coping with dis-
zations followed by off-reservation First Nations ease and responding to adversity. Both Indians in
(59 %) and Metis people (48 %). Services are urban areas and on reservations use traditional
more likely to be accessed by those aged 45 and healing practices in conjunction with Western
older and those who are of lower socioeconomic medicine, with traditional practices to treat the
status (Environics Institute 2010). underlying cause (e.g., violation of a cultural
Similar to AIANs, AP living off-reservations taboo) and Western medicine to treat the symp-
do not have access to the range of federally toms (Fieland et al. 2007). Thin Elk’s (2011)
provided health services that First Nations living model combines a holistic approach with indig-
on-reservations and Inuit living in their commu- enous (e.g., talking circles, healers, seasonal
nities (Place 2012). Eligibility for specific federal ceremonies, and sweat lodge purification cere-
government programs and services for AP monies) and mainstream approaches (e.g.,
depends on a number of factors, including status one-on-one counseling) to wellness and healing.
(i.e., status vs. non-status Indians), residency, However, two-spirit persons may not be open
treaty, and provincial and federal legislation about their identity or all their health practices
(Browne et al. 2009). According to Lavoie et al. because of discriminatory experiences in the
(2008), every scenario of status, residency, and American healthcare system and heterosexist
so forth results in a different set of benefits and attitudes among traditional healers. Among older
services, and ambiguity of eligibility, which, urban AIAN patients in primary care, maltreat-
eventually, leads to gaps and inconsistencies. ment and neglect are relatively common (Grant
One other important consideration in and Brown 2003).
addressing access to services for AP is the dis- One area of concern is the diagnosis of mental
tinct issues related to women. Women make up health functioning of AIANs. AIANs may con-
over half of the urban Aboriginal population. ceptualize mental health differently and express
Although women tend to live longer than men, emotional distress in ways that are inconsistent
they have more instances of health-related issues with the diagnostic criteria of the Diagnostic and
and are more frequent users of the healthcare Statistical Manual (DSM). For example, AIANs
152 D.A. Harley and R.J. Alston
may express distress as ghost sickness and behavioral health care, promotes health, and
heartbreak syndrome. Thus, the question prevents disease. The HSOC integrates mental
becomes how to elicit, understand, and incorpo- health and substance abuse services with medi-
rate such expressions of distress and responding cal, dental, and HIV services and provides sup-
within the assessment and treatment process of port for the entire family. The approach links
the DSM (Grant and Brown 2003). The most prevention, treatment, and recovery and is based
recent edition of the DSM contains an updated on a community strategic planning process that
version of the Outline for Cultural Formulation honors Native culture and relationships while
(OCF), which calls for systematic assessment allowing for integration of Western (EBPs)
five categories and the Cultural Formulation treatment modalities. The HSOC acknowledges
Interview (CFI), which is a set of 16 questions the diversity of traditional healing beliefs among
that may be used to obtain information during a the different tribes and respects each tribe’s
mental health assessment about the impact of practice of traditional medicine. This approach
culture on key aspects of an individual’s clinical deals with the whole person. The emphasis is on
presentation and care (American Psychiatric self-help, empowerment, and building a healthy
Association [APA] 2013). community (Native Vision Project 2012).
Although federal and state funders of behav- Although substantial fragmentation exists in
ioral health services overwhelmingly require use many Native communities, some communities
of evidence-based practices (EBP), of which the (e.g., Native community in Chicago and Port-
“gold standard” of Western-based EBP does not land, Oregon) have developed a strong network
reflect American Indian communities with regard of human services to meet the varied needs of
to cultural, linguistic, and geographical differ- community members (Weaver 2012). In Canada,
ences in prevention and early intervention, Native practices have been implemented for First
American cultural practices (i.e., practice-based Nations and Inuit elders. The First Nations and
evidence) have been increasingly used in effective Inuit Home and Community Care (FNIACC)
service delivery (Native Vision Project 2012). program has been instrumental in facilitating the
There is a distinction between evidence-based development of essential programs within 606
practice (EBP), which is scientifically tested and First Nations reserves and communities and 53
validates, and practice-based evidence or Inuit communities across Canada (Cyr and Oot-
community-defined evidence (CDE), which is a oova 2010). FNIHCC consists of eight regions
validated practice, which is accepted by the AIAN across Canada that engage in collaborative part-
community but not empirically proven. EBPs are nerships that create sustainable change in com-
particularly challenging because they have not munities and jurisdictions.
been tested in AIAN communities; therefore, they
have not been culturally validated. Government
funders mandated that behavioral health providers
observe the same EBP standards in health care Policy Issues
(Nebelkopf et al. 2011). Neblkopf et al contend
that this mandate brings into question, how can Currently, health services in the USA are deliv-
Western science reconcile with indigenous ered through a system of interlocking programs
knowledge to operationalize AIANs and First made up of the IHS, tribal programs, and urban
Nations’ core values to demonstrate EBP? The programs. The structure involves interrelation-
suggestion is to use CDE to identify cultural ships between the federal government, tribal
adaptations to EBPs (Martinez 2011). governments, and urban Indian groups. The IHS
One approach of service delivery that has structure consists of three levels: headquarters,
produced successful outcomes with AIANs is the area offices, and service units including hospitals,
Holistic System of Care (HSOC). The HSOC is a health centers, health stations, and clinics (To-
community-focused intervention that provides satto et al. 2006). The IHS is based on the
7 American Indian, Alaska Native, and Canadian … 153
medical model and as such, one of the major Berdahl 2011; Cameron 2003). From a policy
problems is that the majority of funding goes into perspective, it is important to recognize that the
direct medical care (e.g., hospital and clinical off-reservation and urban Aboriginal populations
care) with limited dollars available for preven- in Canada are not distinct from the on-reservation
tion. Other challenges include a lack of resources and rural. They are interconnected in terms of
and technical knowledge: most tribes do not have mobility, culture, and politics (Graham and
departments of public health, which “is a major Peters 2002). AP are highly mobile between
contributor to the negative health disparities rural/reservations and urban areas, and within
existing among Indian people today, on and off urban communities (“churn factor”), which has
reservations” (Allison et al. 2007, p. 299). implications for policy (Place 2012).
Another crucial problem associated with the IHS The current policy frameworks in Canada for
structure is the inability to bill and collect ade- AP are hampered by fragmented services, judi-
quately for all of the services it provides. cial boundaries, and insufficient funding, which
Exponentially, Native American tribes are is especially challenging for elders. Understand-
assuming more control of their own healthcare ing how two-spirit persons fit into the mix of
delivery systems and making decisions to create things is still unclear. Beatty and Berdahl (2011)
or plan their own departments of public health suggest that Canada look to Sweden, Denmark,
(Allison et al. 2007). Allison et al. propose three and Iceland for alternative ways of thinking
public health organizational delivery models to about options for elderly care in Canada. In
meet the public health needs of small, medium, Sweden, elderly care policy focuses on ensuring
and large American Indian tribes. The models the elderly economic security, adequate housing,
become larger and more complex in the pro- and good services and care. Iceland uses a model
gression along the continuum. Basically, these that consists of a mix of family and state
models create an organizational structure in involvement. Elderly care in Denmark is largely
which services and functions are handled by state funded. These three models contain several
specific departments and are designed with the key components to reconcile the fragmentation
premise that tribal governments are direct care of services for AP. First, they support a public
providers. The models build on existing services push for governments to take more responsibility
provided through IHS. for long-term care with increased support for
In Canada, one of the greatest challenges for families as a means of empowering personal
urban Aboriginal seniors in the healthcare system control among the elderly and their families.
is the issue of jurisdiction, specifically for Inuit Second, they suggest more holistic Aboriginal
and status Indians peoples. Both Inuit and status eldercare models in Canada. Third, they advocate
Indian peoples face jurisdictional challenges, for inclusion of culture, community, and mixed
because while provinces and territories provide systems. Finally, they promote community
healthcare services, the federal government is involvement as integral to proper health care
responsible to pay for status Indian and Inuit (Beatty and Berdahl 2011). Presumably, specific
health care. Although Metis and non-status peo- attention is to be given to two-spirit elders in the
ples are declared as Aboriginal under the Con- redesign of policies and procedures.
stitution Act of 1982, they are not recognized as The future brings new challenges and contin-
a federal responsibility. The result is that Metis uation of existing ones for development of inter-
and non-status Indian peoples receive the same ventions for AIANs and First Nations. One of the
provincial benefits as all other Canadians (Beatty most substantial challenges is EBP. Since EBP is
and Berdahl 2011). The political jurisdiction and grounded in the supposition that the most effec-
administrative barriers between federal, provin- tive practices are demonstrated through carefully
cial, and regional authorities cause ongoing controlled scientific experiments, which assess
jurisdictional disputes in health regarding the the causal efficacy of these practices, Nebelkopf
provision of health services to AP (Beatty and et al. (2011) question the efficacy of EBP for
154 D.A. Harley and R.J. Alston
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Asian American and Native Pacific
Islander LGBT Elders 8
Debra A. Harley
Abstract
The purpose of this chapter is to discuss issues pertaining to LGBT Asian-
American and Pacific Islander (AAPI) elderly in the USA. Attention is
also given to the citizenship status of foreign-born Asian-Americans.
Information is presented on cultural characteristics and values of Asian
culture, acknowledging that there is great heterogenerity among AAPIs.
Discussion focuses on attitudes and perceptions of Asian Americans’
perspectives about LGBT persons, characteristics, and issues pertinent to
Asian American LGBT elders, health status and service delivery for
LGBT Asian-American elders, and current health policy and practices.
Whenever possible, specific reference is made to certain subgroups of
persons of Asian descent.
Keywords
Asian american Native pacific islander LGBT elders
practices pertaining to LGBT Asian American Guamanians, and Samoans (Sue and Sue 2013).
elders are examined, along with recommenda- The six largest Asian American single-race sub-
tions for the future. Throughout this chapter, the groups are Asian Indian, Chinese, Filipino, Jap-
umbrella term Asian-Americans is used to refer anese, Korean, and Vietnamese (US Census
to the various groups that make up this popula- Bureau 2012). The Asian-American population is
tion; however, specific reference is made to cer- growing rapidly and represents about five percent
tain subgroups where appropriate. In addition, of the US population. Native Hawaiian and other
efforts are made to distinguish between data that Pacific Islanders comprise 0.4 % of the total
are group specific and illustrative in content population, with more than half reporting multi-
through examples. Given the limited amount of ple races. Further examination reveals that over
research published on LGBT AAPIs, some 60 % of Asian Americans are immigrants, more
inferences are made from AAPIs in general and than two-thirds speak a language other than
generalizations are made from younger English at home, and approximately 40 % do not
AAPI LGBT persons to older AAPI LGBT speak English well. With the exception of Japa-
adults. nese-Americans, Asian-American groups are
now principally composed of internationally
born individuals. Nearly two-thirds of AAPIs are
foreign born and have arrived in the USA, since
Learning Objective
1965. Of the Asian population in the USA, there
are approximately 3.8 million Chinese, 2.8 mil-
By the end of this chapter, the reader will be able
lion Asian Indians, 1.7 million Vietnamese, 1.6
to:
million Koreans, and 1.3 million Japanese. Cal-
ifornia has the largest and most diverse AAPI
1. Understand the role of AAPI elders in Asian
population in the country (US Census Bureau
communities.
2010).
2. Distinguish among cultural characteristic
The majority of younger Asian Americans are
within AAPI cultures.
highly educated. For Asian American and Pacific
3. Distinguish between generational differences
Islanders over the age of 25, over half have a
among AAPI LGBT persons.
bachelor’s degree compared to 30 % of their
4. Identify the attitudes and perceptions of
White counterparts (US Census Bureau 2011a).
AAPIs toward LGBT persons.
In 2010, the median income of Asian American
5. Identify barriers to health care and social
families was $64,308 compared to $49,445 for
services for AAPI LGBT elders.
the US population as a whole (US Census bureau
6. Identify health issues and disparities of
2011b). According to Sue and Sue (2013), the
LGBT AAPI elders.
presentation of Asian-Americans as the model
7. Understand factors contributing to resiliency
minority is a misnomer because a closer look
among AAPI LGBT elders.
reveals disturbing contrasts with popular views
of their success story. Specifically, Sue and Sue
outline the following contrasts. First, the report
of Asian American families having a higher
Introduction median income than other minority groups does
not take into account (a) the higher percentage of
Great diversity exists among the Asian American Asian American families having more than one
population, with at least 40 distinct subgroups wage earner, (b) between-group differences in
that differ in language, religion, values, and education and income, and (c) a higher preva-
culture. They include Chinese, Filipinos, Kore- lence of poverty despite the higher median
ans, Asian Indians, Japanese, Vietnamese, Lao- income. Second, although collectively Asian
tians, Cambodians, Hmongs, Hawaiians, Americans show a disparate picture of
8 Asian American and Native Pacific Islander LGBT Elders 161
most valued way of achieving position, and suc- The principles of endurance and sacrifice are
cess in education is viewed as an act of filial piety highly applicable to early immigrants who
(respect for parents), a highly important principle worked under extreme conditions in the USA and
(Africa and Carrasco 2011; Hu). Another modern endured racism because of their willingness to
stereotype is that of the silent, unassertive Asian, work hard for so relatively little. Endurance at all
uncomplaining, unemotional, docile, and coop- costs is central to the extent to which all other
erative. Because the well-being of the larger group Asian values are carried out and what distin-
is most important in Asian culture, great impor- guishes Asian values from values in other cul-
tance is placed on maintaining harmony. Thus, the tures that look at first similar. Sacrifice means
greatest virtue that one can achieve is fulfilling his that one’s own situation is secondary to that of
or her role in the whole of the family or group, and the group as a whole. Endurance is a measure of
individual achievement is seen as the result of the self-control and inner strength, and complaining
effort of the family or group. Maintaining har- is seen as a sign of weakness (Hu 2012). Hu
mony also creates a bias against change, which is believes that these values may lead to the per-
opposite of American values to encourage ception of Asians as being uncomplaining and
change. In following these principles, Asians may less vocal than other ethnic minority groups.
hesitate to initially accept invitations, may choose Many Americans are familiar with the concept of
items of lesser value when given the choice, and losing face among Asians. Maintaining good face is
may not be assertive in situations where they essential because shame and honor go far beyond
might speak out (Hu; Sue and Sue 2013). the individual and reflect directly upon one’s family,
Asian culture emphasizes consideration of nation, or related group. The extent to which an
others; thus, benevolence and obligation must be individual is able to maintain good face is a kind of
present to reinforce relationships. As a hierar- measurement of how well one has kept faith to
chical society, Asian relationships involve a lot traditional values and one’s social standing among
of obligation, which might be viewed as depen- others. It is a strong control mechanism, which
dence or domination. In essence, a substantial reinforces all other Asian values (Hu 2012). The act
amount of responsibility and benevolence is of keeping face and suppressing or not admitting
expected in return. For individuals of equal embarrassing situations in the family history often
position, there is still the principle of reciprocity, manifests itself in the reluctance of Asians to seek
goodness given out will come back and kindness mental health services (Sue and Sue 2013).
should be paid back (Hu 2012). Overwhelm- Many AAPIs rely on traditional health beliefs
ingly, Asian culture has a male-dominated power and practices (Africa and Carrasco 2011). To
structure. Equally as important is birth order, illustrate this point, several Native Hawaiian
especially for males who are expected to take on cultural values are presented (Mau 2010). These
more unique responsibilities as they grow into values are often relevant in the healthcare setting
adulthood (e.g., oldest son assists the father). and are not intended to be an exhaustive list of
8 Asian American and Native Pacific Islander LGBT Elders 163
specific attitudes (i.e., acceptance versus rejec- Chapter “The Role of Religious and Faith
tion) toward LGBT persons, even for those who Communities in Addressing the Needs of
were certain about the causes of being LGBT. LGBT Elders” for further discussion of religion.
Culturally, the majority of interviewees believed Boulden (2009) found a clash of culture
that there have always been LGBT in their home between older generation and younger gay
countries and observed that LGBT persons are Hmong men. In this study, the researcher found
afraid to be open in their countries of birth that the participants described the attitudes of
because the culture is not accepting of them. In their parents and the older Hmong generation
addition, they believe that the relatively more concerning the existence of LGBT persons as the
open and liberal nature of American and Western older generation not acknowledging that lesbians
cultures make it possible for LGBT persons to be and gays exists. Hmong elders have never known
more open about their sexuality; consequently, a Hmong who identified him or herself as gay or
the culture is an enabler of LGBT persons being lesbian; thus, it was not an Asian issue, but rather
open about their identities (Tseng 2011). a White disease and a White issue. Participants
The attitudes of the vast majority of Chinese- indicated that if their parents knew that they are
speaking Americans in Tseng’s (2011) study gay, it would “break their hearts” for not having
were anti-same-sex marriage. These attitudes can children to carry on the bloodline. Therefore, to
be categorizes as follows: (a) LGBT persons avoid bringing shame to the family, they moved
should be able to have the same rights but not to away and separated themselves. Some partici-
call it marriage; (b) the function of marriage is pants spoke of trying to manage the multifaceted
reproduction and passing down the family name; conflicts and different aspects of their daily lives
and (c) same-sex marriage is a violation of tra- of being “out” at work, acting straight in public,
dition, and only heterosexual marriage is recog- and being and talking Hmong at home. In sum-
nized around the world. As parents, the mary, nowhere in their multiple environments
interviewees indicated that they would grudg- did the participants have the luxury of interacting
ingly accept a LGBT child but not before making with others while acknowledging their complete
attempts to “correct” the child. In addition, they identity (Boulden 2009).
expressed two types of concerns. First, they were LGBT AAPIs strongly agree that homophobia
concerned about being labeled as ineffective and/or transphobia is a problem within the Asian-
parents who had done a poor job of raising their American community (Dang and Hu 2005). The
children. Second, they felt that it would be dif- perception was consistent among women, men,
ficult to face close friends and relatives who may and transgender persons. For example, in India,
ridicule them, and they would feel a high degree being gay, the term, a recent addition to the
of self-blame if their children turned out to be Indian cultural dictionary, is challenged with
LGBT. On the question of the role that religion substantial resistance. The Indian Penal Code
plays in their attitudes about LGBT person, the #377 states:
majority of Chinese-speaking Americans indi-
Whoever voluntarily has carnal intercourse against
cated that it only played a small role (Tseng). It the order of nature with any man, woman, or
should be noted that the majority of Chinese animal, shall be punished with imprisonment for
Americans identify as not religious (Dang and life, or with imprisonment of either description for
Hu 2005). Dang and Hu found that of the LGBT a term which may extend to ten years, and shall
also be liable to fine (Indian Law Info, n.d.)
AAPIs in their survey, a large majority claimed
to be atheist, agnostic, or without religion. Of The phrase, “against the order of nature,”
those who did identify as having involvement in refers to any non-heterosexual relationship
religion, on average, they said that their church (Bhattar and Victoria 2007, p. 40). Clearly,
or religion views being LGBT negatively and as alternative sexuality is defined only in terms of
wrong and sinful. Only 16 % said that their sexual behavior, not identity, and is compared to
religion fully accepted LGBT persons. See acts of beastiality. In both Indian tradition and
8 Asian American and Native Pacific Islander LGBT Elders 165
pop culture, gay is still defined as abnormal and persons as opposed to areas with higher pro-
evil. LGBT persons are portrayed stereotypically portions of the broader LGBT population.
in Indian society in the form of a very feminine Approximately, one-third of AAPI same-sex
male of hijra. The term hijra is used to define couples live in California, Hawaii, and New
transgender, intersex, and “third gender” people York. LGBT AAPIs are much younger than both
who live in communities outside of society. the non-LGBT population and AAPI persons in
Consequently, a fear exists among Indians that if same-sex couples. Approximately, 4 % of AAPI
a person identifies as gay, he will soon start to persons in same-sex couples are aged 65 and
dress and act as a woman. The acceptance of the over (Kastanis and Gates 2013). Other charac-
Western ideology of LGBT persons is slow teristics of LGBT AAPIs include lower rates of
among more progressive Indians, and Indian college completion (42 %) as compared to AAPI
communities in the USA find it hard to accept non-LGBT adults (59 %); however, AAPIs in
sexual differences because sexuality is a taboo same-sex couples (58 %) have higher rates of
topic in India (Bhattar and Victoria). educational attainment than their different-sex
In general, AAPIs hold negative and prejudicial counterparts (54 %). Unemployment rates are
attitudes toward LGBT persons. However, as with higher for LGBT persons (11 %) compared to
all groups, varying degrees of acceptance exist. non-LGBT AAPIs (8 %). AAPIs in same-sex
LGBT AAPIs report experiences that are equally (81 %) couples are more likely to be employed
negative and positive within in different contexts than their counterparts in different-sex couples
such as family and LGBT and non-LGBT orga- (70 %). Overall, AAPI persons in same-sex
nizations (Dang and Hu 2005). One interesting couples (40 %) are more likely to be US citizens
result of the survey by Dang and Hu is that despite by birth than those in different-sex couples
their experiences with racism in the LGBT com- (14 %), and same-sex couples are more likely
munity, LGBT AAPIs are more comfortable than different-sex couples to have at least one
working in predominately White LGBT environ- partner with US citizenship status (Kastanis and
ments than they are working in predominantly Gates).
straight homophobic AAPI environments. As with many other ethnic minority popula-
tions, not all LGBT AAPIs identify with the
terms lesbian, gay, bisexual, and transgender
because of cultural differences, internalized
Asian American and Pacific homo/bi/transphobia, and the dissociation
Islander LGBT Elderly between identity and behavior (Mangton et al.
2002). Because of cultural pressures and expec-
The US Census has numerous limitations, tations that exist in Asian and Pacific Island
including but not limited to specifically asking cultures, lesbians and gay men and women and
about sexual orientation or gender identity, men who engage in same-sex behavior are
individuals in same-sex relationships who are not required to stick to family values, marry, and
living together, and homeless LGBT persons, have children, or place shame on their families,
which does not reflect the actual full diversity of neighbors, and community (Boulder 2009). In
LGBT persons in the USA (Dang and Hu 2005). fact, many Asian cultural norms render women
However, other data suggest that of the Asian invisible and silent. Compared to heterosexual
and Pacific Islander population, 2.8 % of adults AAPI women and both heterosexual and gay
identify as LGBT, including 3,246,000 in the AAPI men, lesbians have a higher prevalence of
USA, 32,931 of whom are AAPIs in same-sex tobacco use, binge drinking, marijuana, and other
couples, and that 25.9 % of AAPI same-sex drug use. AAPI lesbians are less likely to adhere
couples are raising children. The majority of to traditional family-orientated gender roles,
LGBT AAPI adults live in geographic locations unable or unwilling to gain and receive emo-
where there are higher proportions of AAPI tional support from their families, and more
166 D.A. Harley
likely to compete with men for masculine privi- Dang and Hu (2005) surveyed LGBT AAPIs
leges in order to escape sexist oppression (Hahm to determine the extent to which they consider
and Adkins 2009). their sexual orientation and gender identity or
In the USA, LGBT persons view “coming expression as important. The results revealed that
out” as a final revelation of their sexual orienta- LGBT AAPIs ranked their sexual orientation or
tion or gender identity. For AAPI LGBT persons, gender identity/expression as the second identity
the integration of their ethnicity and their that most heavily influence their daily lives.
nationality as an American is known as “coming Race/ethnicity was ranked as the most influential.
home,” in which they allude to their sexuality to a Although LGBT persons often mask their sexual
family member who may not challenge it, as long orientation or sexual expression and behaviors to
as the status quo within the family is maintained avoid alienating their family and parents’ com-
(Hahm and Adkins 2009). AAPI LGBT persons munities, in their relationships with others, they
tend to have a high degree of internalized biases frequently have to decide which identity will take
about minority sexualities, which frequently precedence—an ethnic or sexual identity (Eng
cause them to be isolated, serve as a barrier to and Hom 1998). The feeling of being caught
accessing services, and increase high-risk between two separate or non-integrated identities
behavior. The internalization of homophobia by was summarized in a dialogue between two
AAPI LGBT persons can serve as a direct health Asian American gay men as, “though we are
risk (Mangton et al. 2002). In a discussion of the both Asian American and gay, our surroundings
LGBT Filipino community, Alcedo (2014) shared rarely allow these identities to coexist” (Bhattar
some perspectives on what LGBT elders confront and Victoria 2007, p. 39). When asked to identify
with being “out” as ranging from not feeling political issues and attitudes that are most
comfortable to being forced to make connections important, LGBT AAPIs ranked immigration,
with more people because of the need to keep hate violence/harassment, media representation,
healthy and being well situated in an intergener- HIV/AIDS, marriage/domestic partnership, and
ational lesbian community. Jim Toy and George health care as the most pressing for them com-
Takei are two examples that illustrate the public pared to immigration, media representation, the
role of AAPI LGBT elders as activists (see economy/jobs, health care, and language barriers
Table 8.2 for their profiles). for Asian-Americans in general.
The survey project, A Census of Our Own, chapter. One of the most important findings of
gathered data from 364 LGBTQ Southeast Asian the National Transgender Discrimination Survey
Americans from across the USA and found (NTDS) of 2013 was that the combination of
several main points (Queer Southeast Asian anti-transgender bias and structural and inter-
Census 2012). First, coming out narratives and personal racism meant that trans and NCG AAPI
data suggest that an alternative coming out model transgender persons of color, including AAPIs,
and culturally competent programming are nee- experience particularly devastating levels of
ded, which addresses the unique experiences and discrimination (Grant et al. 2011). Of the 6456
challenged faced by LGBTQ Southeast Asians. trans and NCG persons in the survey, 212
The ability to communicate in their native lan- respondents identified themselves as Asian or
guage is challenging because, for example, there Pacific Islander, or Asian or Pacific Islander and
are no positive words within the Hmong, Khmer, multiracial. The majority of the AAPI respon-
Lao, or Viet languages to describe alternative dents were US citizens (84 %). The key finding
sexual orientation. Second, a strict adherence to of the survey revealed that AAPI transgender and
and policy of confidentiality is needed among NCG persons often live in extreme poverty
service providers to ensure safety and garner trust (18 %), which is higher than the rate for trans and
of AAPI LGBT persons. In light of the role of NCG persons of all races (15 %). It is six times
family in the lives of elders, this may prove both the general AAPI population (3 %) and over four
difficult and necessary. Third, Southeast Asian times the general US population rate (4 %).
Americans are coming out at a young age (before AAPI trans and NCG persons are affected dis-
the age of 18). Because the process of coming proportionately by HIV at a rate of 5 % com-
out is often accompanied with psychological and pared to 2.64 % for trans and NCG persons of all
emotional stress, education and safety should be races. Forty four (44 %) of AAPI trans and NCG
essential components of any program or service. persons have experienced significant family
Finally, there are harsh realities of income dis- acceptance, with those persons being much less
parities and limited economic opportunities for likely to face discrimination. Finally, 56 % of
Southeast Asian in the USA, which adds to the AAPI trans and NCG persons have attempted
pressure to contribute toward the family incomes. suicide due to discrimination. Other areas in
While there is limited research on which AAPI trans and NCG persons have
AAPI LGBT persons, much less research exists experienced discrimination are presented in
on transgender AAPIs. Thus, transgender (trans) Table 8.3. In particular, discrimination in the area
and nonconforming gender (NCG) AAPIs are of health care is discussed in the following
deserving of a closer examination within this section.
Health Status, Barriers, and Service receipt of health care, challenges with access,
Delivery for Asian American LGBT lack of health insurance, and immigrant status.
Elderly AAPI elders are uninsured at more than double
the rate of non-Hispanic White elders, and spe-
Several barriers prevent obtaining a full and cific subgroups are uninsured at rates as high as
accurate picture of access to services and service 33 % (Sorkin and Ngo-Metzger 2014). Only
delivery for Asian American LGBT elders. First 33 % of AAPIs aged 65 and over have private
is the barrier of the omission of data reports on health insurance (Schiller et al. 2012). Although
Asian American participants from some of the Asian Americans are less dependent on Social
largest national health studies and surveys, along Security than are other groups, according to
with differentiation among various ethnic sub- Williamson et al. (2014), without the safety net
groups in particular (Holland and Palaniappan provided by Social Security, approximately 19 %
2012). Second, research methods for sampling of Asian elders would fall below the poverty line.
respondents are often limited to persons who may Language has been identified as the most
have limited English proficiency and/or low formidable barrier for Asian American immi-
socioeconomic status (SES). Finally, concerns grants in accessing health care, especially for
about the validity of chosen measures for use with older adults, who are the least likely age group to
a particular Asian ethnic group arise because be proficient in English (Jones et al. 2006; Kim
many measures are rarely validated on Asian and Keefe 2010). In fact, only 41 % of AAPI
Americans, and even fewer have been validated elders feel that they speak English “very well”
on the various Asian ethnic subgroups (Sorkin (US Census 2014). AAPIs represent more than
and Ngo-Metzger 2014). Moreover, measures 100 languages and dialects (Africa and Carrasco
have not been validated on either the Asian 2011). Language barriers for elders have impli-
American elderly or LGBT population among cations for both family dynamics and health care.
them. Two areas in which Asian Americans For example, the lack of language proficiency
consistently report low-quality care include pre- may lead to the role disruption in Asian Ameri-
ventive screening and detection and treatment of can families when children speak, read, and
mental health disorders (Haviland et al. 2005). understand English better than their parents,
The contextual factors that impact the health of resulting in a temporarily reversed family role.
elders are influenced by the diversity within the This role reversal creates awkward situations in
AAPI communities with respect to health-seeking the healthcare setting. Moreover, research sug-
behavior and knowledge, SES, educational level, gests that even with the availability of interpret-
cultural traditions, and specific healthcare needs ers, older AAPIs refrain from asking questions
and issues (Trinh-Shervin et al. 2009). about their health (Green et al. 2005; Sue and
The average life expectancy for AAPIs is Sue 2013).
80.3 years compared to Whites at 75.1, and The life expectancy of Native Hawaiian men
overall health among AAPIs as a group tends to (71.5 years) and women (77.2 years) is lower
be better than that of Whites and other ethnic than for the state of Hawaii (75.9 years for men
groups (U.S. Office of Minority Health Resource and 82.1 years for women) and the USA overall
Center 2010). Collectively, the health status of (Anderson et al. 2006). Mortality rates for Asian
AAPIs is remarkably good; however, certain or Pacific Islander elders are lower than the rates
groups have high rates of illness, chronic con- for Whites, Blacks, or American Indians (Minino
ditions, and disability from specific health cau- et al. 2007). However, these results are likely due
ses. As a subgroup, Asian American elders often to the aggregation of data from Asians, who tend
face unique types of barriers to seeking and to have longer life expectancies, with Native
receiving care, including language and health Hawaiians and other Pacific Islander racial
literacy obstacles, culture-specific stigma around groups, who tend to have lower life expectancies
8 Asian American and Native Pacific Islander LGBT Elders 169
(Braun et al. 1997). In addition, death rates for younger adults; (d) females had a higher FMD
Native Hawaiians due to heart disease, cancers, prevalence than males; and (e) among major
stroke, accidents, and diabetes are higher than ethnicities, Hawaiians (including part-Hawai-
those for the state of Hawaii (Mau 2010; US ians) had the highest FMD prevalence and Jap-
Office of Minority Health Resource Center 2010). anese had the lowest; however, this disparity is
Since 2007, cardiovascular disease (CVD) has an artifact of SES factor combined with age.
been the leading cause of death in the USA and in When these factors were controlled for, the eth-
Hawaii. The rates of CVD vary by ethnicity and nic disparity disappeared. The results of this
SES. Filipinos and Native Hawaiians have dis- study also showed a relationship between FMD
proportionately higher age-adjusted mortality and lifestyle behaviors. Those with FMD are
rates for CVD and stroke. The lowest SES groups more likely to engage in smoking or heavy
and the rural counties of Hawaii consistently drinking than those without FMD.
report the highest areas with CVD-risk factors Africa and Carrasco (2011) conclude that
(i.e., high blood pressure, smoking, obesity, among all ethnicities, AAPIs are the least likely
physical inactivity, and diabetes). CVD is also to seek mental health services because of a
responsible for a large portion of healthcare costs variety of factors such as, but not limited to,
in Hawaii due to costs associated with hospital- stigma, cultural impact of shame, language bar-
izations (Balabis et al. 2007). riers, economic reasons, mind–body conceptual-
AAPI elderly people have a disproportion- ization, and racial discrimination (see Table 8.4
ately high prevalence of hepatitis B. In addition, for additional barriers to seeking mental health
AAPI elderly people exhibit a greater prevalence treatments and supports). Regardless of sexual
of dementia than the total older population. orientation and gender identity, many health
Tuberculosis is 24 times more common among disparities encountered by AAPIs have their
AAPIs than among Whites (Office of Minority origins in “cultural historical trauma” (Blaisdell
Health, n.d.). Generally, Native Hawaiian elders 1996), the psychological, physical, social, and
were similar to their Caucasian counterparts in cultural aftermath of the colonialism many
receiving certain preventive health care and in
having healthcare coverage. In other areas of Table 8.4 Barriers to AAPIs seeing mental health and
preventive care, AAPIs have lower rates of vac- healthcare services
cination, underutilize mental health and specific Cultural
health services such as cancer screening, and Health beliefs
have poorer early detection rates compared to Lack of research
other ethnic groups (Reyes-Salvail et al. 2008;
Immigrant status
Salvail et al. 2003). Consistent across various
Avoiding shame and stigma
ethnic groups, AAPI elders are less likely to see a
primary care provider or take prescription med- Access to healthcare/insurance
ication for their mental health compared to non- Fear of breach of confidentiality
Hispanic White older adults (Sorkin and Ngo- Homophobia and heterosexism
Metzger 2014). In an examination of frequent Experience of prejudice and racism
mental distress (FMD) prevalence rate and dis- Help-seeking behavior (e.g., traditional medicine)
parity, Reyes-Salvail et al. (2008) found the Lack of linguistically and culturally responsive
following: (a) the FMD prevalence rate in the providers
state was 8.3 %, 8.0 % prevalence rate for life- Exclusion of traditional or indigenous providers by the
time anxiety, and 8.8 % for lifetime depression; Western system
(b) no significant difference in the average FDM Health literacy (ability to read and understand health
prevalence rate between counties in the state of content in the context of specific health situations)
Hawaii; (c) adult aged 65 and over had a sig- Adapted from Africa and Carrasco (2011) and Kim and
nificantly lower prevalence rate for FMD than Keefe (2010)
170 D.A. Harley
indigenous people have experienced. Cultural Alcohol and substance abuse is increasing
historical trauma also refers to the cumulative significantly among AAPIs, with tremendous
emotional and psychological wounding that variance among subgroups. According to the
seems to carry forth into successive generations National Asian-Americans Families Against
and affects all aspects of health (Mau 2010). Substance Abuse (n.d.), Japanese Americans
According to Mau, “cultural wounding” can have the highest lifetime prevalence for alcohol
result in communal feelings of disruption and a abuse, and Vietnamese Americans are at high
sense of collective helplessness, which can in risk for heavy drinking. Immigrants from Japan
turn impact one’s ‘sense of self’ and health- and Korea are almost twice as likely to use
seeking behaviors (p. 21). AAPI LGBT persons alcohol than those from the Philippines, China,
identify the extent to which the underlying rac- Vietnam, and India. Moreover, Filipino men are
ism and discrimination that they experience at greater risk than Chinese men for a lifetime
within the mainstream, majority culture is substance abuse disorder. Research also suggests
stronger than the homophobia within the AAPI an association between generational status and
community (Boulden 2009; Mangton et al. depressive and substance abuse disorders among
2002). Dang and Hu (2005) found that LGBT women, with second-and third-generation
AAPIs overwhelmingly experience racism within women being at increased risk.
the White LGBT community and transgender As a subgroup, AAPI trans and NCG persons
persons somewhat more so than lesbians or gay refuse medical care due to bias. In addition, they
men. In addition, LGBT AAPIs experience some postpone care when sick or injured due to fear of
degree of racism or ethnocentrism with other discrimination. AAPI trans and NCG persons are
AAPI LGBT persons. less likely to have accessed counseling and
As a largely immigrant and refugee popula- mental health services. For AAPI trans and NCG
tion, Asian Americans face stressors related to elders, inaccessibility to mental health services in
immigration and acculturation, and confounding the USA is attributed often to language and
factors such as war experiences and abuse that cultural barriers. Thus, there are consequences
make them more vulnerable to advanced depres- for those wishing to seek certain forms of tran-
sion and other mental health disorders (California sition-related medical care that is dependent on
Health Information Survey 2010). Takeuchi et al. prior counseling (Grant et al. 2011).
(2007) indicate an individual’s age at immigration The role and care of AAPI elders within
adds to the complexities of immigration and the families vary depending on factors such as cul-
experiences of adjustment, acculturation, and ture, filial piety values and behavior, tradition-
assimilation when looking at the AAPI commu- alism, and acculturation. AAPI elders serve as a
nity (see Chapter “Immigrant LGBT Elders” for family resource while they are healthy, but they
additional discussion on issues relevant to may be a source of burden when their health
immigration). Specifically, Asian immigrants fails. Conditions in the household and commu-
who arrived at age 12 or younger were at greater nity influence how long elders are able to func-
risk for psychiatric disorders and substance abuse, tion independently as their health declines (Yee
while those who arrived before age 41 also had et al. 2008). According to Yu et al. (1993), more
greater risk for mood disorders, and those who traditional desires such as living with one’s
came after age 41 were likely to have experienced family increased as an elder’s health declined
symptom onset before immigrating to the USA. among Chinese and Korean American elders. An
Older Asian American women have the highest acculturation-related consequence for Asian
suicide rate of all women over age 65 in the USA American families is that they have become more
(Office of Minority Health, n.d.). Although AA- accepting of the institutionalization of the
PIs’ use of mental health services is low, they elderly, but are still more reluctant to access that
have rates of psychological distress comparable to care than the general population (Watari and
the general population. Gatz 2004). South Asian elderly women find it
8 Asian American and Native Pacific Islander LGBT Elders 171
Our Own, recommended that to counter the et al. 2002). Likewise, policy development and
debilitating effects of racism, homophobia, and implementation will need to address potential
genderphobia, more education, resources, and barriers that filial piety values and behaviors may
systems of support are needed. In addition, impose for service intervention.
mainstream LGBTQ organizations and programs A major barrier to effective policy develop-
fail to address the unique ways in which AAPI ment regarding AAPI families, subgroups, and
LGBT persons face multiple identities and mul- LGBT AAPIs is the model minority myth ste-
tiple oppressions. Thus, there is a need for more reotype. This model minority myth stereotype
inclusive practices, including an analysis and obstructs the examination of how AAPIs cope
acknowledgment of racism, class, and gender- with normative and non-normative life span
phobia (Queer Southeast Asian Census 2012). developmental hurdles that expend the resources
To improve access and quality of health care, of even the most resilient individuals and fami-
health, and social policy, analysts need to consider lies. Furthermore, Yee et al. (2008) contend that
several important factors that can either remove or the model minority myth stereotype, in con-
mitigate the effects of barriers for AAPIs. First, junction with an overrepresentation of Asian
patient characteristics such as primary language, American investigators conducting research in
ethnicity, culture, health literacy, insurance cover- the biomedical and physical sciences, has rein-
age, and immigration status must be taken into forced the mistaken notion that there is a suffi-
account (Kim and Keefe 2010). Africa and Carr- cient AAPI family research infrastructure.
asco (2011) emphasize that acknowledging the Similarly, the same error in reasoning may lead
wide diversity of experiences within the AAPI to such an assumption about LGBT AAPI elders.
community is critical for providing effective and AAPIs as a population and LGBT elders in
efficient services responsive to particular needs and particular have been omitted from national data
influential cultural factors. AAPI elders may exhi- sets and studies. Many researchers who study
bit a high degree of mistrust toward service pro- AAPIs contend that since 1976, which marks the
viders and institutions because of past negative pivotal beginning in the use of data for evidence-
personal and historical experiences endured from based health policy in the USA, core issues about
the government (e.g., internment camps, exploit- the lack of data persist for this population (Ponce
ative labor practices) and racism and discrimination 2011). Clearly, organizations and service pro-
that have lingering impacts upon cultural groups viders must expand efforts to serve AAPI LGBT
today. The recommendation from participants in elders.
Africa and Carrasco’s report is for service provid-
ers to have a “balanced approach to representation
of both communities and perspectives at different
levels” (p. 13). Summary
Strength and Resiliency. AAPIs have cultural
values that provide strength and resiliency and AAPI LGBT elders represent a unique subgroup
help them deal with difficult life events (Sue and within culturally specific populations. Their
Sue 2013). Enculturation or identification with value systems are influenced by tradition, lan-
racial and ethnic background can buffer prejudice guage, and a host of other factors. Many AAPI
and discrimination, family conflicts, and psy- LGBT elders maintain a covert lifestyle in order
chosocial adjustment issues (Kim 2011). Thus, to save face and to not bring shame to their
both policy and practice should be geared toward families. Their multiple identities are encapsu-
promotion of cultural strengths. In addition, lated not only by cultural attitudinal barriers, but
practitioners should maintain a distinction also by racism, discrimination, and phobias
between identity and behavior because AAPIs within society as a whole. All of these factors
participating in same-sex behavior may not contribute to the limited research and available
always identify with the terms LGBT (Mangton information on AAPI LGBT elders.
8 Asian American and Native Pacific Islander LGBT Elders 173
In general, AAPIs bear the burden of the 3. The religious view of many AAPI groups is
stereotyped model minority, which puts them at a that alternative sexuality is wrong and sinful.
disadvantage for various services. AAPI LGBT Develop a presentation to address their view.
elders may never exercise the option of “coming Be sure to include cultural concerns.
out” because they may view the risks as far too
great. Thus, for both AAPI LGBT elders who are
“out” and for those who are not, there is utility in Multiple-Choice Questions
using lay health workers and service providers or
“cultural communicators” as facilitators for 1. Which of the following Asian American
improving communication and shared decision- cultural values creates a bias against change?
making (Sorkin and Ngo-Metzger 2014). In the a. Cooperation
final analysis, service providers must be able to b. Harmony
work around many barriers that put AAPI LGBT c. Education
elders at risk for poor health, social, and emo- d. Benevolence
tional outcomes. 2. Which of the following means respect for
parents?
a. Ohana
b. Uncomplaining
Learning Exercises c. Filial piety
d. Emotional centeredness
Self-Check Questions 3. Which of the following is a concern of AAPI
parents whose child is gay?
1. What is the general perception of AAPI cul- a. Being labeled as ineffective parents
tures toward LGBT persons? b. Ridicule from relatives and close friends
2. What is meant by the stereotype of Asian c. Self-blame
Americans being seen as the model minority? d. All of the above
3. Who are the largest Asian American single- e. None of the above
race subgroups? 4. Which of the following terms is used to
4. What are some of the often unseen challenges define transgender, intersex, and third gender
in Asian American communities such as Asian Indians?
Chinatowns, Manilatowns, and Japantowns? a. Hijra
5. Were the majority of older Asian Americans b. Kuelna
born inside or outside of the USA? c. Laulima
d. Lokahi
5. LGBT AAPI adults live in geographic loca-
Field-Based Experiential Assignments tions with higher proportions of which type
of populations?
1. Conduct a survey of healthcare service pro- a. LGBT persons
viders or social service provider to determine b. AAPI persons
their knowledge level about working with c. Diverse persons
AAPI LGBT elders. d. No data are available
2. Interview an AAPI LGBT elder to understand 6. What is the integration of their ethnicity and
issues and concerns they had about “coming their nationality known as for AAPI LGBT
out” and how they addressed them. persons?
a. Coming out
b. Assimilation
174 D.A. Harley
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European LGBT Elders
9
Melanie D. Otis
Abstract
The focus of this chapter is on understanding relevant factors that may
contribute to the unique experiences and challenges faced by LGBT elders
of European descent. While it is often assumed that all white LGBT elders
are part of a homogeneous group, the diverse cultures that can be found
across the fifty countries that comprise Europe suggest that such an
assumption would be misguided. In addition to the misconceptions that
may result from researchers and helping professionals viewing European
elders of LGBT descent as a monolithic group, is the fact that the heritage
of many LGBT elders of European descent may encompass more than one
country, and thus include influences from more than a single culture. This
chapter considers the ways human service professionals can improve their
capacity to meet the needs of all LGBT elders by considering the myriad
factors that make individuals unique.
Keywords
European descent Ethnic ambiguity
Intersectionality Cultural
competence Families of choice
larger field of inquiry. The chapter seeks to 1. Explain reasons why it is important to con-
extend our explication of what we know and sider the relevance of country of origin in the
what we still need to learn about the diverse lives lives of LGBT elders of European descent.
and needs of all LGBT elders. This reorientation 2. Explain why research involving predomi-
of framework permits the understanding that nantly or entirely white samples should be
alongside failures to include race and ethnicity as viewed with caution even when applying the
meaningful distinctions in research and practice findings to persons who identify as white.
knowledge, we also have little awareness of what 3. List steps that need to be taken to develop
it means to live in rural areas or what it is like to culturally competent practice and policies to
be a poor or working-class LGBT elder of any meet the needs of LGBT elders.
race or ethnicity. A primary goal of this chapter 4. Identify key historical events that may impact
is to dismantle counterproductive yet persistent the lives of LGBT elders of European descent.
stereotypes that the lives of all LGBT persons
can be sufficiently understood through the lens of
the lives of White, Anglo-Saxon, middle-class,
college-educated young gay men and lesbians. Introduction
To lay the foundation for a more nuanced
understanding of LGBT elders of European This chapter marks a notable departure from past
descent, a brief discussion of the history of approaches to acknowledging the diversity and
research and practice as it relates to this popu- complexity of the LGBT population. The pres-
lation will be articulated, and a framework will ence of a stand-alone chapter focused on LGBT
be developed to identify parameters that define elders of European descent alongside the chap-
LGBT elders of European descent as a unique ters dedicated to Hispanic (e.g., Chap. 10),
group of individuals distinguishable from others Native American (e.g., Chap. 7), and African
with whom they are often grouped. This defini- American LGBT elders (e.g., Chap. 6) (among
tion will lead to delineating challenges of others) (e.g., Chaps. 8, 13) makes a significant
understanding the experiences of individuals of statement about the importance of viewing
European descent. Once the population has been diversity in all its forms. Rather than simply
defined, perspectives on coming out and creating a juxtaposition of other racial and ethnic
self-disclosure as lesbian, gay, bisexual, or groups against the backdrop of some previously
transgender at different points across the life established and tacitly accepted one-dimensional,
course will be considered. The potential rele- monochromatic mass labeled “Whites,” this
vance of cohort effects (e.g., pre/post-Stonewall, chapter represents an explicit effort to clarify
Baby Boomers) on decisions about when and if what we do know and do not know about this
one discloses his/her status as a sexual minority group by integrating the discussion of LGBT
will be considered, along with an exploration of elders of European descent within the larger field
the difficulties that come with having the power of inquiry in a more balanced and informative
to control the decision to disclose taken away by way. The challenges of identifying, studying, and
circumstances associated with one’s own aging responding to the experiences and needs of other
or the aging of one’s partner, friend, or family groups generally acknowledged as representa-
member. tives of the face of diversity in the LGBT com-
munity tend to encourage us to ignore the
heterogeneity of members of this (current) racial
Learning Objectives majority. It has been suggested that the tacit
acceptance of the dominance of the majority
By the end of the chapter, the reader should be group leads members of the group to fail to see
able to: their own characteristics (e.g., race, ethnicity,
9 European LGBT Elders 179
social class) (Gelfand 2003). In so doing, we lose lesbians, gay men, bisexuals, and transgender
track of the reality that the white LGBT elder persons have ancestral histories that encompass
population consists of people from numerous more than one national lineage. Once the popu-
countries characterized by diverse heritages and lation has been defined, perspectives on chal-
cultural norms, who self-identify across the lenges associated with coming out and
gender spectrum and who live in different geo- self-disclosure as a lesbian, gay, bisexual, or
graphical corners of the USA under different transgender at different points across the life
economic conditions. Thus, this chapter seeks to course will be considered. The potential rele-
extend our explication of what we know and vance of cohort effects (e.g., pre/post-Stonewall,
what we still need to learn about the diverse lives Baby Boomers) on decisions about when and if
and needs of all LGBT elders. It represents an one discloses his/her status as a sexual minority
effort to move scholarly inquiry, the development will be considered, along with an exploration of
of best practice models, the enhancement of the difficulties that come with having the power
health and human services, and the relevant to control the decision to disclose taken away by
policy-related knowledge beyond crude distinc- circumstances associated with one’s own aging
tions based solely on race and ethnicity, without or the aging of one’s partner, friend, or family
ignoring the reality of the importance of either member.
(McDermott and Samson 2005). This reorienta- Utilizing Crenshaw’s (1989) notion of inter-
tion of our framework for defining difference will sectionality1 will offer a framework for examin-
allow us to see that alongside our frequent failure ing the somewhat unique way that individuals
to include race and ethnicity as meaningful dis- who may be viewed by many as a member of the
tinctions in our research and practice knowledge, majority (without the privileges that accompa-
we also have little awareness of what it means to nying that position of power) become a double
live in rural areas or what it is like to be a poor or (and in the case of lesbians triple) minority by
working-class LGBT elder of any race or eth- virtue of their immutable status associated with
nicity. In the end, a primary goal of this chapter being elderly and their ascribed status as a result
is to move us one step closer to dismantling the of being a sexual minority. Further distinctions
counterproductive yet persistent stereotype that among LGBT elderly of European descent will
the lives of all LGBT persons can be sufficiently be considered in terms of the impact of geo-
understood through the lens of the lives of white, graphical location, population density, and eco-
Anglo-Saxon, middle-class, college-educated nomic status. Finally, the chapter offers a look at
young gay men and lesbians. extant service delivery models and interdisci-
To begin to lay the foundation for a more plinary approaches currently being used in the
nuanced understanding of LGBT elders of USA and considers the influence of various dis-
European descent, a brief discussion of the his- ciplines on these models and programs. These
tory of research and practice as it relates to this models and programs will be considered in
population will be articulated. With this back- relation to efforts that are currently being
ground in place, a framework will be developed
to identify parameters that define LGBT elders of
1
European descent as a unique group of individ- Crenshaw’s (1989) notion of the intersectionality of
uals that can be distinguished from others with disadvantaged minority statuses focused on the multiple
intersecting forms of oppression and discrimination that
whom they are often lumped based solely on skin
serve to compound the disadvantaged status of black
color. This definition will provide a platform for women. This work was later revisited and further
delineating the challenges of understanding the developed as a key part of Patricia Hill Collins’s (1990)
experiences of individuals of European descent standpoint theory which offered a perspective for under-
standing the unique experiences of individuals who
when so much about how we view the group is
embody different minority statuses based on sex, race,
based on ignoring any factors that make indi- ethnicity, socioeconomic status, sexual orientation, and
viduals unique and when so many of these gender identity.
180 M.D. Otis
undertaken in European countries, offering a the times (Fredriksen-Goldsen and Muraco 2010,
foundation for identifying issues that are still in p. 402). They identified a total of 58 studies that
need of resolution. included samples of LGBT elders (50 years of
age or older). Regardless of whether the work
focused on gay men, lesbians, or both, much like
research reported prior to 1984, samples were
History of Research and Practice predominantly white and urban. For instance,
Related to LGBT Elders of European 17 % involved samples that were exclusively
Descent white, and another 43 % were predominantly
white (75 % or more of the sample were white).
Compared to that of non-LGBT persons, research An additional 24 % of the studies either failed to
on the lives of LGBT persons of any age is fairly collect or failed to report this information, sug-
new, with the earliest scholarly work predomi- gesting a greater likelihood that these studies
nantly focusing on the lives of younger gay men involved predominantly or exclusively white
and, to a lesser degree, lesbians (Brown 2009). In participants as well. Unlike much of the pre-1984
the 1970s, however, a number of studies shifted research, this body of work demonstrated a bal-
their focus to LG elders. That early work was ance between exclusively male (21 %) and
plagued by a variety of methodological prob- exclusively lesbian (22 %) samples, with all
lems, not the least of which was the reality of other samples involving both male and female
sampling limitations associated with barriers participants that were represented in fairly bal-
(e.g., fear, discrimination, victimization) that anced numbers within studies.2 Approximately
limited access to the full spectrum of persons one-third (31 %) of the studies included some
representing the LGBT population…a challenge bisexual participants (ranging from 2 to 25 %3 of
that continues to impact LGBT-focused research the total sample); however, transgender persons
today (Bettinger 2010; Grossman 2008; Meezan were only included in two of the studies, and the
and Martin 2009). With much of this early (and study findings failed to specifically address them
current) research relying on non-probability as a unique group. In terms of location, only 5 %
sampling techniques such as snowball sampling of studies involved exclusively rural samples
of friendship networks and readily accessible compared to 34 % involving urban samples.
convenience sampling of patrons at gay and With 41 % failing to identify the geographical
lesbian bars and LG community events, the location of respondents, it is again likely that
developing images of LG lives suggested that these samples were either exclusively or largely
LGBT elders simply did not exist—and if they urban.
did, they were best characterized as lonely, iso- While this work had broken through the lim-
lated, and depressed. Based on the dominance of ited perspective offered by previous studies of
gay men in much of this research, those early younger lesbians and gay men, the challenges of
studies also seemed to suggest that lesbians, achieving representativeness were far from
bisexuals, and transgender persons were also overcome. This was particularly true when con-
nonexistent (Shankle et al. 2003). sidering LGBT elders who were born in the early
In 2010, Fredriksen-Goldsen and Muraco 1900s, where access can be described as difficult
published a systematic review of 25 years of at best. Additionally, while some limited success
literature on LGBT elders (1984–2008). They may have been achieved in efforts to engage
utilized a life course perspective to examine “the
2
interplay of the social context and historical One study did not collect data on gender
times” to understand how both the lives of LGBT (Fredriksen-Goldsen and Muraco 2010).
3
This study involved a snowball sampling of 16 women
elders and the research that has attempted to
(75 % lesbian and 25 % bisexual) who were interviewed
illuminate our understanding of those lives are about their experiences as grandmothers (Orel and
embedded in the social and historical context of Fruhauf 2006).
9 European LGBT Elders 181
elder lesbians and gay men in research, the problem. Exacerbating the negative impact of
inclusion of bisexual men and women in research these physical and mental health problems, we
has lagged far behind this initial research also know that lesbians and bisexual women are
involving lesbians and gay men—and at best we more likely to live in poverty than gay men or
can say that we are just now beginning to con- heterosexual men or women (Albelda et al. 2009;
duct meaningful focused inquiry into the lives of Prokos and Keene 2010), a reality that often
transgender persons of any age limits access to needed healthcare and other
(Fredriksen-Goldsen and Muraco 2010; Grant services as these women age (Espinoza 2011).
et al. 2011; Hartzell et al. 2009). As previously noted, much of the extant
Despite the limitations of this early research, research has failed to specifically address the
we can say that we know a bit more about the experiences of bisexual men and women. Yet,
lives of lesbian, gay, bisexual, and transgender the limited information we have to date suggests
elders today than we did in the 1970s. We know that the lives of bisexual men and women differ
that gay and lesbian elders are more likely to be from the lives of lesbians and gay men in a
single (Brennan-Ing et al. 2014; IOM 2011; number of relevant ways. For instance, elder
MetLife 2006, 2010), live alone (Brennan-Ing bisexual men and women are more likely to have
et al. 2014; Shippy et al. 2004; Wallace et al. been married to an opposite-sex partner at some
2011), and more likely to not have children time in their lives and more likely to have chil-
(Fredriksen-Goldsen et al. 2011). Studies focus- dren compared to lesbians and gay men (Pew
ing on mental well-being have often identified Research Center 2013). While this may change
higher levels of psychiatric disorders among for future generations, this reality in the lives of
LGB persons when compared with their hetero- contemporary bisexual men and women offers
sexual counterparts (Cochran et al. 2003; Meyer both pluses and minuses. Bisexual men and
2003). A variety of studies have found higher women have been found to have a larger support
rates of disability, cardiovascular disease (Dia- network in the heterosexual community than
mant and Wold 2003; Roberts et al. 2003), and their lesbian and gay counterparts (Grossman
certain cancers, as well as other health conditions et al. 2000). This increases the likelihood that
among lesbian elders (Fredriksen-Goldsen et al. bisexual men and women may have additional
2011). These issues may be tied to higher rates of forms of support, but it also decreases the like-
obesity among lesbians (Boehmer et al. 2007; lihood that they will be integrated into the LGBT
Clunis et al. 2005) and cigarette smoking which community and the potential sources of individ-
have been found by numerous studies (Case et al. ual and organizational support that may be
2004; Conron et al. 2010; Valanis et al. 2000). accessed there (Grossman et al. 2000).
While gay men do not experience the same Our understanding of the lives of transgender
higher rates of obesity, a number of studies elders is even more limited. In general,
indicate that gay men are more likely to be dis- researchers have either failed to ask whether
satisfied with their bodies, which may contribute study participants identify as transgender or,
to eating disorders and concomitant health when the information is gathered, have ended up
problems as they age (Kaminski et al. 2005; with samples of insufficient size to offer any
Russell and Keel 2002). Additionally, a signifi- meaningful insights that extend our understand-
cant, and growing, number of gay elders are ing of their lives much beyond that of a case study
likely to be living with HIV/AIDS (Dolcini et al. (Brown and Grossman 2014). These studies do
2003; Effros et al. 2008), and their risks of con- offer some important insights into the unique and
tracting the virus or other STDs are elevated by difficult experiences of transgender elders, how-
the fact that they are often sexually active in the ever. A notable exception to this dearth of
absence of using safe sex practices. The failure of research is the Transgender Discrimination Sur-
medical professionals to acknowledge LGBT vey that was conducted by the National Center for
elders as sexual beings contributes greatly to this Transgender Equality and the National Gay and
182 M.D. Otis
Lesbian Task Force (Grant et al. 2011). Family country—Russia (population of 142.1 million)—
rejection was found to be a significant issue to the smallest—the Republic of San Marino
(reported by 57 % of the sample) in the lives of (population of 40,000),4 with the most sub-
transgender persons in their study, thus increasing stantial influence on the current US population of
the likelihood that transgender elders live alone. European descent originating from England,
Finally, a certain irony of the limitations of Ireland, Scotland, and/or Italy. The daunting
much of LGBT research is particularly relevant numbers of distinctive heritages, and associated
to this discussion. Whether it be due to a lack of cultural norms, languages, religions, and per-
access or methodological issues, our knowledge spectives, represented by the countries that con-
of LGBT elders is dominated by information that stitute Europe have generally been ignored by
has been gleaned predominantly from individuals researchers considering the relevance of ethnicity
who are presumably primarily of European des- in lives of the diverse population that lives in the
cent. These studies offer us the best insight into USA (see Table 9.1 for a list of European
the lives of LGBT elders of European descent, countries). Increasingly, however, alongside the
despite the fact that they include white people persistent call to conduct research that allows for
from non-European countries and may also meaningful examination of differences that may
include a small number of persons of color who be associated with being African America,
are unable to be analyzed separately or compar- Latino or Latina, Native American, among oth-
atively. However, given the dominance of whites ers, has been at least some recognition that
in these studies, they offer us a better under- “white” is simply an insufficient distinction to
standing of LGBT elders of European descent capture the meaningful differences that impact
than do any other group who may be marginally the lives of this heterogeneous group (McDer-
represented. Thus, it is noteworthy to acknowl- mott and Samson 2005; Richmond and Guindon
edge that research intentionally focused on 2013).
studying the lives of LGBT elders of European Estimating the portion of the US population
descent does not exist by design; however, albeit that can be identified as elders of European
by default, there is a growing body of work descent is equally challenging. Our most com-
dominated by a well-educated, largely prehensive accounting of persons in the USA
middle-class, urban subset of elders of European comes from the US Census Bureau. Estimates
descent that continues to influence practice and from the decennial census (last completed in
policy related to all LGBT elders. 2010) provide us with a fairly accurate enumer-
ation of the number of people living in the
country at the time of data collection, yet Euro-
pean descent is not captured as a distinct cate-
Defining the European LGBT Elder gory in the census data collection process.
Population Instead, much like other less comprehensive ac-
countings of the population, individuals of
Simply put, LGBT elders of European descent European descent are included in the broader
are those individuals whose ancestry is rooted in category labeled “White, non-Hispanic.” This
Europe. In the USA, this group includes indi- group consists not only of individuals of Euro-
viduals who may have been born in Europe and pean descent, but also individuals who originate
subsequently immigrated to the USA either as a
child or as an adult, as well as many who rep- 4
Technically, the smallest country in Europe is the
resent the subsequent generations of earlier Vatican City (population approximately 840). This sov-
immigrants (some of whom may have US roots ereign city-state covers 110 acres within the city of Rome,
Italy. It is the home of the Pope, with all other citizens
that span multiple generations). Their ancestral
being either clergy (the majority of the population),
background can be traced to any one of the 50 officials of the state, or members of the Swiss Guard
countries that make up Europe, from the largest (responsible for the Pope’s safety).
9 European LGBT Elders 183
from either North Africa or the Middle East. The best represented by the face of Americans of
2010 Census estimates that there were approxi- European descent. That notion has since been
mately 40 million White, non-Hispanic persons challenged both from within the LGBT com-
who were 65 and older at that time (roughly munity and by those outside the community.
13 % of the total population). Of that number, Today, the LGBT elder population of European
around 5.5 million were 85 or older. While these descent is understood as one part of a very
estimates can be viewed as fairly accurate, the complex and diverse population, rather than
next step of attempting to estimate the number of being viewed as the gold standard for under-
these individuals who are LGBT elders of standing all LGBT persons. While this issue is
European descent is far more challenging and not unique to research involving sexual and
precludes creating any particularly precise gender minorities, the exposure of the color
parameter estimates of this group. In the face of blindness of LGBT research was an important
these limitations, we must draw on our best key to the development of a broader, more cul-
available data as a basis for estimating this turally competent approach to research focused
population. Based on the initial consistently cited on the lives of sexual and gender minorities
estimates established by the Kinsey Institute (Donahue and McDonald 2005; Meezan and
(Kinsey et al. 1947) of 10 % and more recent Martin 2009). Whereas the body of work focus-
studies which place the percentage of LGBT ing on ethnically and racially diverse samples of
persons somewhere around 3.5 % of the popu- LGBT elders remains limited, new scholarship
lation (Gates and Newport 2013), we can assess appears on a regular basis. We are beginning to
the current number of LGBT elders (65 and better understand the unique impact (or at least
older) of European descent living in the USA to the reality of its existence) of ethnicity and race
be somewhere between 1.1 and 3.4 million. on the lives of lesbians, gay men, bisexual men
Based on broader demographers’ estimates for all and women, and transgendered persons (Herek
persons in the USA, with the aging of the Baby et al. 2010). Yet, like so many debates on inter-
Boomer cohort (those born between 1946 and sectionality and its impact on well-being, we are
1964), by 2030, we can expect this number to challenged to find ways to avoid trading one
double (Gates and Cooke 2011). myopic approach to scholarship and practice for
Historically, the US LGBT population has another. For instance, missing in much of the
been treated as some monolithic entity that is extant literature is any recognition that being
184 M.D. Otis
poor and lesbian, gay, bisexual, or transgender is subcultures and ethnically homogeneous neigh-
different than being an L, G, B, or T person who borhoods within the larger community. Within
is economically and/or socially defined as these areas, numerous restaurants and businesses
working class, middle class, or upper class. As a exist that retain and celebrate the culture of origin
group of individuals of European descent may be of the inhabitants. Outside these communities
more likely to inhabit particular socioeconomic and across the country, “Americanized” versions
strata in some geographical locations, economic are marketed to others (often by corporations
differences impact individuals from all races and which have no connection to the represented
ethnicities. Thus, in many ways, we are still culture), thus exposing others to the food and
trying to understand the needs and experiences of culture of distant places like France, Greece,
poor and working-class LGBT persons of Euro- Italy, or Spain. For the most part, we know little
pean descent. Similarly, we know relatively little else about what makes these places unique…
about the lives of LGBT elders who live largely what makes them more than just European
hidden in rural areas and small towns and cities countries. Yet, for many who retain close con-
throughout the country (Jackson et al. 2008; Otis nections to their heritage, culturally bound norms
2009; Willging et al. 2006). See Chap. 25 for related to things like gender roles, sexual
further discussion of LGBT elders in rural areas. behavior, and religious beliefs may still have a
significant impact on their personal identity.
Depending on a variety of factors, most peo-
ple we encounter throughout the day to day of
Cultural and Ethnic Ambiguity our lives will have little if any awareness of our
ancestry. If we immigrated as a child or later in
Understanding what constitutes an ethnic group life, we might present with a slight (or pro-
is an important first step in considering the nounced) accent that leads people to wonder (or
challenges that are faced by elders of European readily identify) our country of origin, but if we
descent. Ethnicity has both geographical and are US born and/or raised, the original founda-
cultural relevance. First, ethnic groups are linked tion of our heritage may remain invisible to
together by a common origin—no matter where others. In research and practice, the diverse cul-
one may be living today, his or her Scottish (or tural backgrounds of individuals of European
Irish, or Russian, or Italian, or Slovakian) descent are largely ignored in favor of focusing
ancestry offers an historic link to the past and a on presumed commonalities and similarities
personal (or virtual) connection to others with associated with race—more specifically, white
whom he or she shares a common lineage. race (McDermott and Samson 2005). While it
Beyond a simple geographical place on a globe, can be argued that the response of others may be
one’s ethnicity can be understood in terms of the dominated by assumptions that are based on the
many unique cultural norms, values, beliefs, and color of one’s skin, this reality speaks to only one
traditions that define one’s heritage as distinct piece of what influences our life experiences and
from some other outwardly similar, yet unique personal identities. The relevance of these cul-
group. Some of these cultural realities have been tural factors may become increasingly important
adopted and co-opted in myriad ways as part of as one ages and moves into a developmental
US culture, while others may only endure stage in life where reflection on the past may be
through purposive effort on the part of group an important and valuable part of the aging
members. For instance, many of us may have process (Erikson 1982).
food as our only insight into other ethnic groups. Historically, American culture has often been
In larger cities, evidence of the importance of defined by a presumed universality of the
those roots is found in the contemporary pres- meaning of being of European descent. When a
ence of places like Little Italy, Chinatown, and critical lens was first placed on the practice of
other purposively created and sustained assuming that White, Anglo-Saxon people could
9 European LGBT Elders 185
Research involving older LGBT persons often of same-sex unions, with 11 of these countries
paints a very different picture. For instance, Grov having legalized same-sex marriage, in June
and colleagues found that many of the partici- 2013, Russia passed a new law banning “pro-
pants in their study reported that they had not paganda of nontraditional sexual relations”
experienced same-sex attraction until well into (Herszenhorn 2013).
adulthood or that they opted not to act on such In 1999 Rosenfeld, a sociologist, published
attractions and chose a traditional path of one of the first studies which attempted to cap-
opposite-sex marriage and children (Grov et al. ture the “interplay between identity, generations,
2006). Understanding the historical and social and social change.” The qualitative study
context in which these experiences unfolded is involving 37 lesbians and gay men over the age
essential to understanding how older LGBT per- of 65 demonstrated the importance of consider-
sons experience their sexual minority status ing not only the timing of coming out but also the
today. As a point of reference, a 65-year-old in cultural and historical context in which it takes
2014 was 13-year-old in 1962—he or she expe- place. We know that in the midst of all of the
rienced his or her adolescence in the 1960s. Thus, chaos of the 1960s, there were many individuals
even the youngest of our older citizens experi- leading secretly “out” lives within their com-
enced adolescence prior to the 1969 Stonewall munities and others who traveled to large urban
Riots and came of age while homosexuality was areas for the occasional opportunity to be around
still identified as a mental health disorder by the other LGBT persons. Given that LGBT persons
American Psychiatric Association (Blank et al. of age 65 and over grew up in the pre-Stonewall
2009; Floyd and Bakeman 2006). On a broader era, coming out may have been impacted by fear,
spectrum, today’s LGBT elderly had front row practical concerns (e.g., loss of job, housing,
seats either directly or via television and other family support), views on the appropriateness of
media to the unrest and social change associated talking about sexuality, or even the fact that they
with the Civil Rights Movement, the Women’s simply had never considered the possibility they
Rights Movement, and protests of the Vietnam might be lesbian, gay, bisexual, or transgender
War. LGBT Baby Boomers were in their thirties (Hunter 2007; Jensen 2013; Johnston and Jen-
during the most volatile period of the AIDS crisis, kins 2003).
a reality that means many elder gay men may Does coming out matter? For those who
have experienced the loss of partners and friends either choose not to come out or feel unable to do
during that time. For those living in urban areas so, life can often be stressful and fraught with
like San Francisco, New York City, Los Angeles, ongoing concerns about exposure (Hunter 2007).
and Atlanta, those losses may have been numer- As we age, these concerns may move from fear
ous (Rosenfeld et al. 2012). of losing one’s job (see Chap. 28) to increasing
During this same time period, the social concerns about experiencing discrimination and
context surrounding sexual minorities living in victimization in healthcare settings and/or senior
European countries was quite diverse. While housing (Johnson et al. 2005) (see Chap. 21).
many European countries had never had laws This pervasive fear of being out has been noted
that criminalized same-sex relationships, others in a number of recent studies, with many elder
were often quite punitive (ILGA-Europe 2014). LGBT persons indicating that they believe it is
The diversity of responses across the continent unsafe to be out in long-term healthcare settings
underscores many of the reasons European (IOM 2011). A survey of service providers in
immigrants to the USA may hold very divergent those healthcare settings affirmed these fears
views about their own sexuality. The recent (Johnson et al. 2005; National Senior Citizens
controversy surrounding the 2014 Olympics Law Center et al. 2010). These concerns can also
which were held in Russia remind us that this serve to increase the likelihood of isolation that
diversity of views remains. Despite the fact that may often accompany aging. For persons who
24 European countries now recognize some form came to acknowledge their same-sex attractions
188 M.D. Otis
later in life (after children are grown, spouses die, invisible as a sexual minority may impact their
retirement, etc.), the risk of experiencing isola- well-being and successful aging process.
tion is even greater as long-term support systems Against this backdrop, it is important to
may disappear (Brennan-Ing et al. 2014; De remember that while the research on coming out
Vries and Hoctel 2007; Fitzgerald 2013; Kuyper has documented a number of challenges for those
and Fokkema 2010). who are not out and benefits for those who are,
A number of studies have identified higher the bulk of this research is based on samples that
rates of mood and anxiety disorders (IOM 2011; are not representative of the spectrum of LGBT
Shippy et al. 2004), alcohol and drug use, and persons. In general, much of what we understand
suicidal thoughts and attempts among LGBT about coming out is based on middle-class,
persons compared to heterosexuals (D’Augelli college-educated LGBT persons in their twenties
and Grossman 2001; King et al. 2008). Juster and and thirties. As a result, our understanding of the
colleagues found the role of disclosure to be an implications of a variety of factors, including
important contributing factor to the existence of cohort effects related to being out/not out, age
these disparities (Juster et al. 2013). Their study and the timing of the decision to be out/not out,
compared a gender-mixed sample of LGB people and potential cultural differences in the primacy
with a sample of heterosexuals (49 % women) to and/or necessity to be out, is largely unexplored.
see whether there were differences in levels of Still to be considered is the question of whe-
psychiatric disorders, levels of stress hormones, ther being out is an essential part of successful
and physiological dysregulation (allostatic load). aging and well-being for all LGBT persons
Although the study did not involve LGBT elders, (McGarrity and Huebner 2013; Purdie-Vaughns
its findings have important implications for aging and Eibach 2008). As previously noted, studies
LGBT persons. Specifically, the study found that that account for cohort and/or cultural differences
individuals who had completely disclosed their related to coming out are limited. Much of the
sexual orientation experienced lower levels of work that has been done in the area starts from an
anxiety and depressive symptoms compared to assumption that not being out is universally
LGB persons who had not fully disclosed. problematic; thus, the subsequent inquiry is
Notably, other studies have supported a cohort framed accordingly. The combination of this
effect related to the impact of disclosure on framing and the myriad of issues and barriers that
psychological well-being (Hunter 2007). These challenge efforts to do population-based research
studies found that older cohorts of LGBT persons contributes to the dearth of knowledge about
who indicated that they were not out to their distinct age cohorts that represent the spectrum of
healthcare and service providers did not neces- unique racial, ethnic, and cultural groups. Chal-
sarily display higher levels of psychological lenged by the same difficulties in terms of gain-
distress. A number of scholars have suggested ing access to representative samples, research in
that this is a result of the development of crisis European countries offers little additional insight.
competence, or a level of resilience, that has Of the few studies that might shed light on
evolved as a result of years of navigating a potential differences, some points of divergence
homophobic environment (IOM 2011). As a have surfaced. For instance, in a probabilistic
result, LGBT persons develop important coping sample of sexual minority men (n = 372, aged
skills that serve as protective factors in daily life. 50–85 years), Rawls (2004) found that among
While these findings are certainly a positive sign men 60 years of age and older, level of disclosure
for LGBT elders who are not out, the studies are of sexual minority status had no meaningful
based on samples that may have experienced impact on reported levels of depression and dis-
fairly limited needs in terms of service access. tress. Fifteen years earlier, Adelman’s (1990)
As LGBT elders have more reasons to draw upon study of older lesbians and gay men (born prior
community, social service, and healthcare sys- to 1930) living in the San Francisco area reported
tems, it is unclear how attempting to remain similar findings. This suggests that for elderly
9 European LGBT Elders 189
people who came of age in the 1940s and 1950s studies in Georgia and Azerbaijan were out to
when sexuality was not a topic of public dis- very few family members, and many indicated
cussion, openness about one’s sexual orientation that disclosures were often accompanied by some
may be no more relevant than openness about form of hostility, violence, and/or rejection. With
any individual’s sexual behavior. In fact, the such divergent responses to homosexuality7
notion that such things are important to share being experienced by sexual minorities living in
publicly may be a greater source of discomfort different European countries, it is understandable
than the experience of being a sexual minority in that individuals of European descent living in the
a heterosexist environment. USA may have very divergent views of both the
While those studies offer a modicum of necessity and the potential costs and benefits of
insight into general age cohort differences that being out.
may exist, studies addressing cultural differences Social and instrumental support. Although
in views on coming out/being out among LGBT isolation and absence of social support can
persons of European descent now living the USA impact people’s lives at any age, social and
are nonexistent. For those who were born and instrumental support can be particularly impor-
spent a significant part of their formative years tant for LGBT elders. LGBT elders tend to rely
there, research characterizing the lives of sexual more heavily on families of choice, while heter-
minorities in various European countries does osexual elders’ support systems are more likely
exist, albeit based on very limited samples. Since to be made up of one or more persons who are
1996, the International Lesbian, Gay, Bisexual, biologically or legally related. While studies
and Intersex Association Europe (ILGA-Europe) indicate that many LGBT elders are satisfied with
has been conducting studies examining issues the level of support they receive from their
related to social justice, inequality, and chosen families, individuals in these constructed
well-being associated with being a sexual families of choice tend to be of similar ages and
minority in Europe (ILGA-Europe 2014). Addi- thus have/will have their own needs for support
tionally, the Council of Europe and the European and caregiving services as they age. Over time,
Union collect annual data on a variety of human this leaves many LGBT elders alone and isolated
rights and equality issues, including numerous as members of their support system become in-
factors related to the treatment and protection of firmed and subsequently die. This reality along
sexual minorities. Collectively, this information with the fact that LGBT elders often live alone
makes clear the importance of considering the contributes to many LGBT elders expressing a
specific country of origin when seeking to fear of dying alone (Emlet 2006). Being an
understand the needs and concerns of LGBT LGBT elder living with HIV/AIDS only serves
persons of European descent. As a contrasting to exacerbate these concerns (Brennan-Ing et al.
case-in-point, consider the experiences of LGBT 2014; McFarland and Sanders 2003; Poindexter
elders in Sweden, Georgia, and Azerbaijan. In and Shippy 2008).
2014, Europe’s first LGBT retirement home
opened in Stockholm, Sweden—a country that
legalized same-sex behavior in 1944. Just seven
years prior, separate ILGA-Europe studies in
Georgia (Quinn 2007) and Azerbaijan (Van der 7
These studies noted that most of the individuals they
Veur 2007) found that the vast majority of sexual
interviewed did not typically identify as lesbian, gay,
minorities remained closeted for fear of dis- bisexual, or transgender, but instead simply acknowl-
crimination and/or victimization.6 Most of the edged their same-sex attractions. This finding is consistent
individuals who participated in the qualitative with studies in the USA that have suggested that one
barrier to reaching a diverse population of sexual
minorities is the difference in researcher versus potential
6
In 2009, a similar study conducted in Armenia echoed participant’s use of language and identity-related
these findings (Carroll and Quinn 2009). constructs.
190 M.D. Otis
LGBT Elders and Being a Double factors associated with racial majority status.
Minority Against this backdrop, Fredriksen-Goldsen and
colleagues have identified a number of actions
Being young, White, and heterosexual has its that must be undertaken in our effort to train
privileges. While we may be uncomfortable culturally competent service providers and
acknowledging that such privilege still persists in develop and deliver services that are responsive
the twenty-first century, many are also silently of the needs of LGBT elderly
resistant to voluntarily relinquishing the benefits (Fredriksen-Goldsen et al. 2014) (Table 9.2).
that come from inhabiting majority status These guidelines underscore the need for human
(Richmond and Guindon 2013). As an LGBT service professionals to begin the process of
elder of European descent, that place of privilege becoming a culturally competent and sensitive
is challenged on at least two fronts (perhaps more practitioners through a process of introspection
if you are a lesbian or bisexual woman or if you and willingness to examine and challenge
identify as transgender). Most of today’s elderly potential biases.
population came of age in a time when open
hostility toward sexual minorities was the norm,
and discrimination and victimization was not
uncommon (Hunter 2007). For many LGBT Related Disciplines Influencing
elders of European descent, this environment Service Delivery and Interdisciplinary
made staying closeted not only an option, but Approaches
often a necessity. As LGBT elders age, however,
the capacity to hide one’s sexuality may be As is noted throughout this book, numerous
increasingly difficult, thus leading some to disciplines, professions, and institutional settings
experience a double-dose of disenfranchised play pivotal roles in the lives of elderly LGBT
minority status for the first time in their lives— persons. Individual life trajectories, mental and
being elderly and identifying as a sexual minor- physical health needs, economic conditions, and
ity. For lesbians, bisexual men and women, and geographical factors coalesce to shape the nature
transgender persons, this is compounded by of LGBT elders’ engagement with different
either gender or being a sexual minority within a entities at different times in their lives, but the
sexual minority. inevitability of aging and its concomitant needs
make the institutional and systemic response
critical to successful aging. Policy makers, social
workers, mental health professionals, and public
Responding to the Needs of LGBT health officials all engage in decision making and
Elders of European Descent actions that have the potential to impact the lives
of LGBT elders in a multiplicity of ways—some
The response of various helping professionals positive, yet historically, primarily in negative
and related systems to the needs of LGBT elders ways. An effective road map to proactively
has been varied. In the USA, the limitations of working to meet the needs of LGBT elders
efforts to encourage and train helping profes- requires an integrated, interdisciplinary response.
sionals to develop and deliver culturally compe- The lives of sexual minorities are impacted by
tent services for LGBT elders have been federal and state laws and regulations, institu-
consistent with the limitations identified in the tional policies, and social norms and expecta-
scholarly literature. What knowledge has been tions. Addressing uneven and sometimes harsh
garnered has focused on racial minorities and treatment of LGBT elders living in long-term
non-White ethnic groups, with LGBT elders of care facilities is important, but it represents only
European descent being treated as homogeneous one piece of what influences quality of life for
and universally privileged or challenged by this population. Prior to living in a long-term care
9 European LGBT Elders 191
Table 9.2 Recommendations for the development of culturally competent service providers and programming for
LGBT elders
Critically analyze personal and professional attitudes toward sexual orientation, gender identity, and age, and
understand how factors such as culture, religion, media, and health and human service systems influence attitudes and
ethical decision making
Understand and articulate the ways that larger social and cultural contexts may have negatively impacted LGBT older
adults as a historically disadvantage population
Distinguish similarities and differences among the subgroups of LGBT older adults, as well as their intersecting
identities (such as age, gender, race, and health status) to develop tailored and responsive health strategies
Apply theories of aging and social and health perspectives and the most up-to-date knowledge available to engage in
culturally competent practice with LGBT older adults
Consider the impact of larger social context and structural and environmental risks when conducting a comprehensive
biopsychosocial assessment
When using empathy and sensitive interviewing skills during assessment and intervention, ensure the use of language
is appropriate for working with LGBT older adults to establish and build rapport
Understand and articulate the ways in which agency, program, and service policies do or do not marginalize and
discriminate against LGBT older adults
Understand and articulate the ways that local, state, and federal laws negatively and positively impact LGBT older
adults, to advocate on their behalf
Provide sensitive and appropriate outreach for LGBT older adults, their families, caregivers, and other supporters to
identify and address service gaps, fragmentation, and barriers that impact LGBT older adults
Enhance the capacity of LGBT older adults and their families, caregivers, and other supporters to navigate aging,
social, and health services
facility, LGBT elders lived in communities A handful of studies have examined the
where they struggled to survive economically response of various helping professionals to the
due to persistent discrimination that reduced their needs of LGBT elders. These studies suggest the
lifelong earning capacity, lost homes due to the presence of homophobic and heterosexist views
death or institutionalization of a life partner they that influence healthcare and social service pro-
were legally prohibited from marrying, and viders’ views when working with sexual minor-
accelerated health decline due to delayed utili- ities. A recent study examined these issues in
zation of healthcare services and incompetent terms of long-term care facilities by asking a
providers (Durso and Meyer 2013). Elder gay sample of LGBT elders and a sample of hetero-
and bisexual men and transgender persons have sexual men and women what they thought about
been disproportionately impacted by the global the potential treatment LGBT elders would
failure of our initial response to the AIDS pan- encounter in long-term care facilities (Jackson
demic (Gorman and Nelson 2004). Additionally, et al. 2008). Jackson and colleagues found that
they continue to suffer higher levels of risk due to both the LGBT respondents (ranging in age from
the ongoing failure of medical professionals to 15 to 72) and heterosexual respondents (aged
address the reality of sexual behavior across the 18–90) believed that LGBT persons would
life course: an oversight that leaves many of encounter discrimination in healthcare settings.
these men at elevated risk of contracting HIV and In response to these concerns, educational and
other STDs through unprotected sex (Effros et al. professional development programs are focusing
2008; Sullivan and Wolitski 2008). on the development of curricula that will increase
192 M.D. Otis
cultural competence of current and future human examples, comprehensive assessments of the
service professionals working with LGBT elders health and social service responses to the needs of
(Erdley et al. 2014; Fredriksen-Goldsen et al. LGBT elders living in Europe have not been
2014; Hunter 2005; Leyva et al. 2014; developed. As might be expected, available
Obedin-Maliver et al. 2011; Porter and Krinsky research conducted in European countries shares
2014). A survey of Area Agencies on Aging many similarities with research conducted in the
across the USA found that one-third of the 320 USA—it generally reflects non-probability sam-
participating agencies had already provided ples of LGBT persons who are out to some degree
training focused on the needs of LGBT elders, and thus do not represent the scope of LGBT
and the vast majority (approximately 80 %) were elders in Europe, nor does it offer detailed insight
open to offering such trainings (Knochel et al. into the presence or absence of needed services
2012). In guiding the efforts of human service and resources (European Union Agency for
professionals to think more expansively about Fundamental Rights 2014; ILGA-Europe 2014).
what it means to be culturally aware, Hudson and
Mehrotra (2014) call on us to think about both
geography and migration as we seek to under-
stand the stories of LGBT persons. Summary
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Hispanic/Latino LGBT Elders
10
Debra A. Harley
Abstract
The purpose of this chapter is to understand the challenges faced by
LGBT Hispanic/Latino LGBT persons in older age. In order to provide the
reader with a contextual framework of Latino elders, a statistical profile is
presented. Similar to other ethnic groups in the USA, Hispanics have
intracultural as wells as intercultural differences. Information is presented
on the Latino community’s perceptions of LGBT persons, current
characteristics and values and the role of acculturation, service delivery
models for LGBT Hispanic elders and health policy. Attention is given to
the generational difference and immigrant and US-born influences among
Latinos.
Keywords
Hispanic Latino Elders LGBT Immigrant Same-sex couples
white counterparts, with greater life expectancies 5. List areas in which policy development is
at all ages. This paradox is attributed to better needed to address concerns of Hispanic/
health habits and stronger networks of social Latino LGBT elders.
support (Osypuk et al. 2009), which may offer
protection from diseases such as heart disease,
cancer, and stroke (Zhang et al. 2012). Palloni
and Arias (2004) suggest that Hispanics who
migrate to the USA tend to be healthier than Introduction
those who remain in their home countries.
The purpose of this chapter is to present issues There are approximately 2.3 million Hispanic
pertaining to LGBT Latino/a LGBT elders in the elders aged 65, comprising 6.5 % of the US
USA. Similar to other ethnic minority groups, elderly population (US Census 2010a). By 2050,
Hispanics have been subjected to discrimination, projections indicate that the population of His-
exclusion, and inequities in employment, edu- panic seniors will increase to 15 million,
cation, housing, health care, and access to vari- accounting for 17.5 % of the US elderly popula-
ous opportunities, all of which contextualize their tion (National Hispanic Council on Aging 2008).
experiences. First, information is presented on It is estimated that there are 1,419,200 (4.3 %)
cultural characteristics and values and the role of LGBT Latino/a adults in the USA, 146,100 in
acculturation. Next, research on the attitudes and same-sex couple relationships, and 29.1 % of
perceptions of Hispanics’ perspectives about Latino/a same-sex couples who are raising chil-
LGBT persons is discussed. In order to provide dren. Latino/a LGBT adults tend to live in geo-
the reader with a contextual framework of Latino graphic areas where there are higher proportions
elders, a statistical profile is presented. Informa- of Hispanics than that of the broader LGBT pop-
tion is provided on characteristics of and issues ulation. Almost 1/3 of Hispanic same-sex couples
pertinent to Latino/a LGBT elders. Then, service live in New Mexico, California, and Texas. East
delivery models for LGBT Hispanic elders are coast states with substantial percentages of His-
reviewed. Finally, current policy pertaining to panic LGBT adults include Florida, New Jersey,
LGBT Hispanic elders is examined and recom- and New York. The states of Nevada, Arizona,
mendations for the future are presented. Wyoming, Colorado, and Kansas round out the
top ten (Kastanis and Gates 2010). In a compari-
son of Latino/a same-sex couples with
Learning Objectives different-sex counterparts, same-sex couples fare
better; however, socioeconomic vulnerability
By the end of this chapter, the reader should be exists among Latina or female same-sex couples,
able to: couples raising children, and couples where one or
both partners are non-citizens.
1. Identify relevant characteristics of Other demographic characteristics reveal that
Hispanic/Latino culture that influence atti- Latino or male same-sex couples earn almost
tudes and behaviors. $15,000 more than Latina/female same-sex cou-
2. Discuss the concepts of homo–bi–transphobia ples. In 63 % of same-sex couples, the other
in the Hispanic/Latino community. partner is not Latino/a compared to 32 % of
3. Describe sociocultural issues, health dispari- different-sex couples. LGBT Latino/a adults have
ties, and health-seeking patterns of higher rates of unemployment than do
Hispanic/Latino LGBT elders. non-LGBT Latino/a adults; among Latino/a
4. Explain service models and intervention individuals in same-sex couples, rates are simi-
strategies that are effective with Hispanic/ lar to their different-sex counterparts. About
Latino LGBT elders. 15 % of both LGBT and non-LGBT Latino/a
10 Hispanic/Latino LGBT Elders 201
adults have completed a college degree, and Family and gender role expectations. Family
26 % of Latino/a individuals in same-sex couples is the most important social unit among Latinos,
have completed a college degree compared to and it plays a central role in how they care for
14 % in different-sex couples. Individuals in aging relatives (Cummings et al. 2011). Exten-
same-sex couples are more likely to be US citi- ded family includes relatives, close friends, and
zens than their counterparts in different-sex godparents. Hispanics are a collectivist group
couples (80 % vs. 62 %) (Kastanis and Gates). who depend on family and friends (i.e., interde-
Elder Hispanics, LGBT and non-LGBT, face pendent) during the course of their everyday
significant challenges in older age, primarily lives and for getting ahead (Bohorquez 2009).
having to do with attaining financial security; Each member of the family occupies a specific
maintaining good health status; accessing needed role and function: grandparents (wisdom),
services; and having low levels of education mother (self-denial), father (responsibility), god-
(Administration on Aging 2010), language and parents (resourcefulness), and children (obedi-
communication barriers, and insufficient retire- ence, adolescents work to help meet family
ment security and other investments (Kochhar financial needs) (Lopez-Baez 2006). The house-
et al. 2011; US Bureau of Labor Statistics 2011). holds of Latino families often consist of five or
Many Hispanic elders in the USA are more members (US Census Bureau 2010b).
first-generation immigrants and are less likely to Traditional families are hierarchical in the form,
speak English as well as subsequent generations, with special authority given to parents, older
which disadvantages them in the job market family members, and males–family roles are
(Hakimzadeh and Cohn 2007). The majority of clearly delineated (Lopez-Baez 2006). The sex-
Hispanic elders speak Spanish at home and this ual behaviors of adolescent females are severely
linguistic isolation means that many cannot read restricted, whereas male adolescents are afforded
or write well in English, and low educational greater freedom. Marriage and parenthood tend
attainment limits their literacy in Spanish as well to occur early in life and are viewed as stabilizing
(Valdez and Arce 2000). influences. In social activities, emphasis is placed
on involving extended family and friends rather
than on activities as a couple (Flores 2000).
Cultural Characteristics Although Latinos with greater ethnic identity
and Acculturation are more likely to adhere to traditional gender
role expectations (males machismo, female ma-
Latinos are made up of diverse groups with rianismo), immigrants often experience conflict
varying characteristics. The majority of US in several areas. First, Latino men may lack
Latinos assert that they have many different confidence dealing with authority figures and
cultures rather than one common culture (Taylor agencies outside of the family, which can result
et al. 2012). However, some common cultural in feelings of inadequacy and concern about
values and characteristics do exist across groups. diminished authority. Second, Latino men may
In this section, information is presented on these experience feelings of isolation and depression
characteristics as they pertain to traditional because of the need to be strong. They avoid
Latino/a families. Interpersonal relationships are talking about stressors for fear of appearing
integral to the Latino/a culture, typically includ- weak. Third, Latino men may have conflict over
ing respect and affection among a network of the need to be consistent in their role, and they
family and friends (Sue and Sue 2013). Family, may become more rigid in holding to traditional
religion/faith, unity, respect (respeto), and tradi- roles (Constantine et al. 2006). For Latina
tion are important aspects of life for Latinos that women, conflicts may involve (a) expectations
are shared across Latino groups, and regarded as associated with traditional gender roles, (b) anxi-
cultural strengths. ety or depression over not being able to live up to
202 D.A. Harley
standards and roles, and (c) inability to express established before a task can be accomplished. In
feelings of anger (Lopez-Baez 2006). These many Latino families and communities, tasks are
challenges are manifestations of Latina immi- assigned because of the relationships that have
grants being socialized to feel inferior and been established based on the inner respect. The
self-sacrificing. The perception of Latinas as “goodness” of the person determines the task he
submissive to males often leads to a misunder- or she is assigned, especially to be trusted with
standing and omission of their influence indi- loved ones and who could be given responsibility
rectly (e.g., behind the scenes), which preserves (Flores 2000).
the appearance of male control. However, with Religion and faith values. Religion plays an
greater exposure to the dominant culture and important role in the lives of Latinos, is highly
acculturation, Latina women may question tra- regarded, and is considered equally as important
ditional expectations, and certain roles may as family. As with other values and practices, the
change more than others. It is important to point role of religion in the lives of Latinos has shifted
out that traditional gender role expectations are among subsequent generations. In addition, the
not negative or restrictive. That is, the expecta- religious profile of Latinos varies by Hispanic
tion of men to be good providers is part of group and nativity. For example, majorities of
machismo and egalitarian decision making and Hispanics (55 %) of Mexican (61 %) and
appears to be increasing among more accultur- Dominican (59 %) descent identify as Catholic,
ated Latinos (Sue and Sue 2013). 49 % of Cuban Americans, 45 % of Puerto
Ironically, given the importance of family in Ricans, and 42 % of those of Salvadoran descent.
Hispanic culture, LGBT Latino elders are less The remainder of the Latino population is
likely to have social support and more likely to roughly evenly divided between adherents of
endure victimization and neglect than the general various Protestant traditions (22 %) and those
LGBT older adult population (Fredriksen- who are religiously unaffiliated (18 %). More-
Goldsen et al. 2011). Many LGBT Latino over, some Latinos take part in other forms of
elders indicate that their ties with family and the spiritual expressions that may encompass a mix
Hispanic community are often broken. Some of Christian and indigenous influences, which
participants in the Hispanic LGBT Older Adult indicate a strong sense of the spirit world in the
Needs Assessment (National Hispanic Council on everyday lives of many Latinos (Pew Research
Aging 2013) expressed feelings of social isola- Center 2014). Nevertheless, the majority of
tion within their own families because of their Latinos maintain some type of religious beliefs
identities as LGBT persons. Even LGBT Latino and practices. Key among these beliefs and
elders who do not face prejudice from their practices is how the Church influences family life
family or community still encounter problems of and community affairs, giving spiritual meaning
rejection, emotional and psychological abuse to Hispanic culture, and religion as central to
(including from social service organizations), and marriage and family life. Religion has been so
low self-esteem. These individuals felt that as much a part of Latino culture for centuries that it
painful as rejection by family members is, soci- cannot be separated from the cultural values of
etal rejection is even more so because it causes a the Latino people. Furthermore, even if a person
greater degree of isolation. Elders who reported a does not participate in organized religion, reli-
more positive experience with their families gious beliefs are still part of family life (Pew
indicated that a dire need exists for more infor- Research Center 2014).
mation and education for families to better Bendixen & Amandi International (2010)
understand sexual and gender diversity. found that the faith experience of Latinos, par-
Personal quality. Respect (respeto) and dig- ticularly Catholics, informs their support of fair-
nity (dignidad) are at the core of personalism ness and equality for LGBT persons.
(inner quality). Personalism is a group norm Specifically, 69 % of Latino Christians state that
emphasizing that relationship formation must be their religion is accepting of all people, including
10 Hispanic/Latino LGBT Elders 203
LGBT persons, and 79 % of Latino Catholics say Acculturation is moderated by gender, age,
that a person could express support for LGBT and country of origin. For Hispanics who ascribe
equality and still be a good Catholic. Latino to traditional gender roles, it is more likely that
Catholics are among the stronger supporters of males will have contact with non-Hispanic
equality. According to the Pew Hispanic Center acculturation agents and exhibit faster language
(2007), the Catholic Church’s position on acculturation than do Hispanic females. Give the
homosexuality is based on a distinction between socialization difference among age groups, it
being lesbian or gay and acting on it, which would be expected that younger Latinos are more
allows for acceptance of being lesbian or gay likely to acculturate faster than older Latinos.
while at the same time considering acting on Puerto Ricans have different language usage
such to be wrong and sinful. However, the compared to other Hispanic groups and prefer the
message that seems to come through is that use of English at home, work, and in social
merely being gay is sinful (Human Rights occasions (Alvarez, n.d.). Acculturation and
Campaign, www.hrc.org/resources/entry/ assimilation have specific implications for Latino
religion-and-coming-out-issues-for-latinas-and- elders, many of whom immigrated to the USA.
lations). The impact of the demographic shift in The immigration process and transition from
the USA by Hispanics is becoming more evident country of origin to the USA has been difficult
in their influences concerning religious percep- for Latino elders because of increased pressure to
tions about LGBT persons. The Pew Hispanic acculturate and assimilate, as well as how to deal
Center asserts that Hispanics are changing the with stress from hardship and poverty and a
nation’s religious landscape, especially the range of adverse experiences (e.g., stigma, dis-
Catholic Church, both because of their growing crimination, trauma, and abuse) (Aguilar-Gaxiola
numbers and because they are practicing a dis- et al. 2012). Alegria et al. (2008) found that a
tinctive form of Christianity. Marianne decline in health status of immigrants (more so
Duddy-Burke of Dignity/USA (http://www. for Mexicans and less for Puerto Ricans) over
dignityusa.org/) reveals that “a lot of gay and time in the USA is associated with higher social
lesbian Latinas and Latinos are out in English but acculturation including lifestyle, cultural prac-
not in their Spanish-speaking church” and some tices, increased stress, and adoption of new social
individuals choose to be only partially out. norms, depression and other mental health dis-
Acculturation. Acculturation, the process of orders, which are discussed later in this chapter.
learning about the language, cultural values, and Some research demonstrates that less accul-
behaviors consistent with the host society, is turated older adults are more likely to experience
acknowledged as a critical factor in understanding depressive symptoms. One plausible explanation
the experiences of immigrant populations (Berry is that immigrant older adults lack the knowledge
2002). The effects of acculturation are distinct about the host culture, which creates multiple
among Hispanics. About half (47 %) of Hispanics challenges in one’s life, ranging from daily has-
indicate that they consider themselves to be very sles (e.g., difficulties in maneuvering everyday
different from the “typical” American, and only activities) to chronic strains (e.g., discrimina-
21 % say they use the term “American” most tion). The result may be diminished feelings of
often to describe their identity. Among this group, self-worth and sense of control, which in turn
US-born Latinos (who now make up 48 % of may lead to elevated symptoms of depression
Hispanic adults in the USA) have a stronger sense (Chiriboga et al. 2002; Gonzales et al. 2001;
of affinity with other Americans and America Jang and Chiriboga 2010; Kwag et al. 2012).
than do immigrant Hispanics (Taylor et al. 2012). Other research suggests that acculturation may
The key findings of how Hispanics view their influence the experience of pain. Jimenez et al.
identity, language usage patterns, core values, and (2013) conducted a cross-sectional study to
their views about America and their families’ estimate the association between acculturation
country of origin are presented in Table 10.1. and the prevalence, intensity, and functional
204 D.A. Harley
limitations of pain in older Hispanic adults in the health functioning, and familial relationships
USA and found that compared to non-Hispanic (Archuleta 2012). Kwag et al. (2012) examined
whites and English-speaking Hispanics, the correlation between acculturation, depressive
Spanish-speaking Hispanics had the highest symptoms, and perceived density of neighbor-
prevalence and intensity of pain. However, the hood characteristics in Hispanic older adults and
differences were not significant after adjusting found the impact of acculturation on depressive
for age, sex, years of education, immigration symptoms to be moderated by the perceived
status (US-born vs. non-US-born), and health density of Hispanic neighborhoods. The
status (i.e., number of health conditions). researchers concluded that neighborhood char-
Lokpez (2010) distinguishes acculturated acteristics are important in the lives of immigrant
Hispanics as those, for whom English is the older adults.
dominant language, are born in the USA or have Acculturation is not unidirectional, thus
been here for 10 or more years, live in suburban drawing any conclusion about its impact is
areas, conduct business in English, prefer Eng- complex. In a review of the literature on accul-
lish media, have similar purchase behaviors as turation and Latino health in the USA and its
the general market, and observe few or no His- sociopolitical context, Laea et al. (2005) con-
panic traditions. The transition of first- and cluded that “the effects of acculturation, or more
later-generation Hispanics requires significant accurately, assimilation to mainstream U.S. cul-
social and cultural adjustments, which are asso- ture on Latino behaviors and health outcomes is
ciated with changes in perceived health, mental very complex and not well understood” (p. 374).
10 Hispanic/Latino LGBT Elders 205
Even with the identification of certain positive or society (Bendixen & Amandi International 2010;
negative trends in the subject areas reviewed Dutwin). Dutwin found that one concern with
about Latino acculturation, the effects are not LGBT acceptance in the Hispanic community is
always in the same direction and often times are at the “intersection of Hispanicity and religion”
mixed. The results were influenced by the subject (p. 5). The most traditional (i.e., unacculturated)
area, measure of acculturation used, and factors religious Latinos are the most intolerant. How-
such as age, gender, or other measured or ever, as Hispanics reside longer in the USA, the
unmeasured constructs. Nevertheless, accultura- more interaction they have with other segments
tion is associated with several negative of society, which may potentially increase their
health-related behaviors and health outcomes in exposure to LGBT issues and contact with LGBT
Latinos: (a) illicit drug use, (b) drinking, persons. Thus, Dutwin hypothesizes that because
(c) smoking, (d) poor nutrition and diets, and generations correlate with acculturation and
(e) worse birth and perinatal outcomes (e.g., low future generations are far more likely to comingle
birth weight, prematurity) as well as undesirable and be acculturated than earlier ones, over time,
prenatal and postnatal behaviors (e.g., substance Hispanics will become more tolerant.
use during pregnancy). On the positive side, In the Pew Hispanic Center Survey (2012),
acculturation is associated with improved access 52 % of Latinos favored same-sex marriage
to care and use of preventive health services compared to 34 % who opposed it. When asked
among Latinos (Laea et al. 2005). In an exami- whether sexual minorities (the term homosexual-
nation of the role of acculturation in health ity is used in the survey) should be accepted or
behaviors of older Mexican Americans, similar discouraged by society, a majority of Latinos
results were found by Masel et al. (2006), who (59 %) and 58 % of the US general population say
found that those who were proficient in English homosexuality should be accepted, as compared
were more likely to have a history of smoking to 30 and 33 %, respectfully, say it should be
and drinking. Masel et al. concluded that this discouraged. Views on homosexuality vary by
knowledge can assist health promotion programs immigrant generation. Second-generation His-
in identifying those at-risk of engaging in nega- panics (68 % vs. 24 %) and third-generation
tive health behaviors. The reader is referred to Hispanics (63 % vs. 32 %) are generally in favor
Laea et al. for additional information. of acceptance. Females (62 %) more than males
(55 %) support acceptance, and younger (18- to
29-year-olds, 69 %) and middle-aged (30- to
Hispanic Perspective Regarding LGBT 49-year-olds, 60 %) more than older (age 50–64,
Persons 54 %, 65+, 41 %) (Taylor et al. 2012). These
findings are consistent with those of an earlier poll
Bendixen & Amandi International (2010) sug- conducted by Bendixen & Amandi International
gest that it is best to start from a point of shared (2010), which found Latinos are broadly sup-
values to understand and effectively relate to portive of equality for gay people (Table 10.2).
Latinos/Latinas about LGBT issues: family, The attitude of people toward LGBT persons
respect, faith, and opposition to discrimination. is shaped, in part, by the degree to which they
Hispanics have been portrayed as particularly believe sexuality is innate, shaped by upbringing,
anti-gay and more anti-legal gay marriage than or a matter of personal preference. In 2011, a
other segments of American society (Dutwin Gallup Poll found that 42 % of Americans
2012). As with any population, there are varying believe that homosexuality is due to upbringing
degrees of tolerance. In fact, different from the or environment, and 40 % believe people are
general population, Hispanics are slightly more born homosexual. In a survey of Latinos beliefs
likely to support legal gay marriage and be open toward lesbians and gay men, Dutwin (2012)
more generally toward lesbians and gay men in found that 62 % believe homosexuality is due to
206 D.A. Harley
biology, and 20 % to personal preference. Not lives in poverty. Foreign-born Latinos elders are
surprisingly, non-religious Latinos are most more likely to live in poverty than native-born
likely to believe that homosexuality is biological, Latinos. Latinos born outside the USA may be
followed closely by Catholics compared with less likely to speak English, have lower levels of
those who go to church, who are substantially education, and have less access to Social Security
less likely to believe that homosexuality is benefits than their native counterparts (Pew His-
something with which people are born. In fact, panic Center 2010). The median annual income
Latinos who do not go to church at all or go for households headed by a Latino adult aged 65
infrequently are twice as likely to believe that and older is $22,116, compared with $29,744 for
homosexuality is biological compared to Latinos all households headed by someone aged 65 or
who go to church twice per week. older and $31,162 for households headed by
Research documents that LGBT persons non-Latino whites in the same age range (Bureau
experience a high degree of discrimination. In of labor Statistics & US Census Bureau 2009).
response to questions about beliefs of the dis- Latino elders have a different source of
crimination they experience in the USA relative income than older adults from other racial and
to other minority groups, Latinos generally ethnic groups with higher income levels. The
believe that Latinos and gays and lesbians are greatest source of income is from Social Security
discriminated against to a greater degree than are income (82 %), property (27 %), earned money
African Americans and women. Furthermore, from wages, salary, or self-employment (20 %)
Latinos believe that, of all minority groups, gays and pension (17 %). In contrast, non-Latino
and lesbians experience the most discrimination whites aged 65 and older have greatest income
(Dutwin 2012). These beliefs are linked to Lati- sources that include Social Security income
nos’, especially younger Latinos, views of fair- (90 %), property (61 %), pension (33 %), and
ness and social justice. earned money (21 %) (Bureau of labor Statistics
& US Census Bureau 2009). Although fewer
Latino elders receive Social Security benefits,
A Statistical Profile of Latino Elders Social Security income is more important and
provides at least half of their total income
The Latino population is younger than any other (National Committee to Preserve Social Security
racial or ethnic group in the USA; thus, a small and Medicare 2008). Latinos receive Social
proportion of the Latino population is aged 65 Security at lower rates because they are less
and older (i.e., 7 % or 3 million) (US Census likely to have paid into the system for enough
Bureau 2010a). Approximately two of three years to become eligible to receive benefits, are
Latinos aged 65 and older live in one of four immigrant workers without the appropriate legal
states: California, Texas, Florida, or New York. status to receive coverage, or work in the type of
The Latino elderly population disproportionately jobs (e.g., domestic and agricultural) in which
10 Hispanic/Latino LGBT Elders 207
employers tend to underreport Social Security the following comments: (a) acceptance of
earnings (Torres-Gil et al. 2005). The extent to LGBT persons is very difficult among Latinos
which these data are applicable to LGBT Latino because of our nature (i.e., culture); (b) family is
elders is not known. the most important nucleus in society from which
Older Hispanic adults are vulnerable to the we receive understanding, love, and affections
stresses of immigration and acculturation (National and if we do not receive that, other factors hap-
Council of La Raza 2005). Health status differs pen, such as depression or suicide; and (c) there
across national-origin groups. In addition, the are people who are 90 years old and have never
health of US Hispanics differs by generational said they are gay, they are bearing the cross
status. Among foreign-born Hispanics, health sta- because their family cannot accept that (National
tus and health behaviors may differ by degree of Hispanic Council on Aging 2013).
acculturation to American culture. The two leading LGBT Hispanic elders face many of the same
causes of death are heart disease and cancer among challenges as do older adults in the general
Hispanics, with homicide responsible for the population, such as accessing community ser-
higher death rate among Hispanic men aged 15–24 vices and benefitting fully from Medicare,
(Tienda and Mitchell 2006). While Latinos use Medicaid, and Social Security. However, their
mental health services less than the general popu- challenges in these areas are more difficult
lation, rates of usage have increased. However, because of the marriage inequity for same-sex
bilingual patients are evaluated differently when couples, which adversely affects retirement ben-
interviewed in English as opposed to Spanish and efits and health insurance (National Hispanic
Hispanics, who are more frequently undertreated Council on Aging 2013). Research on LGBT
(American Psychiatric Association 2014). Health Hispanic elders is limited and based on the
and health behaviors of Hispanic adults are dis- information from those individuals willing to
cussed in detailed later in this chapter. acknowledge their identities and relationships.
The ability of researchers to identity, recruit, and
maintain contact with LGBT Hispanic elder
Latino/LGBT Older Adults participants for research is limited by their mis-
trust of unfamiliar institutions, cultural and lin-
With the growing number of Hispanic LGBT guistic barriers, lack of transportation, limited
elders, a tremendous need exists for formal education, financial constraints, negative
community-based organizations that serve them stigma associated with mental health problems,
in a culturally and linguistically competent and lack of understanding of the purpose of the
manner. As they age, many LGBT Hispanic research and how it will benefit the community
elders feel excluded and isolated. Exclusion and (Alvarez et al. 2014; Kuhns et al. 2008). In
isolation is compounded by societal prejudice addition, transgender Hispanics tend to be
and discrimination, they are as members of both excluded because of their unwillingness to
a sexual minority and ethnically marginalized self-identify or come out. Much of the informa-
group. Furthermore, LGBT Hispanic elders may tion in this section consists on an overreliance on
become estranged from family members who data from the Hispanic LGBT Older Adult Needs
condemn their sexualities on religious grounds or Assessment (National Hispanic Council on Aging
who lack understanding. Similarly, they may 2013).
experience alienation from their faith commu- The economic status of LGBT Hispanic elders
nity, depending on the community’s stance is similar to that of their non-LGBT counterparts.
toward LGBT persons (National Hispanic Hispanic male same-sex households have an
Council on Aging 2013). An analysis of quali- average annual income of $49,800; female
tative data from focus group discussions of same-sex couples have an average yearly income
LGBT Hispanic older adults revealed some of of $43,000, compared to Hispanic married
208 D.A. Harley
opposite-sex household earning $44,000 on aver- transgender Latino elders who are frequently
age (Cianciotto, 2005). The lower level of eco- diagnosed in advance stages of sexually trans-
nomic security and being disadvantaged in the job mitted diseases because they never got tested.
market has implications for housing and home Medical providers only pay attention to the pre-
ownership of LGBT Latino elders. Many LGBT senting problem and do not ask or check other
Hispanic elders who qualify for Section 8 housing problems. LGBT Hispanic elders indicate that
are unable to receive it because they lack immi- most doctors lack education about the LGBT
gration status documentation of Social Security community, are homophobic/heterosexist, and are
registration (National Hispanic Council on Aging unaware of their own insensitivity. These factors,
2013). Many LGBT Hispanic elders are living coupled with doctors who do not speak Spanish or
below the federal poverty level with insufficient train in centers in Hispanic communities, further
funds to cover their basic living expenses. Before impede LGBT Hispanic elders’ access to and
the US Supreme Court decision to strike down utilization of services and may have detrimental
Section 3 of the Defense of Marriage Act effects on this population’s health (National His-
(DOMA), which discriminated against the eco- panic Council on Aging 2013).
nomic security of LGBT persons across the
country, LGBT seniors of a single-income house-
hold could not claim the retirement, Social Secu- Social and Health Inequities of Latino
rity, or survival benefits of a deceased partner. and LGBT Latino Elders
However, the invalidation of Section 3 of DOMA
only applies in states that recognize the equality of Health inequities among LGBT populations of
same-sex marriage. color are largely a product of unaffordable health
Aging is a difficult experience in the LGBT insurance, lack of cultural competencies among
Hispanic older community. Many LGBT Latino healthcare providers, and prejudice about race
elders feel that, unlike Latino culture, LGBT and ethnicity (Krehely 2009). Hispanic elders
elders are marginalized and forgotten as they age have health disparities and face numerous chal-
in a LGBT community that values youth and lenges to accessing social programs and health-
physical attractiveness. LGBT Hispanic elders care services. Adults in Latino families are more
feel that aging in the LGBT community is likely to be primary caregivers for elders in the
associated with loneliness, illness, and loss of home setting for extended periods of time, and
economic opportunities because of being unable without supports from professional community
to advance professionally or compete in the job services, than are adults in non-Latino white
market, particularly for those without support of families (Koerner et al. 2013). Of 65 million
their families and do not have children to take Americans who provide unpaid care to an adult,
care of them. Isolation is heightened because of Hispanic households have the highest prevalence
the limited number of gathering places for older of unpaid family caregivers (National Alliance
LGBT persons to socialize, in contrast to the for Caregiving and AARP 2009).
number of programs and center for LGBT youth Hispanic elders have a relatively high preva-
and senior centers for the elderly lence of diabetes, and 56 % of Hispanics aged
Spanish-speaking community. The significance more than 50 have at least one chronic health
of this becomes evident for LGBT elders who are condition (National Healthcare Disparities
rejected by their families for their sexual orien- Report 2005). Compared to non-Hispanic whites,
tation or sexual identity (National Hispanic Hispanics have higher rates of Type 2 diabetes
Council on Aging 2013). and other manifestations of abnormal glucose
The health status of LGBT Hispanic elders is metabolism. For Hispanics aged 45–74, 23.9 %
further compromised because they are uncom- of Mexican origin 15.8 % of Cuban origin, and
fortable with sharing their sexuality with their 26.1 % of Puerto Rican origin have diabetes
provider. The situation is magnified for (Tienda and Mitchell 2006). Other prevalent
10 Hispanic/Latino LGBT Elders 209
health conditions include Alzheimer’s disease, marketing and promoting of healthcare products
depression, and fatal falls. According to the and services to Hispanic elders. These include
National Healthcare Disparities Report, com- knowledge, access, language, education, and
pared to the majority non-Hispanic white, elderly culture. Hispanic elders have a desire for healthy
population, Hispanic elders have the following living and behavioral changes but are less aware
prominent disparities. They are less likely to: and knowledgeable of steps to take than the
(a) achieve diabetes control (e.g., more likely to general senior population. Although Hispanic
be hospitalized for diabetes), (b) receive vacci- elders have less access to a regular physician or
nations for pneumonia or influenza, (c) receive insurance compared to the general population,
recommended hospital care for pneumonia, the magnitude of access as a barrier is less than
(d) receive cancer screening services, (e) have an expected. The issue is that they are less likely to
ongoing source of care, and (f) receive counsel- use services provided by healthcare profession-
ing to increase physical activity, if overweight. In als. This reluctance to use healthcare services
addition, Hispanic elders are more likely to fall may be linked to a language barrier, which
multiple times in one year (Wallace 2006) and makes access a daunting task and an unpleasant
are less likely to receive preventive care. experience. Low educational level is related
Hispanic adults have lower rates of hyper- more to existing Hispanic elders than baby
tension than non-Hispanic whites but are less boomers, who are more educated and have
likely to have their blood pressure controlled. higher earning power as they attain higher edu-
Few data are available on heart disease among cation (Bohorquez). In addition, many Latinos
Hispanics; data on the incidence and prevalence elders have an external locus of control related to
of stroke are also scarce. The utility of existing health barrier perceptions (Valentine et al. 2008).
data is limited because of issues of generaliz- Bohorquez’s (2009) cultural manifestations
ability. Rates of obesity have increased among that serve as barriers to Hispanic elders receiving
Hispanics and are higher than for non-Hispanic timely and appropriate health care include prac-
whites (Tienda and Mitchell 2006). Acculturated tices include interdependence, reactivity, home
or US-born Hispanics have higher rates of remedies, fear, and marianismo/machismo. In
obesity than immigrant counterparts because of a fact, Bohorquez considers culture to be “the most
higher consumption of fatty foods. Park et al. invisible yet powerful barrier” (p. 52). The cul-
(2003) found that Hispanics of Mexican origin tural manifestations interdependence of Latino
have the highest age-adjusted prevalence of culture are not a barrier, but are introduced here
metabolic syndrome (abdominal obesity) of any as one cultural manifestation. Cultural interde-
racial or ethnic group. Moreover, Mexican-origin pendence is evident by the living arrangements of
women are more likely than non-Hispanic white Latino elders as members of an extended house-
or black women to have metabolic syndrome, hold. In fact, the number of Latino elders living
even after controlling for predisposing factors alone is almost half that of the general population.
such as body mass index, alcohol consumption, The family acts as a motivator for elders for
physical activity, and carbohydrate intake. maintaining good health and to be self-sufficient
Cultural (e.g., linguistic), socioeconomic (e.g., and to contribute to the family (Bohorquez).
education, occupation, income), and geographi- The use of home remedies or natural supple-
cal (e.g., rural) (Erving 2007) lack of awareness ments to treat illness as an alternative to Western
about services, and stigma associated with men- health care is commonplace among Latinos. In
tal illness (American Psychiatric Association some ways, the use of home remedies is linked to
2014) are barriers to health care and are main spirituality, and in other ways, it is linked to
predictors of health outcomes. Bohorquez con- financial constraints, distrust of Western medi-
tends that while Hispanic elders share some cine, and lack of knowledge or awareness about
behaviors with non-Hispanics, many traits are health issues. Hispanics generally lack a pre-
unique to Hispanic seniors, which dictates the ventive mind-set. They are more concerned about
210 D.A. Harley
current needs as opposed to future ones. Even Hispanic lesbians and bisexual women are at
those with healthcare coverage will typically visit a heightened risk or health disparities compared
doctor only when they are very ill. This reactive with Hispanic heterosexual women and
mind-set prevents detection of illness that could be non-Hispanic white bisexual women. Kim and
treated at an earlier stage. The belief is that what- Fredriksen-Goldsen (2012) suggest that although
ever happens is “Si Dios quiere” (“It is God’s sexual minority women are at increased risk for
Will”) (Bohorquez). Many Hispanic elders may poor health and, within-group differences among
feel that their health may be out of their control and sexual minority women exist, evidence of health
in the hands of a “higher being,” resulting in a disparities by race/ethnicity and sexual orienta-
fatalistic viewpoint (fatalism) toward their health tion tends not to generalize to sexual minorities
condition (Desai et al. 2010). It is important for of color. Furthermore, the consequences of
healthcare providers to recognize that Hispanic multiple stressors such as racial discrimination
elders are more likely to take the advice of within sexual minority communities and
respected community members than the advice of anti-LGBT values within Hispanic communities
their physicians. Other cultural beliefs and prac- may lead to an increased risk of poor physical
tices that affect Hispanic elders’ response to health and mental well-being (Diaz et al. 2006;
healthcare intervention are presented in Table 10.3. Harper et al. 2004). Kim and Fredriksen-Goldsen
Fear is a factor that results in increased poor (2012) found that Hispanic bisexual women are
health status of Latino elders. Both thinking more likely to experience frequent mental dis-
about and talking about the future health needs tress than are both non-Hispanic white bisexual
are seen as emotionally frightening and imprac- women and Hispanic heterosexual women. The
tical. In part, the fear is an outcome of Latinos cumulative risk related to multiple marginalized
waiting for an illness to advance before seeking statuses appears to lead to greater mental distress.
health care. As a result, their health is too poor to
yield a positive outcome, consequently health-
Research Box 10.1: Hispanic
care providers are associated with severe illness
Lesbian and Bisexual Women
and death. Fear is also a reaction to not wanting
Health Disparities
to burden their families with healthcare costs.
Kim, H. J., & Fredriksen-Goldsen, K. I.
Finally, the ability of women (marianismo) to be
(2012). Hispanic lesbians and bisexual
successful as mother/nurturers and men
women at heightened risk or health dis-
(machismo) as fathers/providers does not meet
parities. American Journal of Public
these standards, and Latino elders feel dimin-
Health, 102(1), e9–e15.
ished as individuals (Bohorquez). As a result of
trying to live up to these gender role expecta- Objective: This study investigated whether
tions, especially in light of being LGBT, Latino elevated risks of health disparities exist in
elders may experience depression. Hispanic lesbians and bisexual women
Table 10.3 Cultural beliefs and practices affecting health care of Hispanic elders
Espiritismo—the belief in the existence of malevolent spiritual beings who may be able to negatively or positively
influence the health of material beings
Prresentismo—the belief that only issues that are immediate problems should be dealt with—a belief that may cause
some patients to delay seeking treatment until after complications develop
Jerarquismo—the interplay of family members in the social structure of Hispanic culture, which is predominantly a
patriarchal society
Promotores—the use of trained lay persons to assist navigating the complexities of the healthcare arena
Adapted from Desai et al. (2010)
10 Hispanic/Latino LGBT Elders 211
Research Box 10.2: Discrimination and sexual partner violence. Those who repor-
Depression ted more frequent discrimination were
Bazargan, M., & Galvan, F. (2012). Per- likely to be identified with severe depres-
ceived discrimination and depression sion. There was also a notable association
among low-income Latina male-to-female between self-report history of sexual part-
transgender women. BMC Public Health, ner violence and depression severity.
12, 663–760.
Conclusions: A significant association
Objective: This study examines exposure between depression severity and perceived
to perceived discrimination and its associ- discrimination was identified. The manner
ation with depression among low-income, in which discrimination leads to increased
Latina male-to-female transgender women risk of mental health problems needs fur-
as well as evaluates the impact of sexual ther investigation. Models investigating the
partner violence and mistreatment on association between perceived discrimina-
depression. tion and depression among transgender
women should include sexual partner vio-
Method: A total of 220 Latina lence as a potential confounding variable.
male-to-female transgender women in Los
Angeles, California, were recruited through Questions
community-based organizations and refer-
rals. Participants were aged 18 and older. 1. In what ways do you think that the
Interviews were conducted using a struc- result could have been different if this
tured questionnaire. Depressive symptoms study examined subgroups of trans-
were assessed using the Patient Health gender Latina older women?
Questionnaire (PHQ-9). Perceived dis- 2. Are these results generalizable to
crimination was assessed using a 15-item transgender Latina women throughout
measure that was designed to assess the the USA?
experiences of maltreatment of transgender 3. How do cultural values and sexual
persons. Multinomial logistic regression partner violence confound these results?
was used to examine the association
between perceived discrimination and
depression after controlling for the pres- Health disparities among Hispanics in general
ence of other variables. and Hispanic LGBT populations in particular are
substantial compared to other groups in the USA.
Results: Of the sample, 35 % reported An understanding of social and health disparities
significant depressive symptoms (PHQ-9 among Hispanic LGBT elders is essential in
>15). Additionally, one-third of the par- development and implementation of culturally
ticipants indicated that in 2 weeks prior to appropriate models of service delivery. Health
the interviews, they had thought either of disparities continue to grow among Latinos
hurting themselves or that they would be because of a lack of culturally appropriate
better off dead. The extent of perceived intervention strategies and services, and mental
discrimination in this population was health professional shortages (American Psychi-
extensive. Many experienced discrimina- atric Association 2014). The following section
tion on a daily basis (14 %) or at least once presents some effective service delivery models
to twice a week (25 %). Almost six out of that have been used with Latino populations.
ten admitted that they had been victims of
214 D.A. Harley
provide language training to overcome linguistic skilled across the spectrum on gerontology
barriers to obtaining services. However, one of (Institute of Medicine 2008), cultural diversity
the major challenges of Latino community-based (Lehman et al. 2012), and LGBT populations
organizations is a lack of adequate funding, (Funders for Lesbian and Gay Issues 2004).
which directly affects their frontline staff and
continuity of services. Cunnings et al. identified
critical gaps in service infrastructure for Latino Policy
elders that must be addressed to ensure them
better quality of care (see Table 10.5). One area In order to meet the challenges of an increasingly
in which there is a dramatic shortage is in all older and diverse Hispanic population, the USA
types of healthcare workers, especially those must set a course for a comprehensive
preparedness initiative that includes systematic have access to written materials explaining
attention to several factors. Cummings et al. availability of services, and are unaware of their
(2011) offer recommendations for several areas rights to certain benefits (National Hispanic
of policy and/or funding challenges. First, Council on Aging 2013). In response, organiza-
attention must be on building a gerontology- tions must develop the capacity to provide
centered educational pipeline, developing an home-based assessment services, patient educa-
ethnically and linguistically diverse workforce, tion, and supportive service visits (Rodriguez-
and building the capacity of community-based Lopez and Tirado 2005). A desired outcome is to
organizations to serve both older adults and link services to those elders in need of services.
ethnically diverse populations. There is a clear Fifth, implement organizational best practices
need to increase the number of bilingual and that make services more accessible. For LGBT
bicultural service providers for upgrading the Hispanic elders, accessibility is achieved through
service capacity of Latino community-based making sure that services are culturally appro-
organizations through core funding. In fact, ser- priate, logistically appropriate, inclusive of sex-
vice providers must accelerate efforts to hire ual identities, and age-specific. Finally, create a
bilingual staff (Rodriguez-Lopez and Tirado LGBT Latino aging agenda (Cummings et al.
2005). Second, it is critical to enhance the 2011). Each of these recommendations is geared
capacity of the existing aging service providers toward sustaining an aging infrastructure that
to serve ethnically and linguistically older adults. meets the needs of Hispanic LGBT elders. It is
The general consensus of experts in the field is vital that Hispanic non-English-speaking elders
that there must be a significant increase in communicate effectively with their health and
funding to agencies to provide their existing social service providers.
services and meet the needs of a growing popu- Policy pertaining to LGBT Hispanic elders
lation (Rodriguez-Lopez and Tirado). Third, should be grounded in both evidence-based
community-based organizations should practices and participatory research. There is a
strengthen partnerships and organizational plan- need for better data on LGBT Hispanic elders. In
ning. Organizations should review their mission 2009, the report on How to Close the LGBT
and objectives on a regular basis and explore Health Disparities Gap proposed establishing an
partnerships with compatible organizations as a Office of LGBT Health in the US Department of
way to extend their mission and strengthen their Health and Human Services (HHS) (Krehely
programs. A key factor to building partnerships 2009). The intent of this Office is to collect and
is trust. The National Hispanic Council on Aging examine data on health outcomes and conditions
(2013) encourages the development of partner- of people based on sexual orientation, gender
ships that are inclusive of LGBT Hispanic elders, identity, race, and ethnicity. According to Kreh-
which allows for shared ownership of an agenda ely, “to improve overall public health and to use
of for improving the quality of life of LGBT public dollars effectively and efficiently, the
Hispanic older adults. government must consider these factors when
A fourth recommendation is to create Latino crafting public health programs and policies”
outreach programs. Research suggests that many (p. 4). Information about the LGBT health and
Hispanic elders who do not speak English do not well-being from the Department of Health and
proactively seek services. Service providers Human Services can be found at www.hhs.gov/
indicate that LGBT Hispanic older adults are lgbt/index.html. The 2011 (http://www.hhs/gov/
frequently unaware of how the “system” works, lgbt/resources/reposts/health-objectives-2011.
they do not know how to ask for help, do not html), 2012 (http://www.hhs.gov/lgbt/resources/
10 Hispanic/Latino LGBT Elders 217
2. Hispanics/Latinos who depend on family and (a) Talking about future health needs is seen
friends during the course of their everyday as emotionally helpful
lives and for getting ahead, are referred to as (b) Talking about future health needs is seen
____. as practical
(a) Individualist (c) Talking about future health needs is seen
(b) Hierarchical as frightening
(c) Collectivist (d) Talking about future health needs is seen
(d) Independent as nurturing
3. Which of the following informs 8. Which of the following is most likely for
Latinos/Hispanics’ support of fairness and Hispanic bisexual women?
equality for LGBT persons? (a) Less likely to have social support than
(a) Faith experience lesbians
(b) Acculturation (b) More likely to share the challenges they
(c) Assimilation face of being both a sexual and ethnic
(d) Immigration status minority
4. Which of the following is the greatest source (c) Less likely to have attempted suicide
of income for Latino elders? (d) More likely to self-report their mental
(a) Earned income health status
(b) Pension 9. In which setting does Latino elders prefer to
(c) Welfare assistance live?
(d) Social Security (a) Long-tern care facilities
5. Which of the following is a major contributor (b) Their own home
to transgender Latinos never being tested and (c) A commune
diagnosed in advance stages of sexually (d) Retirement community
transmitted diseases? 10. Why is outreach programs recommended for
(a) Isolation health and social service work with Latino
(b) Lack of English proficiency elders?
(c) Rejection by their families (a) Latino elders response better to orga-
(d) Lack of comfort with sharing their nized services
sexuality with a service provider (b) Latino elders frequently visit senior
6. Which of the following is recommended for citizens community centers
healthcare providers to recognize about (c) Latino elders frequently explore part-
Hispanic elders? nership services
(a) They are more likely to take advice of (d) Latino elders who do not speak English
their physician do not proactively seek services
(b) They are more likely to take advice of
respected community members
(c) They are more likely to visit a doctor on Key
a regular basis
(d) They are more likely to be preventive in 1-b
their approach to health 2-c
7. Which of the following best reflects Latinos’ 3-a
attitude toward future health needs? 4-d
10 Hispanic/Latino LGBT Elders 219
5-d Alegria, M., Chatterji, P., Wells, K., Cao, Z., Chen, C. N.,
6-b Takeuchi, D., et al. (2008). Disparity in depression
treatment among racial and ethnic minority popula-
7-c tions in the United States. Psychiatric Services, 59
8-a (11), 1264–1272.
9-b Alegria, M., Mulvaney-Day, N., Torres, M., Polo, A., Cao,
10-d Z., & Canino, G. (2007). Prevalence of psychiatric
disorders across Latino subgroups in the United States.
American Journal of Public Health, 97(1), 68–75.
Alexopoulos, G. S., Meyer, B. S., Yug, R. C., Campbell,
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Report 1032. Washington, DC: Author.
Elder LGBT Veterans and Service
Members 11
Thomas W. Miller
Abstract
This chapter explores the experiences and status of lesbian, gay, bisexual,
and transgender (LGBT) older veterans and service members. Examined
are the history and background of LGBT veterans, the efforts of the
Department of Veterans Affairs to address the recognition and needs of
these service members and veterans, and the creation of the VA Office of
Diversity and Inclusion (US Department of Veterans Affairs, 2014 VA
Diversity and Inclusion Strategic Plan for FY 2012–2016) and key
policies and procedures that have addressed the discriminatory practices
that have been a part of the military and post military experiences of
LGBT individuals. A meta-analysis of elder LGBT veterans and military
personnel is offered as are mental health and psychosocial adjustment
issues for LGBT elder veterans. Discussed is the Transitional Accommo-
dation Syndrome providing insight into understanding the process faced
by LGBT veterans. Finally, clinical considerations with elderly LGBT
veterans are offered as are a set of resources and references that may be
beneficial for further inquiry into understanding of the issues faced by
LGBT veterans across the life span.
Keywords
LGBT veterans Military personnel Equality Public policy
Overview
Veterans Affairs to address the recognition and battle,” as well as for all of one’s family mem-
needs of these service members and veterans, and bers by serving and honoring the men and
the creation of the VA Office of Diversity and women who are America’s veterans. This com-
Inclusion (US Department of Veterans mitment must include LGBT veterans. As human
Affairs 2014) and key policies and procedures beings and as veterans, we all have a sexual
that have addressed the discriminatory practices orientation and a gender identity, and this shared
that have been a part of the military and post fact means that discrimination against members
military experiences of LGBT individuals. of the LGBT community, based on sexual ori-
A meta-analysis of elder LGBT veterans and entation and/or gender identity, is an issue that
military personnel is offered as are mental health transcends that community and affects all of us.
and psychosocial adjustment issues for LGBT When we speak of sexual orientation, it must
elder veterans. Discussed is the Transitional be realized that this concept covers one’s sexual
Accommodation Syndrome providing insight into desires, feelings, practices, and identification.
understanding the process faced by LGBT vet- Sexual orientation conceptually can be toward
erans. Finally, clinical considerations with people of the same or different sexes. Gender
elderly LGBT veterans are offered as are a set of identity refers to the complex relationship
resources and references that may be beneficial between sex and gender, referring to a person’s
for further inquiry into understanding of the experience of self-expression in relation to social
issues faced by LGBT veterans across the life categories of masculinity or femininity (gender).
span. A person’s subjectively felt gender identity may
be at variance with his or her sex or physiological
characteristics (Shipherd and Kauth 2014).
For many of today’s older veterans, their
Learning Objectives experiences in the military was not under the
auspices of Public Law 103-160, commonly
By the end of the chapter, the reader should be known as “Don’t Ask, Don’t Tell” (DADT). It is
able to: important to note that transgender persons (those
who have undergone gender reassignment sur-
1. Identify the transitions faced by LGBT vet- gery) cannot openly serve in the military and thus
erans across the life span were not included in the DADT Repeal Act.
2. Explain the history and significance of mili- Older lesbian veterans served at a time when
tary policies regarding their sexuality was scrutinized if they did not
3. Discuss research findings addressed in the conform to gender stereotypes. They may have
meta-analysis experienced lesbian baiting, “the practice of
4. Present insights into understanding the dis- pressuring women for sex and sexually harassing
crimination faced by LGBT veterans them by using the threat of calling them lesbians
5. List and discuss the stages of the “Trauma as a means of intimidation” (Legal Policy
Accommodation Syndrome” for LGBT Department of the Campaign for Military Service
veterans 1993). Furthermore, older LGBT veterans face a
host of service-connected physical and mental
health issues, and their partners are denied many
rights and benefits, which heterosexual partners
and spouses enjoy, including health benefits and
Introduction family supports (Service Women’s Action Net-
work, n.d.). Similar to their nonmilitary coun-
It was President Abraham Lincoln whose sensi- terparts, older transgender veterans are reluctant
tivity to human rights etched a promise for all to seek health care and report negative experi-
veterans to expect “care for all who bore the ences with healthcare institutions including thee
11 Elder LGBT Veterans and Service Members 225
VA, are refused medical treatment for being maintaining the trust and confidence of all with
transgender, and postpone or neglect to seek whom the Department of Veterans Affairs
medical care when they are sick for fear of dis- engage. There is also a commitment to serve all
crimination or maltreatment (Grant et al. 2011). veterans and other beneficiaries by being
As a population, older LGBT veterans and “veteran-centric.” Excellence strives for the
service members represent a unique population. highest quality and continuous improvement
Estimating the number of LGBT veterans and through thoughtful and decisive leadership and
service members is difficult for various reasons accountability (Department of Veterans
ranging from many of them being “closeted” to Affairs 2015).
the current Veterans Health Administration ODI prepares program reviews and annual
(VHA) demographic data-collection strategies accomplishment reports for such programs as
not allowing for routine identification of LGBT Federal Equal Opportunity and Recruitment,
veterans and service members within the system. Disabled Veterans Affirmative Action, Affirma-
This limitation makes a population-based tive Employment, and People with Disabilities.
understanding of the health needs of LGBT The organizational structure for this office is
veterans receiving care in VHA difficult, yet summarized in Fig. 11.1.
because of its patient size, the VHA is likely the The identified mission of the ODI is to build a
largest single provider of health care for LGBT diverse workforce and to cultivate an inclusive
persons in the USA (Mattocks et al. 2014). workplace to deliver the best services to our
nation’s veterans, their families, and
beneficiaries.
Identified as its vision, it states that the VA is
US Department of Veterans a leader in creating and sustaining a
Affairs’ (VA’s) Office of Diversity high-performing workforce by leveraging diver-
and Inclusion (ODI) sity and empowering employees to achieve
superior results in service to our nation and its
The US Department of Veterans Affairs’ (VA’s) veterans (Department of Veterans Affairs 2015).
Office of Diversity and Inclusion (ODI) mission
statement draws on a set of traditional core val-
ues. The VHA defines a culture and dedication
involving respect, integrity, commitment, integ- Focus on the LGBT Elder Veteran
rity, and excellence toward all veterans in their Community
care. Respect involves treating all those indi-
viduals in their care and whom they employ with It has been estimated that 9 million Americans
dignity and respect. Integrity refers to adhering identify as LGBT (Gates 2011). It has also been
to the highest professional standards while approximated that 1.5 million adults, aged 65 or
older, are LGB (no transgender estimate pro- VA will not tolerate discrimination or harassment
vided) (Movement Advancement Project) on the basis of race, color, religion, national origin,
sex, pregnancy, gender identity, parental status,
(MAP), Services and Advocacy for Gay, Les- sexual orientation, age, disability, genetic infor-
bian, Bisexual, and Transgender Elders (SAGE), mation, or retaliation for opposing discriminatory
the Center for American Progress (CAP), and practices or participating in the discrimination
LGBT Older Adults: Facts At A Glance (National complaint process. This applies to all terms and
conditions of employment, including recruitment,
Academy on an Aging Society (GSA) and SAGE hiring, promotions, transfers, reassignments,
(2011). It should be noted, however, that esti- training, career development, benefits, and
mates of the LGBT population may vary separation.
depending upon measurement methods and
consideration of those who may not self-identify While sexual orientation, genetic information,
as LGBT due to societal stigma. Gates (2010) parental status, marital status, and political affil-
estimated in a report to the National Center for iation are not listed as protected bases in Title VII
Transgender Equality that there are 70,871 of the Civil Rights Act, discrimination on these
LGBT individuals currently serving in the US bases is strictly prohibited by VA. Complaints of
military and over 1,000,000 veterans who are discrimination filed on these bases will be pro-
LGBT. Though the number of transgender ser- cessed according to the aforementioned Fed-
vice members and veterans is notoriously diffi- eral EEO complaint process up to and through
cult to count, the National Center for the investigation stage of the EEO process.
Transgender Equality estimates that transgender The VA Office of Employment Discrimination
individuals are twice as likely to join the US Complaint Adjudication will issue a Final
military compared to the general population. Agency Decision on the merits of the claim
The Department of Veterans Affairs states a within 60 days of its receipt of the complaint file.
commitment to a diverse workforce and an Complaints filed solely on this basis will not
inclusive healthcare delivery environment. We proceed to the US Equal Employment Opportu-
understand that diversity and inclusion are nity Commission. Other avenues of redress
essential for a high-performing organization that available to raise a claim of discrimination based
delivers the best service to our veterans. on sexual orientation, gender identity, or parental
The LGBT community is an integral aspect of status include the negotiated or administrative
our human diversity. To that end, VA has grievance procedure. Both permit claims of dis-
implemented several policies and programs over crimination, and if otherwise appealable, raising
the last few years that specifically address the the matter with the Office of Special Counsel
needs and concerns of the LGBT community and/or the Merit Systems Protection Board if the
(Frazer 2009; Department of Veterans Affairs claim of discrimination is coupled with adverse
2013, Movement Advancement Project 2009, impact and/or prohibited personnel practices.
2010a, b, National Institute of Drug Abuse 2015; Although a discrimination allegation may be
National Institute of Mental Health 2015). Since raised with these avenues, it does not constitute
2009, VA has included equal employment initiation of a complaint through this internal
opportunity protections for employees on the complaint process, and it does not extend the
basis of sexual orientation in the Secretary’s 45-day time limited to initiate such complaint
Annual EEO, Diversity, and No Fear Policy with the VA Office of Resolution Management.
Statement, which added protections based on The VA Office of Diversity and Inclusion (US
gender identity and parental status as well. To Department of Veterans Affairs 2014) is leading
complement this, the Department of Veterans the effort to increase education and awareness of
Affairs developed and implemented an internal the LGBT community by establishing a formal
complaint process to provide employees with an LGBT special emphasis program. To enhance
internal avenue of redress for complaints based that program, an LGBT employee resource group
on these areas: under the auspices of the VA Diversity Council
11 Elder LGBT Veterans and Service Members 227
was also established. ODI holds annually lesbians age 63–67 report that they served in
nationally broadcast VA-wide LGBT Obser- Korea, compared with less than one in 100 of
vance Program in Washington, DC, in June other women. Even in the most recent service
focusing on LGBT veterans. Additionally, we are period from 1990 to 2000, service rates among
developing cultural competency training in this coupled lesbians age 18–27 are more than three
area for employees, supervisors, and managers, times higher than rates among other women
throughout the VA system. (Department of Veterans Affairs 2012).
In the area of healthcare delivery, the VHA is While years of service do not differ much
committed to a patient-centered approach that between coupled gay men and other men, lesbi-
organizes services around the needs and values ans report longer terms of service than other
of the LGBT veterans. To that end, in 2010, VA women. Among all women aged 18–67 who
issued a policy statement last June providing for report military service, nearly 82 % of coupled
patient visitation rights in support of the needs of lesbians and less than 74 % of other women
LGBT family members. Last June, VHA issued a report serving more than two years (Cáceres
policy directive on respectful delivery of health et al. 2008). Coupled gay men who are veterans
care to transgender and intersex individuals and or report training in the guard or reserve show
is currently providing training for healthcare greater racial and ethnic diversity than do other
providers on services for transgender veterans. In men. Among men who report guard or reserve
2013, VA’s commitment to LGBT health care training, the proportions of coupled gay men who
resulted in 120 VA’s participating in the Human are African-American and Latino exceed those of
Rights Campaign (HRC) Health Equity Index other men. Among female veterans, the pattern is
(HEI) almost 80 %, which was voluntary par- the opposite of that shown with men. Coupled
ticipation. An impressive 91 of those facilities lesbians are more likely to be white than other
reporting or 76 % were awarded HEI 2013 female veterans and are less likely to be
Equality Leader status. African-American. Coupled gay men who report
guard or reserve training or who are veterans
report annual incomes below that of other men,
while coupled lesbians report incomes above that
Meta-Analysis of Elder LGBT of other women. An exploration of employment
Veterans and Military Personnel status provides some explanation for the income
gaps observed. Coupled gay men with guard or
Elder LGBT must begin with understanding the reserve training are less likely to be employed
incidence and prevalence rates for the presence full time and more likely to not be in the labor
of LGBT military and veterans in our society. force than other men. Conversely, coupled les-
The Department of Veterans Affairs’ Office of bians who are veterans or report guard or reserve
Diversity and Inclusion (ODI) estimates suggest training have substantially higher rates of
that more than 36,000 gay men and lesbians are full-time employment than other women and are
serving in active duty, representing 2.5 % of less likely to report not being in the labor force.
active duty personnel (Department of Veterans There are five states including Dakota, Hawaii,
Affairs 2012). When the guard and reserve are Alaska, Virginia, and Idaho having the largest
included, nearly 65,000 men and women in proportion of veterans among same-sex couples.
uniform are likely gay or lesbian accounting for Men and women in same-sex couples in North
2.8 % of military personnel. Gay men and les- Dakota are twice as likely to be a veteran as the
bians have served in all military eras in the later national average. Among metropolitan areas,
part of the twentieth century. In particular, mili- Pensacola, Florida; Norfolk, Virginia; San Diego,
tary service rates for coupled lesbians far exceed California; Dayton, Ohio; and Santa Rosa, Cali-
rates for other women in every military era of the fornia, have the highest rates of veterans among
later twentieth century. Nearly one in 10 coupled same-sex couples. Pensacola’s rate of 34 % is
228 T.W. Miller
more than three times the national average. Discrimination and the Don’t
Nearly one million gay and lesbian Americans are Ask, Don’t Tell Policy
veterans. The states with the largest population of
gay and lesbian veterans include California, The Department of Veterans Affairs’ Office of
Florida, Texas, New York, and Georgia. Among Diversity and Inclusion (ODI) acknowledges that
metropolitan areas, Los Angeles, Washington, discriminatory practices have occurred toward
DC, San Diego, Chicago, and New York have the both VHA providers and LGBT veterans. Sev-
highest populations of gay and lesbian veterans. eral policies, perhaps the most significant of
The District of Columbia leads all states with a which was the “Don’t As Don’t Tell” effort,
rate of 10.2 gay or lesbian veterans per 1000 resulted in reported concerns about stigma and
adults, more than double the national average. Per discrimination against LGBT veterans (Shipherd
capita rates are also high in Vermont, Hawaii, and Kauth 2014).
Maine, and Washington. Among formal polices that have been cited as
most discriminatory against LGBT military and
veterans since its inception has been the “Don’t
Ask, Don’t Tell” policy. Military and veterans
LGBT Elder Veterans who are lesbian, gay, bisexual, and transgender
and Challenges of Aging Americans have experienced historic progress
over the past three years. In 2010, Congress
LGBT elder veterans face the typical challenges of repealed the discriminatory “Don’t Ask, Don’t
aging, including the possibility of elder abuse or Tell” policy, which prevented gay, lesbian, and
domestic violence, in combination with the threat bisexual service members from serving openly
of discrimination and abuse due to their sex- and with honesty. More recently, the Supreme
ual orientation or gender identity (Cook- Court struck down Section 3 of the Defense of
Daniels 1998). The reader is referred to Marriage Act (DOMA), which forced the federal
Chaps. 16 and 17 for additional information on government to deny more than 1000 federal
elder abuse and mistreatment. In a 2006 study by benefits and protections to legally married
the Metlife Mature Market Institute, 27 % of LGBT same-sex couples that were freely available to
Baby Boomers reported that they had great concern different-sex couples. The Pentagon has resisted
about discrimination as they age. Cook-Daniels such legislation, stating that current law already
(1998) notes that growing up in a homophobic or grants “reasonable accommodation” of religious
transphobic environment, some LGBT elders may freedom to service members. At the same time,
go to extraordinary measures to hide their sexual the White House pointed out that the amend-
orientation. There may be such significant stigma ment would actually tie the hands of com-
for these elders that they will not label themselves. manders, who have the ultimate responsibility of
This may affect an abuse victim’s willingness to ensuring good order, discipline, and unit morale
seek help, out of fear of needing to “out” them- and who would be helpless to stop religious
selves to authorities and face possible hostility. bullying under the amendment. Since the suc-
This may also affect his or her desire to enlist home cessful repeal of “Don’t Ask, Don’t Tell,”
care services out of fear of abuse. LGB adults from opponents of LGBT equality have made con-
older generations lived under severe stigmatization siderable efforts to undermine the effort toward
of their identities. Many victims of attacks due to inclusion and respect for both active military
sexual orientation do not tell others of the attacks and for veterans. The Department of Veterans
out of fear that their sexual orientation will be Affairs has demonstrated efforts to address this
disclosed or that authorities will act with hostility policy and correct the discriminatory impact of
or indifference (D’Augelli and Grossman 2001). LGBT veterans.
11 Elder LGBT Veterans and Service Members 229
military even if they are stationed in a state that Don’t Ask, Don’t Tell received Honorable or
does not recognize their marriages. General under Honorable discharges. Before
The military has authorized commanders to 1993, service members who were found to have
grant up to seven days of leave for stateside engaged in homosexual conduct were likely to
couples and 10 days of leave for couples over- receive discharges that were “Less than Honor-
seas so they can travel to a state in America and able.” This affects several elder veterans who are
legally wed. Although traveling to a state with LGBT. A less than onorable discharge charac-
marriage equality imposes a significant financial terization can have severe consequences that
expense for military families—especially for follow a veteran for his or her entire life. In most
junior enlisted members and those stationed states, it is legal for private employers to dis-
outside the continental USA—the military’s criminate on the basis of a discharge character-
willingness to accommodate the marriage of ization, and a less than honorable discharge all
same-sex couples despite disparate state laws is a but disqualifies a person from working in the
significant step toward equality for all service public sector. While there are efforts to address
members. this issue, a less than honorable discharge
A concern is that the situation for veterans characterization may mean forfeiture of veteran’s
seeking benefits for a same-sex spouse is less benefits, such as G.I. Bill education benefits and
clear. In an August 2013 letter to Congress, healthcare coverage.
Secretary of Veterans Affairs Eric Shinseki Elderly veterans who were LGBT discharged
expressed concerns about a separate statute before 1993, undergo additional hurdles and a
governing veteran’s benefits, which legally pre- lengthy review process in efforts to obtain an
vented the department from extending these upgrade for VA benefits. With the additional
benefits to the same-sex spouse of a veteran. Less hurdles, advocates have called the current pro-
than a week after that announcement, a federal cess “cumbersome and bureaucratic” and have
judge in California overturned the statute, which noted that it could take several years for LGBT
arguably created a legal pathway for the veterans to receive a response from the review
Department of Veterans Affairs to recognize board. In summary, the repeal of DADT and the
same-sex spouses. As a result, the Department of Supreme Court’s decision on DOMA does not
Justice announced that it would no longer mean the end of discrimination for the LGBT
enforce the law that restricted veteran spousal veterans who serve in our nation’s military. It is
benefits to different-sex couples. not clear whether gay and lesbian veterans will
While the Department of Veterans Affairs receive spousal benefits if they do not reside in a
now finds it lawful to extend veterans benefits to state that recognizes same-sex marriage.
same-sex spouses, another factor complicates the
situation. Though the Department of Defense has
decided, it will judge the validity of marriages
based on where a couple was married instead of Elder LGBT Veterans
where the military member is currently stationed,
it is uncertain whether or not the Department of In 2012 that the VHA initiated an effort to
Veterans Affairs will authorize veterans in address the specific needs of elder LGBT veter-
same-sex marriages eligibility for federal benefits ans. The Metlife Mature Market Institute study
if they reside in a state that does not recognize (2006) reveals that about one in three LGBT
their marriage. aging veterans did in fact report that they had
“Less than honorable discharges” for LGBT great concern about discrimination as they
veterans have provided another area of concern mature and age. There are several subtle dis-
for former service members. Veterans who were criminatory practices facing elder LGBT veter-
discharged for “homosexual conduct” under ans, but among these the most significant are
11 Elder LGBT Veterans and Service Members 231
regularly denied same-sex partners and restrict and LGBT communities may contribute to a
the most basic rights such as hospital visitation or higher level of risk for poor health than mem-
the right to die in the same nursing home. bership in just one of these populations (Mat-
Many LGBT elders experience social isola- tocks et al. 2014). Existing regulations and
tion and ageism within the LGBT community proposed policy changes in programs such as
itself (see Chap. 29). Also, Social Security pays Social Security or Medicare, which impact mil-
survivor benefits to widows and widowers but lions of LGBT elders, are discussed without a
not to the surviving same-sex life partner of LGBT perspective engaging the debate.
someone who dies. This may cost LGBT elders Federal programs designed to assist elderly
$124 million a year in unassessed benefits. Americans can be ineffective or even irrelevant
Married spouses are eligible for Social Security for LGBT elders. Grant et al. (2011) and others
spousal benefits, which can allow them to earn have documented widespread homophobia
half their spouse’s Social Security benefit if it is among those entrusted with the care of America’s
larger than their own Social Security benefit. LGBT seniors. Most LGBT elders do not avail
Unmarried partners in lifelong relationships are themselves of services on which other seniors
not eligible for spousal benefits. In examining the thrive. Many retreat back into the closet, rein-
Medicaid regulations that protect the assets and forcing isolation. Several federal programs and
homes of married spouses, when the other spouse laws blatantly treat same-sex couples differently
enters a nursing home or long-term care facility, from married heterosexual couples.
no such protections are offered to same-sex
partners. Finally, tax laws and other regulations
including 401(k) and pensions discriminate
against same-sex partners. This often results in Mental Health and Psychosocial
costing the surviving partner in a same-sex Adjustment Issues for LGBT Elder
relationship financial penalties during their life. Veterans
There is an extensive summary of benefits for
LGBT veterans available on the Department of Cook-Daniels (1998) has addressed critically
Veterans Affairs Web site at: http://www. important strategies necessary in the care and
benefits.va.gov/persona/lgb.asp. This resource treatment of LGBT veterans. There are both
may be beneficial in addressing benefits for physical and mental health issues faced by these
LGBT veterans. veterans. They often face a lack of legal protec-
LGBT elder veterans face several challenges tions, which results in insecurity, uncertainty,
with respect to benefits. Summarize the key and avoidance. For example, an elder male vet-
benefits to which they are entitled and how these eran who is gay with limited income has no legal
benefits have changed for elder veterans receiv- right in many states to a portion of his abusive
ing care and treatment by the Department of partner’s income.
Veterans Affairs. VA healthcare professionals are encouraged
There are additional concerns faced by LGBT to connect and build rapport with the elder vet-
veterans. They often struggle with their access to eran who is LGBT by asking about their
adequate health care, affordable housing, or other career/profession, friends, and personal effects.
social services that they need due to institution- Attention is needed especially to the LGBT elder
alized heterosexism. Veterans who use VHA ted veterans’ input and awareness that not all couple
to be older, less educated, and unemployed than relationships are heterosexual. Changes are war-
veterans who do not use VHA. Moreover, vet- ranted to use the same terminology used by the
erans who receive services from VHA have elder (e.g., partner, roommate, friend) when
worse perceived health, use more health care, referring to the other member of the couple. It is
and have multiple medical comorbidities. Fore critical to ask the elder whether the
LGBT veterans being a member of both veterans partner/roommate/friend can be counted on to
232 T.W. Miller
provide care or financial assistance to him or her, In February 2012, the Department of Veterans
keeping in mind that a large age gap between Affairs extended similar protections to lesbian,
partners in a gay couple does not necessarily gay, and bisexual veterans. A department-wide
imply an exploitative relationship. memorandum required that all VA medical cen-
ters adopt nondiscrimination and visitation poli-
cies protecting the rights of veterans, regardless
of sexual orientation or gender identity. The
Elder LGBT Veterans’ Integrative Department of Veterans Affairs has comple-
Health Care mented these policy directives with guidelines
for implementing LGBT-inclusive care in local
Integrative health care is the provision of coor- VA healthcare facilities. The VHA provides
dinated care, comprehensive care, and seamless clinical competency training for VHA physicians
care that is accepted as a worldwide trend in to ensure that transgender veterans receive
healthcare provision (Miller 2012). Many LGBT high-quality, comprehensive health care. VHA
elderly veterans have never heard of integrative medical providers are given additional guidance
health care, but this holistic movement has left its on meeting the medical needs of transgender
imprint American medicine and health care in the veterans through medical guidance on the use of
twenty-first century. Treating the Whole Person hormone therapy. This kind of training and use
has become the standard of practice for all of clinical standards is particularly significant
Americans including our veteran population. because medical providers are often given
Both healthcare providers and patients alike are insufficient training in medical school on the
bonding with the philosophy of integrative provision of care to transgender patients. VA
healthcare provision and its whole-person medical centers have been quick to adopt these
approach, which is designed to treat the person, changes, and LGBT special emphasis groups
not just the disease or illness as in the past. may assist many of them in increasing cultural
The physical and mental health of all veterans competency and conducting outreach to LGBT
served through the Department of Veterans veterans. These significant advances in
Affairs is achieved through a consumer friendly LGBT-inclusive health care have been noted by
integrative approach to meeting the health and the HRC’s 2013 Healthcare Equality Index.
well-being of all veterans. Even before the repeal Eighty percent of VHA facilities nationwide
of Don’t Ask, Don’t Tell, the Department of participated in the index, and of those, more than
Veterans Affairs launched initiatives to ensure three-quarters were awarded “Leader in LGBT
that LGBT veterans have access to the health Healthcare Equality” status.
care and coverage they need. In 2011, the VHA
released a groundbreaking policy statement on
the provision of care to transgender veterans.
VHA Directive 2011-024 established a policy for Mental Health Care for Veterans Who
the department about the respectful delivery of Are LGBT
care to transgender veterans. Directive 2011-024
affirmed VHA’s zero-tolerance policy for The National Academy on an Aging Society/GSA
harassment, required respectful treatment of and SAGE (2011) identified stigmatization and
veterans according to their self-identified gender, its consequences along with the fear of discrim-
and clearly stated that nonsurgical ination, and its reality result in underutilization of
transition-related care is available to transgender VA healthcare services. Mental health needs are
patients under the VA’s medical benefits pack- among the spectrum of health care sought by
age. A second directive renewed these policies in veterans who are LGBT through the Department
2013 and extends through February 2018. of Veterans Affairs and other community
11 Elder LGBT Veterans and Service Members 233
services. The Institute of Mental Health (NIMH) features and may show itself clinically through a
and the National Institute of Drug Abuse (NIDA) limited motivational response as well as the usual
report that veterans within the LGBT community signs of clinical depression.
have complications of depression, substance Clinically, the Trauma Accommodation Syn-
abuse, and traumatic stress disorder for which drome (1989) is summarized through the phases,
they seek treatment. In addition, LGBT Veterans which match DSM-5 (American Psychiatric
face a number of transitional challenges in life. Association 2013) criteria for traumatic stress
Accommodation theory (Miller 1989, 2010, disorder and are summarized in Fig. 11.3. It
2014) has relevance for elder LGBT veterans and reflects what any person would experience
may aid in understanding how one cognitively through discrimination or a hostile environment
processes one’s understanding of self and their that results in traumatic stress for a human being.
identity. The Trauma Accommodation Syndrome Discriminatory behaviors often faced by elder
(1989) has aided mental health professionals in LGBT veterans can result in this sequence of
understanding and recognizing the process of clinical symptoms. Initially, the individual
coping with stressful life transitions including experiences a stage of secrecy and helplessness.
isolation, bullying, and stigmatization experi- During this stage, the person may develop char-
enced by some LGBT veterans across the life acteristic symptoms of anxiety and stress that is
span. not easily managed. Often this may lead to psy-
The Trauma Accommodation Syndrome chological reactivity, a sense of fear or feelings of
(1989) identifies five sequential stages in helplessness. At the same time, it may lead to
understanding what a person goes through when physiological reactivity as realized through
he faces an environment, which is hostile dis- somatization. Such reactivity, whether physical
criminatory and or traumatizing as is experi- or psychological, often results in individuals
enced by some LGBT veterans. It is summarized revisiting the life transition they are facing both
in Fig. 11.2 and includes the following stages: consciously and unconsciously. The revisiting
secrecy, helplessness, avoidance, and accom- process is often cyclical for the individual, which
modation, which many LGBT veterans and leads to ineffective coping strategies such as
nonveterans can recognize having experienced avoidance, detachment, irritability, numbing,
in coping with the stigmatization they have hyper-vigilance, marked by cognitive disorgani-
often faced and the isolation that they have often zation, sleep difficulty, and recurrent distress. For
felt. an elder LGBT veteran, these symptoms may
The stage of secrecy involves stigmatization, result in a functional depressive reaction to the
isolation, and self-blame. Secrecy often occurs thoughts and feelings they experience. Eventu-
and is prompted by feelings of uncertainty or ally, this leads the individual to accommodate the
inadequacy, guilt, and shame. Secrecy about trauma and learn to cope with the discrimination
one’s LGBT may lead to feelings of helplessness. resulting in adjusting or adapting to the
The helplessness experience results in depressive discrimination.
Fig. 11.2 Stages of the Stages of the “Trauma Accommodation Syndrome”for LGBT Veterans
“Trauma Accommodation Trauma
Syndrome” for LGBT Occurs to
LGBT
veterans veteran
Secrecy Helplessness Avoidance Accommodation
through
discriminatio
Withdrawal Stagnation Conscious & Acceptance
n or bully
Stigmatization Cognitive Unconscious Action
behavior by
Isolation Confusion Denial Resolution
others
Self-Blame Disorganization Self-blame Medical
Depression Management
Stage 1 2 3 4
234 T.W. Miller
Physical changes,
Injury trauma, Revisit the
Physiological trauma
Reactivity experience
I II III IV V
Fig. 11.3 The five phases of the “Trauma Accommodation Syndrome” adapted for LGBT elderly veterans
The impact of discrimination experienced by mentors and community support. Issues related
LGBT elder veterans has led to mental health to self-image, coming out, managing identities in
issues. Explain how the Transitional Accommo- different environments, alcohol and substance
dation Syndrome provides insight into under- abuse and anxiety, depression, and other typical
standing the process faced by these veterans. mental health concerns.
Summarize the key stages of accommodation for
some elder LGBT veterans.
Summary
Clinical Considerations with Elderly
LGBT Veterans The Department of Veterans Affairs has made
inroads in the care and treatment of elderly LGBT
There has been a growing literature on clinical veterans since the joint memorandum on LGBT
care and treatment interventions that are directly inclusion was sent to Veterans Integrated Service
relevant to elderly veterans who are LGBT Network VISN and VA Medical Centers Direc-
(Israel et al. 2008; Riggle et al. 2008; Shelton and tors by the Principal Deputy Under Secretary for
Delgado-Romero 2013; Gonzalez et al. 2013; Health and the Deputy Under Secretary for Health
Simmons and White 2014). Most seek profes- for Operations and Management. That memo-
sional assistance, care, and treatment for sup- randum directed VA medical facilities to under-
portive identity affirming counseling, along with take at least three specific initiatives in Fiscal
negotiating new, contextual understanding of Year 2013 to “help build a welcoming and
self. There is also often the need for guidance inclusive environment for LGBT Veterans within
and brainstorming ways to navigate various their facility.” Among the suggested initiatives
social systems and locating resources such as was participation in the Healthcare Equality Index
11 Elder LGBT Veterans and Service Members 235
Available at: http://www.sageusa.org/uploads/PPAR% Shelton, K., & Delgado-Romero, E.A. (2013). Sexual
20Summer20111.pdf orientation microaggressions: The experience of
National Institute of Mental Health (NIMH). (2015). lesbian, gay, bisexual and queer clients in psychother-
Transforming the understanding and treatment of apy. Psychology of Sexual Orientation and Gender
mental illnesses. Bethesda, Maryland. Available at: Diversity, 1(S), 59–70.
http://www.nimh.nih.gov/index.shtml Simmons, H., & White, F. (2014). Our many selves. In L.
National Institute of Drug Abuse (NIDA). (2015). The Erickson-Schroth (Ed.), Trans bodies, trans selves: A
science of drug abuse and addiction. Bethesda, resource for the transgender community (pp. 3–23).
Maryland. Available at: http://www.drugabuse.gov/ New York: Oxford.
Riggle, E. D. B., Whitman, J. S., Olson, A., Rostosky, S. Shipherd, J.C., & Kauth, M.R. (2014, August 8). LGBT
S., & Strong, S. (2008). The positive aspects of being Veteran health care is coming out of the closet.
a lesbian or gay man. Professional Psychology: Washington, D.C: American Psychological
Research and Practice, 39(2), 210–217. Association.
Service Women’s Action Network. (n.d.). After repeal:
LGBT service members and veterans—The facts. New
York, NY: Author.
LGBT Elders and the Criminal Justice
System 12
Tina Maschi, Jo Rees, Eileen Klein and Ron Levine
Abstract
This chapter explores LGBT elders with histories of incarceration. Due to
the paucity of the literature available on this population, this chapter
provides new data from a qualitative study of ten formerly incarcerated
LGBT elders’ experiences prior to, during, and after release from prison.
Consistent with intersectionality theory, a core theme of self and the social
mirror emerged from the data that represented LGBT elders’ ongoing
coming out process of unearthing their ‘true selves’ despite managing
multiple intersectional stigmatized identities, such as being LGBT, elderly,
HIV positive, Reverse order, a member of a racial/ethnic minority, and
being formerly incarcerated. These exploratory findings further our
awareness of an overlooked population of LGBT elders involved in the
criminal justice system. The implications for interprofessional and
interdisciplinary policy and practice that incorporate suggestions from
the formerly incarcerated LGBT elders for systemic reform are presented.
Keywords
Aging Older Adults Elders Minority issues Public health LGBT
issues Intersectionality Prisons Community reentry Community
reintegration Social integration
immigration status, and sexual minority status sexual violence than were other prisoners (Jen-
(Maschi et al. 2014). These accumulated ness et al. 2007). Incarcerated LGBT persons
inequalities can influence access to health and also have health care concerns that include sex-
social services, economic resources, and justice ually transmitted diseases (STDs), including
across the life course. This is uniquely applicable HIV/AIDS, and mental health and substance use
because of their criminal justice history, which is disorders. The health care of transgender pris-
largely not addressed in intersectionality theory. oners is often an administrative issue versus a
health care issue due to institutional policies
preventing hormone and/or transition-related
care (Marksamer and Tobin 2014).
History of Research and Practice
LGBT persons are also at high risk of family
Pertinent to This Topic
rejection, homelessness, and unemployment due
to bias and discrimination based on their LGBT
Civil and human rights advocacy groups that
status. LGBT persons may reject (lack) access to
respect an inherent dignity of older and LGBT
prison-based rehabilitative services for fear of
persons are gaining momentum. The United
being assaulted by other incarcerated persons or
Nations has designated a number of special needs
correctional staff. Incarcerated LGBT people
populations that are subject to special protec-
have special considerations pre- and post-release
tions. These special populations include lesbian,
because they may not have ready access to
gay, bisexual, and transgender (LGBT) prisoners
family supports or therapeutic services, espe-
and older prisoners in addition to prisoners with
cially if they have experienced trauma during
mental health care needs, disabilities, racial and
their incarceration (UNODC 2009). These scant
ethnic minorities, women, foreign-born nation-
findings suggest that LGBT elders released from
als, and prisoners with terminal illness or under a
prison, especially those with complex issues,
death sentence (United Nations Office on Drugs
such as being HIV positive with comorbid health
and Crime [UNODC] 2009). Given that many
and mental health issues, may also experience the
people in prison have complex needs, the likeli-
collateral consequences of incarceration, ageism,
hood is quite high that incarcerated people who
and homophobia. The complexity of their situa-
are LGBT would also be represented in one or
tion may create additional barriers for (LGBT)
more of these vulnerable care populations.
them to gain access to culturally responsive
Yet, the little information available on LGBT
healthcare, housing, employment, and social
people in prison is mostly based on younger as
welfare benefits (Maschi et al. 2012c). Additional
opposed to older persons. In a US Department of
research is needed to further our knowledge of
Justice report on sexual victimization in jails and
public health issues, especially as it relates to
prisons (Beck et al. 2013), inmates identifying
diverse elders who are at a heightened risk of
their sexual orientation as gay, lesbian, and
health and justice disparities. Therefore, in this
bisexual were among those with the highest
next section, we present new findings on the
rates: 12.2 % of prisoners and 8.5 % of jail
experiences of LGBT elders before, during, and
inmates reported sexual victimization from other
after prison and service providers that were used
inmates, and 5.4 % of prisoners and 4.3 % of jail
to identify research, practice, and policy gaps.
inmates reported victimization by staff. It is of
concern that inmates with mental health needs
who were identified as non-heterosexual reported Discussion Box 12.1
the highest rates of inmate-on-inmate sexual The current literature finds that there are
victimization (i.e., 14.7 % of jail inmates and scant findings that suggest that LGBT
21 % of prison inmates). In a study of violence in elders released from prison, especially
California prisons, transgender women in men’s those with complex issues, such as being
prisons were 13 times as likely to experience HIV positive with comorbid health and
242 T. Maschi et al.
responsive services for incarcerated and formerly experiences, and future goals. The footage was
incarcerated LGBT elders. Ron Levine, a social edited to be a 5-min documentary short.
documentary photographer and creator of the
‘Prisoners of Age’ project, was recruited to be a
part of the team. The ‘Prisoners of Age’ project
Self and the Social Mirror
has been an ongoing is a series of photographs
and interviews with elderly inmates and correc-
tions personnel conducted in prisons both in the Phase One Qualitative Results
USA and Canada since 1996. A photograph of an
elder transgender person in prison can be found An overarching theme ‘self and the social mir-
in the chapter appendix (See Image 12.1). The ror,’ emerged from data about that described
exhibit is designed to play a role in stimulating their lifelong process of managing the ‘visible’
social and institutional change by addressing the and ‘invisible’ prisons of oppression, social
issues of social justice and human dignity stigma, and criminal justice involvement. Self in
through images and interviews. The photograph the social mirror was defined as a dynamic per-
exhibits have been shown internationally. sonal, interpersonal, and historical process that
For the first round of recruitment, three for- involved the mutual reflection (or deflection) of
merly incarcerated LGBT elders agreed to par- participants’ diverse selves with family and
ticipate in a short documentary project. The friends and society. Many participants described
participants signed a release form for their pho- a lifelong process of integrating aspects of their
tographs and interview excerpts to be used for the social identities or location that were commonly
documentary project. The 90-min interviews were subject to bias, discrimination, and violence.
shot with a Canon 5D mark II camera and 50- and Many participants viewed themselves by one or
85-mm lenses. Sound was direct to film using a more of following identities (or social location):
RODE shotgun microphone attached to the flash being a racial/ethnic minority, older, HIV posi-
plate. During the shooting, the filmmaker asked tive, LGBT, formerly incarcerated with a mental
the participants to describe their past and current health and/or substance diagnosis, occupational
Image 12.1 Prisoners of age photograph of Christine White. Photo © Ron Levine. Reprinted with permission
12 LGBT Elders and the Criminal Justice System 245
status and income, and geographic location. out’ and self-acceptance process, which included
Participants shared their views on how they being LGBT. Social and historical circumstances
multiple social identities or locations, such as influenced how they negotiated this identity
race/ethnicity, sexual orientation, or their serious before, during, and after prison. One 55-year-old
mental health status. When asked to ‘tell me formerly incarcerated woman shared the
about yourself,’ participants commonly identified following:
themselves as LGBT and then added one or more
Well, no, well I don’t know if it’s me, but I per-
other aspects of themselves. sonally don’t care how a person feels about me.
You understand what I’m saying. My attitude is
I am an African-American female, 55, um, what
that if you don’t like what I represent, don’t, don’t,
else do I want to say. Um, I’m presently unem-
you know, don’t say nothing to me. I can keep it
ployed. I was incarcerated for like six years on a
moving and that’s it and that’s all so nobody, I
drug charge. Um, and um, it wasn’t easy, but I’m
never got approached on that but I’m quite sure you
okay now.
know, it would whatever but I never personally got
I’m a lesbian um, presently. I’m not in any com- approached about it so as far as me being LGBT
mitted relationship or anything like that and um, and being incarcerated, it wasn’t a problem for me.
well. I’m presently doing, I’m focusing on my
recovery you know and just trying to stay in the Another participant described how he was
community. always prepared to protect himself and vocalize
his rights, especially to culturally incompetent
Um, Latino and I’m LGBT, GQ. And I did sixteen
years in prison for manslaughter and I learned a lot
community professionals and service providers.
in prison. It took me time to learn about myself. You have to put your guards up in every way
I was a closet gay person, didn’t want nobody to possible that’s going to help you to get ahead,
know who I was, and I’m learning how to live life, being gay for me, HIV positive, black, you know,
and I’m in a relationship for six years, and I love a whole lot of stuff, you know. So, you have to set
myself today. up certain things that are going to defend you
I did ten years, six months in prison. I am a gay along the way. Otherwise you’re going to get
male. I’m in a committed relationship for the last swallowed up. I’m not just accepting anything but
six years. Um, I’m presently working in the mental capable of advocating for myself, especially when
health field in a psychosocial club and advocacy I need affirming program services. If you can’t
program for LGBT members. Um, helping to be a advocate, that becomes a stumbling block.
liaison between their therapist and the support they
Many participants shared their earlier life
receive. Um, one of the things that um, I’m trying
to do after coming out of prison for so long is to experiences in which mirroring from families,
establish a working relationship um, and being a peers, and communities varied concerning how
productive person. they chose to share one or more of their ‘inter-
sectional’ aspects of self. It is important to
understand that identity is comprised of many
Building ‘Immunity’ to Social Stigma different facets, including, but not limited to, our
biological sex, gender identity and expression,
Participants commonly reported that they faced sexual identity, class, race, and age. We make
challenges to developing a strong sense of self choices throughout our lives to express or hide
and a relationship to their families and commu- these aspects of ourselves. Ward (2008) has
nities. Social stigma was described as a com- shown that race, class, gender, and sexuality are
municable disease in which some participants important in structuring our identity and that
developed immunity to external oppressive atti- examining our sexuality is integral to viewing the
tudes and practices. Some feedbacks seemed to intersectionality of the many facets of self.
accurately mirror and support the expression of Being HIV positive, having a serious mental
their ‘true selves.’ Other feedback was poten- health illness, or being LGBT and engaging in
tially obstructive to that expression. Many par- criminal behavior are often selectively disclosed
ticipants described a multi-dimensional ‘coming to families, peers, and other social circles.
246 T. Maschi et al.
Being HIV Positive: By immediate family, like my especially for gay men and transgender persons in
mother, father, sister, and brother, I know and they men’s prisons compared to lesbian, bisexual, or
all know my HIV status. Uh, my father, I haven’t
really told my status, you know, um. You know, transgender person in a women’s prison. As par-
even though I know he would love me because I’m ticipants described below, the culture of prison
his son and, and he would just, I mean, he was full of systemic bias and discrimination that
wouldn’t have a choice, but I just don’t feel limited their access to rehabilitative services and
comfortable coming out telling him that I’m HIV
positive. I brought it to my mother’s attention, and basic safety and protections.
my mother, she’s like, she says, no, don’t tell him,
It was like this in jail, if you are male and gay so
you know, and I don’t know why, but I just keep,
you should like it, you know. So um, it was really
we’re just keeping that a secret. But everybody
hard to go through that and try to deal with the
else knows. My brother knows. My sister knows.
day, you know, and days were long, you know.
My aunt knows, you know.
You were up at 7, you know, and even your time
Being Diagnosed with a Mental Illness: Growing locked in your cell wasn’t a safe time, because if
up, my family wasn’t really cool with being they wanted you, they could tell a CO to crack
mentally ill so I couldn’t be mentally ill. I was not your cell and they would run in on you. You know
able to go to a psychiatrist. I was not able to take it was really frightening. It was hard to get yourself
medication, and I was damn sure not able to talk mentally ready for the morning because you never
about how I felt or what was going on. So, I knew what was going to happen that day, and
self-medicated with drugs. The voices were getting that’s a real terrible feeling like, what’s going to
loud, drink a little bit more, smoke a little bit more. happen to me today. Every day was like, I got to
keep up. I got to keep up. I got to look left. I got to
Most of the time voluntary um, but a lot of the look right because people were just being abused
times involuntary because my mother had to put all throughout my stay, and the LGBT was just
me there. I can’t even count. Let’s say 30 times assaulted so many times on a regular basis.
from the age of 26 to 35. I think I went to the Everyone got it, but the LGBT men, they just you
psych hospital, about two or three times a year for know, they were washing and underwears and
like 10 to 12 years. anything their parents sent them or friends sent
them, they would take them you know and they
Being Gay and Engaging in Violent Behavior: That would make them cook for them and wash their
they all knew my name in jail. One guard, her name pots. It was just frightening.
was R, said yo, R’s back. I used to stay in the lock
up a lot and she would ask, ‘Like are you sure you The CO’s didn’t care about anything. They watched
are a homo?’ The officers used to tease me like how gay people get raped. They would walk the tier and
could a homo be doing all this. Homos don’t do this. see you being raped in your cell or being beaten in
your cell, and they would keep on walking, you
know. Um, they would see you get beat and raped in
the shower room, and they wouldn’t say anything,
‘Inside’ Prison and when you needed help to cry out to the CO, it
was like crying out to air, you know, because they
The legal system itself may have imposed dis- weren’t going to do anything.
crimination prior to actually being sentenced and
entering prison. Individuals may be exposed to the
personal feelings or biases of the police, lawyer, or
judge who impacts their treatment and sentencing. ‘Gay’ Coping in Prison
Participants described prison as a mixed experi-
ence of self in their social mirror. All participants When it came to negotiating their sexual and
acknowledged the cruelty of prison, especially for gender identity, participants described choosing
LGBT persons. Yet, despite the conditions of among one of three ‘gay’ coping strategies: fight
confinement, participants also acknowledged that (i.e., defending the right to be openly gay), flight
they could use their time to gain greater insight (i.e., complete distancing from one’s LGBT
and clarity about themselves and take account- identity in prison often out of fear of safety), or
ability for their crimes. Many participants pro- keeping it out of ‘sight’ (i.e., selectively dis-
vided a thick description of the grave and closing one’s LGBT identity). The choice to use
dangerous social conditions of confinement, one of these coping strategies influenced their
12 LGBT Elders and the Criminal Justice System 247
level of access to health, mental health, and frightening, and I just made it a way of my
rehabilitative services, including education. dealing in jail that it wouldn’t happen to me so I
became a really, really wild person um, they
Flight: Well, nobody, nobody, nobody knew I have a name for gays like me in jail and it’s
was gay. Only a few guys I let know, but other homo thug. I became like one of the fearless gay
people, I just say no, I’m not gay. I’m old man. people in jail um, I just didn’t want to be raped.
Having sex in prison is not acceptable. No, if
you get caught, they send a letter to your house,
or they tell your family over the phone, you ‘Coming Out’ of Prison
know. You go to the box. Some, some officer,
some CO, some correctional officer, they’ll let Return to Community. Participants’ perceptions
you be with your lover in, in the other cell. Some of self in the social mirror continued to evolve
people you just paid the officer off, be kind of after they ‘came out’ of prison. Many partici-
cigarette or with drugs. pants, especially those with long-term prison
Out of Sight: Um, it was a hard life in jail sentences, described feeling fear if correctional
because you had to walk around like on pins on or community program staff did not help prepare
needles. It wasn’t that good especially if you was them for impending release. Preparation for
gay or bisexual. I wasn’t the type of person to reentry is essential for individuals to reintegrate
walk around and? Advertise, and only a few into the community successfully. Aside from
people knew. I wasn’t the type of person that challenges of returning to the community with
wanted to be taken advantage of and being raped, the stigma of having served time, there may be
so I had to learn how to defend myself in jail. essential skills that have to be mastered for them
I went through a lot of, lot of tough times. It to manage in the community, such as budgeting,
wasn’t that easy for me. But I’m easy to get along meal preparation, and accessing essential social
with so I guess my uh, word of mouth got me by. services for medical and mental health needs.
I was able to get along with everybody. I wasn’t Some of those returning to the community have
selfish. You know, try to stick with this one, that been ‘in the system’ for so long that they have
one. I stuck with who I needed to stick with to get lost their ability to care for themselves indepen-
by in jail if it helped me that way. dently and have become ‘institutionalized.’ Since
Fight: How did I cope with being gay in prison? entering prison, they have been told when to get
I did when in Rome, do as Romans. When in up; had their meals prepared; and were provided
Rome, do as Romans. I was in jail I did what jail with shelter, medical care, and direction for most
people do. So I hung out with a crew that were of their daily activities.
crazy. I was hearing voices, I was crazy so we Isolation in Community. Entering the com-
did the same thing and the only reason they munity and relearning self care, managing the
accepted me is because I was just as dangerous demands of maintaining housing in terms of
as they were. I was always gay all my life so cleaning, shopping, and cooking, and interacting
when I got in jail um, I never went into you with others in a socially acceptable way are crit-
know, segregation or into the gay quarters. ical to remain outside of incarceration. For some,
I always went into general population and um, I life outside of prison is isolating, and they have
made myself deal with what was going on and I very little left of family, friends or social supports.
became one of the people that were there.
Fighting was just, I don’t know if it was more There was nothing for me out there, which made
coming home a little more frightening, and for the
because I was LGBT or because it’s just what LGBT it’s like that. Why leave prison, I’m getting
you do in jail, but I know that I went through a three hots and a cot. I don’t have to fight for the
lot being an openly gay person in jail because the food, you know. Some of us don’t want to come
attacks and things that happen to uh, that I had out, and it was a feel like, what am I going to do at
this late age. I think I came out at, I’ve been out
observed happen to gay people were really
248 T. Maschi et al.
almost four years. I came out at 46 years old. don’t find something for yourself, you’re going to
I didn’t know what, what am I going to do, where the street.
am I going. I knew I didn’t want to go to a pro-
gram and stay at a program you know, like pro- Referral for services to assist with mental
grams and, you know, it pushes us out to the street. health, health, housing vocational and/or educa-
Other participants reported adopting a positive tional services is very important in community
attitude of success on their road to recovery despite reentry. Having the dual stigma of being incar-
anticipated challenges posed by the culturally cerated, having a medical or psychiatric diagno-
destructive social mirroring and practices. One sis, and needing social and financial supports
participant described how he prepared himself
psychologically, emotionally, and spiritually to upon release are critical for most individuals
triumph over challenges, especially bias and dis- released from a forensic setting. Participants
crimination, he believed he would face being older shared how reentry or housing supports and
and gay and serving a 15 year sentence for services that were not LGBT and aging friendly
attempted murders.
influenced their ability to express to be open
Everything’s been beautiful. I just don’t allow it to about themselves and receive adequate peer,
be any other way. Every day I wake up, I’m so family, professional, and/or community support.
appreciative to not be behind bars. Nothing that
comes up, no weather conditions or anything, and The housing that I was in was lovely, but I was
my partner says, baby, you are up at 6 o’clock no with people that weren’t LG affirming and weren’t
matter what goes on. I praise God in the morning, as mentally equipped as I was so I was having to
and just like yeah, it’s time to go. I think I was live in. Sometime in the environment that wasn’t
given a second chance. My second chance. A sec- safe for me, and sometime wasn’t healthy for me.
ond chance at life, and I just don’t want to mess it
up. I can’t say there has been any difficulties. Well, when I came out um, there was a reentry
There’s been situations, and I just take them in program, I worked with them very well. They
stride. Because all of it is a work in progress. helped me out in a lot of ways. I went to school
I went into mainstream, I didn’t wait for the with them um, I went through their training pro-
housing because I was in a relationship that I gram, and I even got jobs through them so they
wanted to do, and they had informed me that any helped me out a long way until I was able to get on
of the housing that I got would not allow me and my feet again at a reentry program. But they did
my partner to merge. And as I said, I’m 50. I’m not not have LGBT and aging services. That right
going to be living alone. And going to see my there if it was it was kept in the closet. I didn’t see
partner who lives in the Bronx and I’m over here, too many open gay people there you know saying
you know. They are not recognizing LGBT rela- just straight thugs, you know, from the street and
tionships. That’s an issue. stuff like that from locked up, but it wasn’t really,
if it was it was under the cover, it was in the closet,
Access to Services. Some participants talked but it wasn’t brought out in the open like that, it
about the advantages of having a stigmatized was just mostly thugs.
label that comes with legal protections and ser- Housing. Another important consideration in
vices, which include having an HIV positive housing is the restrictions placed on certain types
status or diagnosed with a serious mental illness. of offenders. There may be restrictions on where
And you were talking about like supports coming they can reside, such as not within a certain
out of prison, you know, being LGBT and be distance of a school, park, or public housing.
labeled HIV, you get a lot of stigma but you get a This may make returning to family or their prior
lot of support on your transition out. Otherwise, we
don’t get anything. Um, we don’t even get the residence impossible. Being relocated after
assistance to try to get housing. You have to find a serving time to an unfamiliar, or unsafe area, has
social worker and tell her look, can you start the obvious implications. There may be curfews or
paperwork, because I heard it could be done from required appearances that make finding employ-
here, and then she be like, well I don’t know about
that. Will you look it up while the paperwork’s ment, or attending a program, difficult. One
here, you know, and be on them like I know participant described the drawbacks for not
something that you could do for me. But if you having services that integrate LGBT, aging, and
don’t, you know what I’m saying, but for us criminal justice services:
coming out and you’re not HIV positive, then you
12 LGBT Elders and the Criminal Justice System 249
I don’t think like, when you get out if you are upstate New York. Recently, Randy and Mark
LGBT they have a few things but you age out at 24 were legally married under New York State law.
and those are the couple of things that they have
right now but for our age 40 and 50 there are no The photograph and interview session lasted
specific services. They don’t even have housing about an hour and a half. An excerpt of the
where they can sufficiently put you. Yeah, they got interview transcript can be found in Table 12.1 in
one LGBT elder program now, but I don’t seem the chapter appendix, and photographs can be
them helping people coming out of jail. That’s
support for, you know, people on the street for found in Images 12.2 and 12.3 in the appendix.
LGBT but coming out for senior citizens like if The final short documentary was edited down to
you are LGBT in jail and you’re getting out, they 5 minutes by Mr. Levine. In the interviews,
going are going to push you over there at the Randy spoke about his life before prison and his
LGBT youth center. But for anybody over that
age, there’s nothing. And then when you get 40, life within the penitentiary, emphasizing his
it’s like you’re on your own, we’re letting you go, experiences as a gay man within the prison sys-
but where you going is on you. They don’t have no tem. He talked generally about survival in prison
kind of referrals. They have no kind of support so and specifically about his survival techniques as
everything is really on you to be strong and look
for, but people get discouraged really quickly a member of the LGBT community in prison, his
because it’s like next to no that you are going to coping skills, and his own personal experiences.
find services. And the services that they have, they Mark appeared to be shy and spoke minimally
may not be able to accept you because they are at about his experiences. Dwon discussed his
their quota with LGBT but 40–50+. We have to
depend on our family and most of us don’t have experiences living his life on the ‘down low,’ and
that. about hiding his homosexual identity by dating
both men and women in the past. He emphasized
Rainbow Heights: A Pocket of Hope. All of his wish to find a life mate like Randy and Mark
the participants were members of the Rainbow have done. The five-minute short documentary
Heights Club, which is an LGBT affirmative can be found on the Prisoners of Age Facebook
psychosocial service provider in Brooklyn, New page at the following link: https://www.
York. Their staff has been trained to work with facebook.com/photo.php?v=1020421799903883
LGBT-identified clients with multiple problems 4&set=vb.1493049016&type=2&theater.
related to their mental health, past history, and
skill set. The participants described their experi-
ences there:
Research Critical to Issues Discussed
There’s not a lot for the LGBT. I thank God for
Rainbow Heights and being a person that can
in This Chapter
provide service for people that have nowhere to go
to be themselves, to be safe, to eat a meal. To get This qualitative study explored the experiences
support and referral to a lot of things that they may of formerly incarcerated LGBT elders. A central
need in their life but we are only one and we’re the
only one in the whole United States, Rainbow
theme of self and the social mirror-emerged
Club so more. participants described a process in which they
built a strong sense of self and pride, often in
response to bias, prejudice, discrimination, and
violence due to the nature of their multiple
Phase Two Results minority identities, which included being LGBT,
HIV positive, racial/ethnic minority, formerly
For phase two, the first filming took place in incarcerated, and being diagnosed with a serious
Bedford-Stuyvesant in April 2014. The three mental illness. Despite the many challenges,
volunteers, Randy, Mark, and Dwon, identified most of the participants described resilient cop-
themselves as formerly incarcerated LGBT elders ing strategies that helped them navigate oppres-
who had spent most of their recent prison sen- sive attitudes and practices that were pervasive in
tences at Sing-Sing Correctional Facilitate in community and institutional settings.
250 T. Maschi et al.
Table 12.1 Excerpt from interview transcript prisoners of age documentary on formerly incarcerated LGBT elders
RE: My name is Duwan. I’m 55-years old. I was born in Brooklyn, New York. I was on the down low. You know, I
didn’t really start coming out into—well I came out when I was young. But, I mean, it was just really hard for me to
accept that, you know, and I went through men and women, because I was trying to find myself, you know
RE: I’m Randy Killings, and I’m 49. Well I was originated in Brooklyn, and my mom had me in Jamaica and came
back to New York
RE: My name is Mark. I’m 44-years old. I was born in Manhattan. Went to prison for a while. And now I’m here
enjoying my life
IN: So tell me, I want to hear the love story
RE: Well, actually we met on the medication line going to medication that one night. And one of our mutual friends
had brought Mark down. I think he had just got transferred here
RE: Yeah, I got transferred here
RE: He said I got somebody I want you to meet, and he told him the same thing. And when we met I just was attracted
instantly, which was unusual for me, because I don’t usually deal with any kind of activity in jail. But when I saw him
I said you’re going to be my husband. And he laughed. And the next day we started a relationship
RE: I grew up always gay, but I was so boisterous and strong with it I didn’t get a lot of abuse or stigmas or things that
most gays go through
RE: Everywhere I went everyone would be like, you know, that’s Randy, he’s gay, but you all don’t mess with him.
He ain’t dealing with that, you know
RE: We were in something called maximum prison. Maximum prison, people who are not actually coming home for a
very long time if they’re coming home. So the mindset is like this is mine, this is how I’m going to run it, and that’s
how it was, and there was no changing it
RE: Because you have to get stronger in jail, you really do, because there’s such a closed in community where if
you’re not strong enough you’ll get sucked under
RE: Yes, you get sucked under
RE: You’ll be devoured
RE: I was always a good person, but the reason I was in jail this time was because at that time I was into a lifestyle
where it was a lot of money. I hung out with a lot of guys, it was a stick up crew. And we wore a lot of jewelry and
stuff. And I smoked crack. As I was leaving the guy tried to rob me outside of the crack house, and we were fighting,
and I punched him hard, and he fell backwards onto the Johnny pump, and it went through his head. In the time it took
for me to be released they told me, they gave me a CRD to get out. I immediately just laid down everything. I stopped
using, which was predominately my problem. I transferred to another side of **, which was called the Core Program,
which helped people integrate back into society and give them an option. And I knew that if I went back to where I
was from that it would be really, really hard for me. I signed for Project Renewal PTS Program. It was Transition
Housing for Parolees. Right there I prayed that God would take the taste out of my mouth not to get high, because I
got clean, but it was a different feeling when I was in the free air, you know. So I had to go to a program for a year,
which I completed very, very quickly. I graduated in like four months. And my director said, you know, you have a
gift, because I was always helping people and connecting with them. And he said maybe you need to think about
counseling
RE: I look at them, and I see these two how their relationship, you know, I mean, they’re married and stuff like that,
and that’s what I want to be. Right now, you know, I’m looking. I’m hoping to find somebody nice that, you know, I
could grow old with, you know, spend the rest of my time with
Link to 5 min documentary: https://www.facebook.com/photo.php?v=10204217999038834&set=vb.1493049016&
type=2&theater
These findings build upon the existing litera- sexual orientation has a major impact on meeting
ture on marginalized LGBT elders. Similar to their needs in health and social services. The
Addis et al. (2009), review of the literature on the narratives from the current study of formerly
needs of LGBT older people, these findings also incarcerated older adults underscore their strug-
showed that discrimination based on a LGBT gle to be recognized for their true selves, which
12 LGBT Elders and the Criminal Justice System 251
Table 12.2 Formerly incarcerated LGBT elders recommendations for system reform
1. Adoption of more compassionate and affirming practice and policy approaches
We need to reform the whole criminal justice process. Like the intake process in prison. I don’t know if they do it like
that as some type of scare tactic or what. The way they the intake is like they can give you like a very negative outlook
on, on, on, on life in prison. And if you’re not an open-minded person, you can go through your whole sentence being
in fear. I think they need to be a little bit more compassionate on intake because if you’re full of fear, you’re not open
to anything, you know. So you go in jail or prison and you think you got to fight or you got to do this. It’s just not true.
You don’t have to fight your way through jail. It’s like anything in life. If you’re not educated about the situation, it
can be bad
We need a special unit in prison for only the -LGBT. Some, some of them can’t be in population. They’re scared to go
to population to get raped or get stabbed. They could separate the LGBT person from population, you know, put
another jail for them only. I seen lot of LGBT people in prison got beat up, stabbed, all, all type of worse things
happen to them
I think they need to start hiring more LGBT more correction officers. Like LGBT, you can’t be a part of the LGBT
community and be a corrections officer, did you know that. Not be openly gay. You can be an openly lesbian but you
can’t be an openly gay man and they let women, they put in areas where they are not going to do any good. They put
the women in non-visiting room. They need to let female correctional officers to be up on the tiers or in the dorms.
They put the men up there and that is all corrupt. They think it’s cute to see if the homo get beat up because they don’t
like
I believe that if people had better, like if there was better planning for people that’s coming out, out of prison system, a
lot of them wouldn’t be going back to jail. A lot of them would change their ways, and they would become productive
members of society, LGBT or not
2. Nondiscrimination and special population considerations
And one of the things you were talking about in jail that really needs to change, gays in prison should be able to safely
go to school. Right now they can’t. They’d be attacked. In prison, they need to separate the jobs for older and people
that’s younger. I worked in a mess hall, and that’s a hard job, and, you know, if you’re up in age and you got your, you
know, the older you get, the more aches and pains you have, you know, and working in the mess hall, I don’t see it
being good for somebody that’s 55 or 60
They need to have senior citizen things up there in prison for people that are senior citizens, I mean, because when
you’re old, I mean, everybody gets old. I mean, already you’re forgetful in the mind and stuff like that. You get senile
and stuff like that, you know. Um, they should have just a, I can’t say, um, a certain place, but, I mean, they should
have something for seniors too, you know, because - How can you put a 60-something year-old man in with the
regular population of 15 and 16-year-old kids. I wish they would have places for people who are of that age,
something to do for them and something to keep their mind on the right thing, you know, where they won’t get into
trouble or get hurt
3. Post reentry access to culturally responsive safe and affordable housing and social services
Cheaper housing, housing, affordable housing, connected to a therapist, connection to treatment. All these things—
Affordable treatment because now, safe housing is essential in being able to successfully adjust back into the
community. Living in a high crime area, that has a majority of unemployed or underemployed residents that may be
socially stigmatized will reduce the ability to manage. In addition, some of these areas have high rates of victimization
of residents, and easy access to illegal activities and drugs. Adding identification as LGBT can exacerbate community
discrimination and oppression
Housing is a big issue. Let’s say you’re coming out of jail, and, and you’re eligible for SSI or whatever, right? They
should have some type of housing program that will meet like the budget of a person that’s on SSI. I think that’s
another reason why a lot of people go back to jail because they feel safer there, because at least they know that when
the night comes, they got somewhere to sleep. They got some food and they’re comfortable with it, for some people
One thing that was really hard and I found a couple of things when I got out of jail that were LGBT and the housing
situation. There was some terrible housing. And that’s not just for the LGBT over 50, it’s the housing situation but it
harder for an LGBT person because like I said we are pushed into mainstream and they’re not friendly. So having
something housing where it could be more LG affirm and I’m not saying build a big house for only LGBT but at least
let it be affirming where I can go there and be okay and not go shopping and my neighbor come busting my door
because I’m gay and take my food because that happens
We need intergenerational services for LGBT people. I work in a LGBT program and I think we’re from age 21 to I
think closer to 60. I see the age integration of the people. I think we need to learn to live together even age differences
because that makes a community. To be able to respect or the, I know when I grew up how I respected the older
people. And I like to be around the older people. And, and I help the older people and that’s one of the things we need
to get back into what a community is integration of LGBT people of all ages
Specific services for people who are at least age 50 or older, LGBT, and formerly incarcerated. For programs, we need
them more affirming. See everyone says we need something for the gays, something for the, no, we need a firm thing
so we can integrate and learn to live
(continued)
254 T. Maschi et al.
providers, and lack for training to work with creates a ‘prison in the community’ and asked,
LGBT elders that have multiple intersectional ‘what’s the difference from being in jail?’
identities that may include race and ethnicity, A recovery approach is recommended to assist
gender, HIV/AIDS history, serious mental ill- LGBT elders being released from the criminal
ness, substance use issues, and criminal offense justice system to feel more comfortable in
histories. accessing services for their mental health, health,
In general, there is a significant need for housing, and other important 'social, legal' and
affirming services in health and mental health, other supports. Engagement without exacerbat-
law, social services, education and vocational ing stigmas of their LGBT identity and criminal
training to help people in the prison and com- history is essential to begin establishing a helping
munity reintegration process. A comprehensive relationship. It is important to provide services
response is needed to address the pervasive and that consider diverse needs including, vocational,
multisystemic biases, prejudice, and discrimina- educational, financial, clinical and housing ser-
tion experiences of LGBT minorities across the vices. The Substance Abuse and Mental Health
life course that places them at risk of criminali- Services Administration (SAMSHA 2012) has
zation and/or involvement in the criminal justice estimated that 12 percent of male offenders and
system. When LGBT elders feel that they cannot 24 % of female offenders have a mental health
reveal their true identity to access services they and/or substance use disorder. Many researchers
need in prison or in the community, it leads to a indicate that this may be even higher in the
disregard of their unique challenges by health, LGBT population (Brown and Pantalone 2011;
mental health, and other service providers that Mustanski et al. 2010).
would be instrumental in accessing housing and For any treatment to have efficacy, it must treat
financial resources. Fear of discrimination and the whole individual, not only the presenting dis-
exclusion may lead to an avoidance of disclo- order. Best practices include addressing and inte-
sure, and therefore, a true evaluation of service is grating services with culturally responsive
needed. This group tends to remain marginalized providers. These services may include supported
and invisible to heterosexual social service pro- employment, family education, peer support, case
viders (Addis et al. 2009). management, and advocacy services. Organizations
In the prior literature and current study find- like The Rainbow Heights Club, a self-help and
ings, access to education in prison or after prison advocacy program specifically designed to provide
release is important. Both in prison and in the services to LGBT individuals, may be a key com-
community, LGBT people experience discrimi- ponent in community reintegration (Hellman and
nation in accessing education. However, in Klein 2004). Places for socialization and accep-
prison, this is even more so because many LGBT tance are crucial as one reenters the community
people in prison did not attend or were not from prison. Isolation, discrimination, and lack of
allowed to attend educational classes because of stable supports can only have a negative outcome.
personal safety and prison management issues. In Mental health and other educational and ser-
the current study highlighted in this chapter, vice providers need to provide trauma-informed
clients who attend the Rainbow Heights psy- care for those reentering from the criminal justice
chosocial club clearly described facing discrim- system. To adequately adjust to the community,
ination from other service providers, such as people have to be taught strategies to address
medical professionals, therapists, and social ser- traumas they have experienced and to overcome
vice providers, especially with housing. In fact, some of the detrimental coping mechanisms they
many of the narratives suggest the visible and may have employed in the past, which may
invisible ‘prisons’ in which society attempts to include substance abuse. Partnering with crimi-
place them. One participant described how dis- nal justice professionals and working on a com-
crimination on the basis of LGBT identities prehensive culturally competent unified plan is a
256 T. Maschi et al.
10. An essential element or elements of treat- Services and Advocacy for Gay, Lesbian,
ment with LGBT elder released from prison Bisexual Elders (SAGE): http://sageusa.org/
is the following: index.cfm
(A) Engagement without exacerbating Transgender Law Center: http://transgenderla-
stigma wcenter.org/issues/prisons
(B) Child care availability Transequality-Jails Prison Resource: http://
(C) Offering space for socialization and transequality.org/PDFs/JailPrisons_Resource_
acceptance FINAL.pdf
(D) Both A and C United Nations Office on Drugs and Crime:
http://www.unodc.org
United Nations Office on Drugs and Crime
Key
Handbook on Prisoners with Special Needs:
http://www.unodc.org/documents/justice-and-
1–2-D
prison-reform/Prisoners-with-special-needs.pdf
3-C
United Nations-Free and Equal Campaign:
4-C
https://www.unfe.org/en
5-D
6-D
7-D
8-E
References
9-D
10-D
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Immigrant LGBT Elders
13
Amanda E. Sokan and Tracy Davis
Abstract
LGBT immigrant elders suffer multiple jeopardy by virtue of being
members of disadvantaged groups (i.e., elders, LGBT, immigrant).
Although it is invisible to many, immigration is an important issue for
LGBT populations due to its impact on the individuals who may be
seeking refuge, same-sex couples, and their families. Immigration status
can determine a lifetime of opportunity or disadvantage. The striking
down of Section 3 of DOMA is a much-needed step in the right direction,
but there is much more that needs to be done. Comprehensive immigration
reform is critical to address the needs and concerns of this vulnerable
population.
Keywords
Immigrant/immigrant population Undocumented Life course Multiple
jeopardy Cumulative advantage/disadvantage
a status, and if so, how does it compare to the documented immigrants, while those who do so
status of non-immigrant populations? In order to without legal authorization are considered
explore these questions, important undocumented immigrants.
immigration-related concepts must be identified According to the US Census Bureau’s
and defined, such as immigrant populations, American Community Survey (ACS), in the
documented versus undocumented, naturalized USA, the term foreign born refers to persons
versus non-citizens. who are not US citizens at birth, including nat-
uralized citizens, legal permanent residents, and
other classes of migrants such as the temporary
Immigrant Populations—Definitions (e.g., students), humanitarian (e.g., refugees), as
well as undocumented migrants (US Census
Definitions of immigrant populations, as well as Bureau: American Community Survey Report
the criteria that determine these definitions, differ 2012b). Native born refers to those born in the
from one country to another. However, according US, Puerto Rico, or the US Island Area, or those
to the Organisation for Economic Co-operation born abroad to at least one parent who is a US
and Development (OECD), the most commonly citizen (ACS 2012b). In 2012, the total US
used definitions are based upon country of birth population was 313,914 million (Census Bureau
and nationality (OECD 2013). Using country of 2012a, b; OECD 2013a). According to the 2010
birth criteria, immigrant populations are defined ACS, about 13 % of US population (40 million)
as those who live in a country (known as host is foreign born. Department of Homeland Secu-
country) different from that in which they were rity estimates indicate that approximately 11.5
born. Where nationality criteria are used, million are undocumented (Hoefer et al. 2011).
immigrant populations are defined as those OECD data reflect a growing trend in immigrant
holding a nationality different from the host populations, with higher immigrant numbers for
country. Under this scenario, a person may be countries such as Canada, Australia, Israel, and
considered an immigrant even if he or she was New Zealand that range from 20 to 40 % of their
born in the host country. The criteria used can total populations (OECD 2013b).
also reflect the host country’s view of how citi- In sum, immigrant populations include
zenship may be acquired (OECD 2013). For foreign-born persons or persons who still hold a
instance, country of birth criteria reflects jus soli nationality other than that of the host country;
—the right of the soil by which citizenship is they may be documented or undocumented, and
automatically linked to place of birth, while their numbers continue to increase (OECD
nationality reflects jus sanguinis—the right of 2013b).
blood, wherein citizenship is derived from the
nationality of the parents. Generally, countries
have self-determined paths from “immigrant” to Immigrant Populations—Status
“national” status. Variations exist and depend
upon or are influenced by each country’s rules Immigrant populations often exhibit demographic
governing how citizenship may be acquired by and socioeconomic differences when compared to
non-nationals, however defined. Foreign-born their native-born counterparts. Status differences
persons may acquire citizenship through a natu- within immigrant populations exist, for instance,
ralization process, while those who do not do so by race, country of origin, length of stay in the
remain non-citizens. host country (recent or earlier immigrants), and
Countries also prescribe the manner in which whether they are documented or undocumented
immigrants may reside legally in the host coun- aliens (OECD 2013). The vast majority (about
try. For instance, in the USA, those who follow 2/3rds) of immigrants have come to the USA
established rules for migration are known as since 1990. Generally, compared to native-born
264 A.E. Sokan and T. Davis
populations, immigrants are more likely to be at a immigrants who have aged in place within their
disadvantage socioeconomically: with lower host country. Together, they make up a signifi-
levels of education, higher levels of labor force cant segment of the US population. This fact,
participation, lower income, and a higher likeli- coupled with the fact that there are currently a
hood of living in poverty (ACS 2010). large number of younger LGBT immigrants who
will likely age in place over time, makes a focus
on this group pertinent and timely.
Immigrant LGBT Elders
Table 13.1 Median annual personal income by sex, couple type, and citizenship status
Same sex Different sex
Non-citizens Naturalized Native Non-citizens Naturalized Native
born born
In labor Men 14,000 40,000 48,500 26,000 45,000 50,000
force Women 22,400 45,000 38,500 16,800 30,000 31,500
Not in Men 0 13,000 14,000 7800 15,600 24,000
labor Women 1500 28,000 11,500 0 3,100 6600
force
Source Gates (2013), LGBT adult immigrants in the USA, Williams Institute
educational levels, regardless of labor force Levitan (2013) cite the example of the United
participation. Nations Human Rights Committee that extended
• Female same-sex couples report higher med- the principles of the International Covenant on
ian annual personal incomes compared to Civil and Political Rights (ICCPR) to LGBT
those in different-sex couples, regardless of persons by expanding the reference to “sex” in
labor force participation or citizenship status. Article 26 to include sexual orientation. They
• Among LGBT couples, both male and female argue that such actions are important because of
have higher labor force participation rates their potential to impact states that are parties to
(Table 13.1). these treaties, and as such are required to be
compliant with their provisions.
Protecting the human rights of LGBT immi-
grants is important because even when they leave
their home countries, they may still face dis-
Countries that Recognize Same-Sex crimination and disadvantage in host countries.
Relationships for Immigration In many countries, including those with condu-
Purposes cive environments, LGBT persons may face
discrimination and persecution especially from
Like other migrants, LGBT individuals migrate immigration laws, policies, and practices.
for many reasons: personal, political, religious,
and economic. LGBT individuals may also
migrate to avoid persecution from their family, Discussion Box 1
community, and even government because of How have human rights agencies/bodies
their sexual orientation or gender identity (Tabak attempted to extend their provisions to
and Levitan 2013). cover LGBT populations? Look up the
Although there are no international legal agencies or bodies provided below. What
instruments tailored to offer protection for LGBT do you think?
human rights, there has been an increasing trend
toward recognition of the necessity and impor- (a) Committee on Economic, Social and
tance of assuring that human rights extend to Cultural Rights http://www.ohchr.org/
LGBT populations. In a paper discussing global EN/HRBodies/CESCR/Pages/
human rights and LGBT migrants, Tabak and CESCRIndex.aspx
Levitan (2013) state that this increased awareness (b) European Court of Human Rights
can be seen in the actions of international and http://www.echr.coe.int/Pages/home.
regional legal bodies who have sought to extend aspx?p=home
the application of human rights principles to (c) Inter-American Commission on Human
LGBT populations. For instance, Tabak and Rights
266 A.E. Sokan and T. Davis
Table 13.2 Countries that recognize same-sex relationships for immigration purposes
Country Who Status Rights Criteria (examples)
1. Australia Lesbian or gay Interdependency visa Same as for Exclusive relationship;
partner heterosexual 12-month duration
common-law spouses
2. Belgium Legal Visa Type D; Extended stay for more Stable relationship;
marriage/spouse; Type C (with view to than 90 days; Family unification
Partnerships marry) Same for heterosexual
(includes other relationships
countries)
3. Brazil Partners Visas: No comprehensive Legal/formal
– temporary national-level relationship;
– permanent acknowledgment; Proof of stable
– concubine Some rights recognized relationship;
by the federal Certificate of
government (e.g., concubinage
rights to social security
and pension)
4. Canada Spouses, Broad immigration Same as for Marriage in Canada;
common-law rights different-sex couples Partner age = 16 or
partner, conjugal older;
partner Cohabitation for at
least a year to establish
conjugal status
5. Denmark Registered Typically residence Same general At least 24 years old;
partner, spouse permit in either foreign immigration policies Ability of resident to
or cohabiting partner’s country, or apply provide support;
partner Denmark depending on Attachment to
individual’s Denmark more than
circumstances any other country
6. Finland Spouse (includes Residence permit, fixed Residence permit; Family ties;
registered term or permanent, Migration benefits 18 years old;
partner), depending on Proof of marriage,
cohabitant individual’s partnership, or
circumstances cohabitation
7. France All unmarried Legal status, with some Residence: Civil Solidarity Pact;
couples (same or rights of marriage - Temporary (post-I Personal connections to
different sex) year wait period, renew France
yearly)
– Permanent (after
5 years; renewable
every 10 years)
8. Germany Registered life Residence permit Most rights enjoyed by Sponsor must be citizen
partner Long-stay visa heterosexual couples; or permanent resident;
Equal immigration Able to provide
rights financial support
9. Iceland Registered Permit to stay; Same immigration 18 years old;
partnerships; Permanent residence rights as married Cohabitation for at
Cohabiting (spouses) spouses least 2 years, plus
partner; intent to continue if
Spouses unmarried
10. Israel Partners No national-level legal 1-year work permit; Evidence of sincere,
status Temporary residence genuine relationship
(yearly renewal);
Permanent residence
after 7 years
(continued)
268 A.E. Sokan and T. Davis
that LGBT elders may face, many federal, state, accessing health care for a number of reasons
or local agencies that provide services for older including, language barriers, unfamiliarity with
adults are not designed to address the specific the health care system, lack of immigration status
concerns of LGBT elders. In fact, several studies documentation, and lack of health insurance.
have found that widespread homophobia exists Undocumented LGBT immigrants are barred
among individuals and organizations entrusted to from accessing federal health care benefits,
care for America’s older adults (National Gay including the exchanges established through the
and Lesbian Task Force Foundation 2011). 2010 Affordable Care Act (Wasem 2012). This
Prior to 2013, the immigration system in the lack of coverage is why many undocumented
USA did not recognize same-sex marriages. In LGBT individuals forgo medical treatment, and
June of 2013, the United States Supreme Court when they do attempt to access care, many times
ruled Section 3 of DOMA unconstitutional, they are unable to afford the care (Baker and
requiring the US immigration system to recog- Krehely 2011).
nize same-sex relationships for immigration
purposes (US Citizenship and Immigration Ser-
vices 2014a, b). While this is a major milestone
the issues with immigration for LGBT individu- Invisibility of LGBT
als have not been eliminated. With the striking in the Immigration Debate
down of Section 3 of DOMA, there are more
opportunities for immigration to the USA for The LGBT population has long had a history of
LGBT individuals; however, a strong infra- exclusion in society generally, often born out of
structure for supporting immigrant LGBT elders fear, ignorance, negative stereotypes, or pre-
does not yet exist in the USA. For example, judice about LGBT sexual orientation or gender
LGBT elders often face economic challenges, identity. Especially where prejudice exists or
such as finding and maintaining employment due attitudes to LGBT sexual orientation and gender
to discrimination and anti-LGBT bias (Services identity is negative, there often exists at best, a
and Advocacy for Gay, Lesbian, Bisexual, and paucity of, or at worst, a total lack of awareness
Transgender Elders; National Hispanic Council and sensitivity to LGBT issues, needs, and con-
on Aging; and Diverse Elders Coalition 2014). cerns. To the extent that these go unnoticed,
Furthermore, some states within the USA main- LGBT populations are effectively rendered
tain bans on same-sex marriages; thus, same-sex invisible and therefore marginalized.
couples in those states are not recognized as Invisibility also occurs because of the reluc-
surviving spouses or dependents, which pre- tance, reticence, or inability of many in the
cludes them from receiving surviving spouse LGBT population to self-identify as LGBT or
benefits if their partner dies, further exacerbating publicly acknowledge their sexual orientation or
economic challenges. gender identity, due to fear of retribution, stigma,
Economic realities may pose challenges to or otherwise. As members of a legally and
basic survival, because they affect other issues socially disfavored minority group (Services and
such as housing. Of the LGBT elders who Advocacy for Gay, Lesbian, Bisexual, and
qualify financially for Section 8 housing, many Transgender Elders (SAGE), and Movement
are ineligible due to lack of immigration status Advancement Project (MAP) 2010), exclusion
documentation or social security registration can occur at personal and societal levels, with the
(Services and Advocacy for Gay, Lesbian, latter being more systematic. For instance, his-
Bisexual and Transgender Elders; National His- torically, non-inclusive laws, policies, or prac-
panic Council on Aging; and Diverse Elders tices have placed LGBT individuals at a
Coalition 2014). In addition to housing chal- disadvantage in various spheres including access
lenges, immigrant LGBT elders may have issues to jobs, housing, and social services (Burns et al.
13 Immigrant LGBT Elders 271
2013). Also, damaging has been exclusion from social, employment/work, health, economic),
public discourse on issues with salience for the enjoyed by opposite-sex couples in similar cir-
LGBT population, an example being immigra- cumstances (Burns, et al. 2013). Misinformation,
tion and immigration reform. misconceptions, and lack of awareness of the
Immigration reform has been a hot topic in application and effect of immigration law and
recent years, generating a lot of discussion across system increase LGBT vulnerability to discrim-
all sectors of society. Such discussion often ination and disadvantage. An article entitled, Not
centers on the need for reform of the existing law Just an “Issue”—Invisibility in the Immigration
to address challenges posed by an estimated 11 Debate Hurts Real People, by Brian Pacheco and
million undocumented immigrants in the USA published in the Huffington Post on May 7, 2013,
(Gates 2013). Public opinion and discourse often reflects this position.
center on issues such as refugees, and illegal or
undocumented immigrants from Latin, Asian,
Discussion Box 3
and African countries; in particular, the influx of
In the news media:
Latinos from Mexico, migrant labor, and status
Separately, both LGBT rights and
of the so called “DREAMers”—children brought
immigration reform have been topical
to the USA illegally by their parents. Debate also
issues recently, receiving a significant
focuses on high visibility cases such as the 1999
amount of news coverage. When these
Elian Gonzalez case, illegal border crossings, and
issues overlap, they raise pertinent ques-
issues of territorial or homeland security, as well
tions and concerns for LGBT elders. Con-
as foreign nationals seeking the “American
duct an online search for news items and/or
Dream.” However, issues of concern to gay and
find news articles on the intersection of
lesbian populations do not garner the same level
LGBT rights and immigration law/reform,
of discourse or awareness and so are invisible in
such as Not Just an “Issue”—Invisibility in
the immigration debate.
the Immigration Debate Hurts Real People
Notwithstanding the silence on the issue,
by Brian Pacheco and published in the
immigration reform is an LGBT issue for a
Huffington Post on May 7, 2013.
number of reasons. First, about 267,000 of the 11
What issues of relevance to LGBT
million undocumented elders in USA are LGBT
elders are raised when these areas overlap?
(Gates, 2013). Second, Hispanics, who make up
In what way, if at all, does this overlap
a large percentage of the undocumented popu-
increase LGBT vulnerability to discrimi-
lation, constitute the largest segment of LGBT
nation and disadvantage?
populations, making immigration reform doubly
How might this affect well-being in later
pertinent for those who fall within these two
life?
categories—(i.e., both a Latino and LGBT issue).
Third, and most importantly, the major challenge
under the current immigration system is the lack
of parity in status and recognition afforded to
same-sex relationships as compared to
Immigration Reform as an LGBT Issue
opposite-sex relationships. For instance, this lack
of parity creates problems for binational couples,
As a result of the events of September 11, 2001,
whereas the US citizen or legal resident is unable
concerns around citizenship and immigration
to sponsor a partner or spouse for legal residence.
have risen to the forefront of political discussions
Immigration inequality for LGBT couples has
in the USA. Some argue that in the wake of the
created a number of hardships, including the
events of 9–11, anti-immigration policies were
forced separation of families, threat of or actual
put into place making it more challenging or
deportation of foreign-born/non-citizen partners,
impossible for some to immigrate to the USA
as well as exclusion from benefits (e.g. legal,
272 A.E. Sokan and T. Davis
(Lewis 2010–2011). Though some of the policies unrealistic requirements, which in turn could lead
were put into place subsequent to September 11, to increased wages and job security, preservation
2001, some policies were in place prior to Sep- of family unity, greater access to social services
tember 11, 2001. A lot of these policies were (Burns et al. 2013), increased opportunities to
enforcement immigration policies rather than pursue higher education, and the chance to live
immigration reform policies. Many believed that without the constant threat of deportation (Gru-
enforcement immigration policies would lead to berg 2013a, b, c). Second, reforms need to include
reductions in illegal immigration and produce serious changes to detention center standards to
positive outcomes in the future (Giovagnoli ensure the protection, dignity, and privacy of those
2013). Regardless of when the policies were detained who are frequently victimized. Unfortu-
implemented, certain groups are more vulnerable nately, LGBT immigrants who are detained while
to the anti-immigration policies, such as LGBT awaiting deportation or trial are often sexually
individuals seeking asylum in the USA from assaulted and harassed by guards or other detain-
Middle Eastern countries (Lewis 2010–2011). ees (see Chap. 12), subjected to prolonged periods
Enforcement immigration policies led to in solitary confinement, denied necessary medical
increased spending on immigration in the USA, care, and/or denied proper hormonal therapy for
increased numbers of deportation, additional transgendered individuals (Gruberg 2013a, b, c).
state implemented anti-immigration laws, Typically, solitary confinement is used for pun-
increased separation of families, and increased ishment; however, in the case of many LGBT
discrimination (Lewis 2010–2011). In 2012, individuals, it is used to “protect” them from
federal election results indicated that voters were assault. Thus, many LGBT individuals are in
not satisfied with enforcement immigration and essence being punished for their sexual orienta-
sought a shift toward immigration reform (Gio- tion. One potential solution to this problem is to
vagnoli 2013), hence the proposal of bills such as utilize alternative detention programs in an effort
the Border Security, Economic Opportunity, and to decrease the number of LGBT immigrants in
Immigration Modernization Act of 2013, which detention centers, which may be a more
is still pending. cost-effective strategy (Gruberg 2013a, b, c).
Currently, about 11 million undocumented Third, immigration reform has the potential to
immigrants are living in the USA of which hun- positively influence well-being and increase
dreds of thousands identify as LGBT. Unfortu- immigrants’ access to health care and social ser-
nately, little is known about undocumented elder vices, including culturally competent care for
LGBT individuals. This subgroup (i.e., undocu- LGBT immigrants. Finally, reforms should
mented LGBT individuals, including elders) is in improve the US asylum programs, specifically by
desperate need of immigration reform. LGBT lifting the one-year ban for submitting asylum
undocumented elders find themselves at the claims (National Immigrant Justice Center 2010).
intersection of three marginalized groups: the One in five refugees seeking protection in the USA
LGBT population, the undocumented population, is denied asylum claims because he or she misses
and the elderly population, thus making them one the one-year deadline for filing such claims
of society’s most vulnerable populations. Immi- (National Immigrant Justice Center, 2010). Since
gration reform would assist undocumented LGBT the deadline for filing was initiated in 1996, over
immigrants in four ways: (1) create a path to 79,000 cases have been denied simply based on
citizenship; (2) improve the treatment of immi- the deadline (Gruberg 2013a, b, c). While this
grants held in detention centers; (3) improve the deadline and unfortunate denial of asylum cases
health, safety, and well-being of LGBT immi- affect all immigrants, it disproportionately affects
grants; and (4) improve the US asylum system for LGBT immigrants who are seeking asylum from
LGBT applications. countries that criminalize homosexuality (Gru-
First, immigration reform has the potential to berg 2013a, b, c). Additionally, immigration
create paths to citizenship that do not include reform would significantly increase the number of
13 Immigrant LGBT Elders 273
their partners or from their family of origin. pathway to citizenship for undocumented immi-
For LGBT elders, this is critical because it reduces grants, needs to go further. In a report for the
their social convoy or networks, which is a source Center for American Progress, authors Burns,
of social support, especially if they suffer stigma Garcia, and Wolgin (2013) note issues that
and lack of acceptance within the community. In reform must address. Burns et al. state that the
the absence of familial caregivers, they may have law needs to eliminate discrimination against
to live in residential facilities where they may be binational same-sex couples and afford them
exposed to stigma, prejudicial treatment, or hostile rights and protections given to heterosexual
environments (SAGE and MAP 2010). couples by recognizing same-sex unions and
Living in long-term care institutions may also committed partnerships for those in jurisdictions
create other challenges. Non-inclusive polices or that ban same-sex marriages. These changes or
homophobia may cause facilities to indulge in amendments would help promote family unity
practices that abrade individual rights. For and reduce the number of deportations, or those
instance, a nursing home may not allow cohabi- who live under the threat of deportation.
tation or support the individual’s expression of If passed by Congress, such a bill will open the
gender identity. Also, giving priority to biological way to equality for LGBT immigrants. For
families or families based upon opposite-sex example, the right to sponsor a same-sex partner
unions exposes LGBT elders to unequal treat- or spouse would allow the sponsored individual
ment under immigration laws and other programs to obtain the legal right to live and work in the
and services. The implication is pertinent espe- US. This in turn would allow such individuals to
cially for health matters. Lack of legal status can invest and save for the future, be engaged in the
bar LGBT elders from health care benefits, visi- community, and live openly and with dignity with
tation rights, as well as medical and end-of-life loved ones—all of which benefits both present
decision making. Its effect on employment, job and future cohorts of LGBT elders. We have
security, and income over the life course affects begun to see a trend in changing public opinion
financial welfare in later life and during retire- and in the judiciary about same-sex couples,
ment. The 2010 multi-agency report, “Improving which may bode well for immigration reform.
the Lives of LGBT Older Adults,” provides illus-
trative examples of the implications of exclusion
Case Discussion 1: What would you
on same-sex couples. According to the report,
do?
Most Americans and their elected leaders are You are the Administrator-in-Training at
unaware of the many ways in which unequal Rest-A-while Acres, a 30-bed nursing
treatment and ongoing social stigma can hurt and
impoverish LGBT elders. Consider the older gay
home. You have a recently arrived resident
man who loses the family home when his partner Kevin (Kay) A. Scrunchman. Kay’s birth
requires long-term institutional care; a heterosex- certificate and records show that she was
ual spouse would be protected from the same fate born 70 years ago, a male child. For the past
under Medicaid rules. Or consider the lesbian elder
who is forced to spend her last days alone in the
45 years or so, Kay has lived her life as a
hospital because the federal government will not female. She intends to continue to do so and
grant family medical leave to a close friend who has requested a room with a female room-
would otherwise take care of her at home (SAGE mate. The Director of Nursing and staff insist
and MAP 2010).
on placing Kay with a male roommate, and
Advocates for immigration reform for LGBT assistants report discomfort with helping her
immigrants continue to draw attention to these wear dresses and apply makeup. You do not
and other concerns. Even the stalled Border have any single rooms in your facility.
Security, Economic Opportunity and Immigra- What if any are Kay’s rights?
tion Modernization Act of 2013, which sought to What, if any, are your responsibilities?
address some of these challenges by providing a What would you advise?
13 Immigrant LGBT Elders 275
relationships (ICWC 2014). Additionally, the prove that their marriage is a heterosexual mar-
non-abused same-sex spouse of a US citizen or riage due to the repeal of Section 3 of DOMA
legal permanent resident whose children are (Immigrant Legal Resource Center 2013). Prior
abused by the citizen may qualify as well (Gru- to June 2013, these benefits were not available to
berg 2013a, b, c). same-sex partners, as they were not recognized
Same-sex couples can now access the K visa, by the federal government. With the repeal of
which allows fiancé(s) and the unmarried minor Section 3, significant strides have been made in
children of US citizens to legally enter the USA affording same-sex couples the same benefits as
so that they can be married within 90 days of others. However, there is still a long way to go.
entrance. It also allows the fiancé to immediately For instance, there are thousands of undocu-
apply for work authorization. Once the couple is mented LGBT immigrants and unmarried immi-
married, the foreign citizen can then apply for grants who await immigration reform, so that
permanent legal resident status and can remain in they can have a clear-cut pathway to citizenship
the country until the application is processed in the USA.
(USCIS 2014a, b).
Some LGBT legal permanent residents who
were married or had children before becoming
legal permanent residents and whose spouses or LGBT Couples that Include
children did not initially accompany them to the a Foreign-Born Spouse
USA are now eligible for the follow-to-join
benefits. Follow-to-join benefits mean that the In 2013, there were an estimated 113,300
spouse or children who did not physically foreign-born individuals, including naturalized
accompany the legal permanent residents to the citizens and non-citizens who are part of a
USA do not have to wait until a visa number same-sex couple (Gates, 2013). Approximately,
becomes available. Instead, the legal permanent 54,600 of these individuals are not US citizens
resident is required to notify the US consulate (Gates 2013). Additionally, there are an esti-
that he or she is a legal permanent resident, and mated 24,700 same-sex couples that are bina-
the spouse can then apply for an immigrant visa tional (i.e., one US citizen and one non-citizen)
(USCIS 2012). and approximately 11,700 same-sex couples
Individuals who illegally enter the USA must comprised of two non-citizens (Gates 2013). In
first leave the country before becoming eligible total, 87,900 same-sex couples residing in the
to apply for a green card. Typically, spouses and USA include a foreign-born spouse or partner
children of a US citizen who entered illegally (Gates, 2013). When compared to foreign-born
have to wait 3 or 10 years depending on how individuals in heterosexual relationships,
long they were in the USA before leaving vol- foreign-born individuals in same-sex couples are
untarily or being deported, before they can gain more likely to be male and younger (Gates
authorization to apply for legal permanent resi- 2013). Non-citizens in both same-sex and heter-
dent status. However, if the immigrant is able to osexual couples are economically disadvantaged
obtain a hardship waiver, he or she may not have (Gates 2013). Naturalized citizens who are in
to wait for 3 or 10 years before applying for a same-sex couples are more likely to be Hispanic
green card. Hardship waivers reduce the amount (37 % vs. 31 %, respectively) and White (30 %
of time an undocumented immigrant must wait vs. 26 %) and less likely to be Asian, as com-
before applying to be a legal permanent resident. pared to their heterosexual counterparts (Gates
Hardship waivers are only available to spouses 2013). Regarding non-citizens, individuals in
and children of US citizens. same-sex couples are also more likely than those
Transgender individuals in heterosexual mar- in heterosexual couples to be White (28 % vs.
riages should no longer be subjected to any 16 %, respectively) but less likely to be Hispanic
special requirements or conditions in order to (46 % vs. 58 %) and Asian (16 % vs. 20 %)
13 Immigrant LGBT Elders 277
(Gates 2013). Regardless of citizenship status, and care providers span a broad range of disci-
the majority of men and women in same-sex plines, including social work, health
couples have higher levels of education as care-including mental health, financial planning,
compared to their counterparts, with the excep- geriatric services management, legal services
tion of non-citizen same-sex women (Gates (elder law), as well as advocacy groups. Each
2013). The aforementioned data, while not spe- professional or service provider must begin by
cific to LGBT elders, provide an overview of asking at least these two salient questions:
LGBT couples that are comprised of a (1) In order to optimally identify and address
foreign-born spouse or partner. my client’s needs and maximize benefits, what
Specifically, focusing on older adults, approx- challenges and opportunities are posed by being
imately 10,000 undocumented LGBT immigrants an immigrant LGBT elder? and (2) Understand-
are 55 years of age or older, while approximately ing these, how can I best assure, promote, or
140,800 of documented LGBT immigrants are protect his/her interests?
55 years of age or older (Gates 2013). Adults 55 Potential implications for service delivery are
and older account for 23 % of naturalized citizens many and will vary depending on the disciplinary
who are foreign born and living in the USA, and area and individual client circumstances. How-
10 % of non-citizens (Gates 2013). In general, ever, there are some general guidelines that are
there is very little demographic data available helpful to consider when providing care and ser-
regarding LGBT immigrants and even less vice to immigrant LGBT elders, regardless of sta-
regarding LGBT elder immigrants. With the tus and situation. These general guidelines have
striking down of Section 3 of DOMA, there are been articulated by a number of advocacy and
more opportunities for LGBT couples that include research groups with expertise in and knowledge of
a foreign-born spouse or partner—with that LGBT population, such as the National Center for
change may come more opportunities to learn Lesbian Rights, Transgender Law Center; Ameri-
more about LGBT elders in binational couples. can Immigration Council Legal Action Center; and
Services and Advocacy for Gay, Lesbian, Bisexual
and Transgender Elders (SAGE). According to
these groups, in order to provide competent care
Implications for Service Delivery and services to immigrant LGBT elders, service
from an Interdisciplinary Perspective and care providers must do the following:
In this chapter, we have introduced and discussed • Be tolerant and comfortable with LGBT
some of the major issues that affect immigrant people and issues
LGBT elders and how current immigration pol- It is important to examine personal attitudes
icies and practices act to disadvantage and mar- and their effect on how one perceives, thinks,
ginalize immigrant LGBT elders through unfair and treats LGBT people, in order to overcome
and unreasonable treatment. People are a product or address disinterest, discomfort or apathy
of their life course and the events, challenges, which may have a negative impact on service
and opportunities, which shape them to create delivery.
patterns of accumulated advantage and/or disad- • Be knowledgeable and aware
vantage over time. These cumulative advantages Knowledge and awareness of the challenges
or disadvantages impact later life in terms of both faced by LGBT populations pave the way to
experiences and expectations, and ultimately understanding and empathy. Knowledge can
affect well-being and adjustment in old age. be acquired by getting to know and building
Bearing this in mind, it is important for those relationships with LGBT individuals, com-
who work, provide care, or otherwise interact munity, advocates, and organizations, as well
with LGBT elders to be cognizant of these issues as through training and education. It is
and their implications for clients. These service important to learn about myths regarding
278 A.E. Sokan and T. Davis
LGBT, and to develop familiarity with and/or and confidentiality should always be respected.
obtain access to local, regional, and national Also be aware of the implications of past his-
resources for LGBT populations. In addition, tory on LGBT elders. For example, consider the
exposure to positive imagery and por- potential for social isolation due to past issues
trayal of LGBT people can also help improve with family separation, the possibility of a def-
knowledge, sensitivity, and awareness. inition of “family” which may be different,
• Create an LGBT-friendly work likelihood of poverty or financial challenges
environment due to unfavorable work experience or inability
As with other minority/disadvantaged groups, to work because of immigration status, and
providing staff education and sensitivity train- other consequences of marginalization.
ing, as well as instituting LGBT-friendly poli- • Recognize that not all issues are about
cies are useful strategies. Resources or materials LGBT status
for clients should be inclusive and diverse. LGBT elders may face concerns or challenges
Hiring LGBT personnel not only ensures that do not pertain to sexual orientation and
inclusion of LGBT views, but also promotes gender and should be treated accordingly. In
overall diversity in the organization or work- so doing, it is important to be aware of the
place. Providing LGBT cultural competency potential effect of a history of prejudice, dis-
training can enhance the creation of a culture of crimination, and stigma both on LGBT
inclusivity and a safe environment where clients elders’ self-perception and their response to
feel able to discuss sensitive issues. others. Being an advocate for clients may
• Language involve confronting prejudice, stereotypes,
Language is often a barometer for attitude, and discrimination in others.
understanding, and expertise. Inclusive lan- • Be mindful of available resources
guage treats all clients fairly and reasonably and Know where and how to contact LGBT
avoids assumptions about sexual orientation organizations and advocacy groups as needed
and gender identity. For instance, in a practice and to keep information current. This is
advisory entitled “Tips for legal advocates especially important as the LGBT landscape
working with lesbian, gay, bisexual and trans- undergoes legal and public opinion changes.
gender clients,” the National Center for Les- These organizations have access to and offer
bian Rights (NCLR) and its partners California valuable information, research, and counsel to
Rural Legal Association(CLRA) and Legal help inform effective strategies.
Services for Children (LSC) recommend asking • Know your limitations
clients questions such as “are you in a rela- Be self-aware. Know when to seek outside
tionship” rather than “do you have a boy- help and to make referrals for service, advo-
friend?” (NCLR, CLRA, and LSC 2013). It is cacy, resource needs, support groups, and the
also important to consider each individual cli- like if appropriate and as necessary.
ent, and their unique circumstance(s) as far as In sum, always consider the client’s needs.
practicable. Avoid generalizations and assum Make him or her comfortable, follow her lead, or
ptions about LGBT clients, by using language let her set the tone and build trust. Avoid a “one
used by the client to define him/herself. This size fits all” approach. Try to understand the
avoids using language which may imply judg- unique issues, problems, situations, and factual
ment, e.g., words such as “lifestyle” or “sexual circumstances faced by the client. Keep abreast
preference” (NCLR, CLRA, and LSC 2013). of changes in the law, educate staff, and be
• Be sensitive and astute in approach cognizant of the various avenues for help,
Acknowledge the client’s use or choice of information, or other resources.
name, pronoun especially in transgender cases, Finally, consider how best to optimize service
and request clarification if in doubt. Privacy delivery using an interdisciplinary approach
13 Immigrant LGBT Elders 279
because of the benefits that seamless delivery and more specific research questions, for instance, the
a continuum of care offer to older adults. Ulti- role and meaning of marriage in same-sex rela-
mately, the best approach is one within which tionships in terms of access to, preference for, and
professionals understand not just how to address feasibility of marriage among LGBT individuals
the issues they confront in a way that shows compared to heterosexual relationships. This is an
cultural competence in LGBT issues, but also important question in light of the recent Supreme
how best to do so in order to support the work of Court ruling. That decision created marriage
others so as to provide seamless and optimal equality for same-sex couples, but is it sufficient?
service to clients. Immigrant LGBT elders face Do we need to address other forms of commitment
disadvantage on three fronts—ageism on account among those in same-sex relationships, such as
of old age, immigrant status (both documented civil unions or registered partnerships? If so, what
and undocumented) and because of sexual ori- are the implications for immigration? Are there
entation or gender identity. Multiple jeopardy and barriers to being married, and if so, how should
its implications for well-being and adaptation in these be considered or addressed? Should those
later life must be considered in service delivery. who show commitment be considered similar to
spouses, for immigration purposes and benefit?
This is important because we have seen how
immigration status contributes to socioeconomic
Implications for Future Research disadvantages, which accumulate across the life
and Summary course and ultimately determine well-being and
adaptation in old age.
In early 2015, as we complete this chapter, immi- Public attitudes are changing toward LGBT
gration reform is topical and in a state of flux. We individuals, toward immigration issues, and spe-
are currently awaiting action from Congress. cifically relating to immigrants who are undoc-
Although recent changes to immigration policies umented; these changes will likely impact
have been beneficial for LGBT immigrants, immigration reform. As the numbers of LGBT
immigration reform is still a major issue for the elder immigrants and their partners increase, the
LGBT immigrant population and its non-immi issues that confront this demographic are only
grant partners. There is a paucity of data on LGBT going to become more salient. Thus, develop-
populations in general and, more specifically, ments in this arena need to be monitored and
LGBT elder immigrants, despite the amount of understood if we are to promote policies and
fragmented information from advocacy groups, practices, which work to optimize service deliv-
Web sites, and other publications. While there are ery to this population.
inherent challenges to collecting data on undocu- This chapter has emphasized that LGBT
mented people, especially undocumented LGBT immigrant elders suffer multiple jeopardy by
individuals due to fear and stigma, we are sorely in virtue of being members of disadvantaged groups
need of systematically and rigorously conducted (i.e., elders, LGBT, immigrant). Although invis-
quantitative and qualitative research data that can ible to many, immigration is an important issue
support policy reform and practice. Because of the for LGBT populations due to its impact on the
many issues that affect LGBT elders and their individuals who may be seeking refuge, same-
non-immigrant partners, there is a wide open vista sex couples, and their families. Immigration
for research—we suggest several areas. We need a status can determine a lifetime of opportunity or
better idea of the demographic scope of docu- disadvantage. The striking down of Section 3 of
mented and undocumented immigrant LGBT DOMA is a much-needed step in the right
elders and their partners. We must assess the needs direction, but there is much more that needs to be
and challenges of LGBT elders and their partners in done. Comprehensive immigration reform is
order to develop policies and practices that will critical to address the needs and concerns of this
address their service needs. Additionally, there are vulnerable population.
280 A.E. Sokan and T. Davis
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Understanding Transgender Elders
14
Loree Cook-Daniels
Abstract
No stigmatized group in U.S. history has seen as much progress as quickly
as transgender people. Current transgender elders represent virtually the
full history of the transgender experience; this chapter explores how this
history has impacted language, generational rifts within the community,
and trans elders’ self-image. It discusses what is known about
trans-specific health care (hormone use and gender-related surgery),
including trans older adults’ experiences of health care discrimination. It
covers the two primary approaches to trans health care—the Standards of
Care and the informed consent models—and why identification docu-
ments are so important to trans people. General health, mental health, and
violence issues are covered, along with “stages of emergence” of trans
identity and social relationship issues. Sexuality and safer sex comes next.
It closes with recent policy changes, including developments related to
marriage, Social Security, veterans, employment, housing, long-term care
facilities, and services for victims of violence.
Keywords
Transgender LGBT Aging Health disparities Standards of care
Violence
policy for, make community with, befriend, and marriage, Social Security, veterans, employment,
love transgender elders. housing, long-term care facilities, and services
The chapter starts with terms and definitions for victims of domestic violence, sexual assault,
by focusing on how much change there has been dating violence and stalking.
around transgender issues during the lifetimes of
current trans elders. This discussion should
explain why a variety of terms will be used Learning Objectives
throughout this chapter: it is critical that those
working with the transgender community not By the end of this chapter, the reader should be
become wedded to any particular term or defi- able to:
nition, as they are in constant flux and vary from
individual to individual. (We do the same with 1. Discuss some reasons for the existing diver-
pronouns, including using “they” as a personal sity of terms and beliefs among trans elders.
pronoun, for the same reasons: to help the reader 2. Give possible reasons for the dearth of
get used to recognizing that a variety of pronouns research on transgender elders.
are currently being used within the trans com- 3. Describe some of the unique ways in which
munity.) We next move on to explore genera- professionals of various sorts influence trans
tional issues affecting the trans community, people’s identities and lives.
including those that cause intra-community strife. 4. Explain how violence and discrimination
After reviewing the limitations of existing might affect a trans elder’s life circumstances.
research on trans elders, the chapter discusses 5. List some of the concerns SOFFAs—Signif-
what is known about trans-specific health care icant Others, Friends, Family, and Allies—of
(hormone use and gender-related surgery), trans elders might have.
including trans older adults’ experiences of dis- 6. Discuss some of the ways in which federal
crimination within the health care system. One of government policies might impact trans
the ways the experience of trans people differs elders’ lives.
from their LGB peers is their dependence on
professionals for health care and identification
papers. The chapter covers the two primary
approaches to trans health care—the Standards of
Introduction
Care and the informed consent models—and why
Development of Terms, Identities,
identification documents are so important to trans
and Communities
people. General health, mental health, and vio-
lence issues are tackled together to reflect
Unlike some other cultures, Western industrial-
emerging research on the effects trauma has on
ized nations such as the U.S. have had no tradi-
physical as well as mental health. The section on
tional role for people who do not spend their
therapy includes one expert’s “stages of emer-
lives fully identifying with the “boy” or “girl”
gence” of trans identity. The chapter then
label they were given at birth (Feinberg 1997).
addresses social relationships, covering some of
That does not mean the people we now call
the issues with which SOFFAs (Significant
transgender or trans did not exist; it does mean
Others, Friends, Family and Allies) may struggle.
that they had no common term for themselves
Sexuality and safe sex comes next, with brief
and, for the most part, no or few role models.
discussions of sexual orientation and libido
Some, like jazz musician Billy Tipton (1914–
changes, how trans elders handle dating disclo-
1989), succeeded in living as their preferred
sure, and how religion has affected some trans
gender for years or even decades, often without
elders’ sexuality. We end with an overview of
anyone else knowing their gender history
recent policy changes in the lives of American
(Middlebrook 1999). Others found more or less
trans elders, including developments related to
14 Understanding Transgender Elders 287
comfortable homes in gay male or lesbian “transitioned” (begun living publicly as a gender
communities, which have been more tolerant of different from the sex they were assigned at birth)
cross-dressing, masculine women, and feminine anytime from their 20s through their 70s.
men. People who were assigned male at birth and The point at which this transition occurs is
who were attracted to women often married critical. As we just discussed, families and soci-
women and dressed in women’s clothing in ety do their best to teach trans people how not to
secret or with their wives’ consent. The stories of be trans. (Contrast this with an African-American
how people who were assigned female at or Catholic person who is taught by their parents
birth, had a masculine identity, and were attrac- and others how people of their race or religion
ted to men before the modern transgender con- are expected to act, believe, and survive.)
cept emerged have, for the most part, not been Instead, trans people learn “how to be trans”
told. from other trans people once they make contact
The lack of both role models and language with them.
began to change when Christine Jorgensen’s “sex “How to be trans” has been under constant
change” was widely publicized in 1952. This and rapid change since Christine Jorgensen came
“ancient history” is, in fact, within the lifespan of to public awareness. The time period in which a
current trans elders: if Jorgensen had not died of trans elder first made contact with the trans
cancer in 1989, she would now be entering her community therefore will significantly influence
90s. Indeed, many current trans elders start their both how he or she thinks of himself or herself
“coming out” stories by recounting how they first and gender identity, and the terms they use.
ran into an article about her (Brevard 2001; In the 1950s and 60s, Virginia Prince worked
Feinberg 1997; Sanchez 2015). to create an identity that was neither homosexual
The publicity about Jorgensen did not mean nor “transsexual” (a term that had been coined in
that everyone who had a gender identity different 1949). She called heterosexual men who wore
from the sex they were assigned at birth ran out women’s clothing (part-time or full-time)
and had a sex change (which was still very hard “transvestites” or “transgenderists” and sought to
to procure). Even if they do not talk about their delineate the differences between the various
gender identity or show “cross-gender” behav- categories so that the male cross-dressers were
iors, trans people pick up society’s message: if not “made to bear stigma they do not deserve.”
you were “born a boy,” you will always be male (Meyerowitz 2002, p. 181). Prince’s careful
and vice versa: anyone who believes differently parsing of “types,” accompanied by disdain for
is not just mistaken, but possibly sinful, dan- those in other categories, remains sadly common.
gerous, perverted, and/or mentally ill. It could The trans community to this day still has
also be illegal. Beginning in the mid-1800s, often-vicious arguments over who belongs and
many jurisdictions passed laws forbidding which groups are more “real” or “deserving”
cross-dressing. Some laws specified how many than others. We will return to the implications of
pieces of clothing must belong to the person’s these divisions later.
assigned sex in order to be legal (Brevard 2001; Some did find their way to helping profes-
Meyerowitz 2002). Consequently, most current sionals, although this was not always a pleasant
trans elders spent decades trying to fit into their experience. In 1962 professional entertainer
assigned roles (sometimes by entering Aleshia Brevard felt the surgeon she found was
“hyper-masculine” careers such as the military or “twisted and disgusting,” but he was willing to
construction or striving to be the most “femi- perform surgery when no one else would
nine” person on the block) and/or denying or (Brevard 2001, p. 10). Unfortunately, she had to
suppressing their feelings. The timing of when castrate herself first because U.S. law otherwise
any given person realizes that these attempts to required her surgeon to place her testicles—
fit in are failing differs for each individual. which would have continued to produce testos-
Therefore, current trans elders could have terone—inside her body.
288 L. Cook-Daniels
Case Study 1: Aleshia Brevard a strong possibility existed that the police
Ten years after Christine Jorgensen intro- would discover my transsexual identity.
duced herself to America, Aleshia Brevard Even genetically-born female victims of
transitioned at age 23. physical rape are required to defend
Although even then male-to-female themselves in court. I feared the police
(MTF) transsexuals were expected to live more than I hated my assailant. They might
publicly as women for “several years” consider my attacker’s actions reasonable.
before they had gender reassignment sur- With my history, I didn’t dare take the
gery, Brevard’s surgeon waived that risk.” In the last chapter of her book she
requirement because she had been per- summarizes, “My need for love and
forming professionally as a drag queen. acceptance, when coupled with an over-
But in San Francisco in the 60s, drag whelming lack of self-esteem, made me a
queens were forbidden by law from willing victim.”
appearing on the streets in female clothing. Twice she had to prove her “womanly
“Ultimately,” Brevard said, “his decision worth” by submitting to a genital exami-
to waive my daily, comprehensive experi- nation: once by police when a person who
ence as a woman made my transition much had tried to rape her reported her to police,
more difficult.” Brevard had grown up and once when an employer was tipped off
totally entranced by glamorous Hollywood that she was “really a man.”
movies, and it was Hollywood’s vision of In her autobiography, The Woman I
femininity that formed her view of wom- Was Not Born to Be: A Transsexual
anhood. She said, “‘Passing’ for female Journey, she said: “At the time of my
was not my dilemma. Ensuring a com- surgery, the prevailing professional and
fortable passage into the real world of personal advice for a transsexual was for
women could only come with exposure to her to totally turn her back on the past. As
their daily experiences.” The world of most in a witness-protection program, to create a
genetic women is made up of the little new life, everything and everyone you’d
things, not the glamour. While my daytime known must cease to exist.” She writes,
‘real girl’ sisters toiled for unequal pay, “‘Do you have children, Aleshia?’ was an
rocked society’s cradle, and struggled for invariable first-date question. I didn’t
complete emancipation, I waited impa- always meet it head on. The minute my
tiently for twilight hours when I could pose boyfriend asked about children, I pulled
and preen.” out a tear-stained portrait of my mythical
As with many other women of her time, late son, Jason. I carried a picture of a
Brevard’s primary goal was to snag a man beautiful four-year-old boy in my wallet.
to put a ring on her finger. She dated many ‘Jason’ was my protection. I shared the lie
men and won the brass (or gold) ring 3 of his drowning so often that I started to
times. At least two of those times, she wonder if it wasn’t true.”
never told her husband of her transsexual
history.
Keeping stealth didn’t protect her from One of the first U.S. professionals openly
violence; many husbands and boyfriends linked with trans people was endocrinologist
as well as strangers were abusive. After Harry Benjamin, who had begun treating what
one attempted rape she wrote, “I did not we would now call transgender patients in the
file charges. I had not been sexually 1920s and 1930s (Meyerowitz 2002). He con-
assaulted, and should I accuse my attacker, sulted with Dr. Alfred Kinsey on several patients
14 Understanding Transgender Elders 289
and met and befriended Christine Jorgensen at a Not every development could be considered
dinner party in 1953. Although Benjamin had progress. In 1980, the American Psychiatric
published papers and spoken to professional Association (APA) took its first official notice of
audiences for years, the publishing of his 1966 trans people with the new mental health diagnosis
book, The Transsexual Phenomenon, is viewed of Gender Identity Disorder (GID) (APA 1980).
as seminal. The year 1966 also saw the estab- Despite the removal of homosexuality from the
lishment of John Hopkins Hospital’s Diagnostic and Statistical Manual (DSM) in
sex-reassignment surgery program. Other, usu- 1973, being transgender remains a mental illness,
ally university-based, sex reassignment clinics although the name of the diagnosis was softened
soon followed. These clinics often had onerous in 2013 to Gender Dysphoria (APA, 2013). Trans
requirements for their applicants. For one thing, social and advocacy groups began organizing in
all those seeking to move from MTF were the late 1960s and early 1970s, but the ‘70s was
required to be attracted to men and FTM had to also when many feminist groups split over whe-
profess attraction to women, as the surgery was ther transwomen should be treated like other
in part viewed as a cure to homosexuality. women (Meyerowitz 2002; Stryker 2008).
Applicants were also expected to have similar
life histories, which led to trans people counsel-
Case Study 2: Lou Sullivan
ing each other on “what to say.” Interestingly, the
In the 1980s, Louis Sullivan illustrated the
professionals drew a different conclusion about
possible interrelationships among figuring
what was happening: one wrote, “These patients
out one’s own identity, matching that with
are simply awful liars. They lie when there is no
and against the surrounding institutions,
need for it whatsoever.” (Meyerowitz 2002,
and leading social change. Lou originally
p. 164). Even with coaching from other trans
thought he was a “female transvestite.”
people, most applicants “failed”: of the more
Later he heard about a female-to-male
than 2000 people who applied to John Hopkins’
(FTM) transsexual, and began to believe
clinic in its first two and a half years, only 24 got
he, too, could be a man. The sex change
the surgery they sought. (Meyerowitz 2002).
clinic at Stanford University disagreed;
Another major milestone occurred in 1979
Lou was attracted to men and, while les-
when the first professional organization devoted
bian transwomen had by then been repor-
to the subject emerged: the Harry Benjamin
ted on, the professionals were not yet ready
International Gender Dysphoria Association
to “create” a gay transman. Lou increased
(Meyerowitz 2002). One of its first acts was
his efforts to find and help other FTMs, in
issuance of “Standards of Care” (SOC), which it
the process publishing “Information for the
recommended that all professionals follow. (In
FTM Crossdresser and Transsexual,” the
2007, the organization changed its name to the
first FTM-specific resource document, in
World Professional Association for Transgender
1980–1981, and in 1986 founding what
Health, or WPATH.) The SOC included such
became FTM International. He also
protocols as requiring trans people to have had
embarked on what was ultimately a suc-
extensive psychological counseling and a “real
cessful educational and advocacy cam-
life test” of living for a prescribed period of time
paign to convince the powers-that-be that
in their target gender before accessing hormones
gender identity and sexual orientation are
and/or surgery (WPATH 2015). Although many
separate aspects of a person’s identity and
of the requirements followed what the university
should not be the basis of discrimination
clinics had previously mandated, the SOC did
by health care professionals.
permit and encourage independent therapists and
Lou ultimately did secure the surgeries
health care providers to provide care to trans
he wanted. He also contracted AIDS.
people, making it easier for trans people to access
Before his death in 1991, Lou said of
care.
290 L. Cook-Daniels
A Dearth of Research
NOT pick up people who cross-dress
Research on trans elders is sparse. The first (whose gender identity may still match
problem is defining who is under the “trans the sex they were assigned at birth).
umbrella.” Does one include people who identify Recommended measures for the
as the sex they were assigned at birth, but who “two-step” approach:
dress in the “other” gender’s clothing? Are
Assigned sex at birth
“genderqueers” who may present to the world as
“typical” men or women but who have a different
What sex were you assigned at birth, on
internal identity included? Or are we just talking
your original birth certificate?
about people who are living full-time in a gender
Male
not congruent with the sex they were assigned at
Female
birth?
Until very recently, there have been no Current gender identity
nationally representative studies that have inclu-
ded questions around gender identity, and so no How do you describe yourself? (check
way to draw any conclusions about trans people one)
as a whole. Instead, what research exists has been Male
based on “snowball” or convenience sampling, in Female
which trans elders are identified through orga- Transgender
nized trans or LGBT groups and/or by one trans Do not identify as female, male, or
elder connecting researchers to another. These transgender
research methods have many drawbacks in gen-
eral, but the problems are intensified because of
the unique way trans elders connect (or not!) We discussed earlier the generational divide
with other trans people. between current trans elders and today’s gener-
ation of trans youth, many of whom will be able
to grow up without visible physical traces sug-
Policy Box 1 gesting they were born a different sex. Another
Trans people are invisible in most research type of “generational” divide is less tied to age
simply because researchers have not asked than to when a given trans elder “came out” as
about gender identity. When advocates trans. Some who are now in their 70s and 80s
began pushing to change this practice, transitioned in their 20s and 30s and have lived
questions arose about what, exactly, to ask. most of their lives simply viewing themselves
One study of university students found that (and being viewed by others) as “male” or
twice as many trans people were identified “female.” Many others struggled to fit into their
when a two-step question was asked com- assigned roles for decades and “came out” only
pared to one question that gave four when they learned about trans people from the
response options: female, male, transgen- Internet (or, now, from shows like Transparent).
der, other (Tate 2012). This occurs in part Still others “come out” when a major life event
because many trans people identify them- occurs. Mid- or late-life transitions can occur
selves simply as female or male and not as when certain people are no longer in the picture
transgender. due to death, retirement, or an empty nest. They
The Williams Institute convened a panel can also occur when an individual has a heart
of experts who now recommend this attack or cancer diagnosis and realizes that time
two-step question for determining whether for living authentically may be running out.
respondents are trans (Herman 2014). Note Some reach a point of sacrifice fatigue and
that this recommendation would likely decide that they have devoted enough of their life
14 Understanding Transgender Elders 293
to being what other people want them to be. Still connect with such groups do so because they are
others remain comfortable with early compro- more isolated and/or have higher social and
mises, such as making a living as a man but practical needs that they are trying to fill. The
socializing as a woman. Aging and Health Report trans respondents pro-
How involved any given trans elder is with duced data more in line with having experienced
the larger trans community obviously varies from decades of discrimination, violence, and stigma.
person to person. In general, however, many try The third primary source of data on trans
to connect with other trans people in local sup- elders comes from various FORGE studies, in
port groups and/or online in order to “learn the particular ones focused on sexuality, sexual
ropes” and find referrals to trans-friendly pro- violence, and elder abuse (Cook-Daniels and
fessionals such as therapists and doctors. Once Munson 2010). Although these were national,
they have successfully transitioned, however, online studies aimed at all ages of trans people,
many prefer to live their lives as any other man our Transgender Aging Network and ElderTG
or woman would, and so they sever their ties to programs led to much higher than usual elder
the trans community. This is one reason why it is participation. These three sources provide most
so difficult to research trans elders: many are not of what we now know about current generations
connected to any trans group or even to other of trans elders, which we will review next.
trans individuals. Each of these studies recruited anyone who
A vivid example of the results of this defined themselves as “transgender”, and so may
“woodworking” or “going stealth” phenomenon include a wide variety of identities, physical
comes from the groundbreaking 2011 survey of presentations, and histories. FORGE surveys
more than 6400 trans people, Injustice at Every may also include SOFFAs speaking about their
Turn (Grant et al. 2011a). Although its authors— trans loved one’s experience.
the National Center for Transgender Equality and
what was then the National Gay and Lesbian
Task Force—issued additional analyses of mul-
tiple sub-populations, they were reluctant to Trans-specific Health Issues
publish separate findings on trans elders because
that data seemed so “off.” It took careful The first health concern many people think of
cross-walking of the data to understand what had when they think of trans people is, “what are the
happened: barely 2 % of the Injustice at Every health effects of long-term hormone use?” Most
Turn respondents age 55+ had been living in of the long-term prescription medications that
their current gender for more than 10 years. In Americans take—including anti-depressants,
other words, virtually all of them were mid- or statins, beta-blockers, and pain-killers as well as
late-life transitioners (Grant et al. 2011b). hormones—have not been around long enough to
Because nearly 80 % of them were also MTFs, show what happens when taking them for
that means that most had likely had successful 30 years. However, a 2014 Medscape article,
careers as men and faced anti-trans discrimina- “Largest Study to Date: Transgender Hormone
tion only late in life. They therefore had higher Treatment Safe,” reported that very few side
incomes, higher educational levels, higher home effects were found among 2000 trans people who
ownership rates, better health, and fewer dis- had taken hormones for an average of 5.6 years
crimination experiences than their younger trans for the MTFs and 4.5 years for the FTMs
peers. (Louden 2014). The most common serious side
In contrast, the Aging and Health Report, effect was venous thromboembolism, which
which also published its first wave of data in affected approximately 1 % of those taking
2011, recruited trans elders primarily through estrogen, causing blood clots that can be serious
local LGBT aging groups (Fredriksen-Goldsen or even fatal. Not all trans people take hormones,
et al.). We can imagine that trans elders who and dosages vary based on the prescribing
294 L. Cook-Daniels
told FORGE Transgender Aging Network: “One and so this process can be costly in both time and
Navy doctor refused me care when a suture site money. When trans people do not change all of
related to my sex reassignment surgery became those documents, they run the risk of everything
infected” (Cook-Daniels and Munson 2010, from intrusive questions to outright violence
p. 156). Another said, “I have decided not to when their normal course of business requires
have any life-extending surgery because of past them to produce a document such as a driver’s
mistreatment by nurses at [the Veterans Admin- license or health insurance card.
istration hospital]” (Cook-Daniels and Munson How big of a problem is this? The Injustice at
2010, p. 153). Every Turn study found that more than 50 % of
One of the most important differences their older respondents had either not tried to
between being lesbian, gay, or bisexual and update the name and/or gender marker on their
being transgender is that transgender is a status driver’s license or state identification card or had
that often can be obtained only through interac- been denied the requested changes (Grant et al.
tion with and even cooperation from profes- 2011b). More than 60 % had not updated (or
sionals. Medical professionals are required to were denied the right to update) their Social
prescribe medications or conduct surgery (unless Security records. Indeed, only 21 % of those
a person accesses “black market” drugs or sili- aged 55–64 and 28 % of those aged 65+ said that
cone injections, for example, with their attendant “all” of their identification had been changed.
health and legal risks). However, many medical That means nearly 80 % of transgender elders are
professionals will not provide gender-related at risk of being involuntarily outed, depending on
services to transgender individuals unless those which forms of identification are demanded by a
individuals have met what is now called the service provider, police officer, or even a retail
World Professional Association for Transgender clerk (Grant et al. 2011b).
Health (WPATH)’s Standards of Care require-
ments, which many trans people view as “hoop
Field-Based Experiential Assignment
jumping” (Susan’s Place 2011). Although more
Box 2
recently many professionals have moved to an
The next time you have to fill out a per-
“informed consent” model that eliminates many
sonal information form for a health care
of the previous “gatekeepers,” some trans elders
professional or agency, examine it care-
remain wary of physical and mental health care
fully. Where would a trans person share the
providers in general (FORGE 2011).
information they are trans? Is there a
checkbox or question that the trans person
can just check or answer? Or would a trans
person have to “bring the topic up” by
Identification Documents
making a note somewhere? If they do need
to write a note, under what section could it
Another way trans people differ from their
go? Does the name of that section suggest
non-trans LGB peers is in their reliance on other
stigma? Now look around the room and/or
types of professionals and bureaucrats to help
examine the way the professional or
them change identification documents. These
agency describes themselves in brochures
changes may require going to court, producing
or websites: do they give any indication
letters from health care and/or mental health care
they know trans people exist? What evi-
professionals, paying fees, and tracking down
dence might a trans client see that would
historical documents. In a (thankfully lessening)
suggest whether or not this professional or
number of cases, trans people must prove they
agency is likely to be trans-friendly? If you
have had surgery on their genitals before their
were trans, would you declare your identity
documents can be reissued. Most people have
or history on this form? If not, why not?
multiple documents that identify who they are,
296 L. Cook-Daniels
Although many trans survivors worry that 1. Awareness—In the first stage, gender-variant
therapists and others will (erroneously) think people are often in great distress. The thera-
they are trans because they were sexually peutic task is the normalization of the expe-
assaulted, there are survivors who feel the two riences involved in emerging transgendered.
are connected: 2. Seeking information/reaching out—In the
second stage, gender-variant people seek to
I understand that my gender dysphoria arises from gain education and support about transgend-
the childhood abuse. I had researched this area
fairly carefully, and if useful, I have literature erism. The therapeutic task is to facilitate
suggesting abuse as a possible cause of gender linkages and encourage outreach.
dysphoria (Cook-Daniels and Munson 2010, 3. Disclosure to significant others—The third
p. 151). stage involves the disclosure of
298 L. Cook-Daniels
dress, are you supposed to open the door for him they will still have to cope with one of the central
when the two of you are out in public? If a store questions the trans person has likely been grap-
clerk mistakenly calls your older companion pling with for years or even decades: is it ok for
“he” when she’s really a “she,” does not cor- the world to see me differently than I know
recting the clerk mean you are disrespecting your myself to be?
companion, or protecting both of you? How are
you supposed to tell your favorite stories if the
Discussion Box 2
person you are talking about is no longer the
Although “LGBT” is a common acronym,
gender they were then?
in practice many people think about this
population only in terms of people with
Field-Based Experiential Assignment same-sex attractions. In addition, many
Box 3 “LGBT” organizations and events are—
Tell someone about a recent experience unconsciously or deliberately—built
you had with another person, but avoid all around an oppositional model: what makes
mention of your companion’s gender. That them LGBT is that heterosexuals are not
will likely mean avoiding their name, present. Many trans people, however, are
gendered pronouns, and gender-related partnered with people who appear to be the
relationship words like wife, grandfather, “opposite” sex, and some partners still
and daughter. identify as heterosexual even if their part-
How easy or hard was it to do? If it was ner has transitioned and they now appear to
relatively easy, what do you think made it be a same-sex couple.
easier for you?
Ask someone who is much older than • What are the ways in which individuals
you to do the same exercise. How easy or or an organization may (perhaps uncon-
hard was it for them? sciously) send a message that they do not
welcome heterosexuals?
• If a group is used to thinking of hetero-
For partners, the challenge is much greater. sexual people as “the others,” what
Everyone assumes everyone else’s sexual orien- might need to happen to make that group
tation based on with whom they partner. (This is safe and welcoming for heterosexual
one of the reasons bisexuals are so “invisible”: trans elders and their partners?
unless they are known to have both a female • What language would you use in pub-
partner and a male partner, most observers “for- licity materials to ensure heterosexual
get” they are bisexual and therefore label them trans elders and their partners know they
according to whether their current partner is are welcome?
same- or “opposite”-sex.) A spouse’s or partner’s • What might need to happen to ensure
transition from one gender to another may help other LGBT participants do not dis-
the world recognize their gender identity, but it criminate against or accidentally offend
will obscure their partner’s sexual orientation. heterosexual-identified participants?
Thus, a long-term lesbian may lose her commu-
nity and be treated as heterosexual when her
partner transitions female-to-male, and the wife Depending on their predilections, the signifi-
of a MTF may find herself being treated like a cant others, friends, family, and allies (SOFFAs)
lesbian when she’s out with her spouse. of a transitioning trans person may also struggle
Although the ongoing reduction of anti-LGBT with much deeper questions. If they believed
discrimination, stigma, and stereotyping will what society has said—that sex and gender are
continue to make transition easier for partners, the same thing, binary, and unchangeable—they
300 L. Cook-Daniels
may wonder if other things they believe are My ex would get drunk and demand sex, starting
actually false. Facing new evidence that people with our ‘wedding night.’ She required me to do
stuff outside, in the pool, on the deck, and some-
can change something as seemingly permanent times in the kitchen with the children or grand-
as their sex or gender, they may wonder if what children out and about in the next room…. My ex
they have personally accepted as permanent is, in liked to try to rip my penis off or cut it off with her
fact, changeable. Their minds may play “what if” nails, and verbally abused me while we had sex
(FORGE 2004).
games with them: Did they do anything that
might have caused their loved one to be trans? A service provider reported what happened to
Could they have changed the outcome? More one trans elder she was working with: “I am
personally, what would their life be like now if currently working with a trans victim who was
they had not abandoned their dream because of assaulted and threatened at the church she has
their parents’ opposition? (Boenke 2003). belonged to for more than 35 years. She was told,
Unfortunately, many trans people and pro- ‘I will beat you like the man you are,’ and as the
fessionals believe that what SOFFAs need to do perpetrator was saying this, he was hitting her
is “understand what being trans is.” All too often and telling her to leave the church”
people respond to SOFFAs’ concerns with (Cook-Daniels and Munson 2010, p. 155).
explanations and books instead of listening to Whether it is easier or harder for SOFFAs to
them and partnering with them as they work cope when a trans person transitions at mid-life or
through the various issues. Some SOFFAs do not later is still to be determined. The Injustice at
get that far: facing just the first layer of adjust- Every Turn study does give us some preliminary
ments, they make a cut-and-run decision. This data, however. For example, 56–59 % of the older
seems particularly likely to happen when there respondents had lost their partnership because of
are young grandchildren involved: the adult child their transgender identity, compared to 45 % of
may say they do not want the grandchild the whole sample. The older group was slightly
“exposed” to the trans person, and so cut all less likely to agree that their family was as “strong
family ties. One trans elder told FORGE Trans- today as before I came out,” but slightly more
gender Aging Network: likely to say their family relationships are
improving over time. They were also slightly less
My son and daughter-in-law will not let me see my
grandson. They think I will do something to him. likely to have their relationship with their children
I don’t even know him now. It breaks my heart not blocked by their ex-partner, although that hap-
to see him (Cook-Daniels and Munson 2010, pened to 22 % of those ages 55–64 and 27 % of
p. 156). those 65+ (compared to 29 % of the full sample).
Ironically, young children are likely to be Their children, however, were far more likely to
unfazed by a gender change. Although children choose not to speak to or spend time with them:
learn the difference between males and females 40–41 % of the older cohort said they had expe-
early on, it is only in later childhood that people rienced this, as compared to 30 % of the whole
learn that people are not supposed to change sample (Grant et al. 2011b).
from one to the other. As long as the grandparent Older trans people also reported a great deal
(or other older person) still loves and plays with of friend loss, with 64 % of those age 55–64 and
them, most young children adapt to a gender 60 % of those 65+ (compared to 58 % of the
change quickly and easily (Haines et al. 2014). overall sample) reporting in the Injustice at Every
Some SOFFAs even fight back against their Turn study that they had lost close friends due to
trans loved one—literally. The wife of one trans their trans status or history (Grant et al. 2011b).
elder used to throw the windows open and yell to One trans elder told FORGE, “My closest friend
the neighbors about the “titted freak” she lived of over 30 years finally said, ‘I just can’t handle
with. Another elder reported that her wife had this [trans stuff].’ No contact in years”
always been abusive: (Cook-Daniels and Munson, p. 156).
14 Understanding Transgender Elders 301
In some cases, SOFFAs do not know they medical condition. Does your root canal affect
have a trans person in their life. This usually your sexuality and identity? (Cook-Daniels and
Munson 2010, pp. 160–161, 169).
happens because a trans person has taken no
steps to change their gender presentation and has Partners of older trans adults also commented
not told anyone their actual gender identity. In on how their sexuality had changed:
rare cases, post-transition elders have succeeded
I had no idea how much change there would be for
in keeping their trans history a secret even from me (non-trans) and how difficult it would be to find
children and partners. In one such case, hospital what works for us [sexually] over the long term.
personnel successfully treated a woman for I was femme and queer identified before I began
prostate cancer without her husband ever learn- to seriously date transmen, but my experience
dating FTM(s) has created new particularities of
ing the specific type of cancer she had (Hop- my desire and identification (Cook-Daniels and
wood, personal communication 2012). Munson 2010, p. 161).
who did have no-touch zones noted they had testosterone are thought to be more fragile and
them for gender related as well as trauma related susceptible to tears, increasing risk (Kenagy
reasons: 2002). Of additional concern is the fact that most
safer sex materials focus only on condom use,
Vaginal penetration is painful and not something a
man wants done to him. which does not adequately address the body
It is off limits to play with trans-person’s boobs parts, sexuality, or psychology of trans people.
because he does not enjoy admitting that he has FORGE found that 33 % of the older trans
them (Cook-Daniels and Munson 2010, p. 162). adults it surveyed were practicing safer sex, 25 %
Many people renamed their “gendered” body were celibate or not in a relationship, and 19 %
parts. Created names included bonus hole, were “fluid bonded.” Another 13 % “sometimes”
chesticles, and trannycock. practiced safer sex, and 10 % “never” did
One dilemma trans people face when dating— (Cook-Daniels and Munson 2010). Some
particularly if they have not had genital recon- respondents appeared unclear on what safer sex
struction surgery—is if, when, and how to dis- is: “I’m sterile and my spouse also is”
close their trans status. Four percent (4 %) of (Cook-Daniels and Munson 2010, p. 165). Some
survey respondents never told their sexual part- noted that their gender role beliefs precluded
ners they were trans. One transmasculine person safer sex: “Mostly I do what my partner wants
said, “I have casual sex with men at an adult (he is the man, I am the woman).” “I am a sex
bookstore once in a while and don’t reveal I’m slave to my male partners, doing whatever they
trans and for the most part hide that I have a want to please them” (Cook-Daniels and Munson
female body.” Another 3 % told only when they 2010, p. 164).
were in bed: one person said she told, “When he One gave more detail:
asks, ‘What’s THAT?’” (Cook-Daniels and I only negotiate for BDSM play in the beginning to
Munson 2010, p. 166). Most—41 %—said they find someone who will allow me to serve and
discussed it “only at the point when we might submit myself to them. I negotiate safer sex
become sexually involved.” Twenty percent opposite maybe what I should but actually I want a
man to cum in me and not use condoms as I feel a
(20 %) told on the first date, and 32 % wouldn’t great need and desire for the seed of a man I guess
set up a date until they had come out to the much like a woman desiring to get pregnant.
person. Disclosure did cause the potential partner Once I have a partner I do whatever pleases Him
to back out a third of the time, but 40 % of the (Cook-Daniels and Munson 2010, p. 164).
time disclosure did not change the interaction Some trans older adults’ sexuality was affec-
and in 27 % of the cases, it actually increased the ted by their religious beliefs:
person’s interest or attraction (Cook-Daniels and
Munson 2010, p. 167). I am a born again Christian. God gives me the
power not to do anything that causes me to act as a
A particular concern for trans older adults is transgendered person. My faith is on Jesus Christ.
HIV and other sexually transmitted infections. All sexual activities are off limits. Prior to
Even now HIV-related safer sex materials have transitioning I believed I was a heterosexual male.
largely been marketed to gay men, leaving many Now I am a lesbian and I am having conflicts with
my walk with Christ and homosexuality
heterosexuals and those in the lesbian commu- (Cook-Daniels and Munson 2010, p. 163).
nity feeling like they do not need to be concerned
with safer sex issues. That means that because
even coupled mid- or late-life transitioners may
want to “try out” their new bodies or appearances In the Public World
with new sexual partners, they may enter the
dating pool with little awareness of how to Although public perceptions about trans people
manage risks. Ironically, both surgically con- are changing rapidly—Time magazine put trans
structed vaginas and vaginas exposed to actress Laverne Cox on its cover in 2014 with the
14 Understanding Transgender Elders 303
adults were veterans, 41 % of the trans elders at Every Turn study reported having become
were (Fredriksen-Goldsen et al. 2011). The homeless as a result of their trans identity or
Veterans Administration has responded to the history, with 10 % of those age 55–64 having
large number of trans vets by issuing two experienced that, and 8 % of those 65+ (Grant
national directives on how they should be cared et al. 2011b). In 2012 the U.S. Department of
for (see policy resources box). Housing and Urban Development (HUD) issued
Employment discrimination against transgen- final rules specifying that any federally-funded or
der people has been widespread, leading to federally-insured housing could no longer dis-
overall low incomes. Injustice at Every Turn criminate against anyone on the basis of gender
found that 27 % of trans respondents had annual identity or sexual orientation (see policy resour-
incomes below $20,000 (Grant et al. 2011a). ces box).
Because of discrimination, many trans people are The HUD rule covers many congregate living
forced into sex work or other forms of the facilities for elders, but a remaining area of need
underground economy. This issue affects older is around long-term care. At press time the most
trans people as well as younger ones. One older that had been done for trans residents of nursing
adult told FORGE: homes and other long-term care facilities was the
Administration on Community Living’s 2014
I prostitute myself at age 55 because even though
I’m a [post-operative transsexual] and passable [as issuance of an online training tool for personnel
a woman], no one passes 100 % of the time. of such facilities on how to appropriately and
NO ONE. Job discrimination is bad because you’re respectfully treat LGBT residents (see policy
stuck with fellow employees 8 hours a day, resources box). Further guidance on behalf of
40 hours a week. That much harassment is bad for
one’s mental health (Cook-Daniels and Munson trans residents of long-term care facilities is still
2010, p. 159). needed, although the federally-funded National
Resource Center on LGBT Aging has issued
Low-income workers (especially if they have some useful documents, such as “I Have a New
been working outside the Social Security system) Trans Client…Now What?” (see policy resources
obviously have lower retirement incomes, as well, box A).
which suggests financial precariousness for many One last recent policy improvement deserves
trans elders. However, the Injustice at Every Turn mention here. In 2013, Congress passed the
study also demonstrated that when in life a person Violence Against Women Reauthorization Act
transitions has a lot to do with income. Only 2 % (VAWA) with a non-discrimination provision
of people age 55 + in that study had transitioned that, for the first time in any federal program,
more than 10 years earlier, so overall incomes explicitly protected beneficiaries from being
were relatively high: half made $50,000 a year or discriminated against on the basis of both gender
above (Grant et al. 2011b). identity and sexual orientation. Since trans peo-
Employment discrimination against trans ple experience such high rates of sexual assault
people is being actively addressed at the federal and domestic violence (the Act also provides
and many state levels. In 2012 the Department of services for victims of stalking and dating vio-
Justice issued a memo officially declaring that lence), this protection may well affect many trans
employment discrimination against trans workers elders (see policy resources box).
is illegal under Title VII’s ban on sex discrimi-
nation (see policy resources box). The Obama
Administration has issued multiple Executive
Orders and other guidance protecting trans peo- Summary
ple who are federal workers or who work for
federal contractors (see policy resources box). Deep down, every elder—indeed, every human
Housing discrimination is also a problem. —wishes for the same thing: see me for who I am
Even the mid- to late-transitioners in the Injustice and love me for who I am. That wish cannot be
14 Understanding Transgender Elders 305
fulfilled by people who bring stereotypes of any 4. Which of the following is NOT a reason
kind to the table, as those stereotypes will many trans people transition in mid- to
obscure who is really sitting before them. That late-life?
insight may be especially true of trans elders, (a) A health scare makes them realize they
who by definition spent at least part of their lives have limited time left
struggling to make the world see something very (b) They lose their youthful attractiveness
basic about them that was NOT being seen: their and decide it would be better to be the
gender identity. Our task as service providers, other sex
caregivers, and advocates is two-fold: 1) to (c) Family members die or move out
counter stereotypes and prejudices wherever we (d) They retire
find them, particularly when they fuel the denial (e) They experience sacrifice fatigue
of rights and/or respect; and 2) to bring to each 5. To “transition” and live as another gender a
trans elder we work with a clean slate so that transgender person MUST:
together, we can write and affirm their unique (a) Use hormones
journey. (b) Have surgery
(c) Change their identification papers
(d) All of the above
(e) None of the above
Learning Exercises 6. Trans people have the following sexual
orientations:
Multiple Choice Questions (a) Lesbian/gay
(b) Bisexual or pansexual
1. What is the Terms Paradox? (c) Transgender
(a) It is critical to know the definitions of all (d) Heterosexual
trans-related terms. (e) All of the above
(b) It is critical to use the same terms the (f) (a), (b), and (d)
trans elder you are working with uses. 7. Which of the following is used as an alter-
(c) Trans-related terms tell you nothing native to the WPATH Standards of Care?
about someone’s experiences or (a) Informed consent model
expectations. (b) The American Psychiatric Association’s
(d) Answers (b) and (c). Diagnostic and Statistical Manual
2. Why is Christine Jorgensen important to (DSM)
many trans elders? (c) Christine Jorgensen’s biography
(a) The publicity around her was when they (d) All of the above
first realized changing your sex was (e) None of the above
possible. 8. Which of the following have been proven to
(b) She was an early organizer of trans be side effects of long-term hormone use?
support groups. (a) Hot flashes
(c) She was the surgeon many trans elders (b) Heart disease
went to for genital reconstruction surgery. (c) Dementia
3. Which of the following might affect what (d) All of the above
words trans elders use to label themselves? (e) None of the above
(a) Their age 9. A person who was assigned female at birth
(b) The years in which they transitioned has a male gender identity and lives as a
(c) Their beliefs about whether they deserve man. Which term would he NOT use to
stigmatization describe himself?
(d) All of the above (a) FTM
(e) None of the above (b) Transsexual
306 L. Cook-Daniels
World Professional Association for Transgender Cook-Daniels, L., & Munson, M. (2010). Sexual vio-
Health http://www.wpath.org/ lence, elder abuse, and sexuality of transgender adults
age 60+: Results of three surveys. Journal of GLBT
Transgender American Veterans Association Family Studies. 6(2), 142–177. Available from: http://
http://tavausa.org/ forge-forward.org/wp-content/docs/trans-aging-3-
surveys.pdf.
Document Resources Box C Feinberg, L. (1997). Transgender warriors: Making
history from Joan of Arc to Dennis Rodman. Boston,
MA: Beacon Press.
Hot, Safe Sex for Transmasculine Folks and FORGE. (2004). Responses from “Sexual violence in the
Partners http://forge-forward.org/wp-content/ tansgender community” survey (Unpublished raw
docs/HIV-FTM-web1.pdf data).
FORGE. (2011). Responses from “Transgender peoples’
Hot, Safe Sex for Transfeminine Folks and access to sexual assault services” survey (Unpublished
Partners http://forge-forward.org/wp-content/ raw data).
docs/HIV-MTF-web1.pdf FORGE. (2012). FAQ: The terms paradox. Milwaukee,
Professional organization statements supporting WI: Author. Available at http://forge-forward.org/wp-
content/docs/FAQ-06-2012-terms-paradox.pdf.
transgender health care http://www.lambdalegal. Fredriksen-Goldsen, K. L., Kim, H.-J., Emlet, C. A.,
org/sites/default/files/publications/downloads/fs_ Muraco, A., Erosheva, E. A., Hoy-Ellis, C. P., &
professional-org-statements-supporting-trans- Goldsen, J. (2011). The aging and health report:
health_4.pdf Disparities and resilience among lesbian, gay, bisex-
ual and transgender older adults. Retrieved from:
Building Respect for LGBT Older Adults (online http://caringandaging.org/wordpress/wp-content/
training for long-term care facility staff) http:// uploads/2011/05/Full-Report-FINAL-11-16-11.pdf.
lgbtagingcenter.org/training/buildingRespect.cfm Grant, J. M., Mottet, L. A., Tanis, J., Harrison, J.,
Herman, J. L., & Keisling, M. (2011a). Injustice at
Creating End-of-Life Documents for Trans
every turn: A report of the national transgender
Individuals: An Advocate’s Guide http://www. discrimination survey. Washington, D.C.: The
lgbtagingcenter.org/resources/pdfs/End-of-Life% National Center for Transgender Equality and the
20PlanningArticle.pdf National Gay and Lesbian Task Force.
Grant, J. M., Mottet, L. A., Tanis, J., Harrison, J.,
Improving the Lives of Transgender Older
Herman, J. L., & Keisling, M. (2011b). Responses
Adults: Recommendations for Policy and Prac- from respondents age 55+ (Unpublished raw data).
tice http://www.lgbtagingcenter.org/resources/ Haines, B. A., Ajayi, A. A., & Boyd, H. (2014). Making
pdfs/TransAgingPolicyReportFull.pdf trans parents visible: Intersectionality of trans and
parenting identities. Feminism & Psychology, 24,
I Have a New Transgender Client…Now What?
238–247.
http://www.lgbtagingcenter.org/resources/pdfs/ Herman, J. L. (Ed.). (2014). Best practices for asking
newTransClientFactSheet.pdf questions to identify transgender and other gender
minority respondents on populationbasedsurveys. Los
Angeles, CA: The Williams Institute.
Kenagy, G. (2002). HIV among transgendered people.
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Bisexuality: An Invisible Community
Among LGBT Elders 15
William E. Burleson
Abstract
This chapter discusses issues relevant to bisexual elders, including
invisibility, homophobia and biphobia, lack of understanding, and a
scarcity of research and resources. Bisexual elders face the same issues as
all elders, such as the need for financial planning, health care, assisted
living, estate planning, and more, not to mention isolation, feelings of loss,
depression, and ageism. Bisexual elders also face the additional issues that
lesbian and gay elders must navigate such as invisibility, coming out, and
marginalization and discrimination due to homophobia. In addition,
bisexual elders also face issues that are either amplified—such as a lack of
supportive social networks—or uniquely theirs—such as biphobia and a
lack of bi-specific research, support, and services. As a consequence, it is
critical for people who offer services to elders to avoid judgment and
assumptions.
Keywords
Bisexual Aging Health disparities LGBT Queer theory
resources often result in increased isolation and It is a small world and an even smaller one
marginalization for the seniors in their care. The when you are on stage with other LGBT speak-
result is measured in health disparities and stress ers, and I knew everyone on the panel quite well.
for bisexual elders. We sat on the riser, in simple hard chairs, in front
of a room arranged classroom style. People filed
in. When the room was full and the panel mod-
Learning Objectives erator began to introduce us, I had an over-
whelming feeling of being one part in a “what do
By the end of this chapter, the reader should be these things have in common” test.
able to:
• We were old. Or, no, not really—we were old
• Describe how bisexuals elders’ experience compared to the youthful audience.
differs from straight and gay and lesbian elders, • Then I knew: I was to be the bisexual elder.
• Communicate how health disparities affect • I WAS the history. They wanted to hear from me
bisexuals, firsthand about my experiences in the ancient
• Articulate the different service needs of days of the seventies, eighties, and nineties.
bisexual elders, and
Since that presentation I have come to expect
• Offer possible solutions to the problem of
to play that role, and when presenting on bisex-
isolation and a lack of community support.
uality, I make sure to talk about the good old
days. I have even come to enjoy it.
For me, aging is an interesting social experi-
ment: I have found people treat me with
increasing respect as I grow older. I am also
Introduction
seemingly less threatening to young men and
increasingly invisible to women. I assume this
I found it not really upsetting, but more unset-
trend will only increase, with watersheds like the
tling. Whoa, what just happened? Or, more
first time someone offers me their seat on the bus
accurately, when? I had to laugh, if just a little. It
and the first time someone talks loudly to me.
felt like the day my AARP invite arrived in the
Those moments I will not enjoy.
mail or the first time a clerk offered me a senior
The point is:
discount.
I’ve given many talks about bisexuality, the • I, as well as many of my peers, are getting
bisexual experience, and the bi community at older.
various venues including colleges, bookstores, • LGBT activism is a mature movement, with
community centers, and conferences. It’s a patter the first waves of people coming out in the
I’ve got down so pat that one time, working 1970s now gray, retiring, and needing services,
without notes, I somehow flipped back to an services that may at times differ from the
earlier part of the talk and repeated ten minutes, general population, services that may need to
I’m told, quite verbatim. Not a failing memory— be delivered in ways that are new.
I’m only fifty-five as I write this—more stuck in • The Bi piece of the LBGT puzzle is no dif-
a rut and time for a fresh speech. ferent, with the first groups of 1970s bisexuals
Therefore, when I was invited to participate in going gray, a group who well remember a time
a panel discussion about bi history, I did not before “LGBT” or even “GLBT,” a group
think much about it. The generally hidden, often having no intention of accepting any less than
forgotten, and always interesting cultural history cultural competence among service providers.
of my community is something I am quite
comfortable talking about and lending a little Therefore, it is critical that service providers
context to. become educated on the issues affecting not only
15 Bisexuality: An Invisible Community Among LGBT Elders 311
lesbians and gays, but also bisexuals (Kimmel still have sex with people of the same gender.
et al. 2006). Conversely, many gay men have had or do have
sex with women, and many lesbians have had or
do have sex with men. For example, in a 2000
Challenges to a Complete Definition survey conducted by the Advocate about 75 % of
lesbian respondents reported having had sex in
How bisexuals and bisexuality fits into a dis- the past with at least once with a man, and 6 %
cussion of aging depends on how we choose to said they have had sex with a man in the last year
define bisexuality. One would think defining (Remez 2000). Meanwhile, the Annual Review of
bisexuality to be easy and the purview of the Sex Research in 1997 reported that 62–79 % of
Oxford English Dictionary. In fact, defining gay identified men report a history of “hetero-
bisexuality is fraught with challenges, mired in sexual contact” (Doll et al. 1997).
culture, and in flux in our changing times. We must think of sexual orientation as some-
In Bisexuality, Not Homosexuality: Counsel- thing different—and more culturally significant—
ing Issues and Treatment Approaches Horowitz than behavior. Being straight, lesbian, gay, or
and Newcomb (1999, p. 148) state: “Bisexuality bisexual is about feelings and attractions, not
is difficult to define. Must one engage in sexual confined to actions alone. Indeed, we see
activity with both sexes to assume a bisexual self-identified bisexuals with all varieties of partner
identity? What if a person has sexual or affec- choices. Vernallis (1999, p. 349) reports in the
tional desires for both sexes but does not act on Journal of Social Philosophy, “Some people
them? What if a person is involved in a identify as bisexuals although they have only
monogamous, long-term same-sex relationship experienced sex with one gender, perhaps because
but has had previous satisfactory heterosexual they have sexual desires for and fantasies about
relationships?” both genders.” Bisexuals may or may not have had
Researchers have often looked at behavior as lovers of different genders. They may or may not
the test, and many people see the gender of one’s be monogamous. They may or may not ever have
sexual partners as proof of one’s sexual orienta- had sex in their entire lives. Take, for example, a
tion. If we define “bisexual behavior” as having catholic priest who has been celibate his entire life,
been sexual with women and men or with more yet this person has a sexual orientation, and he
than one gender, then we are talking about the may identify as straight, or bi, or gay.
needs of a huge part of society. For example, That bisexuality is not defined by behavior is
Alfred Kinsey’s studies done in the 1940s and a very important point for bisexuals because
1950s found that 37 % of men had had at least many people believe bisexuals need both a man
one sexual experience with another man at one and a woman as a sexual partner. For example, if
time in their lives (Kinsey et al. 1948). This a self-identified bisexual woman is in a monog-
number is usually considered an overestimate, amous relationship with, say, another woman,
having been taken from a convenience sample in she is now assumed to be lesbian.
not typical circumstances such as in prisons and Therefore, it is ironic that focusing on behavior
with male prostitutes. Accordingly, published in means that the number of people identified as
1994, the National Health and Social Life Survey bisexual is inflated (counting people who have
(NHSLS) found very different results. It utilized been sexual with more than one gender regardless
face-to-face interviews of 3432 people to find of how they feel or identify) while erasing them as
that approximately 9 % of men and 4 % of well (no longer considering a person’s attractions
women had ever had any same-gender sex part- and self-identity, defining them by their partners).
ners (Michael et al. 1994). It should be noted that psychological research
These data are about behavior and not iden- has provided us with many measures for orien-
tity. Just because a person identifies as straight tation, from the Kinsey Scale (Kinsey et al. 1948)
does not mean that they have not had or do not to the Klein Sexual Orientation Grid
312 W.E. Burleson
(Klein 1993) to M. D. Storms in Sexual Orien- than lesbian, and fewer men identifying as
tation and Self-Perception (1978), and all have bisexual than gay (San Francisco Human Right
some descriptive value as well as challenges, Commission, date unknown). For example,
none of which we will discuss here. Instead, the
focus for our purposes will be on self-perception • 2002 National Survey of Family Growth
and self-identification, and less on diagnosis. If reported that among men, 2.3 % identified as
we are to look at the common challenges and gay and 1.8 % as bisexual, while among adult
solutions that bisexuals face in aging, measuring, females, 1.3 % identified as lesbian and 2.8 %
or questioning people’s identity labels is less as bisexual (Mosher et al. 2005).
useful than acknowledging and embracing an • In The Journal of Sexual Medicine (Herbenick
older person’s choice of orientation label and et al. 2010) reports that among adult males
community and looking at the cultural com- 4.2 % identified as gay and 2.6 % as bisexual,
monalities that these monikers connote. while among adult females, 0.9 % identified as
lesbian and 3.6 % as bisexual.
• In 2007, a survey found that among LGBT
Bisexuality Defined identified individuals, 68.4 % of men identified
as gay and 31.6 % as bisexual, while 34.7 % of
For the purposes, of this chapter, we will look to the women identified as lesbian and 65.3 % as
San Francisco Human Right Commission (2011) bisexual (Egan et al. 2008).
LBGT Advisory Committee (date unknown) for a
good working definition: “…bisexual is the term Although we will be using self-identity to
that is most widely understood as describing those discuss bisexuality, it is safe to assume that many
whose attractions fall outside an either/or para- people who otherwise would do not identify as
digm.” In other words, bisexuals are people who are bisexual because of social barriers. It is difficult
neither straight nor gay or lesbian. to estimate the proportion of the population that
Also, we will use the most quoted definition remains “in the closet,” as it is no easy decision
for “bisexual” within the community itself, from to call oneself bisexual. Plus, “being closeted”
Robyn Ochs (taken from http://robynochs.com/ goes both ways: while many bisexuals identify
bisexual/) long time bi activist from Boston: “I publically—and presumably to people doing
call myself bisexual because I acknowledge that I surveys—as straight, many bisexuals may pub-
have in myself the potential to be attracted— lically identify as gay or lesbian (Keppel 2006)
romantically and/or sexually—to people of more for a host of reasons that will be discussed below.
than one sex and/or gender, not necessarily at the Further reducing the number of people poten-
same time, not necessarily in the same way, and tially identifying as bisexual is that many elders
not necessarily to the same degree.” may not even have the word “bisexual” in their
tool kit (Keppel 2006).
• Are bisexuals mentally ill? Bisexuality is not bisexuals previously identified as gay or les-
classified as a mental illness. However, it is bian before identifying as bisexual (Fox 2004).
worth mentioning that bisexuals, like many
out-groups, face stress from discrimination and
isolation and may show increases in health—
including mental health—disparities (Healthy The Intersection of Bisexuality
People 2020 2010). and Transgenderism
• Is being bisexual a choice? This question
assumes that people who identify as bisexual Bisexuality and transgender identities both resist
should “pick a side” or are actually closeted simplification, both cannot be reducible to some
simple formula.—Bedecarre in the journal Hypatia
lesbians and gays. As previously discussed,
(2001)
recognizing bisexuality as not defined by My transsexuality and my bisexuality are inex-
behavior. Acknowledging bisexuality as an tricably linked. Since the transsexuality has been
orientation helps us see being bisexual as not a there since the earliest times I can remember, that
was the beginning of the journey. Realizing I was
choice, just as being gay or straight is not a
bisexual came much, much later.—A guest on the
choice (Hayes 2001). Bi Cities! Show (Burleson 2005)
• Are all bisexuals non-monogamous? Bisex-
uals may or may not be monogamous (Kimmel In most places around the country, there is a
et al. 2006). Many bisexuals are in long-term strong connection between the transgender and
monogamous relationships, many are single the bisexual communities. Indeed, the two com-
and not sexual with anyone, many travel in the munities have been strong allies.
polyamorous community (which we will dis- Why is this? One reason certainly is because
cuss below), and many are fans of the swinger they both have a natural affinity born of living in
community. In other words, bisexuals are just the gray areas. Both are neither one thing nor the
like straights, gays, and lesbians, and knowing other; both confound the people who view the
that someone is bisexual tells us nothing about world in simple either/or dualist manner. Both
the person’s relationship status or whether or communities get it, and they both are more likely
not the person is monogamous. to get it about each other than people who do not
• Are bisexual men all married guys cheating have a personal relationship to this ambiguity.
on their wives? As with the last question, Another reason the two communities work well
there certainly are a number of bisexual men together is that there are a lot of people who are both
who cheat on their wives. But again, many bisexual and transgender. For example, a female to
bisexual men live quiet lives with their male transgender (FTM) who previously only con-
same-gender or different gender partners and sidered men for partners might well re-evaluate that
would not think of cheating. Some bisexual stand now that he is living as a man. For many, the
men are non-monogamous by agreement with challenges and changes involved in coming to terms
their partners, something far different from with being transgender inevitably leads to
“cheating.” re-evaluating much of one’s life, including sexuality.
• Is bisexuality just a phase on the way to Plus, many bisexuals express that they are
being lesbian or gay? Senior service provid- attracted to people as individuals and not
ers, given the age and experience of their cli- according to their genitalia; therefore, some bi’s
ents, will likely work with many LGBT people may embrace gender ambiguity in a way that
who are very firm in self-identity. That said, leaves more room for friendships and relation-
this stereotype knows no age. Though many ships with transgender people.
gays and lesbians at one time considered the One obvious and important reason is the two
possibility that they may be bisexual, this communities have been allies by virtue of their
experience cannot be generalized to all people exclusion from the lesbian and gay communities,
who identify as bisexual. In fact, one-third of and for very similar reasons. The transgender
314 W.E. Burleson
community is a thorn in the side of many lesbian (Dobinson, Healthy People 2020 2010). Bisex-
and gay people who wish to claim, “We are just uals report higher cholesterol than do hetero-
like straight people.” Many gay and lesbian sexuals (New Mexico Department of Health,
people, and bi people, too, carry around their Healthy People 2020 2010), high rates of
share of trans-phobia. Simply because someone smoking (American Lung Association, Healthy
is not straight does not mean they automatically People 2020 2010) (New Mexico Department of
get a masters in human sexuality or that all their Health, Healthy People 2020 2010), and higher
prejudices magically disappear. As bisexuals rates of current asthma than heterosexuals (New
fight to be included in gay and lesbian events and Mexico Department of Health, Healthy People
in the names of organizations, it is natural for the 2020 2010). Bisexual adults report nearly three
bisexual community to support the transgender times the rate of intimate partner violence as
community in their parallel and simultaneous heterosexuals (New Mexico Department of
struggles for recognition and inclusion. Perhaps Health, Healthy People 2020 2010).
it is an alliance of convenience, but I prefer to Bisexual women were less likely to be insured
think of it as an alliance of understanding. or be underinsured and have difficulty obtaining
medical care (Diamant et al., Healthy People
2020 2000). Bisexual women have higher rates
Bisexuality and Health of all types of cancer (Dobinson, Healthy People
2020 ) and higher rates of heart disease than
It is critical that bisexual health issues be heterosexual women. This should be expected,
addressed in the USA and addressed at their root because bisexual women reported higher rates of
causes. According to Bisexual Invisibility: risk factors for both cancer and heart disease,
Impacts and Recommendations from the San such as the previously mentioned higher rates of
Francisco Human Right Commission, LGBT smoking and high cholesterol, plus high blood
Advisory Committee (date unknown), pressure, and higher average BMI (but lower
than for lesbians) (Dobinson, Healthy People
One area where we see the effects of biphobia and
bi-invisibility is in the health and well-being of 2020 2010). Adding to the problem is that
bisexuals, [men who have sex with men and bisexual women have the higher rate of never
women] and [women who have sex with men and having a pap test than lesbians and straight
women]. This is because, as confirmed by the women (Dobinson, Healthy People 2020 2010)
available research, these groups experience greater
health disparities compared to the broader popu- and were less likely than heterosexual women to
lation, and they continue to experience biphobia have had a mammography (Koh, Healthy People
and bi-invisibility from healthcare providers, 2020 2000).
including providers who may be gay or lesbian, or Bisexuals show higher rates of binge drinking
are knowledgeable about homosexuality and
accepting of their gay and lesbian clients. than do their heterosexual counterparts (Healthy
People 2020 2010), bisexual women report the
Bisexuals on average tend to suffer health high rates of alcohol use, heavy drinking, and
disparities due to the continued marginalization alcohol-related problems when compared to
of the community, minority stress, and inade- heterosexual and lesbian women and higher rates
quate culturally competent services. According of drug use than heterosexual women (Dobinson,
to the Healthy People 2020 Bisexual Health Fact Healthy People 2020 2010). According to
Sheet (2010), bisexual women and men have the Healthy People 2020, bisexual adults report
lower emotional well-being than heterosexuals, twice the rate of depression, higher levels of
gays or lesbians. Bisexual women report lower anxiety, and nearly three times the suicidal ide-
levels of social support than heterosexual women ation compared to heterosexual adults. Bisexual
and lower or similar levels to lesbians, and men and women report high levels of self-harm,
bisexual and gay men have lower social support suicide attempts, and thoughts of suicide (Heal-
levels when compared with heterosexual men thy People 2020 2010).
15 Bisexuality: An Invisible Community Among LGBT Elders 315
Although these numbers reflect ongoing health Identity Issues Bisexual Elders May
disparities across age groups, the implications for Face
service providers to seniors are clear: when it
comes to bisexuals and health, it is critical to be Bisexuals face the same barrier as all parts of the
aware and watchful, offer culturally competent LGBT community: homophobia. LGBT people
care, and to studiously avoid the stigma and have long been deterred from embracing their
isolation that many bisexuals experience. sexual orientation because they are under the
What do we know about the bisexual com- threat of social ostracism, employment and other
munity and HIV? Unfortunately, there is little discrimination, and violence. Considering the
research, with bisexuals usually a subset of a legal sanctions and physical and psychological
study of homosexuals. For example, over a abuse that many bisexuals must identify as
decade into the epidemic one researcher (Doll bisexually at all. This situation has improved
et al. 1997) found that, in 166 articles mentioning greatly since Stonewall (the 1969 riot in New
bisexual men over a ten-year time period, only York that for many marks the beginning of the
twenty-one pointed out any differences between LGBT movement), and tolerance has made
bisexual men and gay men, and only eight gave extraordinary gains in much of the USA. How-
information exclusively about bisexual men. In ever, the growing acceptance of gays and lesbi-
the same ten years, the researchers found only ans—and, perhaps, bisexuals as well—should
sixty-one articles mentioning bisexual women, not be assumed to be the experience of older
twenty-two of which compared bisexuals with bisexuals, who may live in communities or
lesbians. Only three concerned bisexual women associate with peers who they fear—rightly or
exclusively. In fact, even today, the prevalence of wrongly—would be less than accepting.
HIV in the bisexual community is unknown.
Even though 76,075 men with AIDS (21 % of
AIDS cases in men who have reported sex with Biphobia
men) through 1996 report a history of “bisexual
behavior,” as previously discussed, this does not However, bisexuals also face their own unique
mean they were bisexual. We know even less brand of discrimination. Commonly referred to
about bisexual women. as “Biphobia,” bisexuals—despite their greater
And yet, according to Bisexual Invisibility: numbers—may be thought of as representing an
Impacts and Recommendations from the San inferior position to lesbians and gays in the
Francisco Human Right Commission, LGBT LGBT community (Kimmel et al. 2006). Straight
Advisory Committee (date unknown), homophobes seldom bother with nuances
between the L, G, B, and T, and many gay and
In the 1980s and 1990s, bisexuals were vocifer-
lesbian people dismiss bisexuals as pretenders,
ously blamed for the spread of HIV (even though
the virus is spread by unprotected sex, not a straight swingers, confused, mentally ill,
bisexual identity). However, a 1994 study of data immoral, disease vectors, traitors, and more.
from San Francisco is also worth noting: it found When seeking bisexual supportive services, gay
that at that time, bisexually identified [men who
or lesbian, even supposedly “LGBT” services,
have sex with men and women] weren’t a common
vector or “bridge” for spreading HIV from male can constitute a “bait and switch,” promising
partners to female partners due to high rates of understanding and delivering its own variety of
using barrier protection and extremely low rates of discrimination.
risky behavior.
This active discrimination is facilitated by the
These data reveal that there are more defining issue facing bisexuals of all ages:
assumptions about the role of bisexuals in the invisibility. Being gay or lesbian offers role
HIV/AIDS epidemic than there are facts, so once models and a narrative that is well-defined,
again, people should be cautious making however, often inaccurate and problematic in its
assumptions about HIV status or risk. own right. Not so for bisexuals. The reason for
316 W.E. Burleson
the invisibility is obvious. Consider this hypo- What do bisexual elders who find community
thetical: Shirley and Ruth have been together for encounter? There is at present a great deal of
thirty years and now live in assisted living. The discussion in the bisexual community regarding
other residents know them as a lesbian couple. the suitability of the term “bisexual,” especially
Yet, is that accurate? One or both could be bi. among younger people and at colleges. Indeed,
Some fellow residents might know them well in a recent needs assessment I authored (Burle-
enough to know their orientation accurately, or son 2013) on behalf of a Minnesota bisexual
they could metaphorically or literally, fly a big advocacy group, the Bisexual Organizing Pro-
flag saying, “We’re Bi.” Short of these two sit- ject, I identified an uneasy relationship in the
uations, a large majority of people would identify bisexual community between those embracing
them as lesbian. Most people make assumptions “bisexual” and a growing number of people who
about other people’s orientation according to the reject the bisexual identity in favor of “fluid,”
gender of their partner, an easy and it’s practical “pansexual,” “omni-sexual,” “queer,” and other
assumption because it is often correct. Some- new labels. Many people self-identifying as one
times, however, as previously discussed, it is of these new labels expressed how they see
inaccurate; a situation that makes bisexuals “bisexual” as implying there to be only two
invisible (Burleson 2005). genders and thus not recognizing the spectrum of
As a result, many bisexuals feel isolated and gender identity. On the other hand, some reject
may think there is nothing for them or even that these new labels as faddish or hurtful in them-
they are alone. Most bisexuals have little selves: with non-bisexuals once again defining
knowledge of services available to them (should what it means to be bisexual. For the elder hav-
they be so lucky as to have services available to ing grown up at a time when bisexuality was not
them), instead encountering and perhaps even discussed or was discussed and deeply stigma-
internalizing the previously discussed plethora of tized, embracing “bisexual” often took taken
myths and stereotypes. This is true for bisexuals great courage (Keppel 2006), and rejection of the
of all ages, but may be especially true for elders. identity as somehow flawed may be under-
Elder bisexuals may know no one else who is standably unwelcome and painful.
bisexual (or, more likely, know who around them A good example of how generational differ-
IS bisexual). They may not even have the words ences color identity labels is the term “Queer.”
to describe their feelings. Also, while younger Queer as an insult from the past remains hurtful
bisexuals may be coming out and finding support to many, especially those who are older and may
in colleges and in various organizations, current have grown up with the term as only a pejorative
elders grew up in a time that did not allow space one. Meanwhile, for nearly two decades now the
for bisexuals (Keppel 2006). word has enjoyed varying degrees of success as a
Thus bi-invisibility has significant repercus- reclaimed disparagement that is now embracing
sions for locating a supportive community. of all parts of the LGBT family. Many bisexuals
According to Kimmel et al. (2006, p. 45), embraced this term for its inclusiveness and
“Community support is important for everyone perhaps the term that many bisexuals have long
no matter what their sexual identity is.” The vast sought, uniting the LGBT community under one
majority of bisexuals in the USA cannot find a label. However, queer also has the additional
community gathering of any kind anywhere connotation of “Otherness,” of embracing queer
within a reasonable distance. Similarly, bisexual people’s separation from the norm (Burleson
invisibility is an added challenge in locating 2005), a separation that many LGBT people may
services, whether its supportive healthcare pro- not feel, and a separation that many elders may
fessionals or counseling services, both because not embrace as they search for their identity in a
they may not exist because of a lack of under- world offering them so little guidance.
standing the need in provider communities and A proliferation of new identity labels only
difficulty accessing services that do exist. adds to the burden of “coming out” for people
15 Bisexuality: An Invisible Community Among LGBT Elders 317
who are barely embracing or even understanding previously, this is an exciting time in LBGT
their own feelings of multiple attractions, espe- history. In many places, the bi community of
cially a person whose life journey may have been conferences and tents at Pride Festivals repre-
a long. It is hard to guess how this issue will sents a dynamic culture of younger bisexuals on
settle out—fad or sea change—but it would seem the cutting edge of redefining what bisexuality
that this issue will likely continue to challenge, means, if and where the bisexual community fits
and perhaps even redefine, bi activism into the into a GBT narrative, and even if “bisexual” as a
future. term is to be embraced or discarded. This may
not be the discussion for which older bisexuals
are seeking.
Aging as Bisexual For all parts of the LGBT community support
services are critical, but bisexual elders may face
In their search for a supportive community, additional challenges when accessing those.
bisexual elders can be seen as whipsawed by two Should they be in the process of coming out to
competing forces. First, they may suffer the same family and friends, bisexual elders face the same
lack of community that most bisexuals experi- challenges that older lesbians and gays face,
ence, plus more. Finding community has been including the reactions of adult children and even
greatly facilitated by the Internet, either a face to spouses. Service providers to people who are
face community or a virtual one. Not long ago, if elderly may be called upon to help a family deal
there was a bisexual meeting, support group, or with a coming out crisis (Kimmel et al. 2006).
social event, one might call a social service However, the service provider should not assume
hotline for referrals (if one was savvy enough to that people coming out bisexual to their partners
locate the number), count on word of mouth, or want to end their relationships. The person may
hope to be lucky enough to spot a flyer some- be more hoping to live an authentic life with
where. The Internet has changed that, and now those they love.
for anyone—including elders—who are online, if The above was a common situation I found
there is a gathering within a reasonable distance, when I facilitated a group for married men as part
it is as easy to locate as a good sushi restaurant. of an HIV prevention program. The men who
And for those who live in a place where there are attended were often older and many were retired,
no opportunities for physical meetings, one can with nearly all identifying as bisexual, many in
always find a virtual community online. How- the closet, as well as many having been out for
ever, not all have benefited equally. In 2012, decades. The isolation from mainstream LGBT
while 97 % of 18- to 29-year-olds used the organizations and services (other than our little
Internet, only 57 % of those sixty-five and older circle) was nearly universal, and in this group,
did (Zickuhr and Madden 2012). Therefore, the men finally found their community. What
many elders are left behind. may surprise some is that, generally, these men
Second, should they find a “bricks and mor- were not looking to end their marriages, and
tar” local community of regularly scheduled instead often talked of their love and physical
meetings, social nights, and perhaps even an attraction to their wives.
organization of some sort, older bisexual people LGBT elders may or may not be “out” to a
may not feel included by virtue of their age. As therapist or service provider, and bisexual elders
one of our case studies suggests, older adult even less than gays or lesbians (Keppel 2006).
bisexual people may feel that activities are Bisexual elders may want to access heterosexual
designed for young people, or, at least, domi- support rather than LGBT services (Kimmel
nated by a younger generation. et al. 2006) for many reasons. Bisexuals who
In fact, should they locate a community— have been out for many years may or may not be
virtual or in person—it may not be the commu- connected to community or services and may or
nity they were looking for. As discussed may not want to be. They may be single or have
318 W.E. Burleson
a partner/spouse of many years. They may be STDs for bisexuals of all genders (Kimmel et al.
monogamous or not. If not monogamous, they 2006). Service providers should allow for alter-
may be public about it, keep it private between native relationship models, including polyamo-
their families or partners, or they may be secre- rous relationships, both in their support and in
tive. If not monogamous, they may have a pri- accommodations, if they are to effectively serve
mary relationship and occasional more casual bisexuals (and polyamorous people of all orien-
relationships or they may have long-term rela- tations). Lastly, it is important not to assume the
tionships with more than one person (Kimmel nature of someone’s self-identity. Bisexuals are
et al. 2006). rendered invisible by a culture that says they are
However, this latter group deserves further all straight, gay, or lesbian. Assuming people’s
discussion. In the USA, there is a thriving sub- orientation from their appearance, habits or
culture called the polyamorous community. relationships are a sure route to poor services.
“Polyamorous,” or “many loves,” is defined by Becoming more knowledgeable about
the Polyamory Society (2012) as “The resources available in the community (e.g., sup-
non-possessive, honest, responsible and ethical port groups, bisexual friendly churches, com-
philosophy and practice of loving multiple peo- munity organizations, and social events) is
ple simultaneously” (Author unknown, www. critical to offering needed services as well as
polyamorysociety.org). The polyamorous com- demonstrating one’s competence (Keppel 2006).
munity parallels the bisexual community in For example, in the group of married men’s
organization, with clubs, non-profits, groups, and mentioned earlier, one man in his seventies (who
conferences in many major cities. Though people had been out to for decades) lost his wife. This
of all orientations may identify as polyamorous, man benefited greatly from support and under-
most would agree that bisexuals are over repre- standing from the other men in the group who
sented. As one member of a poly group said to understood him in a way non-bisexuals may
me, “You don’t have to be bisexual to be poly, struggle to do. Groups such as this may be crit-
but it sure helps.” ical to a person’s well-being, and the elder in
How do polyamorous bisexuals experience need of face-to-face support services and desire
aging differently, if at all? Given a lack of data on help in locating one.
this topic, it would need to be a question that Lastly, continuing education for service pro-
warrants further investigation. However, it is viders is also critical. I would argue that the best
imperative that service providers avoid judgment education, however, is not from a book but
and biases (Keppel 2006; Kimmel et al. 2006) instead from talking to and getting to know the
while being accepting and supportive of alter- needs individuals. Listening, understanding, and
native relationships, and whenever possible, meeting people where they are may be both the
make accommodations for the bisexual elder’s best education one can obtain and the best ser-
needs. vice one can provide.
The chief implication for people offering services This chapter on bisexual elders is merely start of
to bisexual elders is the need to avoid assump- a conversation about how to offer quality ser-
tions. For example, regardless of sexual orienta- vices to bisexual seniors. There is much work to
tion, healthcare providers need to individually be done in understanding this unique population.
assess the need for pap smears and breast exams For example, little has been written regarding the
for women and provide information on HIV and rich ethnic, racial, cultural, and economic
15 Bisexuality: An Invisible Community Among LGBT Elders 319
(c) Invisibility 10. What one word best describe the community
(d) All of the above of bisexual elders?
3. The single largest part of the LGBT com- (a) Invisible
munity is (b) Well-recognized
(a) Lesbian (c) Well organized
(b) Gay (d) Protected under the law
(c) Bisexual
(d) Transgender
4. What two members of the LGBT community
Key (for multiple-choice questions)
have been strong allies for advocacy?
(a) Gays and Lesbians
1-d
(b) Gays and transgender persons
2-d
(c) Gays and bisexual persons
3-c
(d) Bisexual persons and transgender
4-d
persons
5-d
5. Which LGBT groups identify more strongly
6-b
with ambiguity?
7-d
(a) Gays
8-d
(b) Transgender
9-b
(c) Bisexuals
10-a
(d) (b) and (c)
(e) (a) and (c)
6. Which of the following has the highest
reported rates of binge drinking?
Resources
(a) Gay men
(b) Lesbians
• Bi Resource Center http://www.biresource.net/
(c) Transgender persons
• BiNet USA http://www.binetusa.org/
(d) Bisexuals
• American Institute of Bisexuality http://www.
7. Which of the below is not a health problem
americaninstituteofbisexuality.org/
for older bisexual persons?
• Bisexual Organizing Project http://www.
(a) Overweight
bisexualorganizingproject.org/
(b) Underweight
• Bisexual Community Needs Assessment 2012
(c) High cholesterol
http://www.bisexualorganizingproject.net/Bi-
(d) Intimate partner violence
Needs-Assessment.html
8. Bisexual women have rates higher than their
• Bisexual invisibility: impacts and recommen-
heterosexual counterparts of the following:
dations, San Francisco Human Right Com-
(a) Cancer
mission LBGT Advisory Committee http://
(b) Underinsurance
www.birequest.org/docstore/2011-SF_HRC-
(c) Difficulty obtaining medical care
Bi_Iinvisibility_Report.pdf
(d) All of the above
• Healthy People 2020 http://www.healthy
9. What identify issues do bisexuals face?
people.gov/
(a) Homophobia
• The bisexuality report: Bisexual inclusion in
(b) Employment discrimination
LGBT equality and diversity http://bisexual
(c) Social ostracism
research.wordpress.com/reportsguidance/
(d) All of the above
reports/thebisexualityreport/
15 Bisexuality: An Invisible Community Among LGBT Elders 321
Abstract
Many older adults experience their later life as a time when they may be
able to enjoy the company of family and friends to an extent not possible
during their working years. Most older adults, including those who are
LGBT, remain in their homes as they age; most enjoy good and
appropriate treatment by their family members, their extended family, and
their services providers. However, for some older adults, old age is marred
by unhealthy dependencies of families, friends, and others to the point that
the older adult may experience abuse, neglect, and exploitation discretely
or in escalation. Such harsh and life-threatening treatment of individuals in
later life can occur in community as well as facility settings, as a single
occurrence or over a protracted period of time. Elder mistreatment is
thought to affect one in nine older adults, with 23.5 instances of
mistreatment going unreported for each one reported to authorities.
Keywords
Elder mistreatment Elder abuse Policies Services LGBT
(Acierno et al. 2010), with 23.5 instances of abuse, violence, and neglectful situations as their
mistreatment going unreported for each one heterosexual counterparts, they also encounter
reported to authorities. exploitation because of their sexual identity
(Teaster et al. 2014).
Research suggests that because of their sexual
orientation and gender identity, LGBT elders
Learning Objectives experience victimization in the form of verbal
abuse, threat of violence, physical assault, sexual
By the end of the chapter, the reader should be assault, threat of orientation disclosure, discrim-
able to: ination, and physical attack. Among LGBT
elders, men experience physical attack nearly
1. Identify the types of elder mistreatment. three times more often. LGBT elders are less
2. Understand the scope of elder mistreatment. likely to seek help for abuse (National Center on
3. Explain the settings of abuse. Elder Abuse 2013). Social isolation is also a risk
4. Identify policies and services for LBGT factor for elder abuse. LGBT elders are more
elders who are abused. likely to age alone than their heterosexual
counterparts (Frazer 2009). Because of living in
isolation and fear of discrimination, many LGBT
elders are at high risk for elder abuse, neglect,
and various forms of exploitation (National
Introduction Academy on an Aging Society, GSA & SAGE
2011) See Chap. 30 for additional discussion of
For many people, aging is accompanied by an the impact of isolation for LGBT elders.
increased reliance on family members, caregivers, The purpose of this chapter is twofold. First,
and friends. Reliance on others, especially care- this chapter provides insights into the topic of
givers, can cause enormous stress for LGBT elders elder mistreatment in general. Second, although
because of their vulnerability to those who may issues of elder mistreatment of LGBT elders is
discriminate against and abuse them (Balsam and discussed in detail in Chap. 17, the information
D’Augelli 2006). Every year, one in nine older presented in this chapter is intended to assist the
adults are reported to experience mistreatment at reader to better understand the deeper and more
the hands of a trusted other, and, in most instances, nuanced issue of elder mistreatment as it con-
at the hands of a family member (Acierno et al. cerns adult persons who are LGBT. In one
2010). The most recent prevalence study con- respect, this chapter is a prelude to discussion of
ducted in the state of New York indicates that for LGBT elders as a vulnerable population for
one report to an agency, a staggering 23.5 go mistreatment. Material presented in this chapter
unreported (Lachs et al. 2011). A population of helps readers understand issues surrounding elder
older adults, set to rise to 20 % of the population by mistreatment in general and LGBT elder mis-
2030, portends that the problem will only increase treatment in particular so that the reader can
unabated unless current efforts improve and esca- identify the problem and its context as well as
late. Despite zealous advocacy efforts to staunch mechanisms and systems in place for its ame-
the problem, elder mistreatment remains highly lioration and prevention. Discussed in this
underfunded. According to Teaster et al. (2006b), chapter are definitions of elder abuse, federal
for Adult Protective Services there were 253,421 legislation regarding elder abuse, organizations
reports of abuse of adults age 60 and over or 832.6 that address elder abuse, and information con-
reports for every 100,000 people over the age of cerning the impact of elder mistreatment at fed-
60. Although LGBT elders face the same types of eral, state, local, and individual levels.
16 An Overview of Aging and Mistreatment of LGBT Elders 327
Elder Abuse and Its Definitions Adult Protective Services (see explanation
below) caseloads, was considered elder abuse but
The issue of elder mistreatment has been plagued not elder mistreatment. Also, abuse not com-
by definitional ambiguity in the United States mitted by a trusted other was considered simply a
because, when it is considered a crime as it is in crime with the elder as the victim.
many instances, its definition is one established Another important definition, also well
by state statutes or regulations. Statutory defini- received throughout the world is that promul-
tions have plagued the progress of research, as gated by the World Health Organization (WHO),
collection of elder abuse data did not comport to which indicates that elder abuse is “a single, or
the language of the law or of public administra- repeated act, or lack of appropriate action,
tion. For nearly three decades, the field of elder occurring within any relationship where there is
abuse has wrestled with this incongruity, with an expectation of trust which causes harm or
most researchers ceding to statutory definitions distress to an older person”. It is important to
because of their overwhelming influence on how point out that, under the World Health Organi-
state governments collected the administrative zation definition, elder mistreatment can take on
data upon which they often relied (e.g., Teaster multiple forms or repeated acts of abuse, a term
et al. 2006a, b; Bonnie and Wallace 2003; Ne- referred to as polyvictimization
renberg 2008). (Ramsey-Klawsnik and Heisler 2014). Regard-
The problem of elder abuse and its definition less of whether the abuse is a one-time occur-
is hardly unique to the United States. Both rence or happens multiple times, the broad
developed and developing countries around the definition encompasses a variety of settings and a
world have grappled with the same definitional number of types, which are discussed below.
problem. An international study of elder abuse
by Podnieks et al. (2010), involving a total of 53
countries (362 respondents) from the six WHO
world regions revealed an inadequate knowledge Settings of Abuse
of laws and services about the issue and that
barriers to addressing the problem included lan- Elder abuse occurs in two main settings, in
guage issues and literacy. community settings and in facility settings.
A watershed document, Elder Mistreatment: Community settings can and do include an
Abuse, Neglect, And Exploitation in An Aging elder’s own home or the home of an individual or
America, was produced by the National Acad- individuals with whom the elder lives, typically
emy of Sciences (NAS) in 2003, which has been that of a family member. Family members and
highly influential in subsequent research and has friends with whom the elder may cohabitate,
even gained prominence worldwide (Podnieks typically are the predominant abusers (Acierno
et al. 2010). The document describes elder mis- et al. 2010). It is estimated that 90 % of all elder
treatment as “(a) intentional actions that cause abuse occurs in community settings. These set-
harm or create a serious risk of harm (whether or tings are difficult to permeate because there are
not harm is intended) to a vulnerable elder by a fewer eyes and ears that witness the abuse
caregiver or other person who stands in a trust first-hand than in facility settings (Teaster and
relationship to the elder or (b) failure by a care- Roberto 2004; Teaster et al. 2006b).
giver to satisfy the elder’s basic needs or to Elders are also abused in facility settings.
protect the elder from harm” (Bonnie and Wal- These include a range of locations that provide
lace 2003, p. 40). The NAS definition made the long-term care, including adult congregate living,
important distinction and demarcation that abuse assisted living facilities, group homes, mental
was to be perpetrated by a trusted other. Thus, hospitals, and nursing homes. According to
the issue of self-neglect, the mainstay issue of Hawes (2003), on an average day, approximately
328 A.E. Sokan and P.B. Teaster
1.6 million people live in a about 17,000 licensed (2008) reveal its prevalence to be 0.02 %, and
nursing homes, and another estimated 900,000 to Lachs et al. (2011) found 22.4 per thousand. The
1 million live in about 45,000 residential care most recent national study of elder abuse
facilities. Research suggests that the 2.5 million reporting to APS (Teaster et al. 2006b) revealed
vulnerable individuals in these settings may well 10.7 % of reports of physical abuse substantiated
be at higher risk for abuse and neglect than older over a year’s time.
persons who live at home, as discussed below.
Less is known about the prevalence of abuse in Sexual Abuse Sexual abuse, thought to be the
skilled nursing facilities than in other long-term most hidden of the abuses (Ramsey-Klawsnik
care facilities. For example, elders living in and Teaster 2012; Teaster and Roberto 2004) is
skilled nursing facilities are among the most defined by the NCEA (n.d.) as “non-consensual
vulnerable members of society, precisely because sexual contact of any kind with an elderly per-
they are often dependent on those employed by it son. Sexual contact with any person incapable of
for total care. giving consent is also considered sexual abuse. It
includes, but is not limited to, unwanted touch-
ing, all types of sexual assault or battery, such as
rape, sodomy, coerced nudity, and sexually
Typologies of Elder Mistreatment
explicit photographing.” Acierno et al. found its
prevalence to be 0.06 %, Lachs et al. found 0.03
As context for the global definitions presented
per thousand for a documented case study, and
earlier are the various types of elder abuse that
Teaster et al. (2006b) found 1.0 substantiated
may happen to an elder once or co-occur, these
reports to APS. Occurring in community and
being physical, sexual, verbal/emotional, neglect
facility settings, sexual abuse is difficult to prove
(both active and passive), and financial
when an allegation is not followed up on
abuse/exploitation. Self-neglect is another type of
immediately. For example, Ramsey-Klawsnik
abuse that is also discussed within this chapter
and Teaster et al. (2007) found that very few
because of its implications for the LGBT com-
allegations involved a physical examination,
munity, and a topic that is discussed in greater
let alone an examination by a Sexual Abuse
detail in Chap. 17.
Nurse Examiner (SANE).
Physical Abuse According to the abuse typol-
ogies provided by the National Center on Elder Emotional Abuse/Psychological Abuse
Abuse (n.d.), physical abuse is characterized by According to the National Center on Elder Abuse
the use of physical force that may result in bodily (n.d.), emotional or psychological abuse involves
injury, physical pain, or impairment. Physical infliction of anguish, pain, or distress through
abuse may include but is not limited to acts of verbal or nonverbal acts. This form of abuse
violence including striking (with or without an includes but is not limited to verbal assaults,
object), hitting, beating, pushing, shoving, insults, threats, intimidation, humiliation, and
shaking, slapping, kicking, pinching, and burn- harassment. Infantilizing an older person; isolating
ing. In addition, inappropriate use of drugs and elders from family, friends, or regular activities;
physical restraints, force-feeding, and physical giving elders the “silent treatment;” and social
punishment of any kind also are examples of isolation are examples of emotional/psychological
physical abuse (Table 16.1). abuse. In the Acierno et al. study (2010), its
From research on adults in community set- prevalence was 4.6 %, in Laumann’s study, it was
tings only and conducted by Acierno et al. (2010) 9 %, and in the Lachs study (2011), it was found to
the prevalence of physical abuse was 1.6 %. be 16.4 % per thousand. In the Teaster et al.
Similar studies of abuse by family members of (2006b) study, there were 14.8 % substantiated
community dwelling elders by Laumann et al. reports of neglect in one year’s time.
16 An Overview of Aging and Mistreatment of LGBT Elders 329
Neglect Neglect, which can be either active or person’s money or possessions; coercing or
passive, is defined by the NCEA “as the refusal deceiving an older person into signing any doc-
or failure to fulfill any part of a person’s obli- ument (e.g., contracts or will); and the improper
gations or duties to an elder. Neglect may also use of conservatorship, guardianship, or power of
include failure of a person who has fiduciary attorney. Concerning exploitation, Acierno et al.
responsibilities to provide care for an elder (e.g., (2010) found a prevalence of 5.2 % by a family
pay for necessary home care services) or the member, in the Lachs study (2011), it was found
failure on the part of an in-home service provider to be 42.1 % per thousand, in the Laumann et al.
to provide necessary care. Neglect typically study 3.5 %, and in the Teaster et al. (2006b)
means the refusal or failure to provide an elderly study, there were 14.7 % substantiated reports of
person with such life necessities as food, water, exploitation in a year’s time.
clothing, shelter, personal hygiene, medicine,
comfort, personal safety, and other essentials The Context of Exploitation For the first time,
included in an implied or agreed-upon responsi- a study conducted by the MetLife Mature Market
bility to an elder.” For neglect, Acierno et al. Institute (2009) revealed that exploitation that
(2010) found a prevalence of 5.1 %, in the Lachs was captured by the news media cost $2.6 billion
study (2011), it was found to be 18.3 % per a year. A follow-up study in 2011 revealed that
thousand, and in the Teaster et al. (2006b) study, the dollar amount had escalated to $2.9 billion
there were 20.4 % substantiated reports of per annum. When financial exploitation occurs in
neglect in one year’s time. community settings, it usually involves a family
member who has mental health or substance
Exploitation This form of abuse is much the abuse problems or both. Other forms of exploi-
object of study in recent years because of its tation can involve persons designated as an
association with other forms of abuse. Financial elder’s power of attorney or court-appointed
or material exploitation is defined as the illegal or guardian. When the exploitation occurs in facility
improper use of an elder’s funds, property, or settings, about which less has been studied than
assets. Examples include, but are not limited to, in community settings, it can also involve resi-
cashing an elderly person’s checks without dents of the facility or staff members, in addition
authorization or permission; forging an older to family members. Less examined exploitation
person’s signature; misusing or stealing an older by individuals and entities include magazine
16 An Overview of Aging and Mistreatment of LGBT Elders 331
subscription scams, paving scams, telephone refusal or failure to provide himself/herself with
scams, Internet scams, and religious scams. adequate food, water, clothing, shelter, personal
One way to differentiate the types of exploi- hygiene, medication (when indicated), and safety
tation was conceived by the authors of the Met- precautions. An elder is not self-neglecting if he
Life Mature Market Institute study (2011): or she is mentally competent, understands the
crimes of occasion, desperation and predation. consequences of decisions, and makes a con-
Crimes of occasion or opportunity occur when a scious and voluntary decision to engage in acts
victim is merely a barrier in the way of what the that threaten his/her health or safety as a matter
perpetrator wants. For instance, an elder has of personal choice.
money, assets, and the like, and an occasion
presents itself for the perpetrator to access the Self-neglect is reported to be the bulk of APS
resource. An occasion scenario was seen in the caseloads (Teaster et al. 2006b). When
case of the holiday crime in which a woman was self-neglect of a community member is purported
electrocuted with a stun gun and robbed after to occur, some of the thorniest of problems
allowing someone into her home whom she emerge. This situation could be an example of
thought was a pharmacist delivering medications. triple jeopardy for an LGBT elder who may
The occasion was the open door and a person become isolated due to his or her age, his or her
whom she thought she could trust. sexual minority status, and because of fears about
Crimes of desperation are typically those in coming out to those who might help the situation.
which perpetrators are so desperate for money that Because LGBT elders may have reduced social
they will do whatever it takes to get it. Many per- networks as they age, they may be susceptible to
petrators are dependent on an elder parent for self-neglectful situations. The following scenario
housing and for income. The desire for more money is emblematic: on the one hand, the LGBT elder
may be heightened due to the need for drugs, and his or her deplorable situation is revealed and
alcohol, and their gender, or some combination. he or she, including all the animals and putrid
The exploiter comes to believe that, in return for food, stacks of newspaper and boxes are removed
care, he or she is due compensation (money or and given appropriate care (the appreciative
possessions), and often on a continuing basis. community scenario). Alternately, the elder is
Finally, crimes of predation or occupation forced, by the heavy hand of government, to do
occur when trust is established for the purpose of something that is abhorrent to him or her, and due
financially abusing later. A relationship is built, to being LGBT, may suffer more intrusions
either through a bond of trust created though because she is lesbian, old, and vulnerable. The
developing a relationship (romantic or otherwise) long and intrusive arm of the state has interfered,
or as a trusted professional advisor. Taking assets once again, with a helpless citizen, and he or she
is accomplished by stealth and cunning. is powerless in the face of this unique form of
government intrusion (the elder/community as
Self-neglect Though not regarded as elder victim of government intervention).
mistreatment because it does not involve abuse
by a trusted other, elder self-neglect is one of the
most vexing of the abuses encountered, precisely
because its origin is difficult to pinpoint and Federal Legislation that Addresses
because, in its most extreme form, the problem Elder Abuse
devolves into a public health risk and can result
in removal of the elder from his or her home and
concomitant loss of the individual’s civil rights. The Older Americans Act
According to NCEA (n.d.), self-neglect occurs
when the behavior of an elder threatens his or her The Older Americans Act (1965) was the first
own health or safety and manifests itself as a federal level initiative aimed at providing
332 A.E. Sokan and P.B. Teaster
comprehensive services for older adults. Based World Elder Abuse Awareness Day (WEEAD).
on a model of active aging, the Act created the The Center is re-established through a competi-
National Aging Network, which is composed of tive request for proposals every four years. The
Administration on Aging (now, the Administra- newest iteration of the NCEA was awarded to the
tion for Community Living (federal level), State Keck School of Medicine of the University of
Units on Aging (state level), and Area Agencies Southern California, along with the USC Davis
on Aging (local level). The Act must be contin- School of Gerontology, the American Bar
ually reauthorized by Congress, which has never Association and other organizations dedicated to
allocated funding commensurate with its lofty supporting the aging in America. Through these
aspirations. Though services are supposed to be organizations, the NCEA will provide technical
provided based on age of the recipients (gener- assistance and training to states and
ally 60 years of age and older), they have become community-based organizations to develop
more and more focused due to historically flat or effective prevention, intervention and response
slight increases in funding. Notably, the Act has efforts addressing elder abuse as well as conduct
funded nutrition and supportive home and research and advocate for policy changes on
community-based services, disease behalf of older adults (Snelling 2014).
prevention/health promotion services, training
for employment, the National Family Caregiver
Support Program and the Native American
Caregiver Support Program, and elder rights Long-Term Care Ombudsmen
programs (Title VII or the Vulnerable Elder
Rights Protection Title). The purpose of Title VII Area Agencies on Aging (AAA) are a nationwide
was to strengthen and coordinate the Long-Term network of state and local programs that help
Care Ombudsman Program; Programs for the older people plan and care for their needs. Area
Prevention of Abuse, Neglect and Exploitation; Agencies on Aging receive funds through the
State Elder Rights and Legal Assistance Devel- Administration for Community Living
opment Programs; and Insurance/Benefits Out- (ACL) and were established by the Older
reach, Counseling and Assistance Programs. Americans Act, with their goal being to keep
Two of the programs are discussed below in elders living independently in their own homes
greater detail: the National Center on Elder for as long as possible. Over 600 AAAs exist
Abuse and the Long-Term Care Ombudsman nationwide and provide social services and
Program, predominantly local programs that are nutrition services for elders, as well as support
usually housed in Area Agencies on Aging. for caregivers of elders. In addition, AAA is a
useful resource for professionals and practitio-
ners who care for or provide services for elders.
AAAs typically house the long-term care
The National Center on Elder Abuse ombudsman, which is discussed in greater detail
below (Smith 2010; Stupp 2000).
Directed by the U.S. Administration on Aging, Existing in all states, Long-Term Care
the National Center on Elder Abuse (NCEA) is a Ombudsmen (LTCO), are advocates for residents
resource for policy makers, social service and of nursing homes, board and care homes, assisted
health care practitioners, the justice system, living facilities and similar adult care facilities.
researchers, advocates, and families (National They work to resolve problems of individual
Center on Elder Abuse, n.d.). Operated under the residents and to bring about changes at the local,
Department of Health and Human Services, it state and national levels that will improve resi-
provides such resources as training, advocacy dents’ care and quality of life. The Long-Term
information, research findings, interpretation of Care Ombudsman Program is authorized and
elder abuse statutes, a hotline, and celebration of funded under Title VII, Chapter 2,
16 An Overview of Aging and Mistreatment of LGBT Elders 333
Sections 711/712 of the Older Americans Act, as and participated in 21,812 resident council and
well as other federal, state, and local sources 2,371 family council meetings (Administration
(Administration for Community Living, n.d.). for Community Living, n.d.). Ombudsmen help
Each state has an Office of the State Long-Term residents and their families and friends under-
Care Ombudsman headed by a full-time state stand and exercise rights guaranteed by law, both
ombudsman. Local ombudsman staff and vol- at the Federal level for nursing homes and for
unteers work in communities throughout the States that provide rights and protections in
country as part of statewide ombudsman pro- board and care, assisted living and similar
grams, assisting residents and their families and homes. Table 16.2 lists the responsibilities of the
providing a voice for those unable to speak for long-term care ombudsman.
themselves. The Administration for Community
Living funds the National Long-Term Care
Ombudsman Resource Center, which is operated
by the National Consumers’ Voice for Quality Other Federal Legislation to Address
Long-Term Care (or Consumer Voice), in con- Elder Mistreatment
junction with the National Association of States
Agencies on Aging United for Aging and Dis- In addition to the Older Americans Act men-
abilities (NASUAD), and which provides train- tioned above, there are two other important pie-
ing and technical assistance to state and local ces of federal legislation that address elder
ombudsmen. Program data for FY 2013 provide mistreatment. These are the Social Security
a flavor of the activities by LTCO: services to Block Grants and the Elder Justice Act (EJA).
residents were provided by 1,233 full-time
equivalent staff and 8,290 volunteers, trained
and certified to investigate and resolve com-
plaints who helped resolve 190, 592 complaints, Social Security Block Grants
initiated by residents, their families, and other
concerned individuals, provided 335,088 con- Language in Title XX of the Social Security Act
sultations to individuals, visited 70 % of all of 1974 gave permission for states to use Social
nursing homes and 29 % of all board and care, Services Block Grant (SSBG) funds for the
assisted living and similar homes at least quar- protection of adults as well as children (Mixson
terly, and conducted 5,417 training sessions in 1995). By the early 1980s, all states had created
facilities on such topics as residents’ rights. In an office with the responsibility for providing
addition the LTCO provided 129,718 consulta- protective services to some segment of the pop-
tions to long-term care facility managers and staff ulation, including services to the needy despite
334 A.E. Sokan and P.B. Teaster
the absence of authorizing legislation (NAPSA • Developing objectives, priorities, policies and
2014; U.S. Congress 1981). SSBG funds proved long-term plans for elder justice programs
helpful in the establishment of programs to • Conducting a study of state laws and prac-
address elder mistreatment, especially Adult tices relating to elder abuse, neglect and
Protective Services (discussed below), but the exploitation
funds are inadequate and diminishing even • Making available grants to develop training
though reports of elder mistreatment are and support programs for law enforcement
increasing. and other first responders, prosecutors, jud-
ges, court personnel and victim advocates
• Ensuring that DOJ dedicates sufficient
resources to the investigation and prosecution
The Elder Justice Act of cases relating to elder justice
The Elder Justice Act (EJA) was passed in 2010 A final feature of the EJA is the creation of a
as part of the Patient Protection and Affordable nationwide database and program for back-
Care Act. Although passage of the EJA was truly ground checks for employees of care facilities.
a victory for the field of elder mistreatment, as of The EJA stipulates that elder abuse perpetrated in
yet, the victory has been somewhat pyrrhic, as a long-term care facility must be reported
the EJA never received funding for its many immediately to law enforcement (EJC Fact Sheet
outstanding provisions and it is set for reautho- 2014). (See Policy Box 16.1 on The Elder Justice
rization in 2015. Importantly, components of the Act).
Act have been undertaken, most notably the
formation of the Elder Justice Coordinating
Policy Box 16.1
Committee, composed of representatives from
The Elder Justice Act
such agencies as the Administration for Com-
Elder abuse is a complex issue
munity Living (ACL), the National Institute of
demanding a multifaceted policy response
Justice (DOJ), and the Social Security Adminis-
that combines public health interventions,
tration. The EJA requires that the Department of
social services programs, and criminal law
Health and Human Services oversee the devel-
enforcement for abusive behavior. To
opment and management of federal resources for
address this problem, the Elder Justice Act
protecting older adults from elder abuse,
was enacted as part of the Patient Protec-
including establishing, enhancing, or funding:
tion and Affordable Care Act (ACA, P.L.
111-148, as amended). Provisions of the
• The Elder Justice Coordinating Council
Act attempt to provide a coordinated fed-
• An Advisory Board on Elder Abuse
eral response by emphasizing various
• Elder Abuse, Neglect, and Exploitation
public health and social service approaches
Forensic Centers
to the prevention, detection, and treatment
• Long-Term Care
of elder abuse. The Elder Justice Act is the
• State and local adult protective service offices
first national, comprehensive legislation to
• Grants to long-term care ombudsmen pro-
address abuse, neglect, and exploitation of
grams and for the valuation of programs
elders. To date, most activities and pro-
• Programs to provide training
grams authorized under the Elder Justice
• Grants to state agencies to perform surveys of
Act have not received federal funding
care and nursing facilities
through the appropriations process. More-
over, the authorizations of appropriations
The EJA also includes directives for the U.S.
for most provisions under the act expire on
Department of Justice (DOJ) for the prevention
September 30, 2014. Because of
of elder abuse, which include:
16 An Overview of Aging and Mistreatment of LGBT Elders 335
address the problem, there is still a tremendous The NCEA is one of 27 Administration on
need for greater excellence in research and Aging-funded Resource Centers. The NCEA is
practice (and the two working in concert). It is the place to turn to for up-to-date information
critical that higher levels of attention and funding regarding research, training, best practices, news
be dedicated to this growing issue and problem, and resources on elder abuse, neglect and
particularly because, that in the near future, the exploitation. The Center provides information to
issue and problem of elder mistreatment will only policy makers, professionals in the elder justice
increase in scope and severity. field, and the public.
National Consumer Voice for Quality Long
Term Care
Website: http://healthfinder.gov/FindServices/
Resources Organizations/Organization.aspx?code=HR1872
The National Consumer Voice for Quality
Long-Term Care is a 501(c)(3) nonprofit orga-
Selected Annotated Resources Related nization founded as the National Citizens’ Coa-
to Elder Mistreatment lition for Nursing Home Reform (NCCNHR) in
1975 by Elma Holder. The organization repre-
CANE: The Clearinghouse on Abuse and Neglect sents the consumer voice at the national level for
of the Elderly. quality long-term care, services and supports by
The Clearinghouse on Abuse and Neglect of advocating for public policies that support qual-
the Elderly (CANE), located at the University of ity care and quality of life responsive to con-
Delaware Center for Community Research and sumers’ needs in all long-term care settings;
Service, is the nation’s largest computerized empowering and educating consumers and fam-
catalog of elder abuse literature. ilies with the knowledge and tools they need to
Website: http://www.cane.udel.edu/ advocate for themselves; training and supporting
National Committee for the Prevention of individuals and groups that empower and advo-
Elder Abuse (NCPEA): www.preventelderabuse. cate for consumers of long-term care; and pro-
org moting the critical role of direct-care workers and
NCPEA is an association of researchers, best practices in quality care delivery.
practitioners, educators, and advocates working Safe Horizon
to protect the safety, security, and dignity of Website: http://www.safehorizon.org/
America’s most vulnerable citizens. Established Safe Horizon is the largest victims’ services
in 1988 to achieve a clearer understanding of agency in the United States. Safe Horizon offers
abuse and provide direction and leadership to assistance and support to children, adults, and
prevent it. NCPEA is a partner with the National families affected by crime and abuse throughout
Center on Elder Abuse. New York City, through 57 program locations,
National Clearinghouse on Abuse in Later including shelter, in-person counseling, legal
Life (NCALL): services, and more.
Website: http://ncall.us/
Through advocacy and education, the
National Clearinghouse on Abuse in Later Life
(NCALL) works everyday to improve victim Other Resources
safety, increase abuser accountability, expand
coordinated community response, and ultimately, Websites
put an end to abuse in later life.
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http://www.ncea.aoa.gov/about/index.aspx) aoa.gov)
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Mistreatment and Victimization
of LGBT Elders 17
Pamela B. Teaster and Amanda E. Sokan
Abstract
The mistreatment and victimization of older LGBT adults is slowly
coming to light in both practice and research. However, at this point, few
studies examine this phenomenon. What is certain is that being LGBT
may place elders at increased risk for mistreatment due to factors such as
isolation, previous exposure to a traumatic event, and reticence to seek
assistance from informal and formal networks. Penalties for elder
mistreatment must be utilized by law enforcement more frequently, and
statues that explore elder mistreatment as a hate crime also explored. It is
critical that advocates, practitioners, researchers, and policy makers
understand, intervene in, and prevent the mistreatment of LGBT elders.
Keywords
Mistreatment Victimization LGBT elders Social isolation Elder
abuse
regard. Although LGBT elders often experience (CAP) (2010) estimate that 1.5 million adults
the same types of mistreatment and victimization aged 65 and over are LGB, with no reliable
as elders in general, LGBT elders have their estimates for elders who identify as transgender.
experiences within the context of being sexual All estimates are likely undercounts due to the as
minorities. This additional positionality not only yet considerable stigma associated with “coming
sets LGBT elders apart from their non-LGBT out” at any age. “Coming out” for elders may be
counterparts, it also necessitates specific and even more problematic than for their younger
unique approaches to addressing the problem of counterparts (e.g., historical mistreatment of
elder mistreatment and victimization. Given this those who identify as LGBT, decreased desir-
context, it is our intent to highlight discrimina- ability being older and LGBT, increased possi-
tion by practice and policy against LGBT elders bility of being dependent on others). Elders who
and to focus on disparities in response to mis- identify as LGBT face yet another challenge,
treatment and victimization of LGBT elders as a which is that of experiencing elder mistreatment.
culturally diverse population that is already Some LGBT elders must often contend with
marginalized by age, socioeconomic status, and a abusing, neglecting, or exploiting family mem-
host of other demographic characteristics. bers, including intimate partner violence that can
result in social isolation and low help-seeking
behaviors (National Center on Elder Abuse
Learning Objectives 2013).
authors went on to say that 29 % had been men were routinely fired from their positions,
physically assaulted. Similarly, Frazer (2009) rejected by their families, targets of police bru-
surveyed 3500 LGBT elders aged 55 and older tality and harassment, and, until present times,
and found that 8.3 % reported being abused or denied the right to marry and its associated
neglected by a caregiver due to homophobia; rights. Further,
8.9 % reported being financially exploited for the
Social condemnation of people who have rela-
same reason. Persons who identify as transgender tionships or sex with persons of their own gender
reported that 42 % experienced some type of is so strong that even those who do not identify
physical violence or abuse and that 80 % expe- themselves as gay or lesbian, those who do not
rienced verbal abuse or harassment (MAP 2009). associate with other known Gays or Lesbians, and
those who ‘come out’ late in life nevertheless
Fredrikson-Goldsen et al. (2011) found, in a adopt many of the same protective behaviors and
study of 2560 LGBT elders, that due to the social adaptations as those who have long labeled
perception of being LGBT, 82 % of elders had themselves as Gay (Cook-Daniels 2002, p. 3).
been victimized once in their lives, with 64 %
Although some protective behaviors may
being victimized at least three times.
safeguard elders from abuse (e.g., larger friend
One area almost never considered in the elder
networks in later life), other behaviors result in
mistreatment literature is that of transgendered
becoming more isolated over time and conse-
elders (Cook-Daniels 2002) (see Chap. 14).
quently make the elder more vulnerable to abuse,
Research is bearing out that the social intolerance
neglect, and exploitation (Acierno et al. 2010).
of transgendered people may be even more
A number of factors, including being LGBT, as
intense than that of LGB persons (Lombardi et al.
well as age-related changes, can make an LGBT
2002). Violence is caused both by those who are
elder at risk for abuse.
intimate and by those who are distant to him or
LGBT elders are particularly vulnerable to
her. Such maltreatment serves to decrease
abuse for a variety of reasons. These individuals
help-seeking and increase isolation, which in turn
are more likely to be estranged from family
make transgendered individuals even more at
members or to be childless, which decrease
risk for abuse (e.g., little social support and a
access to children or family members for support
history of experiencing a traumatic event) (Aci-
when they need care. Another reason LGBT
erno et al. 2010).
elders are at risk for mistreatment and victim-
Although research is continually refining
ization is discrimination in healthcare, human
estimates of the incidence and prevalence of
services, and some long-term care (LTC) facili-
elder mistreatment, major national studies of
ties. Too often the forms of discrimination in
elder mistreatment have, in the main, neglected
LTC facilities are dismissed or ignored. Exam-
to include variables that identify elders who are
ples of mistreatment and victimization include
LGBT (Chap. 16). However, it is possible, by
harassment, limits on visitors, prohibiting
extension, to develop a rudimentary understand-
same-sex couples from sharing a room, or refusal
ing of elder mistreatment as it affects LGBT
to recognize a person’s gender identity.
victims, whose unique and individual experi-
Characteristics of Victims. In a national prev-
ences are discussed below.
alence study by Acierno et al. (2010), in which
self-report data were collected from 5777 older
adults, average age of 71.5 years, 60.2 % (3477)
LGBT Victims of Elder Abuse were female and 39.8 % (2300) were male. As of
yet, no information on sexual orientation of the
LGBT victims of elder abuse are victimized in men and women has been discussed in
several ways. First, as Cook-Daniels stressed peer-reviewed publications. Respondents indi-
(2002) the society in which LGBT elders aged cated that 56.8 % were married or cohabitating,
was extremely homophobic. For example, gay 11.8 % (677) were separated or divorced, 25.1 %
346 P.B. Teaster and A.E. Sokan
(1450) were widowed, and 5.2 % (303) had community-based studies by Acierno et al.
never married. Also, and by self-report, 87.5 % (2010) and Laumann et al. (2008) revealed that
(4876) of respondents were White, 6.7 % were young-old individuals (60–69) were more prone
African American, 2.3 % were American Indian to abuse than their older counterparts, especially
or Alaskan Native, 0.8 % (49) were Asian, and emotional and physical abuse. The linkage
0.2 % (13) were Pacific Islanders. between age and risk of mistreatment or abuse
Similarly, in the New York State Prevalence may be related to the increasing numbers in the
study by Life span of Greater Rochester (2011), population of old–old and oldest–old elders,
which surveyed 4136 adults aged 60 years of age many of whom may experience a decline in
and older and which also did not provide infor- health results in greater dependence on others for
mation on sexual preference, respondents’ self-care than for the general population of older
self-reports revealed the following victims’ adults.
characteristics: 20.3 % were between 60 and Lack of social support. Elders at advanced ages
64 years of age, 38.0 % were between ages 65 may also experience reduced interactions with
and 74, 29.1 % were ages 75 and 84, and 12.7 % members of their social network than those of
were aged 85+. The self-reported gender break- their younger counterparts, which may be a
down was 35.8 % male and 64.2 % female. protective factor for mistreatment. According to
Respondents self-reported being 65.5 % were Charles and Carstensen (2010), older adults have
Caucasians, 26.3 % were African Americans; a propensity to judge the trustworthiness of
1.6 % were Asian/Pacific Islanders; 7.6 % were others more favorably than do their younger
Hispanic/Latino; 1.9 % were American/Aleut counterparts and, consequently, may exacerbate
Eskimos; and 2.9 % were “other” races. their vulnerability for financial exploitation.
A much smaller and national study, which Castle et al. (2012) examined age differences in
also did not collect data on LGBT elders, perceived trust using neuroimaging methodology
examined 26 cases reported and screened in for and posited that “older adults might have a lower
investigation concerning the alleged sexual abuse visceral warning signal in response to cues of
of older men (aged 50 and older) residing in untrustworthiness, which could make deciding
nursing homes. Cases occurred in five states whom to trust difficult” (p. 20851).
within a six-month time period. Of these, six Both Acierno et al. (2010) and Amstadter
were confirmed upon investigation by Adult et al. (2011) stress that low levels of social
Protective Services (APS) or other regulatory support are correlated with the occurrence of all
agencies. Victims tended to be predominately types of elder abuse. Elders who are lonely or
white males with cognitive and physical deficits isolated are significantly more vulnerable to elder
that limited their ability for self-care. The most mistreatment than are elders with strong support
typical sexual abuse alleged and substantiated systems. According to Acierno et al. (2010), low
was fondling. Residents were more often sub- social support was associated with more than
stantiated as the abuser than other perpetrators. triple the propensity for mistreatment of any form
The sexual abuse of older men in nursing homes to be reported by elders. Further, Amstadter et al.
crossed gender, cultural, and role boundaries. (2011) found that low levels of social support
Victims’ Risk Factors. Age may well be a risk significantly predicted the likelihood of older
factor for mistreatment, although studies regard- adults experiencing emotional and physical mis-
ing its significance are ambivalent. State agencies treatment (see Chap. 30 for further discussion of
(e.g., APS; Teaster et al. 2006) and empirical social isolation).
studies concentrating on specific types of abuse Gender. In the general older adult population,
(e.g., sexual, financial) have identified adults older women are more likely to be victimized
aged 75 and older as being particularly suscep- than older men (Hightower 2004; Wisconsin
tible to mistreatment (Burgess et al. 2000; Met- Coalition Against Domestic Violence 2009;
Life Mature Market Institute2011). National Krienert et al. 2009). Higher rates of older
17 Mistreatment and Victimization of LGBT Elders 347
women who experience mistreatment may be physical abuse, neglect, and financial abuse and
attributed to their longer life span (and the exploitation of older adults (see Chap. 33 for
associated vulnerabilities mentioned above), additional information on LGBT elders and
which may provide the occasion to be in contact disabilities).
with potential abusers (Krienert 2009). Women Cognitive Impairment. Changes in cognitive
are subjected to higher rates of family violence functioning also have been associated with
across their life span than men. This fact, toge- increased risk of physical abuse, emotional abuse,
ther with research by Acierno et al. (2010) caregiver neglect, and financial exploitation. In a
revealing that previous exposure to a traumatic study of 8932 older adults in Chicago, of which
life event (e.g., interpersonal and domestic vio- 238 were identified as victims of elder abuse by
lence) increases an elder’s risk of late life mis- social service professionals, Dong et al. (2011)
treatment, may explain how vulnerabilities noted that several types of age-related cognitive
related to gender and power dynamics create a changes contributed to elder abuse risk. After
component of risk for elder abuse (Wisconsin controlling for other known risk factors (e.g.,
Coalition Against Domestic Violence 2009). medical conditions, depressive symptoms, and
Race. In addition to gender, Lachs et al. (1997) little social support), lower levels of global cog-
found that race was a risk factor for mistreat- nition, higher dementia severity, lower levels of
ment: more black elders appeared at risk for episodic memory, and slower perceptual speed
mistreatment than their white counterparts. were all independently associated with an
However, the authors acknowledged that a limi- increased risk of abuse. Cognitive impairment
tation of their findings was their use of APS cases increases exponentially with age and is perhaps the
as the unit of analysis. Similarly, Tatara (1999) most pervasive and salient risk factor for financial
found that black and Hispanic elders were over- abuse and exploitation (Sherod et al. 2009).
represented in data on elder abuse victims (31 Other risk factors. Additional risk factors for
state APS systems), whereas nearly one in three the general population of elders were examined
victims known to authorities was a minority by Acierno et al. (2010) who found that 45.7 %
elder. Different cultures and how they define and (2262) of respondents self-reported low house-
approach elder mistreatment may serve to protect hold incomes, 80.9 % (5174) were unemployed
or promote the occurrence of a minority elder’s or retired, 22.3 % reported poor health, 62.0 %
risk for mistreatment (DeLiema et al. 2012; had experienced a previous traumatic event,
Horsford et al. 2010). 43.6 % perceived their social support as low,
Physical health. Poor overall health and dis- 40.8 % used some form of social services, and
abilities that impair an elder’s ability to self-care 37.8 % needed some assistance with activities of
may exacerbate his or her risk for abuse. daily living.
According to Laumann et al. (2008), older adults In the Lifespan of Greater Rochester study
who reported any type of physical vulnerability (2011), for victims for whom respondent
were 13 % more likely to report verbal mis- agency/programs reported about living arrange-
treatment than study participants who reported ments, 45.8 % lived alone, 16.9 % lived with
none. Similarly, Acierno et al. (2010) reported spouses or partners, 17.3 % lived with adult
that the likelihood of financial exploitation by children, 7 % lived with sons-in-law or
both family members and strangers increased for daughters-in-law, 6.3 % lived with grandchil-
older adults with more severe physical disabili- dren, 4.7 % lived with other relatives, and 8.8 %
ties and that poor health predicted neglect. Fur- lived with other non-relatives. Over three-fourths
ther analysis of these data by Amstadter et al. of agencies were unable to provide incomes of
(2011) revealed that the need for assistance with reported victims; however, for the 17.4 % who
activities of daily living and poor health status could report this information, 59.3 % of victims
were significant correlates of emotional abuse, were living at or below the poverty threshold.
348 P.B. Teaster and A.E. Sokan
Remedies
• How might everyone involved be
prepared? Legal Remedies. LGBT elders who are victims
of mistreatment have some remedies available to
them; however, they are not without real costs.
In a national study of APS by Teaster et al. For mistreatment that is criminal in nature, a
(2006), with data from eleven states, 52.7 % of court case could be protracted, and upon all the
perpetrators were female. For the seven states information presented, the result could be that the
reporting ages for alleged perpetrators, 4.3 % perpetrator receives little or no punishment.
were under 18 years of age, 10.6 % were 18–29, Courts may be reticent to execute restraining
16.1 % were 30–39, 25.6 % were 40–49, 18.5 % orders for the harassment of LGBT elders in IPV
were 50–59, and 11.2 % were 60–69. Among cases. Furthermore, for those elders hitherto in
those that provided information on the relation- the closet, pursuing a legal remedy may result in
ship of the perpetrator to the victim, the most more exposure of the victim’s status as LGBT,
common was that of adult child (32.6 %), fol- and consequently to further discrimination and
lowed by other family member (21.5 %), unequal treatment. In the USA, states have laws
unknown relationship (16.3 %), and that address the mistreatment or abuse of elders,
spouse/intimate partner (11.3 %). both community dwelling and those who reside
Ramsey-Klawsnik et al. (2008) discussed in institutions. These laws are varied and may be
research findings concerning 119 alleged sexual statutes, which are part of APS laws, or distinct
perpetrators reported to state authorities for laws criminalizing elder mistreatment. In addi-
abusing elderly individuals residing in care facil- tion, basic or general criminal laws such as those
ities. The largest group of accused was employees relating to assault, battery, manslaughter,
of the facilities, followed by facility residents, or murder may be used to prosecute acts against
followed by victims’ family members and visitors older adult victims (Heisler and Stiegel 2002;
to the facilities. Upon investigation by APS and AARP 2012). Elder victims may also bring civil
regulatory staff, 32 individuals were confirmed as suits against perpetrators. Remedies available to
sexual perpetrators against vulnerable elders. elder mistreatment victims include restraining
Male and female alleged and confirmed sexual orders, punitive damages, compensation, and
perpetrators were identified as well as both male restitution for losses incurred and/or damages
and female elderly sexual abuse victims. suffered (National Center for Victims of Crime
In a study of APS in the state of Kentucky in 1999).
press found that no differences existed between In some states, special laws exist that provide
number of male and female perpetrators when the enhanced penalties for crimes against older
sex of the perpetrator was identified. For the 96 adults, including mistreatment, designed to deter
victims (excluding self-neglect and guardian- such crimes. For instance, in Nevada, the term of
ship), 37.0 % of perpetrators were adult children, imprisonment for a crime against a person aged
30.4 % were staff members in facilities, and 60+ may be double the prescribed term for the
14.1 % were spouses or a significant other. Other offense; in Louisiana, the minimum sentence for
less frequently occurring perpetrators were sib- any violent crime against an older adult is five
lings (5.4 %), niece/nephews and grandchildren years without parole, and in Georgia, enhanced
(3.2 %, each), and other perpetrators (6.5 %). penalties exist such as recovery of punitive in
Though as yet highly infrequently utilized by the addition to actual damages suffered, for those
justice system, states are continuing to develop found guilty of deceptive business practices
remedies for the crime of mistreatment of elders, involving elders (National Center for Victims of
which are discussed in the following section. Crime 1999).
352 P.B. Teaster and A.E. Sokan
Other than laws regarding elder abuse and Table 17.1 States with laws addressing hate or bias
mistreatment, certain general criminal laws, such crimes based on sexual orientation and gender identity
as laws against hate crimes or “bias crimes,” are California Colorado Connecticut Delaware
applicable to victimized LGBT elders (Morrow District of Hawaii Maryland Massachusetts
2001). Hate crimes are defined as crimes where Columbia
the perpetrator’s conduct was driven by bias, Minnesota Missouri Nevada New Jersey
prejudice, or hatred on the basis of actual or New Oregon Vermont Washington
perceived notions of an individual or group’s Mexico
status regarding race, color, religion, national Source Human Rights Campaign (2013). Available at
origin, ethnicity, gender, or sexual orientation www.hrc.org/statelaws
(US Congress 1992). Clearly, LGBT elders fall
within this definition, subject as they often are to tougher penalties and consequences on convicted
heterosexism and homophobia that may place offenders, increasing requirements for mandatory
them in environments that may be fearsome, reporting of offenses, providing training for
dangerous, or hostile (Cahill and Smith 2002). professionals—legal, social, health, criminal
States with bias crime laws often have enhanced justice, and law enforcement to help enhance
penalties, such as harsher sentencing for these prosecution (National Center for Victims of
crimes, because bias/hate crimes cause harm to Crime 1999). In addition, it is important to
and/or increase vulnerability of already disad- increase public awareness and sensitivity about
vantaged individuals or groups, as well as to the vulnerability of LGBT elders as victims of
discourage hate and bias or prevent such crimes abuse and mistreatment, both by virtue of age
(Lawrence 2002). Although all states in the USA and LGBT status.
have some form of hate or bias law, with a
majority including enhanced penalties, as
Table 17. 1 shows, less than one-third have laws Policy Box: Commission for LGBT
that deal with bias or hate crimes based on the Senior Affairs
sexual orientation and gender identity (Human Your local county and city government
Rights Campaign 2013; Leiberman 2010; Lead- recently set up a commission for senior
ership Conference on Civil Rights Education affairs as part of a broader initiative to
Fund (LCCREF) 2009). make the area a livable community and
In these states, laws with enhanced penalties address the needs of its aging population.
may provide remedies to LGBT elders including As a long-term care ombudsman, you are
right to pursue civil action in addition to criminal aware of many of the concerns faced by
penalty and harsher sentencing for offenders older adults in facilities within the county.
(Lawrence 2002). Although the remedies identi- One such challenge relates to the safety
fied above may provide some relief for elder and well-being of elderly LGBT residents
LGBT victims of mistreatment, whether under who suffer discrimination and abuse in
mistreatment laws, general criminal laws, or LTC facilities from staff and residents. You
hate/bias crime laws, more still needs to be done. would like to craft a policy for consider-
In order to provide appropriate protection from ation by the seniors’ commission, requiring
harm as well as to redress or ameliorate harm if LTC facilities to consider the unique needs
and when it does occur, the development of of LGBT residents.
policy initiatives and strategies will be necessary.
Such initiatives and strategies will need to • What factors should be considered in
address increasing the number of states with laws creating this policy? Why?
against sexual orientation or gender • Explain your rationale for targeting
identity-related hate crimes, imposing stiffer or LGBT elders specifically.
17 Mistreatment and Victimization of LGBT Elders 353
old issues of being ostracized or mistreated solely 2. How might agencies and programs better
because of one’s sexual preference could be less intervene in the abuse of LGBT elders?
tolerable than enduring the abuse. Even if an 3. What are risk factors for elder mistreatment?
elder discloses what was previously disclosed, How might these differ for LGBT elders?
many service systems and providers are, as yet, 4. What are the differences between LBGT elder
untrained and unsympathetic for the elder’s mistreatment in community settings and
plight and thus the intervention offered may do facility settings?
more harm than good. These authors stress that it
is high time to include LGBT issues in research
on elder abuse in order to understand incidence Experiential Exercise
and prevalence of the problem in this commu-
nity, to characterize victims and perpetrators, to Arrange a group screening of GenSilent, a doc-
delineate and bolster available remedies, to con- umentary on LGBT elders available from http://
duct meaningful research and advocacy, and, stumaddux.com/GEN_SILENT.html.
most importantly, to improve the quality of life
of present and future LGBT elders. 1. What issues or concerns are raised in this
documentary?
2. Identify factors which may increase or trigger
elder abuse/mistreatment potential.
Summary 3. What strategies would you recommend to
ameliorate the situation? Explain?
The mistreatment and victimization of older
LGBT adults are slowly coming to light in both
practice and research. However, at this point, few
studies examine this phenomenon. What is cer-
tain is that being LGBT may place elders at Resources
increased risk for mistreatment due to factors
such as isolation, previous exposure to a trau- AARP’s Pride Homepage: This is AARP’s
matic event, and reticence to seek assistance online home for the lesbian, gay, bisexual, and
from informal and formal networks. Penalties for transgender (LGBT) community. The page is
elder mistreatment must be utilized by law designed to spotlight articles on news, personal
enforcement more frequently, and statues that finance, relationships, travel, and other topics of
explore elder mistreatment as a hate crime also concern to older gay Americans, and their family
explored. It is critical that advocates, practitio- and friends (http://www.aarp.org/relationships/
ners, researchers, and policy makers understand, friends-family/aarp-pride.html?cmp=RDRCT-
intervene in, and prevent the mistreatment of PRID_MAY10_011).
LGBT elders. CenterLink: The Community of LGBT Cen-
ters: This is the community of LGBT centers
exists to support the development of strong,
sustainable LGBT community centers and to
Learning Exercises build a unified center movement (www.
lgbtcenters.org).
Self-Check Questions Eldercare Locator: Searchable database from
the Administration on Aging on issues such as
1. Why is there so little information available on Alzheimer’s, caregiving, elder abuse, Financial
victims of mistreatment who are LGBT Assistance, Food and Nutrition, Health Insur-
elders? How might researchers go about ance, Healthy Aging, Home Repair and Modifi-
researching this issue? cation, Housing, In-Home Services, Legal
17 Mistreatment and Victimization of LGBT Elders 355
Assistance, Long-Term Care, Nursing Home, healthy and respectful of human diversity (www.
Transportation, Volunteerism (www.eldercare. community.pflag.org/).
gov/). Prime Timers Worldwide: The Prime Timers is
Family Equality Council: The Family Equality a social organization that provides older gay and
Council is America’s foremost national advocate bisexual men the opportunity to enrich their lives.
dedicated to family equality for lesbian, gay, Prime Timers are older gay or bisexual men (and
bisexual, and transgender (LGBT) parents, younger men who admire mature men). Their
guardians and allies. It has grown into the leading members are men who choose to have their social
policy advocate on federal and state issues that lives enriched by the diverse activities in which
impact today’s modern families, including foster our members engage. No single definition can
care and adoption, safe schools, family medical describe Prime Timers, as they come from all
leave, parenting protections, domestic partner- walks of life. Prime Timers involve themselves in
ship, and marriage (www.familyequality.org/). their community with volunteerism, politics, gay
LGBT Aging Issues Network: American Soci- issues, arts, entertainment, and every other facet
ety on Aging’s constituent group who are pro- of healthy living (www.primetimersww.org).
fessionals working to raise awareness about the
concerns of lesbian, gay, bisexual, and trans-
gender (LGBT) elders (www.asaging.org/lain). References
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aarp/aarp_policies/2011_04/pdf/Chapter12.pdf
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The Prevalence of Elder Bullying
and Impact on LGBT Elders 18
Robin P. Bonifas
Abstract
This chapter reviews bullying and relational aggression among LGBT
older adults. The intent of this chapter is to define and characterize late-life
bullying in general and discuss unique manifestations of this phenomenon
for LGBT elders. Special attention is given to peer victimization
associated with intersectionality and microaggressions for this population,
as well as common types of bullying and the impact bullying experiences
have on emotional well-being and quality of life. Promising interventions
to minimize bullying related to sexual orientation and gender identity in
senior living environments are discussed and include civility training,
bystander intervention, and policies and procedures that guide respectful
social interactions and prohibit discriminatory actions.
Keywords
Bullying Relational aggression Peer victimization Micro aggression
Organizational intervention
orientation (Bonifas 2011; Fredriksen-Goldsen The act of bullying may involve but is not lim-
et al. 2011). Because individuals who are per- ited to force, threat, insult, coercion, gossip, or
ceived as different from the dominant population abuse. Although bullying may involve abuse, it
often become targets for bullying, it is likely that is distinctly different in several ways. An
LGBT older adults experience negative peer important difference between the two is who is
interactions on a regular basis and face associated engaging in the negative behavior or aggressive
negative outcomes. The purpose of this chapter is act and who is on the receiving end of it. With
to orient readers to the current state of knowledge elder abuse, the victim is a vulnerable adult,
regarding bullying and relational aggression as it typically in a position of dependency on a
applies to LGBT elders, with emphasis on under- non-vulnerable abuser for some type of personal
standing the phenomenon itself and relevant points care or instrumental assistance, such as bathing
of intervention. The chapter begins with a defini- or financial management. With bullying, both the
tion of bullying and relational aggression, contin- bully and the target of bullying are vulnerable
ues with a review of the characteristics of these adults, and the victim is not dependent on the
phenomena among older adults, and follows with bully for any type of care or assistance. See
a discussion of bullying and relational aggression Chaps. 16 and 17 for a comprehensive discussion
in the context of intersectional LGBT aging, of elder abuse and mistreatment.
drawing on extant research to illustrate prevalence, Bullying of and by elders is a growing problem,
incident characteristics, and negative outcomes. especially for LGBT elders. For example, studies
The chapter concludes by presenting a promising suggest that approximately 20 % of older adults in
framework to guide intervention and service community living settings report experiencing
delivery to this population. some type of bullying since moving in (Bonifas
2011; Trompetter et al. 2011). While there are no
exact statistics on the number of LGBT elders who
are bullied, rates of overall victimization are high
Learning Objectives (Fredrikson-Goldsen et al. 2011). For example, in
long-term care settings, 38 % of individuals who
By the end of the chapter, the reader should be experienced some type of mistreatment were
able to: LGBT; the most common type of mistreatment
was verbal or physical harassment by other resi-
1. Understand the definitions and characteristics dents (National Senior Citizens Law Center 2011).
of elder bullying. Bullying can have serious consequences for
2. Identify bullying tactics used against LGBT LGBT elders, including problems with sleeping,
elders. reduced sense of safety, social isolation, fearful-
3. Describe promising interventions to minimize ness, anxiety, and depression.
bullying of LGBT older adults.
Background: Understanding
Late-Life Bullying and Its Impact
Introduction on Older Adults
beyond this definition to include the experience Physical bullying. Physical bullying includes
of “persistent negative interpersonal behavior” actual bodily contact with the target or the target’s
(Rayner and Keashly 2005, p. 271) that is belongings, including pets. Example behaviors
directed at a specific individual or a group of include pushing, hitting, kicking, destroying
individuals. Within these intersecting definitions, property, or stealing. Hitting can be with a hand, a
three specific types of bullying are recognized: closed fist, or a mobility aid, such as a cane. An
verbal, antisocial or relational, and physical. example of this type of bullying is described in
Verbal Bullying. Verbal bullying refers to the Reese’s (2012) article for ABC News, which
use of words to intimidate or otherwise usurp reports 71-year-old Bernadine Jones’1 bullying
another’s power. Example behaviors include experiences as instigated by her 87-year-old
name-calling, malicious teasing, hurling insults, neighbor, Maria Zuravinski. A resident of a
taunting, threatening, or making sarcastic senior housing community, Ms. Jones stated that
remarks or pointed jokes. For example, George, a she was working in the community’s garden
resident of an assisted living facility, described when “Zuravinski approached her one day and
threatening remarks he regularly endured from a accused her of disturbing some of her personal
co-resident: “There’s one that tries to be the plants…the confrontation escalated when Zura-
number one tough guy. [He comes up] to me vinski began yelling at her, calling her names, hit
[and says] ‘One of these days, I’m gonna smack her with her cane and then spit on her” (p. 2).
you with a hammer’” (Bonifas 2011). While it Reese goes on to explain that Ms. Jones contin-
was unclear as to whether the aggressor actually ued to be subjected to similar behaviors from her
possessed a hammer and intended to use it, neighbor; at one point, Ms. Zuravinski even
nevertheless, the threat alone contributed to attempted to strike Ms. Jones’ dog with her cane.
considerable emotional distress for George. Peer behaviors older adults find most
Antisocial or Relational Bullying. Antisocial problematic. In a study of negative social rela-
or relational bullying involves behaviors that are tionships and bullying in assisted living settings,
intended to hinder another’s social relationships residents described the types of peer behaviors
or limit their social connections; it can either be and interaction patterns they found most dis-
verbal or nonverbal. During late-life, bullying tressing; results are listed in Table 18.1 (Bonifas
often takes this form (Trompetter et al. 2011; and Kramer 2011).
Hawker and Boulton 2000). Example behaviors What is noteworthy about the peer behaviors
include shunning, excluding, or ignoring; gos- and interaction patterns identified as most prob-
siping; spreading rumors; and using negative lematic is that some fit the definition of bullying
nonverbal body language, such as mimicking and victimization described above (i.e.,
someone’s walk or disability, making offensive name-calling, gossiping, and physical aggres-
gestures or facial expressions; purposely turning sion), while others align with the concept of
one’s head or body away when the target speaks, microaggression described by Sue (2010): “brief
using threatening body language, or purposefully and commonplace daily verbal, behavioral, and
encroaching on personal space. John’s experi- environmental indignities, whether intentional or
ence provides an example of shunning behavior: unintentional, that communicate hostile, deroga-
after relocating to senior housing in another state tory, or negative racial, gender, sexual orienta-
following the loss of his home during Hurricane tion, and religious slights and insults to the target
Katrina, several residents of his senior apartment person or group” (p. 5). This definition certainly
complex began spreading rumors that he was a fits negative social interactions such as exposure
longtime homeless man and was the first in a
deluge of formerly homeless people who were 1
Throughout this chapter, when first names are used, the
going to be “dumped” into their building. As a
name is fictitious; when full or last names are used, the
result, other residents began to avoid him (Bon- name is actually the individual’s name as reported in a
ifas and Frankel 2012). publically accessible resource.
362 R.P. Bonifas
Table 18.1 Peer social interaction patterns older adults Table 18.2 Examples of the emotional impact of
report as the most distressing late-life bullying
1. Exposure to loud arguments in communal areas 1. Anger/annoyance
2. Being the focus of name-calling and disparaging 2. Intense frustration
remarks 3. Fearfulness
3. Being the focus of gossiping and rumor-spreading 4. Anxiety/tension/worry
4. Being bossed around or told what to do 5. Retaliation followed by shame
5. Negotiating value differences, especially related to 6. Self-isolation
diversity of beliefs stemming from differences in
culture, spirituality, or socioeconomic status 7. Exacerbation of mental health conditions
6. Competing for scarce resources, especially seating, 8. Reduced self-esteem
television programming in communal areas, and staff 9. Overall feelings of rejection
attention
10. Depressive symptoms, including changes in eating
7. Being harassed to loan money, cigarettes, or other and sleeping
commodities
11. Increased physical complaints
8. Not being able to avoid listening to others complain
12. Functional changes, such as decreased ability to
9. Experiencing physical aggression manage activities of daily living
10. Witnessing psychiatric symptoms that are 13. Increased talk of moving out
frightening or disruptive
14. Suicidal ideation
to loud arguments (#1), listening to others com- individuals who are exposed to the bullying
plain (#8), and witnessing disruptive psychiatric experiences of others, but who are not victimized
symptoms (#10). Microaggressions contribute to themselves report deleterious outcomes. For
harm when no harm is intended, particularly example, one assisted living resident described
related to negative emotional outcomes such as how co-residents’ yelling at one another kept him
reduced self-esteem and lowered self-worth (Sue awake at night, not only because of the noise
2010). In addition, microagressions reflect the disruption, but also because of his fears of
overall milieu of an environment, including per- potential escalating violence. He stated, “It is the
vasive negativity and bias toward certain indi- uncertainty of what [they] are going to do that I
viduals and groups. This is relevant for older find most unsettling” (Bonifas 2011). Fearfulness
LGBT individuals who are often faced with subtle and self-isolation are only two examples of the
heterosexism and homophobia (Erdley et al. negative ramifications of bullying; Table 18.2
2014). As such, microaggressions are considered depicts additional common reactions. Items 1
as a type of bullying throughout this chapter. through 7 are from research conducted by Bonifas
The emotional impact of late-life bullying. (2011), and items 8 through 14 where identified
Contrary to the childhood adage “sticks and by Frankel (2012) during her practice experience
stones may break my bones, but names will never of working with a senior care organization to
hurt me,” older individuals who are the targets of address bullying among older adults.
bullying are significantly impacted by their peers’
negative behaviors. Verbal and antisocial behav-
iors are more common than physical violence, but The Impact of Bullying
all types of bullying negatively affect those who and Relational Aggression on LGBT
experience them. Mrs. Jones, mentioned in the Elders
Reese (2012) news article above, reported feeling
so distressed by her neighbor’s behavior that she As noted above, no research to date has focused
was “afraid to go out [her] door.” She explained, exclusively on the bullying experiences of LGBT
“I have to look out before I leave” (p. 2). Even older adults; however, research on victimization
18 The Prevalence of Elder Bullying and Impact on LGBT Elders 363
relationships in assisted living, he noted that illustrates the emotional impact of bullying
other residents viewed homosexuality with “a lot experiences. Among 28 assisted living residents
of personal hate and fear” and surmised genera- in the sample, one participant self-identified
tional differences played a role in such biases, himself as a gay man. He shared his experi-
explaining “It’s a generational thing…younger ences of co-residents’ verbal harassment associ-
people accept gay people and lesbians; people ated with his sexual orientation and the emotional
my age don’t” (Bonifas 2011). Exposure to pain stemming from repeatedly being referred to
pervasive homophobia in the overall living as a “fag” by his peers (Bonifas 2011). He stated,
environment took its toll on Glen. For example, “It really hurt, like being stabbed in the heart.”
several straight men in the study reported bully- The verbally abusive comments and pervasive
ing experiences that involved being taunted with negativity directed toward his sexual orientation
accusations of being gay; these accusations were contributed to difficulties managing underlying
viewed as highly insulting and the topic of angry mental health issues; he believed that subsequent
debate in communal areas. Glen described what emotional distress fostered behavioral decom-
it was like to regularly hear the outrage of peers pensation, especially related to depression asso-
who felt the ultimate insult was an insinuation ciated with a bipolar condition (Bonifas 2011).
that they were like him. “I got down, really The impact of negativity toward homosexuality
down…it was really, really unfair to say some- cannot be underestimated. For example, as noted
thing like that to be mean, it was awful” (Bonifas above, fears related to the possibility of an
2011). intolerant and homophobic environment contrib-
The characteristics and prevalence of bul- ute to LGBT elders’ reluctance to enter senior
lying among LGBT older adults. While the housing and long-term care facilities (Stein et al.
number of LGBT older adults who experience 2010). Many LGBT seniors are concerned with
bullying and other forms of peer victimization is having to return to the closet in order to be
unknown, Caring and Aging with Pride: The accepted by peers, which is a prospect they wish
National Health, Aging and Sexuality Study to avoid (Sullivan 2014). Similarly, LGBT elders
(CAP) provides evidence for the existence and may experience involuntary outing as a form of
extent of bullying experiences among older bullying; this can lead to significant distress,
LGBT people (Fredriksen-Goldsen et al. 2011). especially for individuals who prefer not to dis-
Study participants reported high rates of victim- close their sexual orientation due to fear of dis-
ization stemming from their actual or perceived crimination or biased treatment in health and
sexual orientation or gender identity. Indeed, social services settings (Erdley et al. 2014).
among the national sample of 2560 LGBT older Policy implications of bullying among
adults, 82 % indicated they had experienced LGBT older adults. As readers may surmise
victimization at least once, and 64 % reported from the limited research on bullying among
numerous incidents of victimization LGBT elders, at this writing there is no legisla-
(Fredriksen-Goldsen et al. 2011). Victimization tion that addresses bullying prevention for this
included behaviors associated with bullying: population group. What is more, there is no
physical assault, property damage, threats of legislation that addresses late-life bullying for
being outed,2 threats of physical violence, and any segment of the older adult population!
verbal assault. However, elder abuse laws, regulations for
The impact of bullying among LGBT older nursing home resident rights, and anti-
adults. A small-scaled study of negative social discrimination legislation do provide some level
relationships in assisted living facilities provides of protection. For example, the following
additional evidence of LGBT bullying and behaviors are addressed by legislation prohibit-
ing elder abuse: physical abuse, emotional abuse,
2
Having their sexual orientation or gender identity sexual abuse, and financial exploitation (National
revealed to others against their will. Center on Elder Abuse, n. d.). Federal legislation
18 The Prevalence of Elder Bullying and Impact on LGBT Elders 365
Table 18.4 Assisted living residents’ suggestions to addressing bullying in their living environments;
address late-life bullying their valuable suggestions are listed in
1. Offer residents or tenants onsite anger management Table 18.4.
classes
2. Set limits with people who bully or “pick on” others
3. Hold regular meetings to promote resident
communication An Intervention Framework
4. Develop rules and expectations that guide acceptable to Reduce Late-Life Bullying
resident behaviors Among LGBT Elders
5. Foster partnerships between residents and facility
management for prevention and problem resolution In this author’s experience, many people view the
individual who bullies as the primary problem
requiring a solution to prevent bullying incidents.
Outcome studies are also needed to determine However, intervention at the organizational level
the impact bullying experiences have on LGBT is the most crucial. Bullying behavior is less
elders’ emotional well-being and quality of life. likely to occur in settings where it is not tolerated
While bullying is consistently associated with and where active steps are taken to both prevent
negative outcomes across the life course, differ- and minimize it. This section reviews promising
entiating outcomes that are unique to LGBT interventions to address LGBT bullying using
elders is warranted given that their life experi- senior housing organizations such as retirement
ences diverge from their heterosexual counterparts apartments, assisted living facilities, and nursing
(Sullivan 2014). The intersectionality of LGBT homes as a backdrop.
aging further supports the necessity of outcome Organizational interventions. Interventions
research whereby LGBT seniors may experience at the organizational level emphasize approaches
disporportionally deleterious effects from bullying that will foster the creation of a caring commu-
due to the conjoint vulnerabilities of age, sexual nity. As identified by Sullivan (2014), acceptance
orientation, chronic illness, and disability (Barker from others in the communal environment is
2008; Fredriksen-Goldsen et al. 2011). paramount to LGBT elders’ emotional
Findings from both descriptive and outcomes well-being. At this level, both residents of the
studies can subsequently inform the development setting and employees of the setting need to work
of interventions to prevent bullying of older LGBT together to promote a pervasive climate of
individuals and minimize the potential for negative equality and respect; all disciplines from man-
outcomes when it does occur. Small-scale inter- agement to direct care staff to maintenance
vention testing is currently underway to evaluate workers can contribute to an organizational
the effectiveness of approaches to minimize milieu that promotes a feeling of safety and
late-life bullying for older adults in general. See the belonging. Key elements for creating a caring
following section for a brief review of the work of community include policies and procedures that
Marsha Frankel and colleagues to promote guide behavioral and social interactions,
bystander intervention among older adults and tenant/resident and employee training that fosters
Alyse November’s work to prevent bullying in inclusiveness and empathy, and environmental
retirement settings. As similar intervention research elements, such as signage, that reflect respect for
expands to larger samples, a specific focus on diversity.
effectiveness for LGBT individuals will help Policies and procedures guiding social
identify modification strategies that can tailor interactions. Policies and procedures guiding
approach to individualized needs. appropriate social interactions are the most useful
Assisted living residents have given their when conjointly developed by tenants/residents
input into the types of organizational-level poli- and management. To ensure that identified
cies that are most important to them in behaviors reflect LGBT elders’ needs, active
18 The Prevalence of Elder Bullying and Impact on LGBT Elders 367
Table 18.5 Exemplary behaviors to include in policy of an overall caring community approach that
and procedure statements (DSACF, n. d.) protects residents and staff, including those who
1. Pay attention are LGBT; and (6) bystander intervention skills.
2. Listen Bystander intervention training involves
3. Be inclusive teaching people who witness bullying incidents
4. Avoid gossip how to effectively intervene to stop the behavior.
Alcon et al. (2014) developed a training program
5. Show respect
to help older adults take action to reduce social
6. Be agreeable
bullying that occurs in their housing communi-
7. Apologize ties. Building on the idea that most bullying
8. Give constructive criticism occurs in the presence of peer witnesses, this 60-
9. Take responsibility to 75-min training aims to enable older adults to
understand what social bullying is, differentiate it
from everyday negative behaviors, and learn
efforts need to be made to include their voices in steps they can personally take to minimize bul-
explicitly stating what types of social interaction lying directed at them or at their peers.
patterns are prohibited. Statements that promote The training intervention has three compo-
respect for diversity should specifically mention nents: (1) an overview of late-life bullying,
sexual orientation and gender identity as exam- (2) discussion of the cycle of bullying and the
ples. In tandem with prohibited behaviors, a list role of bystanders in prevention, and (3) learning
of corresponding behaviors that are encouraged and practicing skills to thwart bullying. The
is helpful to inform tenant/residents and overview component first engages participants
employees as to what is acceptable. Table 18.5 by asking them to reflect on the question “What
lists some examples of positive behaviors sug- do you think of when you hear the term ‘bully-
gested by Speak Your Peace: The Civility Project ing?’” Facilitators then formally define bullying,
sponsored by the Duluth Superior Area Com- detail the nature of bullying among older adults,
munity Foundation (DSACF). including the characteristics of bullies and tar-
Tenant/resident and employee training. In gets, and describe how bullying impacts seniors
addition to policies and procedures that govern and their living communities. The cycle of bul-
respectful social interactions, both lying is then explained, as depicted in Table 18.6,
tenants/residents and employees require training and emphasis is placed on how both bystanders
in how to effectively adhere to the policies. Just and victims can intervene to disrupt the cycle.
because a policy statement dictates that everyone Intervention involves standing up to the
in the community should be treated with respect individual who bullies by first recognizing that
does not mean that people comply! Important the problem resides with him or her, then mak-
elements of a bullying prevention training pro- ing direct eye contact, responding calmly in a
gram include (1) an overview of the bullying and manner that defends the victim, challenges the
its characteristics in late-life with emphasis on bully’s behavior, or redirects his or her negative
uniqueness of diverse groups including LGBT
elders; (2) understanding organizational policies
and procedures for addressing bullying and Table 18.6 The cycle of bullying (Alcon et al. 2014)
relational aggression between tenants/residents; 1. Bully targets victim or victims
(3) responding to tenants/residents who bully 2. Supporters and followers participate in the bullying
without violating individual rights, for example,
3. Victim and onlookers do not intervene
limit-setting, nonviolent communication, and
4. Bully is empowered to continue his or her behavior
promoting strategies that retain power in healthy
ways; (4) how and when to make a report 5. Onlookers do not intervene
regarding problematic behavior; (5) assurances 6. Cycle of bullying continues to repeat
368 R.P. Bonifas
behavior, and then disengaging. The workshop “Empathy Leaders” each month to recognize
involves role-play demonstrations of thwarting tenants/residents and staff who have been espe-
bullying using these strategies and offers partic- cially compassionate to vulnerable individuals
ipants the opportunity to practice new skills. To and groups. Such activities send the message that
specifically address bullying among LGBT older caring and empathy are effective ways to achieve
adults, the model by Alcon et al. (2014) could be recognition, which aid in creating a feeling of
modified to involve employees as well as acceptance and safety for LGBT older adults.
tenant/residents and include a role-play scenario At the same time, it is important to understand
that features bullying involving sexual orienta- that developing a caring community is a process
tion or gender identity minority status. Prepara- and organizational change may be slow.
tory content that sensitizes participants to this Improvements will not happen overnight, and
population’s needs would also be necessary. gains can only be made over time. Indeed, in one
Environmental elements that respect diver- assisted living facility, after beginning a com-
sity and promote inclusiveness. This type of munity culture change effort it was several
organizational intervention addresses the overall months before residents began to report feeling
milieu of the organization and includes specific more respect for diversity and for one another’s
attention to environmental features that promote perspectives (Personal communication, Dr. Jay
inclusiveness and safe spaces for LGBT older Hedgpeth, June 07, 2012).
adults. Such elements include some photos and
artwork that include positive images of same-sex
couples or transgender individuals, books and
magazines that cater to the LGBT community, Summary
and pamphlets and marketing materials for
inclusive health and social services organizations This chapter presented an overview of the current
in the community. To promote LGBT elders’ state of knowledge regarding bullying and rela-
feelings of acceptance, Sullivan (2014) draws tional aggression related to LGBT elders, with
attention to the importance of “reflecting LGBT emphasis on understanding the phenomena itself
seniors in published materials, including impor- and potential points of intervention. Bullying and
tant dates and events such as PRIDE month on relational aggression were defined; bullying was
agency calendars, [and] ensuring in-take forms characterized as repetitive aggressive behavior
are inclusive” (p. 244). Even basic symbols of involving an imbalance of power between the
inclusion and acceptance can create feelings of bully and the target of bullying, and relational
comfort for LGBT older adults, such as rainbow aggression was characterized as a type of bully-
stickers posted in offices (Erdley et al. 2014). ing that involves nonviolent relationship-based
Along with making the physical environment aggression. The chapter discussed how bullying
safe and inclusive, it is critical to incorporate manifests among older adults in general and how
strategies that increase caring and empathetic it is specifically exhibited among LGBT elders
behaviors throughout the organization. As posi- given this population’s multi-intersectional
tive behaviors increase, problematic interactions experiences. The negative impact of being bul-
will naturally diminish. Interventions can be lied in late-life was examined, with evidence of
fairly simple; for example, potential approaches reduced emotional well-being stemming from
might include (1) acknowledging members of the bullying experiences, with example outcomes
community that go out of their way to welcome including social isolation, anxiety, depressed
new tenants/residents and anyone who is per- mood, and pervasive fearfulness. For LGBT
ceived as “different,” including sexual orientation elders, relational aggression based on sexual
and gender identity minorities; (2) institute a orientation and gender identity and fears of
“Caring Squad” whose job is to notice acts of potential discrimination and bias were especially
kindness and reward them, and (3) nominate salient to the felt need to return to the closet upon
18 The Prevalence of Elder Bullying and Impact on LGBT Elders 369
6. Read how lesbian, gay, bisexual and trans- org; Equality Federation http://
gender aging issues are becoming federal equalityfederation.org; and PFLAG http://
concerns by Loree Cook-Daniels (2011) community.pflag.org
available at: http://forge-forward.org/wp-
content/docs/LGBT-federal-policy-changes.pdf
Multiple-Choice Questions
Association, American Health Care. (2006). The long National Center on Elder Abuse. (n. d.). What is elder
term care survey. Washington, D. C.: Author. abuse? Retrieved from http://www.ncea.aoa.gov/faq/
Barker, R. M. (2008). Gay and lesbian health disparities: index.aspx.
Evidence and recommendation for elimination. Jour- National Senior Citizens Law Center in collaboration with
nal of Health Disparities Research and Practice, 2, Lambda Legal, National Center for Lesbian Rights,
91–120. National Center for Transgender Equality, National
Bonifas, R. P. (2011). Understanding challenging social Gay and Lesbian Task Force and Services and
relationships in senior housing communities. Phoenix, Advocacy for GLBT Elders (SAGE). (2011). LGBT
Arizona: Unpublished raw data; Arizona State University. Older Adults in long-term care facilities: Stories from
Bonifas, R. P., & Frankel, M. (March, 2012). Is it the field. Retrieved from http://www.lgbtagingcenter.
bullying? Strategies for assessing and intervening org/resources/resource.cfm?r= 54.
with older adults. Workshop presentation at the Aging Pillemer, K., Mosqueda, L., & Castle, N. (November,
in America Conference of the American Society on 2014). Resident to resident elder mistreatment: Find-
Aging, Washington, D. C. ings from a large scale prevalence study. Symposium
Bonifas, R. P., & Kramer, C. (November, 2011). Senior presentation at the 67th annual scientific meeting of the
bullying in assisted living: Residents’ perspectives. In gerontological society of American, Washington D. C.
Poster presentation at the 64th annual scientific Rayner, C., & Keashly, L. (2005). Bullying at work: A
meeting of the gerontological society of America, perspective from Britain and North America. In S. Fox
Boston, Massachusetts. & P. E. Spector (Eds.), Counterproductive work
Cook-Daniels, L. (2011). Lesbian, gay, bisexual and behavior: Investigations of actors and targets
transgender aging issues become federal con- (pp. 271–296). Washington, DC: American Psycho-
cerns. Available at http://forge-forward.org/wp- logical Association.
content/docs/LGBT-federal-policy-changes.pdf. Reese, R. (March 22, 2012). Georgia woman, 87, accused
Erdley, S. D., Anklam, D. D., & Reardon, C. C. (2014). of bullying neighbor. ABC News. Available at http://
Breaking barriers and building bridges: Understanding abcnews.go.com/blogs/headlines/2012/03/georgia-
the pervasive needs of older LGBT adults and the woman-87-accused-of-bullying-neighbor/.
value of social work in health care. Journal of Stein, G., Beckerman, N., & Sherman, P. (2010). Lesbian
Gerontological Social Work, 57(204), 362–385. and gay elders and long-term care: Identifying the
Forni, P. M. (2002). Choosing civility: Twenty-five tools of unique psychosocial perspectives and challenges.
considerate conduct. New York: Saint Martin’s Press. Journal of Gerontological Social Work, 53, 42–435.
Fredriksen-Goldsen, K. I., Kim, H. J., Emlet, C. A., Sue, D. W. (2010). Microaggressions in everyday life:
Muraco, A., Erosheva, E. A., Hoy-Ellis, C. P., & Race, gender, and sexual orientation. Hoboken, NJ:
Petry, H. (2011). The aging and health report: Wiley.
Disparities and resilience among lesbian, gay, bixex- Sullivan, K. M. (2014). Acceptance in the domestic
ual, and transgender older adults. Seattle, WA: environment: The experience of senior housing for
Institute for Multigenerational Health. lesbian, gay, bisexual, and transgender seniors. Jour-
Hawker, S. S. J., & Boulton, M. J. (2000). Twenty years’ nal of Gerontological Social Work, 57(2–4), 235–250.
research on peer victimization and psychosocial Trompetter, H., Scholte, R., & Westerhof, G. (2011).
maladjustment: A meta-analytic review of Resident-to-resident relational aggression and subjec-
cross-sectional studies. Journal of Child Psychology tive well-being in assisted living facilities. Aging and
and Psychiatry, 41, 441–455. Mental Health, 15, 59–67.
Hazelden Foundation. (2011). Bullying is a serious issue.
Available at http://www.violencepreventionworks.org/
public/bullying.page.
Part IV
Health Care and Mental Health
Impact of Healthcare Reform
on LGBT Elders 19
Debra A. Harley
Abstract
The purpose of this chapter was to examine the impact of healthcare
reform in the USA on LGBT elders, especially the Affordable Care Act
(ACA). Attention is given to health disparities and coming out risk factors
for LGBT elders, health systems challenges for LGBT elders, advantages
and disadvantages of healthcare reform on LGBT elders, and future
directions of healthcare reform in the USA. Where appropriate, discussion
from an international perspective is included, especially Canada and the
UK. It is not the intent of this chapter to endorse any point of view over
the other or to be advisory about healthcare issues. The intent is to present
multiple perspectives concerning the benefits and debates of healthcare
reform on seniors, especially LGBT elders.
Keywords
Healthcare reform LGBT elders’ health LGBT health disparities
and stakeholders, (c) conflict between efficiency 3. Identify gaps in healthcare reform for LGBT
and fairness, (d) deep uncertainty about the elders.
future, and (e) political, social, and cultural 4. Identify future areas of need in healthcare
issues with regard to policy design and imple- reform and implementation for LGBT elders.
mentation (An et al. 2015). In the USA, health-
care reform has an extensive history with limited
change and impact until recently. In 2010, two
major federal statutes became law, the Patient
Protection and Affordable Care Act (PPACA) Introduction
and the Health Care and Education Reconcilia-
tion Act of 2010 (H.R. 4872), which amended Although the focus of this chapter is on healthcare
the PPACA. The purpose of this chapter was to reform, some discussion of healthcare concerns
examine the impact of healthcare reform in the and disparities of LGBT elders is referenced
USA, especially PPACA (more commonly throughout. LGBT elders are at risk of health
referred to as the Affordable Care Act [ACA]) on disparities from several perspectives, including
LGBT elders. In this discussion of the ACA, the minority stress as a sexual minority; a life course
term “Obama care” is not used due to its negative perspective in which events at each stage of life
political and bipartisan connotation, because it influence subsequent stages; legal, political, and
detracts from an examination of what is both social issues; an intersectionality perspective
beneficial and challenging about this legislation. because of multiple identities and the ways in
Attention is given to health disparities and which they interact; and the social–ecological
coming out risk factors for LGBT elders, health perspective in which older adults are surrounded
systems challenges for LGBT elders, advantages by spheres of influence such as families, com-
and disadvantages of healthcare reform on LGBT munities, and society (Ard and Makadon 2012;
elders, and future directions of healthcare reform Institute of Medicine [IOM] 2011). Overall,
for LGBT elders. Although the primary focus of research on the LGBT population and its health
this chapter is on healthcare reform in the USA, status throughout the life course is limited, with
whenever possible, discussion from an interna- more research focusing on gay men and lesbians
tional perspective, especially Canada and the than on bisexual and transgender persons, to a
United Kingdom, is also included. In addition, lesser extent on racial and ethnic minority groups,
this author does not intend to endorse any par- and even less attention on LGBT elders (IOM). In
ticular point of view or to be advisory about 2012, Health and Human Services Secretary
healthcare issues, but rather to present multiple Kathleen Sebelius applauded the ACA as “the
perspectives concerning the benefits and debates strongest foundation we have ever created to begin
of healthcare reform on older adults, especially to closing LGBT health disparities.” There is a
those who are LGBT. consensus in the literature that LGBT populations
have unique health experiences and needs; how-
ever, in the USA, we have not quantified the
Learning Objectives experiences and needs to know exactly what they
are (IOM; SAGE 2012). Nevertheless, we do
By the end of the chapter, the reader should be know that LGBT persons are more likely than their
able to: heterosexual counterparts to experience difficulty
in accessing health care (Ard and Makadon 2012).
1. Identify health risk and challenges for LGBT Before the passage of the ACA, the healthcare
elders. system in the USA was the most expensive in the
2. Understand the advantages and disadvantages world, yet delivered lower quality outcomes than
of healthcare reform legislation for LGBT systems of other industrialized countries (Saul
elders. 2009). The US counterpart, Canada, has the
19 Impact of Healthcare Reform on LGBT Elders 377
second most expensive healthcare system among consequences in healthcare services and other
industrialized countries with universal health sociocultural aspects. The first step in addressing
care (Barua and Clemens 2014). Once the LGBT Americans’ health disparities is ensuring
majority of the provisions of the ACA are that policymakers, medical professionals,
implemented, it is estimated that approximately healthcare workers, and social service providers
thirty million previously uninsured Americans have a clear understanding of those disparities.
will have access to health care (Congressional Federal health surveys are an essential tool in
Budget Office 2012). A key component of the determining how disparities and differences are
ACA, the Community Living Assistance Ser- recognized and addressed in subpopulations
vices and Supports (CLASS) Act, was designed (Rosenthal 2009). Healthcare reform legislation
to provide public voluntary long-term care contains a number of provisions to address
insurance, which could have helped to shield healthcare disparities (e.g., advisory councils,
elderly people from catastrophic out-of-pocket prioritize the elimination of health disparities,
costs, but was dropped in 2011. The primary develop a public health insurance option, expand
reason for discontinuing CLASS was challenges health data collection). Rosenthal stresses that
about financial viability (Kelley et al. 2013). LGBT health disparities in each of these areas
The healthcare reform debate includes argu- should be considered along with racial, ethnic,
ments representing the benefits and disadvantages and geographic disparities.
as well as mixed implications of healthcare reform Health disparities are increased with revealing
legislation. The view of those who espouse mixed one’s sexual orientation and sexual identity to
implications suggests that one has to expect healthcare providers because of discrimination,
negative aspects to any plan that takes monies out stigma, and poor quality of care. LGBT elders
of Medicare and that such a plan will invariably and their caregivers have faced discrimination in
going to cut some people’s benefits. In addition, the healthcare system for most of their lives.
the claim that ACA will close the “doughnut Both historical hostilities and current prejudices
hole” in Medicare Part D is not as generous as against LGBT populations have resulted in many
originally portrayed (Kaplan 2011). In essence, LGBT elders not revealing their identities to
ACA lowers a patient’s cost obligation for healthcare providers or delaying or avoiding
co-payment (i.e., the benefit), but it is not the seeking medical or mental health intervention
same as saying that individuals will not have any (Ard and Makadon 2012). Chapter 20 further
cost exposure whatsoever (Kaplan). Kaplan discusses the risk factors associated with both
stresses that enrollees in managed care disclosure and non-disclosure of sexual orienta-
(MC) plans are likely to be less satisfied with the tion and gender identity in the USA.
new law because MC plans will raise premiums or According to Baker and Krehely (2012),
may discontinue their participation in the program governments and service providers rarely track
altogether. In either case, the result will likely be health data on LGBT persons, resulting in its
higher costs, reduced benefits, and fewer options limited availability, which suggests that later life
for enrollees in Medicare managed care plans. carries unique health challenges for LGBT per-
sons, particularly in areas that have a high con-
centration of HIV/AIDS, mental health, and
chronic health conditions. See Chaps. 20, 23, and
Health Disparities and Coming Out 32 for further discussion on healthcare and sex-
Risk Factors for LGBT Elders ual practices, mental health counseling, and dis-
abilities among LGBT elders. In the study and
This section examines implications of health discussion of LGBT health disparities, the spe-
disparities for LGBT elders. Overwhelmingly, cific needs of transgender persons are seldom
the literature confirms the existence of health explored separately. From the 2011 National
disparities for LGBT elders and adverse Healthcare Disparities Report findings,
378 D.A. Harley
transgender persons (a) are more likely to be Toronto and The Centre in Vancouver that have
uninsured and less likely to have employer-based highly organized and advanced programs for gay
health insurance than the general population; and lesbian elders and their caregivers (Brotman
(b) postpone care when sick or injured and et al. 2007). Brotman et al. (2007) acknowledge
postpone preventive health care due to cost, that even with the efforts, policies, and practices
discrimination, and disrespect by providers, with of these organizations in addressing issues facing
female-to-male transgender persons being most gay and lesbian elders in Canada, they remain
likely to postpone care due to discrimination; and marginalized within mainstream health and
(c) one in five has been denied services by a social service agencies. The result is isolation
doctor or other provider due to their gender, with and invisibility of both LGBT persons and
racial and ethnic minority transgender persons caregivers in environments often marked by
being more likely to be denied services (Agency intolerance and avoidance.
for Healthcare Research and Quality 2012).
Of LGBT populations, transgender persons are at
greater risk of receiving inferior health care or
being denied health care because of their sexual Health Systems Challenges
identity (Fredriksen-Goldsen et al. 2011). In for LGBT Elders
addition, the number of clinicians who have had
knowledge or have received training about health Over 50 years ago, both the USA and Canadian
issues pertinent to transgender persons further healthcare systems were similar. Over time,
exacerbates their risk factors (Kaufman 2010). Canada moved toward a universal single-payer
Healthcare practitioners, for example, may not system that covers the majority of expenditures
realize that physical examinations or intimate and without co-payment or user fees for all
care are sources of extreme anxiety to transgen- medically necessary hospital and physician care
der adults, be unfamiliar with the outcomes of for all fully insured persons as required by the
less refined surgical techniques, which may result Canada Health Act. Over 90 % of hospital
in appearance of genitalia that are “abnormal,” expenditures and almost 100 % of total physician
and may not understand that physical examina- services are funded by the public sector (Library
tions and screening tests should be predicated on of Parliament Research, n.d.). It is important to
the organs actually presented instead of the note that the Canadian system provides pubic
appearance of the person (Feldman 2010; Kauf- coverage from a combination of public and pri-
man 2010). vate delivery and is not a system of socialized
LGBT elders and their caregivers face dis- medicine, but rather one of universal health care
crimination in the healthcare system, and het- (Barua and Esmail 2013). The USA and Turkey
erosexism effectively works to create obstacles to are the only two members of the Organization for
achieving full equality for LGBT persons (Brot- Economic Cooperation and Development
man et al. 2006). Greenesmith et al. (2013) offer (OECD) without some form of formal universal
a guide to understanding the benefits of ACA and health coverage. The OECD is an organization
LGBT families. The guide provides a basic that acts as a meeting ground for 30 countries
overview of the ACA, a review of how the act that believe in the free market system.
helps LGBT persons and their families, and an The OECD provides a forum for discussing
explanation of how the person and his or her issues and reaching agreements (www.oecd.org).
family can access affordable health insurance One of the major challenges the Canadian
(see the “Resources” section of this chapter under healthcare system facing is lengthy wait times for
the Center for American Progress for the location treatment, often months long and sometimes
of the guide). In Canada, two notable organiza- stretching over a year (Barua and Esmail 2013).
tions that are run by lesbian and gay community Wait times are not a characteristic of universal
groups are the 519 Community Centre in healthcare countries. Other countries with
19 Impact of Healthcare Reform on LGBT Elders 379
universal health care (e.g., Belgium, France, perspective of an illness-based focus, such as
Germany, Japan, Luxembourg, Korea, Switzer- HIV/AIDS, and from an oppressive and
land, the Netherlands) typically report few one-dimensional analysis (Berkelman 2012;
problems with wait times (Barua and Clemens Mule et al. 2009). A similar approach is seen
2014). Canadians faced with long periods of wait throughout the world (World Health Organiza-
times have resorted to seeking non-emergency tion 2012). Mule et al. make several observations
treatment outside of Canada. Among the 12 about similarities in public health between the
major medical specialties surveyed by the Fraser USA and Canada. First, although both the USA
Institute, the most patients receiving care outside and Canada recognize health determinants that
Canada were in urology, general surgery, and comprise four health fields: biology, lifestyle,
ophthalmology, and the least likely were in car- environments, and health care, they downplay
diovascular surgeries, radiation treatment for the impact of social structures in health while
cancer, and chemotherapy for cancer (Barua and focusing on individual relational action and
Esmail 2013). Unfortunately, the survey did not responsibility. Second, in the case of LGBT
distinguish the age cohorts of these patients. persons, a microlevel or individualized lifestyle
In addition to concerns and challenges that approach continues to dominate health promo-
confront individuals as they age, LGBT elders tion by targeting high-risk populations through
face at least three unique barriers and inequities large-scale campaigns in which interventions
that impact their health and access to health care, promote risk reduction through behavior change
positive engagement with their communities, and (Mule et al. 2009). Finally, illness and behavior
psychosocial adjustment. These barriers include remain the primary focus and sexual orientation
(a) social stigma and prejudice, past and present; and gender identity, as social locations in the
(b) reliance on informal families of choice for broader social health structures, simply do not
social connections, care, and support; and register. In Canada, LGBT persons are included
(c) laws and programs that fail to address or create in human rights protection, inclusive of health-
barriers to better health and well-being for LGBT care services, but for the most part, they have not
elders (Baker and Krehely 2012). Although there been recognized as an identifiable population
are no LGBT-specific diseases, numerous health within the healthcare sector (Mule 2007), and
disparities affect LGBT persons, especially older gender identity is absent from most human rights
adults. For example, LGBT persons have higher legislation across Canada with the exception of
rates of depression, anxiety, suicidal ideation, and the Northwest Territories and the City of Toronto
substance abuse than their heterosexual counter- (Rainbow Health Network 2008).
parts (IOM 2011; Ruble and Forstein 2008; see In Uganda, health workers could become the
Chaps. 23, 24). These higher rates of pathology frontline enforcers of the newly passed
are attributed to the minority stress they experi- Anti-Homosexuality Act of 2014. The Draft
ence on the basis of sexual orientation and gender Guidelines for Health Workers Regarding Health
identity, and when these identities intersect with Services for Homosexuals suggests that health-
the inequalities associated with race, ethnicity, care facilities would be made more dangerous for
and social class, their trauma is magnified (see LGBT persons. The guidelines specify that
Chaps. 5–10). In addition, the lack of knowledge health workers could break confidentiality of gay
and cultural competency about LGBT popula- and lesbian patients, even when not required by
tions in the healthcare system further discourage law in cases when a person has been sodomized
LGBT elders from seeking care. See Chap. 20 for or in cases of “aggravated homosexuality” (i.e.,
further discussion about cultural competency of same-sex intercourse repeatedly, same-sex inter-
healthcare providers. course with a minor or persons with a disability
In both the USA and Canada, the inclusion of or a persons who has HIV) as defined by the
LGBT persons in health and well-being initia- Anti-Homosexuality Act (Feder 2014). In addi-
tives has been overwhelmingly from the tion, under the provisions of the draft guidelines,
380 D.A. Harley
Table 19.1 Practices by nurses to improve quality of information (e.g., there is not need for an
care of LGBT patients orthopedist to know that a person is gay). The
Realize that they already have LGBT patients or result might be the exposure of too much infor-
residents mation, which in turn could expose LGBT per-
Change the way information is gathered from the patient sons to discrimination by healthcare providers
Ask questions about sexual orientation and gender (Rosenthal 2009).
identity separately
Questions such as marital status may need to be
amended
If an adult identifies as transgender, the nurse must ask Impact of Healthcare Legislation on
how the client wishes to be addressed LGBT Elders
Ask what surgeries have been completed, as it may
directly affect the care needed
Healthcare legislation for older adults in the USA
Adapted from Jablonski et al. (2013) has its origins in the passage of the Medicare
legislation enacted in 1965. At that time, Presi-
healthcare workers might be in a vulnerable dent Lyndon Johnson signed the legislation,
position of being charged with promoting declaring that no longer will older Americans
homosexuality, even in cases where they have loose their life savings due to illness (Beschloss
been approved to provide services or conduct 2006). The intent of Medicare was to provide
research with lesbian and gay persons. healthcare coverage to persons aged 65 and older
Researchers, health workers, or health facilities and to protect elders from financial risks. How-
are solely responsible to ensure that no acts of ever, Medicare does not cover the full financial
promotion or recruitment of subjects into acts of cost of poor health among elders, requiring many
homosexuality, as stipulated by the enrollees to pay significant out-of-pocket
Anti-Homosexuality Act, occurs. In fact, one co-payments and deductibles. In addition, Medi-
clause of the act reads, “In the event of promo- care does not cover a variety of services particu-
tion or recruitment, they shall be held account- larly valuable for those with chronic diseases or a
able” (Feder 2014). lifelong illness (Kelley et al. 2013). Alternatives
In the healthcare system, nurses are typically to ACA have focused on voucher plans with
the first point of contact for patients, and as the greater cost sharing; however, such plans would
front line of care, they can directly impact the most likely increase, not decrease, out-of-pocket
quality of care of LGBT elders’ experience medical expenditures for Medicare recipients
(Jablonski et al. 2013). Jablonski et al. recom- (e.g., the bipartisan options for the future, Choi-
mend practices that nurses can follow to improve ces to Strengthen Medicare and Health Security
the quality of care they provide to LGBT patients for All, by Senator Ron Wyden of Oregon and
(see Table 19.1). Although all clinicians and Senator Paul Ryan of Wisconsin, www.budget.
service providers should be trained in culturally house.gov/uploadedfiles/wydenryan.pdf). The
appropriate knowledge and skills in working primary goal of this plan was “to strengthen tra-
with LGBT elders, it is essential for those who ditional Medicare by permanently maintaining it
initially have contact with patients. as a guaranteed and viable option for all of the
Rosenthal (2009) indicates that health infor- nation’s retirees” and simultaneously “expanding
mation technology will significantly reduce costs choice for seniors by allowing the private sector
and increase coordinated care, but it can also put to compete with Medicare in an effort to offer
LGBT persons at risk. For example, compre- seniors better quality and more affordable
hensive care requires that a primary care provider healthcare choice” (p. 1). The plan included the
to know about a patient’s sexual behavior, gen- following components: (a) choice, (b) affordabil-
der history, and other sensitive information. ity, (c) protecting the guarantee, (d) protecting
However, not all providers need access to all seniors, (e) protecting the safety net, and
19 Impact of Healthcare Reform on LGBT Elders 381
(f) lifelong choices. The Wyden–Ryan plan seek expanding cultural competency in the healthcare
to respond to the fast-paced growth of Medicare workforce to include LGBT issues, improving
spending, which is growing more than twice as data collection to better identify and address
fast as the economy. health disparities, and recognizing the increasing
Throughout the twentieth century, healthcare diversity of America’s families (Baker and
coverage was too expensive and difficult to Krehely 2011). The ACA has implications for
obtain for many Americans and more so for LGBT elders from an intersectionality perspec-
LGBT persons. Michael Adams, Executive tive as well: Sexual minorities, elderly, and per-
Director of SAGE, in 2009 described the lack of sons overrepresented with HIV (SAGE 2014).
attention of federal policy on LGBT issues in the According to SAGE, for older LGBT persons,
past eight years (i.e., President George W. poor health represents the cumulative effect of a
Bush’s administration) as a “wasteland” (SAGE lifetime of discrimination, and the ACA prevents
Matters 2009, p. 3). Kerry Eleveld, Senior health insurers from denying coverage or charg-
Political Correspondent for The Advocate mag- ing higher premiums based on preexisting con-
azine, added, with the attempt of President ditions, or a person’s sexual orientation or gender
Obama and the Congress “to overhaul our health identity. The significance of this provision is that
care system and bring more Americans into the access to care is expanded for transgender per-
fold, older Americans will undoubtedly be a sons and those living with HIV/AIDS, who often
high-priority constituency” (SAGE Matters face life-threatening discrimination in healthcare
2009, p. 5). Moreover, SAGE (2012) asserts that coverage. For older persons who already have
health reform has dramatically improved health- coverage through Medicare, the ACA has pro-
care coverage for LGBT elders who face health visions that improve the benefits available
disparities, aggravated by a lifetime of discrimi- through adding free wellness checkups and pre-
nation and higher economic insecurity, in several vention services. For persons with HIV, the
ways (a) by expanding coverage, (b) strengthen- benefits include prescription drug coverage, lab-
ing consumer rights and protections, and oratory services, and chronic disease manage-
(c) improving data collection efforts and a host of ment. The ACA ended lifetime dollar limits on
other benefits. essential health benefits, cracked down on friv-
In general, most people agree that healthcare olous cancellations of policies, and made it ille-
reform is a step in the right direction in equal- gal to arbitrarily cancel health insurance simply
izing access to and improving the quality of because the policyholder got sick (SAGE 2014).
health care for LGBT persons. The point of See Table 19.2 for ways in which ACA impact
division or disagreement is about the extent to on elders.
which reform is effective beyond access. On the Chance (2013) acknowledges that the ACA’s
one hand, Baker and Krehely (2012) consider the reformatory focus on increasing access to care
Affordable Care Act (ACA) as “the most sig- will likely work to remedy some of the dis-
nificant and far-reaching reform of America’s crimination that results in the LGBT commu-
health system since the creation of Medicare and nity’s disparate access to care. However, Chance
Medicaid in the 1960s” (p. 21). Baker and believes that the ACA “fails to comprehensively
Krehely espouse two major advantages of the combat the broader LGBT healthcare discrimi-
ACA to include (a) the introduction of new nation because it will do nothing to remedy the
protections and options for patients in the private stigma that results in lower quality care” (p. 376).
health insurance market and (b) expansion of Chance identifies the major disadvantages of the
access to more comprehensive benefits and ser- ACA, which result in gaps in access to quality
vices that focus on improving our nation’s health medical services that include failure to address
and lowering healthcare cost by investing in the social stigma associated with a patient’s
keeping people healthy in the first place. LGBT status and failure to address specific needs
The ACA also includes provisions such as of the LGBT community. The recommended
382 D.A. Harley
Table 19.2 Affordable Care Act’s impact on elders lawmakers that healthcare reform would keep the
Reduce prescription drug cost in Medicare Part D Medicare trust in the black for several additional
Provide a free annual wellness visit for all Medicare years is challenged by the Congressional Budget
beneficiaries office (CBO), which claims the government is
Provide free Medicare coverage of vital preventive “double counting.” In 2009, a CBO memo stated
services that “the saving to the health insurance trust
Encourage better care coordination would be received by the government only once,
Expand coverage for seniors under age 65 thus they cannot be set aside to pay for future
Protect patent rights and lower costs in the private health
Medicare spending and, at the same time, pay for
insurance market current spending on other parts of the legislation
Provide new options for long-term care or on other programs” (http://www.cbo.gob/
publications/25017). Second, as providers expe-
Increase access to home-based care
rience cuts and go out of business, seniors may
Nursing home transparency
have reduced access to medical care (TSCL). To
Protecting seniors from abuse and neglect support this notion of the long-term assumption
Implement the Elder Justice Act for Medicare and aggregate national health
Adapted from Baker and Krehely (2012), Medicare.org expenditures, reference is made to the Chief
(2013) Actuary of the government’s Centers for Medi-
care and Medicaid services who connotes that
reforms include a national legislative and regu- providers for whom Medicare constitutes is a
latory effort for training competent providers for substantive portion of their business could find it
LGBT patients. Chance recommends “amending difficult to remain profitable, and without legis-
the ACA to include provisions requiring appli- lation intervention, might end their participation
cable agencies to issue rules aimed at increasing in the program, possibly jeopardizing access to
implementation and utilization of LGBT-specific care for beneficiaries (www.cms.gov/Research-
cultural competence training provides a conve- Statistics-Data-and-System/Statistics-Trend-and-
nient vehicle for such reform” (p. 399). In addi- reports/ReportsTrustFunds/downloads/2010TR
tion, Congress should amend the ACA to require AlternativeScenario.pdf).
agencies that administer research funding to Many LGBT elders are classified as having
place a condition on receipt of those funds to low socioeconomic status and limited resources
treat disadvantaged persons such as those who and, as such, may be eligible for the Medicaid
LGBT (e.g., medical schools). Finally, although program. For persons who are eligible for full
not directly related to the ACA, LGBT-specific Medicaid coverage, Medicare healthcare cover-
cultural competence can also be achieved at the age is supplemented by services (e.g., nursing
state level, stipulating that licensing boards facility care beyond the 100-day limited covered
require a certain number of hours of LGBT cul- by Medicare, eyeglasses, hearing aids) that are
tural competence training as a condition of available under their state’s Medicaid program.
renewed licensure. Chance suggests amending For persons enrolled in both programs, any ser-
the ACA to address discriminatory attitudes is a vices covered by Medicare are paid for by the
better choice for such reform than other avenues. Medicare program before any payments are made
Those who argue that healthcare reform leg- by the Medicaid program because Medicaid is
islation may have potential negative conse- always the payer of last resort (Annual Statistical
quences for seniors suggest several Supplement 2011). Even so, Medicare does not
disadvantages. First, health reform will not shore cover all of a senior’s medical expenses.
up Medicare’s financing, despite claims to the Older adults who qualify for the federal gov-
contrary (The Senior Citizen League [TSCL] ernment program have several options to pur-
www.seniorsleague.org). The assurance by chase additional health insurance called Medicare
19 Impact of Healthcare Reform on LGBT Elders 383
Advantage plans, which is classified into three of medical expenditures will pay about $101,791
basic categories: Private-Fee-for-Service, Health in the five years preceding their death (see
Maintenance Organization (HMO), or Preferred Research Box 19.1).
Provider Organization (PPO). According to the
Centers for Medicare and Medicaid Services, the
most recent addition to the lineup to help manage Research Box 19.1 Out-of-Pocket Medi-
the health care of senior Americans is the cal Costs
Accountable Care Organizations (ACO). ACO is Keyyey, A. S., McGarry, K., Fahle, S.,
a collection of healthcare providers who come Marshall, S. M., Du, Q., & Skinner, J. S.
together and assume responsibility for the care, (2013). Out-of-pocket spending in the last
quality, and cost of healthcare services for a five years of life. Journal of General
specified group of people. ACO is not an insur- Internal Medicine, 28(2), 304–309.
ance plan. The ACO model is designed to Objective: To determine the cumulative
(a) deliver accountable care, (b) emphasize qual- financial risks arising from out-of-pocket
ity of care (a point that Chance (2013) argues is a healthcare expenditures faced by older
shortcoming of ACA), (c) coordinate care for adults, particularly near the end of life.
patients, and (d) reduce costs by reducing waste Method: Retrospective analyses of Medi-
(Botek 2015). care beneficiaries’ total out-of-pocket
healthcare expenditures over the last five
years of life were conducted using the
nationally representative Health and
Future Directions of Healthcare retirement Study (HRS) cohort. The sub-
Reform jects were HRS decedents between 2002
and 2008, using each subject’s date of
The future direction of healthcare reform is death to define a 5-year study period and
uncertain. It is also uncertain whether healthcare excluding those without Medicare cover-
reform will regress to something previously age at the beginning of this period
known and tried or to something innovative and (n = 3209). The total out-of-pocket
exploratory. However, several certainties do healthcare expenditures in the last 5 years
exist. First, there will continue to be opponents to of life and expenditures as a percentage of
whatever type of healthcare reform and health- baseline household assets were examined.
care legislation is proposed, and second, increa- Then, stratified results by marital status and
ses in health care spending along with fiscal cause of death. All measurements were
pressures created by an aging population and adjusted for inflation to 2008 US dollars.
increasing prevalence of debility and chronic Results: Average out-of-pocket expendi-
conditions make it likely that out-of-pocket tures in the 5 years prior to death were
expense will continue to rise (Kelley et al. $38,688 (95 % confidence interval
2013). In addition, an ongoing challenge for $36,868, $40,508) for individuals and
healthcare delivery and healthcare reform is $51,030 (95 % CI $47,649, $54,412) for
related to increasing costs and the ability of the couples in which one spouse/partner dies.
government to continue to fund Medicare and Spending was skewed, with the median
Medicaid in the USA and universal health care in and 90th percentile equal to $22,885 and
Canada, the ability of individuals to be able to $89,106, respectively, for individuals, and
afford health insurance, and the quality of care $39,759 and $94,823, respectively, for
for LGBT elders. According to Kelley et al., the couples. Overall, 25 % of subjects’
“average” elder will pay approximately $39,000 expenditures exceeded baseline total
in out-of-pocket medical cost during the final five household assets and 43 % of subjects’
years of life, and a “typical” elder in the top 25 % spending surpassed their non-housing
384 D.A. Harley
Table 19.4 Medically necessary service covered by H. include legal protections for LGBT elders that
R. 676 prohibit discrimination based on sexual orienta-
Primary care tion and gender identity by hospital participating
Medically approved diet and nutrition services in Medicare and Medicaid (Fredriksen-Goldsen
Inpatient care et al. 2012), the future of healthcare reform must
Outpatient care follow suit.
Emergency care
Prescription drugs
Durable medical equipment Summary
Hearing services
Oral surgery Health care is becoming increasingly expensive,
Eye care particularly for persons with chronic conditions,
Chiropractic which disproportionately affects LGBT elders.
Long-term care Decisions about financing strategies for the
health care of all persons in the USA rests in the
Palliative care
hands of political forces divided not only along
Podiatric care
party lines, but also along judgments about the
Mental health services rights of LGBT persons. Regardless of the
Dentistry direction that healthcare reform takes, cost con-
Substance abuse treatment tainment, access to care, and quality of care
Adapted from Physicians for a National Health Program should be the hallmark. Many LGBT elders have
(2011) been and continue to be victimized by inade-
quacies in the present healthcare system, all the
Since 2003, H.R. 676 has been introduced in more problematic because the USA spends more
every Congressional session. The bill, if adopted, per person on health care as any other country,
would usher the USA into a single-payer model yet lags behind on key indicators such as life
for healthcare financing, mirroring the rest of the expectancy and preventable deaths.
industrialized world. Supporters of the bill see it
as the only way to guarantee quality care and
sustainably cut costs (Federal Information &
News Dispatch 2015). This view is consistent Learning Activities
with that of Chance’s (2013) position for
amending the ACA to ensure the quality of care,
not only access for LGBT persons. Ironically, Self-Check Questions
reintroduction of H.R. 676 came on the same day
as House Republicans voted for the 56th time to 1. What is the relationship between Medicaid
repeal the ACA (Federal Information & News and Medicare for LGBT elders?
Dispatch 2015). 2. What are the reasons for LGBT elders’ health
The future of healthcare policy will need to disparities?
address health disparities of LGBT elders. 3. What are the advantages and disadvantages of
Importantly, LGBT elders themselves are the Affordable Care Act for LGBT persons?
emerging as active participants in the debate on 4. What are some of the challenges to policy
reform—they are forging ahead with their own implementation of healthcare reform?
healthcare planning and are increasingly vocal 5. How are health disparities for LGBT
about LGBT-specific and appropriate services. populations consistent across different
Just as policy and legislation have changed to countries?
386 D.A. Harley
(a) They collect data every 10 years with the Fenway Health/National LGBT Health Educa-
Census tion Center: www.lgbthealtheducation.org
(b) They rarely track health data LGBT Training Curricula for Behavioral Health
(c) They will violate HIPPA in so doing and Primary Care Practitioners: www.hrsa.
(d) They prioritize type of data collected gov/LGBT/lgbtcurricula.pdf
Medicare.org: www.medicare.org
National Resource Center on LGBT Aging:
Key
www.lgbtagingcenter.org
Optimizing LGBT Health Under the Affordable
1-b
Care Act: Strategies for Health Centers: http://
2-c
www.lgbthealtheducation.org/wp-content/
3-d
uploads/Brief-Optimizing-LGBT-Health-
4-c
Under-ACA-FINAL-12-06-2013.pdf
5-a
Rainbow Health Ontario (RHO): www.
6-c
rainbowhealthontario.ca
7-b
The ACA and LGBT Older Adults Discussion
8-d
Guide: www.issues.com/lgbtagingcenter/doc/
9-a
affordablecareactandlgbtolderadults
10-b
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Healthcare, Sexual Practices,
and Cultural Competence with LGBT 20
Elders
Abstract
Research on the health of LGBT elders is limited. However, we do know
that LGBT older adults often have poorer health status as a result of a
combination of factors including health challenges such as sexual
orientation, gender identity issues, as well as a history of marginalization,
prejudice, and the effects of non disclosure in health care encounters.
Additionally, commonly held misconceptions regarding the sexual
practices of older adults contribute to the poorer health outcomes
experienced by some LGBT individuals. LGBT older adults, like others,
are entitled to quality health care. This chapter introduces and discusses
some of the major issues that affect the health of LGBT elders and
explores opportunities to begin addressing these issues. Additionally, it
reviews implications for improving service delivery from an interdisci-
plinary perspective and future research directions.
Keywords
Cultural competence HIV/AIDS Health disparities Minority stress
Non-disclosure
also reviews implications for improving service care. In fact, it may be compounded by health-
delivery from an interdisciplinary perspective. care needs that are unique to the LGBT popula-
tion, such as sexual orientation, gender identity,
and a history of marginalization. In recent years,
Learning Objectives we have seen cultural shifts that have allowed
segments of the LGBT population to achieve
1. Identify the training needs of staff who work legal rights making it easier for some to live
with LGBT elders. openly as LGBT individuals. Some of the recent
2. Describe the obstacles in providing optimal changes have brought the barriers and needs of
health care to LGBT elders. LGBT elders more visibility; however, there are
3. Identify misconceptions regarding the sexu- still many issues to be addressed including the
ality of patients. healthcare practices of LGBT elders.
4. Describe the need for sexual intimacy among
older adults.
5. Explain LGBT elders’ risk factors for
HIV/AIDS. History and Practice
6. Understand the importance of LGBT cultural
competency in healthcare settings. The history and practice relating to health care
7. Describe the major goals and components of with LGBT elders is relatively short. In recent
LGBT cultural competency training program. years, there has been recognition of the impor-
8. Understand the impact of non-disclosure of tance of conducting research in order to better
sexual orientation and gender identity on the understand the needs of LGBT individuals and
care of LGBT older adults. establishing the best practices in order to increase
the quality of health care for LGBT individuals.
However, research efforts specifically regarding
healthcare practices with LGBT elders have
lagged behind. In the USA, we are experiencing
Introduction a tremendous increase in the number of “out”
LGBT elders, which is very different from what
LGBT elders represent an extremely marginal- has been seen, in the past there were relatively
ized population, as a result of age and sexual small numbers of “out” LGBT elders; however,
orientation or gender identity. The number of by the year 2030, it is expected that the number
older adults in the USA is increasing rapidly; in of LGBT older adults in the USA will increase to
fact approximately 10,000 individuals turn 65 more than 4 million (Fredriksen-Goldsen et al.
every day. Healthcare needs often increase with 2011).
age, for instance Medicare beneficiaries on The available research on healthcare practices
average have at least three chronic conditions with LGBT elders has focused on the provision
(Center for Medicare and Medicaid Service and awareness of services specifically for LGBT
[CMS] 2012). Among Medicare enrollees, phy- elders (Knochel et al. 2012; Hughes et al. 2011),
sician visits and consultations increased from promoting awareness of LGBT aging issues in
11,395 per 1000 in 1999 to 15,437 per 1000 in nursing programs (Lim and Bernstein 2012), and
2009 (Federal Interagency Forum on Aging- surveying the training of healthcare providers
Related Statistics [FIFAR] 2012). The LGBT and nursing home social service directors (Bell
population is not exempt from this reality. This et al. 2010; Rogers et al. 2013; Porter and
rapid population aging will significantly impact Krinsky 2013). Services and Advocacy for
the lives of LGBT individuals who often grow GLBT Elders (SAGE) has released several pub-
old without sufficient support, including health licly available documents with recommendations
20 Healthcare, Sexual Practices, and Cultural Competence … 393
for policy and practice. Furthermore, the sexual activity, but may face challenges that may
National Resource Center on LGBT Aging then cause them to miss opportunities for sexual
published a document on collecting health-rela- activity and/or to place themselves at risk for
ted data from LGBT elders. Unfortunately, very contracting sexually transmitted infections and
few practices have implemented the recommen- diseases. The number of older adults being
dations provided by these organizations. While diagnosed with HIV is increasing. In 2010,
there is a limited amount of available research individuals aged 50 and older accounted for
specifically regarding LGBT elders, some of the approximately one-fifth of those living with HIV
available research on LGBT individuals in gen- infection (CDC 2013a). The number of older
eral can be applied to older adults. For instance, adults infected with other sexually transmitted
The Fenway Institute’s (2012) publication on infections is also increasing. For example, the
gathering data on sexual orientation and gender number of individuals aged 55 and over diag-
identity in clinical settings can be used with older nosed with chlamydia increased from 4,311 in
adults. 2009 to 6,801 in 2013, those diagnosed with
In light of the growing number of LGBT older Gonorrhea increased from 2,766 in 2009 to 4,327
adults in the USA and elsewhere, there is a in 2013, and those diagnosed with syphilis
definite need for more research aimed at under- increased from 607 in 2009 to 912 in 2013 (CDC
standing the needs and desires of LGBT elders 2014b). Oftentimes, healthcare providers make
regarding their interaction with health care and assumptions regarding older adult’s sexual ori-
for the development of best practices for entation, assuming that the majority of older
healthcare providers. An initial step in develop- adults are heterosexual (National Resource Cen-
ing best practices for providers should be striving ter for LGBT Aging, n.d.). The possibility that an
to eliminate commonly held misconceptions older patient is lesbian, gay, bisexual, or trans-
about the sexuality of patients. gendered is rarely considered.
Another common misconception regarding
older adults and sexuality is that due to their
advanced age, they should know how to protect
Common Misconceptions About themselves from sexually transmitted infections
Sexuality of Patients and diseases when in fact the opposite is true
(Centers for Disease Control and Prevention
Within our society, there is an extremely pre- [CDC] 2013a). The current generation of older
valent misconception that older adults are not adults grew up in a time when sexual health
sexual beings and that the desire to engage in education was not a part of general education and
sexual activity diminishes with age; research thus never learned how to properly protect
does not support this misconception (Lindau themselves.
et al. 2007; Trompeter et al. 2012). All existing Misconceptions surrounding drug use among
literature suggests the desire to engage in sexual older adults also exist and impact their sexuality.
activity is present among all human beings and Many healthcare practitioners, as well as other
continues into later life. In fact, many older members of society, generally believe that older
people continue to have satisfying sex lives into adults do not use illicit drugs and thus are less
their seventies, eighties, and even nineties (Vann likely to ask older patients questions about illicit
2014). Unfortunately, many healthcare providers drug use. While research does suggest that illicit
also hold these common misconceptions and drug use declines with age, research now shows
therefore potentially miss opportunities to dis- that the baby-boom generation (individuals born
cuss sexuality with their older patients. Discus- between 1946 and 1964) has relatively higher
sions surrounding sexuality with older patients rates of illicit drug use than previous generations
are extremely important because older adults (Wu and Blazer 2010). Illicit drug use can
maintain an interest in and desire to engage in increase the risk of transmitting sexually
394 T. Davis and A.E. Sokan
2013). Women with diabetes are more likely to designed to help guide and support staff
have yeast infections, which can cause sexual responses, much is left up to personal interpre-
activity to be uncomfortable or undesirable (NIA tation of the staff (Katz 2013). Nursing facilities
2013). Medications can help with the side effects should be encouraged to develop policies sur-
of diabetes on sexual intimacy for both men and rounding sexual expression by residents. Such
women. Heart disease can affect both men and policies may help provide guidance for the safe
women in regard to sexual intimacy due to nar- expression of sexual desire and provide training
rowing and hardening of the arteries, which can for staff in how to handle these situations. Spe-
change the blood vessels, so that the blood does cifically, staff training on LGBT older adult’s
not flow freely. Thus, men and women with heart needs should be mandated. It should be made
disease may have problems with orgasm (NIA clear that anti-LGBT discrimination will not be
2013). Heart disease may also cause problems tolerated. Advocates should push for laws man-
with obtaining and maintaining erections for men dating training for nursing home personnel and
(NIA 2013). Loss of bladder control or leakage residents (Redman 2011). For example, in 2008,
of urine can be problematic for many older California passed a law requiring the Department
adults, especially in women. Extra pressure on of Public Health to design and implement regular
the stomach during sex can cause bladder leak- cultural competency training on LGBT issues
age, which may cause some individuals to avoid (Redman 2011). Furthermore, Ombudsman pro-
sex (NIA 2013). Changing positions during sex grams must take a stronger advocacy role in
or seeking treatment for incontinence can help protecting LGBT residents from bullying and
the problem. Also, depression can affect both discrimination (Redman 2011). Further research
men and women’s desire for sexual intimacy. and data collection is needed to uncover addi-
Depression is fairly common among older adults tional problems LGBT residents face in nursing
and should be treated appropriately. A 2011 homes.
national study on LGBT older adults found that It is important for healthcare providers to
more than half of LGBT elders had been told by remember that older adults maintain desires for
their doctor that they had depression, approxi- sexual intimacy. It is important for healthcare
mately 39 % had seriously considered suicide, providers to work with older adults to maintain
and approximately 53 % felt isolated from others their sexual health and to help them meet their
(Fredriksen-Goldsen et al. 2011). intimacy goals and to avoid the transmission of
Sexual intimacy can be problematic in certain diseases.
environments such as nursing care facilities. The
desire for sexual intimacy does not go away with
age, and this is true for those in nursing and Policy Box #1
assisted living facilities, as well. Unfortunately, In conjunction with management at your
conditions in nursing and assisted living facilities local senior center, you recently provided
may hamper the ability to satisfy a need for an educational workshop that addressed
sexual intimacy. Personal barriers (e.g., physical sexuality and health in aging, including
disabilities, the adverse effects of prescribed intimacy, safe practices, sexual orientation,
medications, cognitive impairment, and lack of and gender identity issues to clients and
partners) inhibit sexual intimacy (Katz 2013). In staff. Because of the enthusiasm and posi-
addition, residents also lack privacy, as they are tive feedback received from attendees and
often encouraged to leave their doors open and the potential benefits of such a program,
unlocked, and staff members often come in and you would like to solicit your state
out frequently. The attitudes of staff and families department of Aging’s support in making
often cause significant barriers to sexual expres- this a required annual program in senior
sion in nursing facilities (Katz 2013). Due to the centers statewide. Write a policy paper to
fact that many nursing facilities lack policies the head of the state department of aging,
396 T. Davis and A.E. Sokan
person. The fluids must come in contact with a healthcare providers because they are not open
mucous membrane found inside the rectum, the and honest about their needs. Between the lack
vagina, the opening of the penis or the mouth or of recognition of older adults’ HIV risk factors
damaged tissues or be directly injected into the among many providers and the fears of many
bloodstream in order for transmission to occur elders, HIV screening rarely occurs and early
(CDC 2014a). These risk factors are the same for detection is minimal (SAGE 2010). Again, as
everyone regardless of race, sexual orientation, with previously discussed issues (e.g., sexual
gender identity, sex, or age. Older adults are orientation or sexual intimacy) in older adults
often considered to be at greater risk for HIV due there is a great need to increase the training and
to lack of awareness about HIV and how to preparedness of healthcare providers who see
prevent transmission, and as a direct result, older adults, so that they better prepared to
unknowingly place themselves at risk for HIV inquire and address questions about older pati-
and other sexually transmitted infections. For ents sexuality.
example, many widowed and divorced people
are dating again and are less likely to protect
Profile of LGBT Elders
themselves because of their lack of awareness of
Donald
how the disease is transmitted. Again, as men-
Donald is a 56-year-old white man who
tioned in the previous section, there are physio-
was married for 24 years, a relationship he
logical changes among older men and women
entered into right out of college. He con-
that can increase their risk for contracting HIV.
tracted HIV from an affair with a young
Due to older adults’ increased risk for HIV, it is
man he met at a work-related conference.
extremely important to increase educational
He says they used condoms, but when one
efforts aimed at increasing older adults’ knowl-
“came off” the young man assured him he
edge about HIV and to screen older adults for
was HIV negative. Donald did not think he
HIV (Davis 2013). Early detection improves
had reason to doubt the man, given his
infected persons’ chances of living longer, par-
healthy appearance. Once Donald received
ticularly for older adults.
his HIV diagnosis, he disclosed to his wife
Unfortunately, older adults are more likely to
that he was gay. They stayed together until
receive a late diagnosis and to have a short pro-
“the kids were out of the house.”
gression between HIV and AIDS. Older adults are
more likely to have a delayed diagnosis because
Discussion Questions
symptoms of HIV resemble symptoms of other
chronic illness common among many older adults
What new insights did you gain from
or normal aging. For example, loss of energy,
reading a little bit about Donald?
short-term memory loss, and weight loss are all
Were you surprised about his “coming
symptoms of HIV, but they also may be associ-
out” so late in life?
ated with normal aging or associated with other
common conditions among older adults (SAGE
Ramón
2010). A late diagnosis means a late start to
Ramón is a 50-year-old bisexual Latino
treatment and possibly more damage to an
who has been sexually active since 18.
already weakened immune system (CDC 2013a).
Finding out he had HIV brought up feel-
Despite the fact that we know that early
ings of being punished. He also has had to
detection is essential to improving older adults’
cope with homophobia in Latino culture.
chances of survival, many healthcare providers
He knows of many youth who ran away
still fail to acknowledge older adults risk for
from home to escape their parents’ rejec-
HIV and do not ask questions about sexual
tion. Consequently, some found them-
partners or drug use (SAGE 2010). Additionally,
selves engaging in high-risk sexual
many LGBT elders fear discrimination from
398 T. Davis and A.E. Sokan
Table 20.1 Health disparities: sample conditions and variations by LGBT subgroups
Health condition Lesbian (%) Gay (%) Bisexual (%) Transgender (%)
Men Women
Depression 27 29 35 36 48
Anxiety 22 22 24 34 39
Suicidal ideation 35 37 39 40 71
Disability 50 41 50 50 66
Obesity 34 19 18 34 40
Source Fredriksen-Goldsen et al. (2011)
20 Healthcare, Sexual Practices, and Cultural Competence … 399
treatment to refusal to treat, understandably create Table 20.3 Example of factors influencing
fear, mistrust, and reluctance or refusal to disclose non-disclosure
sexual minority status among LGBT older adults Socioeconomic Race/ethnicity; education level;
(Fredriksen-Goldsen et al. 2011). gender; financial status/income
Beyond fear (of mistreatment), or the desire to Patient Health history; immigration status;
avoid the negative consequences of disclosure, characteristics parenthood status; color; personal
identity as LGBT
other factors also contribute to non-disclosure.
Minority stress Degree of:
Durso and Meyer (2012) identified privacy con- internalized homophobia;
cerns as another reason for non-disclosure, the connection to LGBT community;
presumption of heterosexuality by healthcare discrimination history and
workers, as well as a perception that sexual ori- experience; expectations of stigma;
multiple jeopardy—e.g.,
entation is irrelevant to health care. For these heterosexism/racism/sexism/ageism
reasons, non-disclosure may be even higher in
healthcare settings (Petroll and Mosack 2011;
Bernstein et al. 2008). There is some support for issues that are specific to or shared among sub-
the notion that non-disclosure to providers occurs groups (Durso and Meyer 2012).
even where the LGBT patient has come out to Generally, the likelihood that an LGBT
family, coworkers, and heterosexual and LGBT patient will disclose his or her sexual orientation
friends (Durso and Meyer 2012). This situation or gender identity has been found to be influ-
should be of concern to all, especially in light of enced by (a) degree or strength of connection to
the acknowledged poor health status of LGBT the LGBT community and (b) sense of LGBT
older adults. Studies have found variations in identity (Durso and Meyer 2012). Those with a
patterns of non-disclosure among LGBT sub- lower sense of LGBT identity or poor connection
groups as well as factors likely to predict dis- to the LGBT community are more likely to
closure or non-disclosure in healthcare practice non-disclosure. This finding is important
encounters or settings. For instance, when com- to bear in mind when dealing with older adult
pared to gay men, higher rates of non-disclosure LGBT patients who may have a long history of
were found among bisexual men (Bernstein et al. struggle with their sexual orientation, gender
2008; Durso and Meyer 2012), while factors identity or are isolated from the LGBT commu-
such as health status, relationship status, and nity. Table 20.3 provides examples of factors
level of internalized homophobia were found to influencing non-disclosure.
predict disclosure versus non-disclosure among Regardless of the reason for non-disclosure, it
lesbians (St. Pierre 2012). Socioeconomic factors is important to facilitate disclosure, especially in
are also relevant. Ethnic/racial minorities within healthcare encounters, because of the potential of
the LGBT population have higher rates of non-disclosure to contribute to poor health and
non-disclosure (Bernstein et al. 2008; Petroll and poorer health outcomes. For instance, Durso and
Mosack 2011), as do those with lower income or Meyer (2012) found that non-disclosure related
financial status (Petroll and Mosack 2011; St. to poorer psychological health at follow-up a
Pierre 2012). Other patient characteristics such as year after. Providers who are unaware of the
immigrant status, health history, gender, and older adult’s LGBT identity are less likely to
parenthood status have also been found to provide appropriate patient education on perti-
influence disclosure (Durso and Meyer 2012). nent issues, relevant advice or recommendations
Non-disclosure is also more likely among those regarding preventive care, such as screenings,
with lower levels of education as well as LGBT vaccines, and testings (Petroll and Mossack
who live in rural areas (Petroll and Mosack 2011; Durso and Meyer 2012). They are also less
2011). Thus, it is critical that healthcare provid- likely to recognize the need to connect these
ers recognize the heterogeneity that exists within patients to available support, care, service, and
the LGBT population, and distinguish between other LGBT resources within the community.
20 Healthcare, Sexual Practices, and Cultural Competence … 401
Also, such providers may be less likely to seek LGBT older adults will better equip them to
out information, knowledge and training on encourage and facilitate disclosure of sexual ori-
LGBT issues and concerns because they assume entation and gender identity by LGBT patients.
that their patient base does not require these
skills. Non-disclosure inadvertently contributes
Discussion Box #1
to the “invisibility” of LGBT older adults, their
You have been scheduled for a repeat
issues, needs, and concerns (Jablonski et al.
appointment with a patient whom you
2013) and exacerbates health disparities. Ulti-
think might be a member of the LGBT
mately, non-disclosure negatively affects the
population. You think that obtaining this
ability of providers to identify unmet needs and
information is important to help you pro-
deliver quality and appropriate care to LGBT
vide quality care. Explain your rationale
older adult patients, thereby increasing patient
for thinking so. How would you go about
stress, contributing to poor health outcomes and
facilitating a conversation on this issue?
overall poor health status.
What questions might you ask? What
concerns, if any, do you have?
Promoting Disclosure and Reducing
Non-disclosure
aging of the baby boomers, one of the largest 2010 concluded that on average, five hours were
cohorts in history has resulted in an unprece- devoted to LGBT issues. In addition, a large
dented growth in the size of the population aged degree of variation existed across programs in
65 and over. Of this segment of the population, terms of quantity and content covered, as well as
two-thirds live with multiple chronic conditions perceptions regarding the quality of instruction
and account for 66 % of US healthcare expen- received (Obedin-Maliver et al. 2011). In another
ditures (CDC 2013b). study of social services in Michigan, Hughes et al.
Generally, older adults consume a dispropor- (2011) found that “perceptions of invisibility”
tionate amount of healthcare and long-term care make it difficult to recognize the concerns of
services, as the demand for these services tend to LGBT elders and provide culturally appropriate
increase as age increases, requiring the skills of a services. These barriers have implications for the
variety of staff and personnel in mental health, health of LGBT elders because they increase the
physical health, long-term care, and other aging likelihood of failure or delay in seeking health
services (McGinnis and Moore 2006). According care, which in turn adversely affects overall health
to a report by the LGBT advocacy group, Ser- status and may result in poorer or negative health
vices and Advocacy for Gay, Lesbian, Bisexual outcomes, as well as increased rates of premature
and Transgender Elders (SAGE), healthcare set- need for institutional care. Institutional-
tings can be challenging environments for LGBT ized LGBT elders suffer additional challenges
elders (SAGE 2010). Factors that create barriers because many LTC staff such as social services
and/or influence the care received by LGBT directors, certified nursing assistants, and other
elders are often driven by heterosexism and caregivers lack adequate training in LGBT issues
homophobia. These factors include open dis- and concerns, in addition to homophobia and
crimination by staff which may create a hostile heterosexism (Bell et al. 2010).
environment, lack of familiarity with the needs of Staff Training. LGBT older adults constitute a
LGBT elders, as well as, LGBT elders’ own community despite the variations across these
reluctance to engage because of past negative subgroups, as discussed previously. The increas-
experience. For instance, in a report about how ing recognition that the needs of this community
inhospitable the healthcare environment is for and its unique challenges must be addressed is
LGBT people, the organization Services and evidenced by the statement attributed to Kathy
Advocacy for Gay, Lesbian, Bisexual and Greenlee, Assistant Secretary of Aging, during
Transgender Elder (SAGE) cites a 2006 study by the award of $900,000 for the development of a
MetLife Mature Market Institute that indicates national resource center on LGBT aging in 2010
that more than 50 % of LGBT baby boomers (SAGE 2010). In the same vein of recognition,
believed they would not receive respectful and reporting on the state of aging and health in the
dignified treatment from healthcare professionals USA in 2013, the CDC issued a series of calls to
(SAGE 2010). action that included a call for communities, pro-
The level of provider/staff knowledge, aware- fessionals, and individuals to address aging and
ness, and comfort when dealing with LGBT health issues that affect the LGBT community
elders and the issues they present is a key factor. (CDC—The State of Aging and Health in Amer-
Research indicates that many providers or staff ica 2013b). LGBT older adults have a shared
who work in the aging industry (e.g., healthcare culture that reflects their sexual minority status,
organizations, long-term care facilities, and other history of marginalization, bias, prejudice and
aging services) lack the education or training to stigma, as well as health, social and economic
enable them to care for LGBT elders because of disparities. This shared culture must be under-
LGBT issues in education and training curricula. stood in order to appropriately address LGBT
For instance, a study that examined LGBT-related needs generally and is essential to ensuring that
content in 150 undergraduate medical education LGBT older adults have access to and receive
programs in USA and Canada between 2009 and relevant, quality health services in an inclusive,
20 Healthcare, Sexual Practices, and Cultural Competence … 403
receive requests of assistance from transgender toward reducing the potential effect of multiple
clients than agencies that did not provide cultural jeopardy arising out of aging and sexual orien-
competence training. In other studies, cultural tation in later life.
competency trainings have been found to pro-
duce at least a short-term impact on recipients’
knowledge, attitudes, and behavior intentions Caveat
(Porter and Krinsky 2013). Repetition and rein-
forcement through training updates or refresher A final word (of caution) about cultural compe-
courses, and the establishment of best practices tency trainings: there are some limitations to the
for the care of LGBT elders can extend these effectiveness of cultural competency training. For
short-term benefits. Other studies indicate that instance, staff training does not cover other
repeated opportunities for interaction also potential players in the environment such as
improve sensitivity and awareness of LGBT vendors or other patients or residents in LTC
elder issues and concerns. For instance, a study facilities. An important component of cultural
by Sanchez et al. (2006) found that medical competency training should thus be how to pro-
students who had repeated clinical encounters vide feedback and address bias displayed by
with LGBT patients were more knowledgeable others (Meyer 2011). It is also crucial to recog-
about their health concerns, had more positive nize that the effectiveness of cultural competency
attitudes, and provided better care than those who training is dependent on ensuring that all staff,
did not. providers, or personnel receive timely and
Ultimately, the application of a systems updated training. However, the reality of orga-
approach, which recognizes that elements within nizations, staff turnover, and scheduling con-
a unit or entity are often interactive, interdepen- straints may result in the presence of untrained
dent, and exert influence on each other, may staff. It is important to schedule regular, as well
yield the best results (Bronfenbrenner 1979). as makeup or catch-up sessions, periodic
Healthcare organizations and long-term care updates, and refresher sessions. Finally, embed-
institutions can help improve staff/LGBT elder ding cultural competency in the organization’s
encounters by providing LGBT cultural compe- culture allows inclusion and respect for diversity
tency training, incorporating LGBT curricula to be the usual way of business in the organiza-
into ongoing educational offerings, and providing tion, consequently ensuring that the healthcare
refresher courses. Providing opportunities for environment is a safe place for all, and especially
staff to interact with LGBT elders will boost LGBT older adults (Meyer 2011; National Resou-
comfort and understanding, as will providing less rce Center on LGBT Aging and SAGE n.d.).
experienced staff with mentors who have a track Table 20.5 provides a list of tips that can be applied
record of working well with this population. to promote success in cultural competence training.
HCOs and LTC institutions should also revise See Experiential Learning Activity #1 in
organization-wide regulations, forms, and pro- Appendix.
cesses to be inclusive and respectful of the LGBT
population. In addition, rewarding staff for par-
Discussion Box #3
ticipation in training, recognitions, awards, or
You are the administrator of Restoration
incentives for desired behaviors also reinforce
Acres, a medium-sized skilled nursing
learning and practice (Knochel et al. 2012). Such
facility. You recently became aware of a
practices help reduce health disparities by creat-
CMS memo that requires that LTC facili-
ing environments in which LGBT elders may
ties notify residents of their rights to have
feel safe and validated (Hughes et al. 2011).
visitors, including same-sex relationships
Effective, timely, and ongoing training and edu-
in the definition of spouses and domestic
cation of staff who work with LGBT elders is a
partners, as well as to ensure full and equal
necessary first step and will go a long way
406 T. Davis and A.E. Sokan
Table 20.5 Cultural competence training—tips for Data Collection and Clinical
success Interview
∙ Train all staff, at all levels
∙ Address how to identify and address the needs of The need for cultural competency extends to
LGBT older adults research (i.e., data collection) and to the clinical
∙ Use trusted and credible trainers interview. Healthcare providers, researchers, and
∙ Enhance knowledge and skills about LGBT older other individuals must be culturally competent
adults, and their intersecting identities of race, ethnicity, when collecting data and conducting clinical
and culture interviews. Collecting LGBT data in clinical
∙ Make cultural competency training a mandatory part of settings is extremely important step toward
all on-the-job/in-service training
understanding the healthcare needs of LGBT
∙ Tailor training to provide knowledge useful for the persons and working toward reducing health
role/job performed by the employee
disparities among this population, thus promot-
∙ Become familiar or investigate training resources ing health equity (Bradford et al. 2011). Unfor-
developed by and/or available at advocacy and research
organizations such as SAGE and the National Resource tunately, patient information regarding sexual
Center for LGBT Aging orientation and gender identity is often not col-
∙ Evaluate the options available and select the programs lected or discussed with providers. The majority
that best fit your need. of providers do not know how to have discus-
∙ Remember that inclusion is an ongoing process— sions about sexual orientation and gender iden-
establish processes, measure, evaluate, retool if tity with their patients, which further contributes
necessary to the invisibility of LGBT patients in clinical
Adapted from SAGE (2012) and the National Resource settings and contributes to the lack of
Center on LGBT Aging (n.d.)
LGBT-inclusive cultural competency and clinical
training for providers (Bradford et al. 2011).
visitation privileges to all visitors. To your Many societal and structural barriers still exist
knowledge, there are at least three LGBT that prohibits the collection of data on sexual
elders in your facility, and you want to be orientation and gender identity. For instance,
sure that you provide a supportive structural barriers include poverty in LGBT
environment. communities (Badgett et al. 2013), lack of pro-
vider training to address the specific healthcare
Is compliance with this memo enough? needs of LGBT people (Obedin-Maliver et al.
Why or why not? 2011), low rates of health insurance coverage for
What if anything else would you recom- LGBT individuals, and lack of access to cultur-
mend? Why? ally appropriate health care (Mayer et al. 2008).
Anti-LGBT discrimination still continues to
See Discussion Box #2 occur in healthcare settings, thus creating addi-
tional barriers to care. Surveys of both providers
and patients indicate that LGBT people experi-
Policy Box #2 What effect, if any will the ence prejudicial treatment in clinical settings and
striking down of Section 3 of the Defense that some providers maintain anti-LGBT atti-
of Marriage Act (DOMA), by the Supreme tudes (Lambda Legal 2010; Smith and Matthews
Court have on LGBT elders in the health 2007). Consequently, many LGBT individuals
arena? Why? report culturally incompetent care, and as a result
20 Healthcare, Sexual Practices, and Cultural Competence … 407
fail to seek health care because of fear of poor Valadez 2013), or including brochures and
treatment (Bradford et al. 2011). advertisements specifically for LGBT individuals
The Fenway Institute in Boston, Massachu- can help to convey the messages that LGBT
setts, has suggested that information regarding people are welcomed in a healthcare setting.
sexual orientation and gender identity be col- It is important to acknowledge that there is
lected in two ways: on the patient registration still a long way to go in improving the collection
forms with demographic information and by of data from LGBT individuals in healthcare
having providers gather the information directly settings. It is inevitable that some patients will
from patients (Bradford et al. 2011). LGBT not disclose information about sexual orientation
individuals can be hesitant to provide information or gender identity in clinical settings. However,
about the sexual orientation or gender identity collecting this information can improve health
due to fears about privacy and confidentiality. outcomes of LGBT patients, will help in
These fears are only made worse with the recent advancing the understanding of LGBT health
computerization of health information and highly (Bradford et al. 2011), and enhance the delivery
publicized cases of breaches in confidentiality of culturally competent care.
(Forsyth 2011). With proper techniques and
standards, these threats are manageable. Provid-
Discussion Box #4
ers should ask permission to include information
Practice asking questions about sexual
about patients’ sexual orientation and gender
orientation and gender identity by part-
identity in their medical record (Bradford et al.
nering with a classmate or coworker and
2011). Patients should be assured that all infor-
asking each other the questions presented
mation will be kept confidential and that the
below. Upon completion, discuss the
information will allow healthcare practitioners to
exercise.
provide comprehensive care.
The Fenway Institute has developed several
Questions regarding Sexual Orientation
suggestions on how to collect the necessary data.
1. Do you have any concerns or questions about
For example, the Fenway Institute suggests your sexuality, sexual orientation, or sexual
including the following question on intake forms: desires?a
“Do you think of yourself as: lesbian, gay, or Or, preface the questions with a statement. Some
homosexual, straight or heterosexual, bisexual, patients will be more receptive to that approach.
something else, or do not know.” The Institute For instance, “I am going to ask you some
also suggests that providers ask questions directly questions about your sexual health and sexuality
that I ask all of my patients”. The answers to
of patients about sexual orientation, behavior, and these questions are important for me to know
gender identity during initial patient visits. Pro- how to help keep you healthy. Like the rest of
viders should start with open-ended questions, this visit, this information is strictly confidential.a
such as “Tell me a little bit about yourself” 2. “Do you have a partner or spouse”? or “Are
(Bradford et al. 2011). While sharing information you currently in a relationship”?b
about themselves, patients may bring up infor- 3. “Are you sexually active”?b
mation about issues related to sexual orientation 4. “When was the last time you had sex”?b
or gender identity, which may open the door for 5. “When you have sex, do you do so with men,
discussions. Healthcare settings can create an women, or both”?b
environment in which individuals might feel 6. “How many sexual partners have you had
more comfortable discussing issues of sexual during the last year”?b
orientation and gender identity by conveying the 7. “Do you have any desires regarding sexual
message that LGBT people are welcome in the intimacy that you would like to discuss”?b
clinical setting (Bradford et al. 2011). For Questions regarding Gender Identity
instance, posting a rainbow flag, the logo of the (continued)
Gay and Lesbian Medical Association (Cahill and
408 T. Davis and A.E. Sokan
parallel increase in the number of LGBT older in turn must bear the responsibility for creating
adults. The current paucity of LGBT research has an environment in which discussions about sex-
negative implications for health care and ser- ual orientation and gender identity are welcome
vices, hence the push for cultural competency by their knowledge, attitudes, and behaviors.
training for healthcare providers. Obviously, Unfortunately, the history of marginalization
research must catch up with LGBT aging issues. among LGBT older adults in all segments of
Research has to repsond to the demand for society also contributes to health status. For
knowledge, as well as document current realities instance, the social context and lived experience
of LGBT older adults and project future needs. of LGBT older adults might include challenges
To begin, we need a better idea of the demo- in relationships such as partner violence, poverty,
graphic scope of LGBT older adults and the stigma, and socioeconomic status might affect
perceived needs among this population. In addi- access to quality health care. So, too, does the
tion, rather than treating LGBT as a homogenous legal context of LGBT older adults, for instance,
group, we need research on the health disparities immigration status, same-sex unions, access to
and needs of various subgroups within this social security affects access to quality health
population. Additionally, we should use the life care. Beyond healthcare provider, all disciplines
course perspective to examine cohort differences with the potential to provide care to this popu-
among older adults in health care, particularly in lation would benefit from understanding the need
light of current political shifts. In terms of to be culturally competent when providing ser-
research, we need research aimed at designing vices to LGBT older adults. Ultimately, health
culturally appropriate preventative care for this status for LGBT older adults is best achieved
population based on the information from current through a multidisciplinary team of care and
generations. Among healthcare providers, inter- service providers working together to provide
ventions should be developed and tested to culturally competent and seamless care in all
increase knowledge regarding providing care to sectors.
the LGBT population and the various subgroups LGBT older adults have poorer health status
and to increase cultural competence among as a result of a combination of factors including
providers. health challenges as a result of sexual orientation,
gender identity issues, as well as a history of
marginalization, prejudice, and the effects of
non-disclosure in healthcare encounters. LGBT
Summary older adults, like others, are entitled to quality
health care. A critical step in reducing healthcare
In this chapter, we have introduced and discussed disparities and improving health and well-being
some of the major issues that affect the health of for LGBT older adults requires the creation of
LGBT elders and how current healthcare prac- inclusive healthcare environment. An inclusive
tices and policies act to disadvantage and mar- healthcare environment is one in which
ginalize LGBT elders through unfair and system-wide policies and practices acknowledge
unreasonable treatment. One thing is clear—any LGBT individuals and all staff and personnel are
attempt to mitigate the problems and improve culturally competent in LGBT issues. Further-
health for LGBT older adults must begin with a more, staff and personnel’s knowledge, attitude,
healthcare environment built on trust, honesty, and behavior indicate sensitivity about LGBT
and openness between the healthcare provider aging needs which encourages trust and disclo-
and the care recipient. We need for LGBT older sure among LGBT older adults. Comprehensive
adults to be able to openly discuss their sexual review of policies and practice in the healthcare
orientation and gender identity and health issues environment is needed to address the needs and
when they seek health care. Healthcare providers concerns of this vulnerable population.
410 T. Davis and A.E. Sokan
6. What are the training needs of staff who (d) They feel embarrassed or ashamed
work with LGBT older adults? because they have internalized miscon-
7. Identify the risk factors for HIV/AIDS ceptions regarding older adults and
among LGBT older adults. sexuality.
8. Explain the importance of having LGBT 4. Structural barriers to obtaining health-related
cultural competency in healthcare personnel data from LGBT elder patients include the
and settings. following:
9. Identify the three dimensions of cultural (a) Poverty in the LGBT community
competency. (b) Lack of provider training to address the
10. You are creating a LGBT cultural compe- specific health needs of the LGBT
tence training program/workshop for health- population
care providers in your county. Discuss the (c) Low rates of health insurance among
goals and components required to make it an LGBT individuals
effective program. (d) Lack of access to culturally appropriate
11. Explain why it is necessary not to treat the health care
LGBT population as monolithic group, (e) All of the above
especially in relation to health and health 5. Which of the following statements is NOT
care. true?
(a) HIV is not a concern among older
adults
Multiple Choice Questions (b) Symptoms of HIV are often confused
with symptoms of other chronic condi-
1. Oftentimes, healthcare providers assume that tions that often affect elders.
older adults are as follows: (c) Making a diagnosis of HIV among
(a) Homosexual older adults can be more challenging.
(b) Transgender (d) Older adults get HIV the same way that
(c) Heterosexual young people do.
(d) Asexual 6. A person’s gender identity if different from
2. Compared to previous generations, rates of sex at birth should:
illicit drug abuse among baby boomers are (a) Always be honored
relatively/have relatively higher rates of illicit (b) Never be honored
drug use as opposed to previous generations: (c) Be honored only if you are comfortable
(a) Lower doing so
(b) Higher (d) Be honored only if the person has
(c) Similar undergone particular medical interven-
(d) Nonexistent tions and a legal name change
3. Many older adults do not bring up the topic 7. The terms “sexual orientation and gender
of sexuality with their healthcare providers identity”….
because: (a) Mean the same thing
(a) They do not desire to be sexually (b) Can be used interchangeably
active. (c) Have different meanings and are not
(b) They do not believe that their health- interchangeable
care provider will have the answers to (d) Can be used interchangeably when
their questions. referring to lesbians only
(c) The healthcare provider often brings the 8. Which of the following statements is correct?
topic up before the older adult has a In order to assure better care experience and
chance to. positive outcomes,
412 T. Davis and A.E. Sokan
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LGBT Elders in Nursing Homes,
Long-Term Care Facilities, 21
and Residential Communities
Abstract
This article examines the opportunities and challenges faced by lesbian,
gay, bisexual, and transgender elders who are aging in the long-term care
continuum. From independent and community living, to adult day
services, assisted living and nursing facilities, LGBT elders may face
discrimination from administrators, direct care professionals, neighbors,
and other residents/participants. Ironically, enduring a lifetime of fear and
discrimination has many positive factors for LGBT elders’ resiliency,
self-esteem, and social networking. Further, LGBT individuals are now
increasingly accepted into “mainstream” society. It is, however, important
to understand that that the current cohort of LGBT elders may not only
fear, but lack the funds to participate in, the long-term care continuum.
Keywords
LGBT GLBT Gay Lesbian Bisexual Transgender Elder Older
adult Long-term care
barriers and unique opportunities for successful informal care networks, while still living
aging in the long-term care continuum. We independently.
evaluate reasons why LGBT older adults may Adult Day/Senior Centers:
hide their sexual orientation or gender identity Community-based organization where elders
and spend time defining and treating the differ- access programs, services, and resources ranging
ences between sexual orientation and gender from socialization to nutrition to some basic care
identity. We identify best practices for creating a intended to support independent living/aging in
supportive environment for LGBT elders and place.
evaluate a case study on optimal aging. Assisted Living: Housing for elders or per-
This chapter presents a brief history of the sons with disabilities that provides basic nursing
research and reviews the current state of LGBT care, housekeeping, and prepared meals as
elders aging within the continuum of care. needed.
National organizations, movements, and policies Skilled Nursing: A residential option that
that impact LGBT optimal aging will be identi- provides skilled or advanced care for elders,
fied, as well as state, local, and regional best usually 24 h per day.
practices for support and inclusion. In addition, Hospice: Palliative care that focuses on the
examples of LGBT-inclusive housing develop- holistic needs of chronically or terminally ill
ments throughout the nation, affordability of patients.
long-term care, and emerging options for aging
in place are discussed. We conclude the chapter
by evaluating academic and community stake- Discussion: In what setting would you
holders in service delivery to LGBT elders and prefer to age and among the company of
the roles they can play in future optimal aging what individuals and groups? What per-
and engagement of LGBT elders. sonal resources and networks will you
need to employ and maintain in order to
you age in your preferred setting?
Teaching Tool: http://lgbtagingcenter.org/
training/buildingRespect.cfm
Complete the following one-hour presen-
tation from the National Resource Center
on LGBT Aging. Identify 5 key takeaway LGBT and Aging: A History
points from this presentation. of Research
anecdotal, and qualitative studies (Johnson et al. Major Issues of the Chapter Topic
2005; Addis et al. 2009). and Relevant Policies
Until 1974, the American Psychological
Association classified homosexuality as a devi- Much of the existing literature has relatively few
ant, pathological condition, and so it was not participants, and the data are skewed toward the
until after the mid-1970s that research on environments in which they took place. The
homosexuality shifted from a deviance model to empirical data track heavily toward higher rates
that of a social-constructivist one (Johnson et al. of smoking, alcohol use, and obesity (Hughes
2005). The data for members of the transgender and Evans 2003). They tend to support older
population have only recently been upgraded stereotypes of the LGBT population as immersed
with the release of the DSM V, in 2013. In both in a culture of alcoholism, depression, and poor
cases, data derive from a younger cohort with a health habits. Examples of real evidence-based
different view and values from their elder coun- qualitative and quantitative studies on LGBT
terparts (Quam and Whitford 1992). elders begin to emerge in the 1990s and 2000s
A quote by Berger and Kelly (1996) person- when data from national organizations (Human
ifies just how stereotypes and antiquated data Rights Campaign, National Gay and Lesbian
proliferate: Task Force, SAGE) were mined. Although this
represents an improvement, the data were col-
lected from members of the LGBT population
The older lesbian…is purported to be a who are active, enfranchised, engaged, and more
cruel witch. Cold, unemotional, and likely to participate in “out and proud” organi-
heartless, she despises men. Devoted solely zations. Much of the existing studies lack sta-
to masculine interests and career pursuits, tistical power due to small sample size and high
she has no friends and is repeatedly frus- potential for participant bias. Therefore, it is
trated by the rejections of younger women. unwise to unilaterally rely on research that is still
The older gay man is said to become emerging and calibrating. While there are indeed
increasingly isolated and effeminate as he excellent, rich, statistically significant studies that
ages. Lacking family and friends, he is have been completed, further research is needed
portrayed as desperately lonely. He must that supports a person-centered model of care
settle for no sex life at all, or he must prey and inquiry.
upon young boys to satisfy his lust. (Ber- Emerging scholarship tells us that elders who
ger and Kelly 1996, p. 306) are isolated are at increased risk for premature
death (Pantell et al. 2013). Compounding this,
Stereotypes such as these above originate according to SAGE, LGBT elders are at
within the lifetime of the current cohort of LGBT increased risk for isolation. LGBT elders are over
elders. They inform the conventional wisdom twice as likely to live alone with thinner support
surrounding sexual orientation and one can only networks, three to four times less likely to have
assume gender identity. children, and twice as likely to be single as
compared to the heterosexual population. LGBT
elders have higher disability rates, struggle with
Discuss the genesis of stereotyping. How economic insecurity, and have increased mental
can stereotyping impact optimal aging and health concerns manifest from a lifetime of dis-
person-centered care? crimination (SAGE 2010).
21 LGBT Elders in Nursing Homes, Long-Term Care Facilities, … 421
Visit www.gensilent.com and view the film • Older people without adequate social inter-
trailer and review the following statistics in action are twice as likely to die prematurely
Fig. 21.2. What do you find most startling • This increased risk of mortality is comparable
from this brief introduction to these cases? to smoking 15 cigarettes per day, 6 alcoholic
Why would any elder wait until near the beverages per day, and it is twice as danger-
end of life to reach out for assistance? ous as obesity.
• 43 % of elders experience social isolation
• 11.3 million elders live alone (8.1 million are
The Caring and Aging with Pride Study
women)
(2011) gives additional information on why the
• Based on current demographic trends,
barriers to inclusion and “othering” of LGBT
16 million elders will live alone by 2020
elders are so real and profound. The study found
• Older adults without adequate social interac-
that 82 % reported having been victimized at
tion are twice as likely to die prematurely
least once, and 64 % reported experiencing vic-
timization at least three times in their lives. The
report notes: “The most common type of vic-
timization is verbal insults (68 %), followed by According to the National Gay and Lesbian
threats of physical violence (43 %), and being Task Force, the fear of isolation is real among
hassled by the police (27 %). Nearly one in four LGBT elders. For many elders who have expe-
(23 %) have had an object thrown at them, and rienced marginalization and disenfranchisement
one-fifth (20 %) have had their property damaged over the life span, with advancing age comes an
or destroyed. Nearly one in five (19 %) have increasing reliance on public programs and social
been physically assaulted (i.e., punched, kicked, services. There is less independence or ability to
or beaten), 14 % threatened with a weapon, and retreat from discrimination, reinforcing isolative
11 % have been sexually assaulted. behaviors, and leading to the negative health
This discrimination continues into later life. outcomes outlined above.
According to a 2005 study of LGBT long-term Further, housing discrimination based on sex-
care residents, LGBT elders fear discrimination ual orientation and gender identity is prohibited in
from administration, direct care professionals, only 15 states and the District of Columbia: Cal-
and other residents (Johnson et al. 2005). These ifornia, Colorado, Connecticut, the District of
responses varied widely with regard to the vari- Columbia, Illinois, Iowa, Hawaii, Maine, Minne-
ables of age, income, gender, community size, sota, New Jersey, Nevada, New Mexico, Oregon,
and education level of the respondents but are Rhode Island, Vermont, and Washington. There
concurrent with the notion that, even among are also six states that prohibit housing discrimi-
healthcare professionals and, arguably, younger nation based on sexual orientation (but not gender
members of the LGBT community, that LGBT identity): Delaware, Maryland, Massachusetts,
elders are “homogeneous, isolated, lonely, and New Hampshire, New York, and Wisconsin. In
without hope.” (Johnson et al. 2005 p. 86). addition, many cities prohibit discrimination on
Fig. 21.2 The film trailer and review the following statistics
422 J.T. White and T.L. Gendron
the basis of sexual orientation, including Atlanta, Department of Labor and Human Services, direct
Chicago, Detroit, Miami, New York, Pittsburgh, care is a low-paying vocation. Personal Care
and Seattle. While that status of the LGBT pop- Aides and Nursing Aides earn an average of
ulation is changing, anti-discrimination is by no $10.66/h or $21,320 annually based on a
means universal (Fig. 21.3). 2000 h year (Figs. 21.4, 21.5, 21.6, and 21.7).
According to the data, most direct care
workers have limited education and lower
In terms of barriers to successful aging, household incomes. Women and immigrants are
why might the lesbian population be faced disproportionately represented among direct care
with different barriers than the gay male workers, again according to the data. There is an
population? And what about the transgen- increased prevalence of public assistance pro-
der population? grams, and while we do not wish to engage in
any stereotyping at all, we do need to evaluate
external stressors and the ability to give good,
person-centered care.
With these data, it is reasonable to assume
A Chilly Welcome?
increased stressors among direct care profession-
als. Lower income may mean that a second job is
Even given this newer trend toward LGBT
required. Less formal education may mean that
positive aging, empirical data still indicate a fear
lower levels of cultural competence may be
among LGBT elders of aging into a long-term
expected. Research by Gendron et al. (2013) also
care environment. When one experiences
underscores these findings. In a population of 158
decreasing voice and choice in the healthcare
direct care professionals, a majority represented a
setting, concerns arise. And what about the
minority population, were female, and had a high
relationship between direct care professionals
school diploma or less.
and LGBT residents? According to the US
21 LGBT Elders in Nursing Homes, Long-Term Care Facilities, … 423
Fig. 21.5 Direct care workers have limited education and lower household incomes
Fig. 21.6 Women and immigrants are disproportionately represented among direct care workers
counterparts and most certainly in relation to identity of birth is not always congruent with
heterosexual elders. According to Perrson their manifested gender identity. Interestingly,
(2009), the term transgender denotes a commu- though gender identity and sexual orientation are
nity of individuals whose biological sexual markedly different biological and psychological
21 LGBT Elders in Nursing Homes, Long-Term Care Facilities, … 425
manifestations, aging may be seen as a unifier. their photos. “(A manager) told me it was a DMV
Isolation, health issues, and personal finances are policy that people listed as male could not wear
makeup,” said Kristen Skinner. “The manager
issues that universally challenge. The transgen- referred to me as “it” and told me to take off my
der population experiences these issues at makeup, wig and fake eyelashes.” Skinner, whose
heightened levels. hair and eyelashes were her own and not fake,
One of the most significant barriers to optimal eventually took the license photo after removing
all facial makeup. The 45-year-old IT professional
aging that transgender elders face in the called the experience at the Charles Town office in
long-term care continuum is actual lack of Jefferson County on January 7 “humiliating.”
knowledge by healthcare professionals. Trans- (retrieved from www.cnn.com)
gender elders may present with characteristics of
According to the 2008 National Transgender
both their birth anatomy and transitional anat-
Discrimination Survey, these heightened barriers
omy. They may have unique medication inter-
to successful aging for transgender elders also
actions. Unique healthcare screenings may be
translate into housing. Given the cost of aging
required based on an individual’s biological sex,
into the long-term care continuum, incidences of
surgical status, declared gender, and hormonal
homelessness persist among transgender elders.
therapies. There is significant anecdotal data
To combat this, in 2012, the US Department of
from members of the transgender population of
Housing and Urban Development issued a
healthcare professionals refusing the treat “those
proclamation making housing discrimination
people.” This purposeful “othering” of trans-
based on sexual orientation and gender identity
gender male and female elders further exacer-
illegal. The ruling also makes it possible for
bates social isolation and healthcare challenges
LGBT and T individuals and couples are inclu-
associated with otherwise normal aging.
ded in HUD’s definition of “family” and are,
This “othering” of transgender individuals is
therefore, entitled to HUD’s public housing and
also manifest in social supports. Like members of
voucher programs.
the LGB population, transgender individuals are
Despite these advances, according to SAGE
often isolated from usual social support systems,
and the NCTE’s 2012 report on improving policy
such as parents, siblings, children, and spouses.
and practice related to transgender elders, much
Without identity with the homosexual or heter-
more needs to be done. Long-term care admin-
osexual community, many transgender elders
istrators and public/private housing providers are
face increased social isolation. While the increase
not aware of the new protections for the trans-
in technological connectivity offers social sup-
gender population; therefore, housing discrimi-
ports via the World Wide Web, these supports
nation continues. As a result of amplified
are not adequate for direct care and socialization
“othering” experienced by members of the
and may, ironically, perpetuate the physical iso-
transgender aging population, it is increasingly
lation experienced by transgender elders.
difficult to gather the personal, social, and
Although great strides have been made over
financial resources necessary to combat housing
the last few years toward LGB rights, the trans-
discrimination across the long-term care contin-
gender population continues to face institutional
uum. This continues to be true even in the private
obstacles in employment, health care, and law
sector, and even if adequate funding for
enforcement.
long-term care is available.
Two West Virginia transgender women claim their
recent DMV visits were especially harrowing as
they attempted to update their names and change Food for Thought: Discussion
their driver’s license photos. In separate incidents, Given the data, what are the implications
both recount officials telling them their appearance
looked too feminine for a driver’s license issued to
for LGBT elders who age from community
a male and that they would have to dress down for into a long-term care setting?
426 J.T. White and T.L. Gendron
opened in California, New Mexico, Massachu- Policy and Advocacy Solutions (adapted
setts, and the Blue Ridge Mountains of North from Improving the Lives of LGBT Older Adults,
Carolina. Federal Fair Housing law dictates that 2010)
residential communities cannot exclude the het-
erosexual or non-transgender population but
must be open and welcoming to all. Pass non-discrimination policies or ordi-
According to Gendron et al. (2013), in a nances at the state or local level. Increase
mixed method study of 158 eldercare profes- awareness or enforcement of existing
sionals who participated in an LGBT cultural non-discrimination policies.
competence training, 97 % expressed knowledge Encourage service providers to adopt their
gain and positive feelings about participating in own non-discrimination policies and actively
the training. Even with this professed knowledge promote them.
gain and the growing resources for LGBT cul- Examine state laws on public health, nursing
tural competence training, the literature tells us homes, assisted living facilities, and home
that more needs to be done, particularly toward care agencies for opportunities to support
understanding the unique differences between LGBT elders.
sexual orientation and gender identity. Although Develop evidence-based, person-centered,
the data absolutely support significant barriers to and accessible cultural competency trainings
optimal aging throughout the care continuum, to reach large number of healthcare
currents are changing, and LGBT elders are professionals.
becoming increasingly engaged and Work with accrediting healthcare agencies,
self-advocating. Progress will continue with the such as the National Board of Long-term Care
assistance of social and policy advocates as Administrators, to develop standards for
issues of social isolation and support connectiv- working with LGBT elders.
ity and engagement are addressed., Advocate for better training and support of
Keys Facts in Social Isolation (adapted from states’ long-term care ombudspeople.
SAGE) Seek to reinforce protections for LGBT elders
under the federal Nursing Home Reform Act
Work with US Department of Housing and
Social Isolation is a universal risk for all Urban Development to create regulations that
aging elders. require nursing homes and assisted living
Living alone is the predominant risk for social facilities to allow same-gender couples and
isolation and disproportionately affects LGBT families of choice to share rooms.
elders.
LGBT elders may face increased levels of
social isolation due to disability, economic
security, and mental health concerns.
LGBT caregivers are also at risk for increased
social isolation.
Major life transitions, such as the death of a
Profile in LGBT in LGBT Leadership:
loved one or unemployment, may also impact
Guy M. Kinman, Jr
social isolation disproportionately among the
Optimal aging for LGBT elders is easier said
LGBT population.
than done. It is important to evaluate case studies
Aging in a rural environment, compounded
and anecdotal information for best practices for
with stigma and discrimination, may also
approaching optimal aging in the long-term care
impact social isolation.
continuum for LGBT elders.
428 J.T. White and T.L. Gendron
As of this writing, Guy M. Kinman, Jr., is Richmond. This legacy will allow subsequent
96 years old. He is currently a resident of Imperial generations the opportunity to learn from what has
Plaza, an assisted living facility in Richmond, come before them to help construct their authentic
Virginia’s Bellevue community. After nearly self and, in doing so, to shine.
thirty years of activity in Richmond’s LGBT Guy was married for a number of years and
community, Guy is receiving a good deal of praise did not come out as a gay man until his 60 s in
and attention for his early civil rights efforts. What the early 1980s. At this time of social conser-
is inspiring about Guy’s message is that even vatism where the Moral Majority and Christian
though he recognizes that “and end” to life is real, Coalition were significant cultural players, Guy
this deadline has offered him the courage to be organized a billboard campaign in Richmond,
what he always wanted to be. He realizes that you Virginia.
often you cannot do everything, but you can focus By 1985, Guy had been retired for three years.
on enough to find happiness. Guy is inspired by He believed he had nothing to lose anymore by
the Chinese philosophy that the definition of being “out.” He felt his gay friends’ fears and
wisdom is knowing “what is enough.” wish for them the freedom they deserved and the
Enough, however, continues to be a daily confidence he enjoyed. The mid-1980s were a
motivator for Guy. Enough is finding the things time when the Moral Majority, headed by the
that “turn you on” and bring out the best in you, Reverend Jerry Falwell, was at the high of its
even given limited faculties, limited space, or popularity. The LGBT community in Lynchburg
limited time. Enough, today, for Guy is the elec- and Roanoke were attempting to launch an edu-
tion of the nation’s first African-American presi- cational campaign on billboards that read
dent and even the opportunity to look beyond his “Someone You Know Is Gay. Maybe Someone
approaching ninety-seventh birthday to offer You Love.” As president of the Richmond Vir-
praise and feedback for next year’s Gay Pride ginia Gay and Lesbian Alliance, Guy spear-
Celebration in Richmond. Enough, for Guy Mal- headed the fundraising efforts to erect 11 of these
colm Kinman, Jr., is acquired through an outlook billboards throughout the Richmond region. The
and ethic that has developed over a lifetime that campaign launched in December of 1985 and
matured and flourished over the last three decades, provided Guy a vehicle to use his masterful sales
and continues to grow with each passing day. This and networking skills to raise the funds necessary
wisdom will proliferate through Guy’s informa- to fund the project, as well as serve as spokes-
tional and financial generosity with numerous person for the Richmond Virginia Gay and Les-
charitable organizations as well as the Guy Kin- bian Alliance on numerous occasions (Fig. 21.9).
man Research Award through the Virginia His- Guy offers tribute to many of his colleagues in
torical Society and the Gay Community Center of the development of The Billboard Program. In a
time when attitudes toward the LGBT commu- of the American Legion. Though “terrified” at
nity were predominantly negative and many the prospect of the debate, Guy felt compelled to
members of the minority population were fleeing be interviewed and to have his voice heard on
to larger cities, Guy worked with others to behalf of a community which had little voice at
develop The Billboard Campaign to show not that time. While Guy credits himself with being a
only the heterosexual community, but also the spokesperson for the LGBT movement in Rich-
LGBT population in Richmond that there was mond at that time, he also credits many other
hope for better treatment and a more positive people who assisted in their own ways and
attitude. The project offered a voice to those who within their own spheres of comfort and
felt like they were without one and helped Guy influence.
also develop his very loud, very clear, voice in In addition to the media, Guy also felt com-
order to shout, yet in a peaceful way. The Bill- pelled to reach out to the Richmond Police
board Project was, for Guy, his golden opportu- Department after the murder of two gay men.
nity to make his voice heard. After returning from a visit to Washington, DC,
Guy was, and is, not bashful about speaking Guy again sprang to action. Together with Tony
with the media and public with regard to The Segura, one of Guy’s heroes and founder of the
Billboard Project and on issues of LGBT civil Mattachine Society in New York, Guy made an
rights in the years following. He and others appointment with a representative of the Police
orchestrated a meeting with the Richmond City Department to express concerns that the investi-
Council to request that sexual orientation be gation into the murders might be compromised
added to the City’s non-discrimination policy. because of the victims’ sexuality. The media
Guy recalls that at the time, many of the people were present at the event in the meeting with the
who attended this meeting at City Hall were Richmond Sergeant, who offered equal protec-
afraid to have their faces shown on television. As tion of the law to members of the LGBT com-
a result, the media shot images of the feet of munity in Richmond, a powerful message at a
those in attendance to showcase the numbers as time when many did not feel that law enforce-
well as shooting the elected representative who ment was on their side.
was speaking the City Council from his back. Today, Guy continues to be an advocate for
Guy offers praise to those who were willing to the LGBT movement in Richmond. As a resident
even attend this meeting at a time when many felt of Imperial Plaza, guy is well-known as a gay
like there would be a backlash if they were activist. He has taken his former fear of dis-
identified as LGBT. crimination and taken to the pulpit, pen, and
In addition to television media, the Richmond public with his pro-gay message. He is a unique
print media would also offer a more narrow focus example of how LGBT elders are able to adapt to
of the LGBT population. Guy took the initiative adversity and capitalize of innate strengths and
to contact a columnist with the Richmond environmental opportunities.
Times-Dispatch who had written what Guy per-
ceived as a very one-sided article. Guy met with
the columnist and expressed his negative opinion 1. What unique characteristics does Guy
with him. This act “impressed the hell” out of Kinman have in order to adapt and
Guy’s friends. succeed in what would have been a
Another instance was when a representative of hostile and changing environment?
the American Legion made a derogatory remark 2. Are these characteristics and assets
about gays and lesbians. Guy took the initiative universal to members of the LGBT
to contact the local NBC affiliate and orches- community?
trated a debate between himself and the President
430 J.T. White and T.L. Gendron
Critical Resources and Philosophies the other. The latter gives viewers insight into the
value that gay men often place on youth and
Two critical philosophies are emerging in con- attractiveness. It informs on how aging and isola-
temporary research and scholarship of sexual ori- tion be of even greater concern.
entation, gender identity, and aging. It is important
for readers to note the emerging scholarship that
supports positive aging and resilience, even in the
face of adversity. It is equally important for readers The Service-Delivery Team
to note the absolute difference between sexual
orientation and gender identity and to approach the The long-term care continuum is a complex sys-
LGB and T lens with the steadfast philosophy that tem that involves multiple disciplines of health-
members of the transgender population are not care professionals, particularly as we look through
necessarily gay, lesbian, or bisexual. the holistic gerontological lens. The VCU School
As students and scholars continue to research of Allied Health Professions introduced a program
barriers to optimal aging for the LGB and T some years back titled “Grand Rounds” that
population, there are several resources that are evaluated the care of an individual from this
critical to gathering evidence-based information. holistic perspective of Allied Health Professions.
Services and Advocacy for GLBT Elders This model for interprofessional collaboration
(SAGE) is the country’s largest and oldest generated a truly holistic view of all disciplines
organization dedicated to improving the lives of that impact service delivery.
lesbian, gay, bisexual, and transgender (LGBT) While gerontology looks at aging in its
older adults. Our mission is to lead in addressing entirety, it is possible to focus on disciplines
issues related to lesbian, gay, bisexual, and including rehabilitation counseling, occupational
transgender (LGBT) aging. More information is therapy, physical therapy, patient counseling, and
located at www.sageusa.org. social work to support LGB and T elders in their
In addition to these national organizations, optimal aging. The challenge is creating a
several documentaries are useful teaching tools cohesive network of healthcare management for
and sources for case studies and anecdotal data. each LGB and T elder where treatments are
As previously mentioned, the documentary “Gen comprehensively managed.
Silent” (www.gensilent.org) follows stories of In addition to the allied health professions, it
LGBT elders and their concerns about having to is important to look at a combination of
go back into the closet in order to survive the Departments of Social Services, nonprofit orga-
long-term care continuum. The VCU Department nizations, and the faith-based community to
of Gerontology has developed, in conjunction support person-centered service delivery for
with the director of “Gen Silent” and the LGBT LGB and T elders. According to the National
Aging Project, a teaching tool titled “A Caring Resource Center on LGBT and Aging, several
Response: Giving Care to LGBT Elders.” states have initiated trainings to support positive
Together, the documentary and curriculum are aging for LGBT elders. In New York City,
go-to resources for information on LGBT elders Jewish Home Life Care and Hebrew Home at
and the long-term care continuum. Riverdale have engaged in trainings of their
Two additional documentaries serve as solid direct care professionals working with LGBT
teaching and educational tools. “Ten More Good older adults. Wisconsin’s Agency on Aging
Years” and “Beauty Before Age: Growing Older Resources and Aging and Disability Resource
in Gay Culture” offer a glimpse into the lives of Center has also engaged in comparable cultural
LGBT aging and identity. The former resource competence and awareness building trainings.
offers viewers an idea of how socioeconomic sta- In Virginia, all assisted living and adult day
tus, sexual orientation, and gender identity impact centers are regulated by the Virginia Department
21 LGBT Elders in Nursing Homes, Long-Term Care Facilities, … 431
of Social Services and are bound to specific creates additional barriers to successful aging,
regulations are care requirements. In addition to especially in more structured and formal care
the Virginia Department of Social Services, we environments, such as assisted living, skilled
can look at the Virginia Department for Aging nursing, and hospice.
and Rehabilitative Services (DARS) and Area The message from emerging scholarship and
Agencies on Aging. Programs such as “No personal accounts is equally clear. Many LGB
Wrong Door” support all elders regardless of and T elders are either “surviving and thriving”
sexual orientation or gender identity. Outside of or “working at it” (VanWegenen et al. 2012,
the formal care continuum, we can look at non- p. 1). They are delving into personal resources
profit organizations and the faith community for and networks to overcome and surpass barriers to
both formal and informal assistance and a more successful aging, even in light of barriers.
person-centered approach to care. So, where do we go from here? In keeping
with the gerontological lens of optimal aging and
person-centered care, it is important to under-
stand that more studies are needed. Richer data
are needed from more diverse portions of the
Summary and Opportunities
LGB and T population. We need to engage iso-
for Future Research
lated elders from rural areas. We need to engage
elders who may not be involved in national
In sum, we have reviewed barriers to, and
organizations. And we need to understand that
opportunities for, successful aging in the LGB
there are nearly 8,000,000 LGB and T elders
and T population. In many instances, the picture
right now who may one day be candidates for the
is not pretty. Discrimination is still rampant
long-term care continuum. We need to ask them
among lesbian, gay, bisexual, and transgender
about their preferences for care. We need to train
elders even in light of recent political and social
direct care professionals in cultural competence
progress. The plight for transgender elders is
and person-centered care. And we need to pay
even more challenging, as we have identified
close attention to not creating a long-term care
increased barriers to inclusion and obstacles for
environment where “one size fits all.”
this cohort. A long history of “othering” and
stigmatization by the dominant hegemony has
resulted in biological, psychological, sociologi- Learning Exercise: Conducting an
cal, and spiritual disenfranchisement. Othering, Equity Audit (adapted from Sklra et al.
in short, creates “us versus them” relationship 2009 and Gay and Gray: Welcom-
where a dominant group perceives and promoted ing LGBT Elders in Long-Term Care)
another group as unequal or alien. Othering is If you are an administrator for a
antithetical to a gerontological and long-term care facility, how would you
person-centered care model and is just one of ensure a supportive environment for
many barriers experienced by LBG and T elders. LGB and T elders? Consider using the
In addition to the social phenomenon following questions to inform your ini-
of othering, equal access to formal and informal tial inquiry. Please circle 1 for No, 2 for
healthcare services and residential options for Rarely, 3 for Not Sure, 4 for Often, and
LGB and T elders is also evident. LGB and T 5 for Always.
elders are more likely to be single, less likely to Am I aware of members of the LGBT
have children, and more likely to be discon- population residing in my longterm care
nected from family of origin. This phenomenon facility?
432 J.T. White and T.L. Gendron
1 2 3 4 5
(d) 82 % http://www.aarp.org/relationships/friends-
(Answer: d) family/aarp-pride.html?intcmp=AE-SEARCH-
8. Elements of the direct care professional AARPSUGG-LGBT
demographics include: http://www.aarp.org/politics-society/rights/
(a) Limited education info-06-2009/more_lgtb_resources_from_aarp.
(b) More women and racial/ethnic minorities html
(c) Higher use of public assistance programs http://www.aarp.org/politics-society/rights/
(d) All of the above info-06-2009/lgbt_glossary.html
(Answer: d) http://www.aarp.org/politics-society/rights/
9. ___% of LGBT elders report engaging in a info-06-2009/wisdom_of_the_elders_aarp_and_
health and wellness activity sage.html
(a) 20 % http://www.aarp.org/politics-society/rights/
(b) 50 % info-03-2010/marriage_and_gay_rights.html
(c) 75 % http://www.aarp.org/relationships/love-sex/
(d) 90 % info-02-2008/aids_prevention_for_50plus_
(Answer: d) pushed.html
10. According to the literature, a universal risk AIDS Community Research Initiative of
for all elders, regardless of sexual orientation America (ACRIA)
or gender identity is: ACRIA is the first-ever activist,
(a) Social isolation community-based approach to the study of new
(b) Financial concerns treatments for HIV. ACRIA studies the lives and
(c) Premature death needs of people with or at risk for HIV through
(d) Elder abuse its Behavioral Research Program; offers critical
(Answer: a) HIV healthcare education to HIV-positive people
and their caregivers all around the world through
its HIV Health Literacy Program; and provides a
variety of consulting services (technical assis-
tance, monitoring and evaluation, curriculum
Resources development, and Web-based learning among
them) to strengthen AIDS and other service
AARP organizations across the country, enabling those
American Association of Retired Persons is a groups to better serve their own clients. Addi-
nonprofit, nonpartisan organization, with a tionally, through the ACRIA Center on HIV and
membership of more than 37 million, that helps Aging, the organization is recognized as an
people turn their goals and dreams into real international authority on the emerging issue of
possibilities, strengthens communities, and fights older adults and HIV.
for the issues that matter most to families such as Web site: http://www.acria.org/
healthcare, employment security, and retirement Additional resources: https://www.dropbox.
planning. We advocate for consumers in the com/s/eablp1lb1y6eyqh/Policy%
marketplace by selecting products and services of 20Recommendations%20Older%20Adults%
high quality and value to carry the AARP name 20with%20HIV.pdf
as well as help our members obtain discounts on American Society on Aging
a wide range of products, travel, and services. The American Society on Aging is an asso-
Web site: http://www.aarp.org/ ciation of diverse individuals bound by a com-
Additional resources: mon goal: to support the commitment and
21 LGBT Elders in Nursing Homes, Long-Term Care Facilities, … 435
enhance the knowledge and skills of those who sensitivity, and collaboration among caregiving
seek to improve the quality of life of older adults professionals.
and their families. The membership of ASA is Web site: http://www.grayingofaids.org/
multidisciplinary and inclusive of professionals Additional resources:
who are concerned with the physical, emotional, http://www.grayingofaids.org/modes-of-
social, economic, and spiritual aspects of aging. transmission/
Web site: http://www.asaging.org/ http://www.grayingofaids.org/glossary/
Additional resources: http://www.grayingofaids.org/resource-links/
http://www.asaging.org/lain http://www.grayingofaids.org/training-
http://www.asaging.org/national-resource- materials/
center-lgbt-aging-sage Lambda Legal
FORGE Transgender Aging Network Lambda Legal is the oldest and largest
The Transgender Aging Network national legal organization whose mission is to
(TAN) exists to improve the lives of current and achieve full recognition of the civil rights of
future trans/SOFFA (significant others, friends, lesbians,gay men, bisexuals, transgender peo-
family, and allies) elders by the following: ple,and those with HIV, through impact litiga-
identifying, promoting communication among, tion, education, and public policy work. As a
and enhancing the work of researchers, service nonprofit organization, we do not charge our
providers, educators, advocates, elders, and oth- clients for legal representation or advocacy, and
ers who are interested in trans/SOFFA aging we receive no government funding. We depend
issues; promoting awareness of concerns, issues, on contributions from supporters around the
and realities; advocating for policy changes in country.
public and private institutions, services, organi- Web site: http://www.lambdalegal.org/
zations, programs, etc.; and providing commu- Additional resources:
nication channels through which trans/SOFFA http://www.lambdalegal.org/know-your-rights
elders can give and receive support and http://www.lambdalegal.org/states-regions
information. http://www.lambdalegal.org/help
Web site: http://forge-forward.org/aging/ http://www.lambdalegal.org/publications/all
Additional Resources: http://www.lambdalegal.org/our-work
http://www.lgbtagingcenter.org/ The LGBT Aging Project/Third Sector New
http://www.grayprideparade.com/ England
Gay Men’s Health Crisis (GMHC) A nonprofit organization dedicated to ensur-
GMHC is the world’s first and leading pro- ing that lesbian, gay, bisexual, and transgender
vider of HIV/AIDS prevention, care, and advo- older adults have equal access to the
cacy. Building on decades of dedication and life-prolonging benefits, protections, services,
expertise, we understand the reality of and institutions that their heterosexual neighbors
HIV/AIDS and empower a healthy life for all. take for granted.
GMHC’s mission is to fight to end the AIDS Web site: http://www.lgbtagingproject.org/
epidemic and uplift the lives of all affected. Additional resources:
Web site: http://www.gmhc.org/ http://www.lgbtagingproject.org/resources-
Additional resources: for-lgbt-seniors/
http://www.gmhc.org/about-us/links Medicare Rights Center
http://www.gmhc.org/blog The Medicare Rights Center is a national,
The Graying of AIDS nonprofit consumer service organization that
The Graying of AIDS combines portraits and works to ensure access to affordable health care
oral histories of both long-term survivors and for older adults and people with disabilities
older adults who contracted HIV later in life with through counseling and advocacy, educational
HIV/AIDS information to increase awareness, programs, and public policy initiatives.
436 J.T. White and T.L. Gendron
nation that respects the diversity of human of the national transgender discrimination survey.
expression and identity and creates opportunity Washington: National Center for Transgender Equal-
ity and National Gay and Lesbian Task Force.
for all. Hughes, C., & Evans, A. (2003). Health needs of women
Web site: http://www.thetaskforce.org/ who have sex with women. BMJ, 327(7421), 939–
Additional resources: 940.
http://www.thetaskforce.org/issues Johnson, M., Jackson, N., Arnette, J., & Koffman, S.
(2005). Gay and Lesbian perceptions of discrimination
http://www.thetaskforce.org/reports_and_ in retirement care facilities. Journal of Homosexuality,
research 49(2), 83–102.
McKenzie, K., & Skrla, L. (2011). Using equity audits in
the classroom to reach and teach all students. Corwin:
Thousand Oaks.
References National Center for Transgender Equality. (March 2012).
Know your rights: Fair housing and transgender
Addis, S., Davies, M., Greene, G., MacBride-Stewart, S., people. Retrieved from www.transeqaulity.org.
& Shepherd, M. (2009). The health, social care and National Resource Center on LGBT Aging. (2012). A
housing needs of lesbian, gay, bisexual and transgen- self-help guide for LGBT older adults and their
der older people. Health and Social Care in the caregivers and loved ones: Preventing, recognizing,
Community, 17(6), 647–658. and addressing elder abuse. Retrieved from http://
Auldridge, A., Tamar-Mattis, A., Kennedy, S., Ames, E., www.lgbtagingcenter.org/resources/pdfs/SELF-
& Tobin, H. (2012). Improving the lives of transgen- HELP_elderAbuse_Guide.pdf.
der older adults. Services and advocacy for glbt elders Pantell, M., Rehkopf, D., Jutte, D., Syme, S., Balmes, J.,
and the national center for transgender equality. & Adler, N. (2013). Social isolation: A predictor of
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and gray: Welcoming LGBT elders in long term care. tors. American Journal of Public Health, 103(11),
May/June 2012. 2056–2062.
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(2011). The aging and health report: Disparities and The Equal Rights Center. (2014). Opening doors: An
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Keisling, M. (2011). Injustice at every turn: A report
End-of-Life Issues for LGBT Elders
22
David Godfrey
Abstract
This chapter explores the end-of-life issues and what makes end-of-life
issues different for LGBT adults. The laws and policies relating to
end-of-life have many presumptions that favor family, specifically
biological or adoptive family and family from marriage. These presump-
tions impact health care decision-making, visitation policies, health
insurance, health benefits, retirement plans, taxation, and inheritance rules.
The expansion of same-sex marriage is changing this picture, but a great
deal of work remains to be done. Societal homophobia impacts access to
care, relationship recognition, and even funeral planning. Ageism is
common in some parts of the LGBT community, casting a shadow over
many LGBT elders. Many of the current generation of LGBT elders
survived the darkest days of AIDS and HIV, and this experience
influences their views on aging and end-of-life.
Keywords
Ageism Presumptions Incapacity Inheritance Surrogate
Hospital Visitation Laws [Fact sheet]. Retrieved family. Family of origin or biological family is
from http://hrc-assets.s3-website-us-east1.amazo the family a person is raised within, including
naws.com//files/assets/resources/hospital_visita- birth or adoptive parents, siblings, and blood
tion_laws_12-2013.pdf). relatives. Marital family includes a spouse and
in-laws. Chosen families are the “network of
friends drawn together by affinity rather than
Discrimination and Bias consanguinity that provide a wide arrange of
family support” (Knauer 2009.) For gay and
LGBT elders are at risk of bias and discrimination lesbian adults, chosen family frequently takes the
on multiple fronts. Despite great progress, we live place of marital family. This is especially true in
in a society with a heterosexual bias. An states that do not allow or recognize same-sex
opposite-gender spouse is the default assumption. marriage. Some LGBT adults experience
Gender choices in application or information “estrangement and distance from families of
forms are limited to male and female, leaving origin” and form chosen families in the place or
intersex and trans persons with no appropriate biological family (Knauer 2010.) The law,
choice. Homophobia is still common. A survey of however, frequently views chosen families, as
LGBT elders found that the vast majority, if strangers and outsiders often leaving chosen
needing institutional long-term care, would family with little ability to make health care
choose to be closeted about their sexuality and, if decisions without legal documents.
ever receiving in home care, would fear mis- Adult children and grandchildren play a major
treatment by caregivers based on sexual orienta- role in end-of-life social interaction and health
tion or gender identity. LGBT (2010) older adults care. Adult children often provide a social net-
in long-term care facilities. A fear of discrimina- work, act as caregivers, and participate in making
tion by health care service professionals is cited as end-of-life health care decisions. LGBT elders
a major fear among LGBT elders (Knauer 2010). are less likely to have children, an estimated
Ageism is widespread in society and in the 37 % of LGBT adults have children (Gates
LGBT community. Ageism especially impacts 2013), and by comparison an estimated 74 % of
the gay male community with youth and sexual all adults have children (Newport and Wilke
attractiveness being a significant focus of tradi- 2013, September 25). Desire for children is still
tional gay culture and society (Knauer 2009). the norm in USA (Newport and Willke 2013).
Older gay men are rejected by their younger LGBT elders who do have children may be
peers. For example, one man speculated that he estranged from them. “Coming out” to children
could stand nude in the corner of gay bar and not and the risk of rejection is a great fear of LGBT
be noticed. Another joked that a gay man is dead adults. The mixture of chosen, marital, and bio-
at 30 (Arana 2013, August 22). Much work is logical family is a barrier, which complicate
needed in legal, social, and policy areas for end-of-life issues for LGBT elders.
LGBT elders to age in dignity and without fear Society and the law create preferences or
(Knauer 2010). presumptions that favor families of origin and
marital family. Heterosexuality is presumed in
social interaction. When asking about a person’s
End-of-Life, Death, and Dying: What spouse, the societal norm is to ask about a spouse
Makes LGBT Elders Different of the opposite gender. A female hospital or
from Others? nursing home patient will, by default, be asked
whether she has a husband. Statutes codify these
Dying and death are a universal part of life. The presumptions and preferences in health care
difference for LGBT elders is in the likely mix- decision-making, visitation in a health care
ture of family of origin, marital, and chosen facilities, benefits eligibility, survivorship,
442 D. Godfrey
It is important to be careful about the gener- Only when a person lacks the ability to make or
alization that LGBT adults will be estranged communicate health care decisions does this right
from marital and biological family. Many fami- shift to someone else. Even when the transfer of
lies are very accepting of LGBT family mem- health care decision-making is triggered, it is
bers, while others actively reject LGBT family important that the individual be included in the
members. An individual assessment of the nature decision-making process and that the known
of family relationships is essential to helping an wishes of the patient be honored. Even if unable
LGBT elder with end-of-life issues. In any fam- to make a decision, the individual may be able to
ily, disagreement and strained relationships express preferences or fears that can guide the
complicate end-of-life. The strain of illness and decision-making process. The ultimate goal is for
death can bring to the surface suppressed beliefs, the decision that is made and to reflect the
feelings, and emotions. Families that have gotten wishes, beliefs, goals, and values of the
along for decades, when faced with an end-of-life individual.
illness or death, may feel compelled to argue
religious and societal views to urge an LGBT
elder to change before death. Default Decision Makers
The last caution is that an LGBT individual
can be “out” with one person and in the closet Virtually, all states by statute or common law
with the next person. Sexual orientation is gen- allow someone to make health care decisions for
erally invisible, and LGBT adults spend a life- a person who is unable to do so (American Bar
time deciding what to disclose to whom. When Association Commission on Law and Aging
working with LGBT adults at the end-of-life, it is 2014). All of the default health care
important to honor and respect the choices that decision-making rules turn first to marital and
they have made. Accidental disclosure can strain biological family members. The most common
relationships and cause frustration and confusion provisions first ask the patient’s spouse to make
at a time when the support of family and friends health care decisions. If there is no spouse, the
can be most important. Knowing what to say to person’s adult children are generally second in
whom is especially complicated if the LGBT line to make health care decisions (and the laws
elder near the end-of-life is unable to communi- vary in how they treat disagreement among
cate their wishes regarding disclosure. If unsure them.) If there are no adult children, the rules
of the level of disclosure, the best course of look to the person’s parents. This process con-
action can be to listen carefully for clues—while tinues moving out through the family tree.
maintaining confidentiality. Domestic partners are included on the statutory
lists in five states, and best friends are included in
23 states—but only are called on to make health
End-of-Life Health Care care decisions when there is no spouse or bio-
Decision-Making logical family higher up in the statutory list
(ABA Commission on Law and Aging 2014).
In an ideal world, every person would remain Default surrogate consent statutes). For an LGBT
fully aware and able to make and communicate elder, a “close friend” or chosen family may be
health care decisions until their last heartbeat and his or her preferred health care decision maker.
breath. In reality, most people experience at least The growth of same-sex marriage will change
a short period before death when they are unable this picture, with more and more same-sex cou-
to make or communicate decisions regarding the ples becoming spouses recognized by the law.
kind and extent of health care that they want or The spousal preference disproportionally
do not want to receive. Every adult has a fun- impacts LGBT elders. Same-sex couples are less
damental right to make health care decisions. likely to be married than opposite-sex couples.
22 End-of-Life Issues for LGBT Elders 445
Until recently, few states allowed same-sex designating someone in writing to make health
couples to marry. This is a rapidly changing care decisions in the event that the patient is
area of the law. Time will tell if same-sex cou- unable to do so. A health care surrogate may be
ples marry at the same rate as opposite-sex named in a durable power of attorney for health
couples. Unmarried opposite-sex couples face care, a declaration of a surrogate, or in a combi-
the same issue as unmarried same-sex couples on nation form that serves as a living will and
this issue—with the major difference being that appointment of a surrogate. The legal formalities
opposite-sex couples can marry in every state, of naming a health care surrogate vary from state
and same-sex couples can only marry in some to state, making it difficult to create a single form
states. For same-sex couples who are married, the that works for everyone. There is multistate
marital preferences apply. durable power of attorney for health care that
The health care decision maker presumptions works for most people in about 40 states (Giving
can be overcome by the naming of a health care someone a power of attorney for your health care)
surrogate. This is the same for all adults and (Retrieved from ABA Commission on Law and
requires specific legal steps. Aging Web site: http://www.americanbar.org/
content/dam/aba/administrative/law_aging/2011/
2011_aging_hcdec_univhcpaform_4_2012_v2.
Advance Care Planning authcheckdam.pdf). Many states have a standard
form power of attorney for health care, or stan-
Advance care planning includes naming a health dard form living will directive. Frequently,
care surrogate and communicating health care state-specific forms can be found on the Web sites
goals, values, and beliefs to the health care sur- of the state attorney general, state department of
rogate and health care providers to guide health or aging services, or legal aid Web site.
decision-making when the elder is not able to The health care surrogate should be selected
make or communicate decisions. The process with great care. Being a health care surrogate can
focuses on the needs, goals, preferences, cultural be very difficult. Surrogates are sometimes called
traditions, family situation, values, and the needs upon to make life and death decisions. Health care
and preferences of surrounding family (Levine surrogates, especially for LGBT elders, may find
Feinberg 2013, May 1). themselves at the middle of disputes between
Successful planning involves a spectrum of loved ones. Surrogates also need to be prepared to
people, including the patient, health care pro- advocate with health care providers for the
viders, marital, biological, and chosen family and person-centered care in line with the goals, values,
the health care surrogate. Including the surrogate and beliefs of the person who appointed them. To
early in the process will help the surrogate gain be effective, a surrogate needs to understand the
insight into the choices and preferences of the goals, values, and beliefs of the person, be willing
person for whom they may someday need to and able to make decisions that reflect what the
make decisions (Tilly et al. 2007). person would make, and have the strength to make
decisions even if unpopular with others.
Empowering a surrogate is a human services
Naming and Empowering a Health process that starts with understanding the health
Care Decision Maker care goals, beliefs, and values of the patient. For
many adults, this starts with self-discovery,
Everyone should name a health care surrogate; thinking about the kinds of care wanted or not
doing so is especially important for LGBT adults wanted under various circumstances and who to
because of the potentially complex mixture of include or exclude in a time of illness and dying.
chosen, biological, and marital family. Naming a Tools such as “Five Wishes” (http://www.
health care surrogate is a legal process involving agingwithdignity.org/five-wishes.php.) and the
446 D. Godfrey
“Conversation Starter Kit” (www.theconversation address the elder by their preferred gender and
project.org) can be very helpful both in helping the name (The National Resource Center on LGBT
individual think about these issues and in starting Aging and Whitman-Walker Health 2014).
conversations with others. Once the individual has a Individuals who have had gender reassignment
grasp on his or her health care goals, values, and surgery have special medical needs; the surrogate
beliefs, it is essential that this information be shared needs to be empowered in a power of attorney for
with the health care surrogate, family, and loved health care to advocate with health care providers
ones and health care providers. Without this con- and insurance companies for appropriate care.
versation, the health care surrogate may lack critical Creating advance directives such as appoint-
information for making health care decisions. It is ing a health care surrogate or completing a living
important to include health care providers in the will directive can be a do-it-yourself (DIY) pro-
advance planning conversations. Health care pro- ject. However, there are risks in DIY planning.
viders need to know who to turn to for health care Many standard forms are poorly written, and few
decisions and to understand the health care goals come with clear instructions on how to complete
and values of the patient. The potentially com- them. The witness or notary instructions are
plex mixture of chosen, biological, and marital state-specific and must be followed precisely.
family increases the need for advance health care Using a lawyer to complete advance directives
planning for LGBT elders. Without advance costs money (though many legal aid programs
planning, health care providers will default to the provide this service free of charge for older
standard assumptions and protocols with a hetero- Americans). The assistance of a trained profes-
sexual bias. sional can increase the likelihood of success.
Human and aging services professionals must For LGBT elders, who fear a challenge to
be careful not to give legal advice when assisting advance care planning by family members,
with standard forms. Providing a form is not the working with an attorney on advance health care
practice of law. Providing information is gener- directives adds an additional layer of protection
ally not the practice of law. The challenge is that the planning is done correctly, and at a time
avoiding the tipping point between providing when the elder has capacity and is not subject to
information and interpreting the law. When in undue influence. Unmarried couples should
doubt, ask an attorney what to do and where to avoid helping one another with advance health
stop. Alterations or changes in the standard forms care directives, as this may be interpreted as
should be done by an attorney. It is very easy undue influence and used to challenge the
when making changes to invalidate forms. Some validity of the documents.
states have specific language that must be Advance care planning should not stop with
included for an advance health care directive to the creation of documents. To be effective,
be valid. Special care must be taken when cre- advance care planning needs to include mean-
ating clauses about specific treatment—to assess ingful conversations with family, friends, and
the impact on other treatment options. Most health care providers. The goal is for everyone to
states have strict limitations on who can serve as understand the goals, values, and beliefs of the
a witness or notary when advance health care individual regarding health care, especially
directives are signed. Missing any one of these end-of-life health care. Advance care planning
can cause the planning to be ineffective. carried out, without creation of legal documents,
Advance directives for trans elders need to especially for LGBT elders who wish to appoint
include specific instructions. The forms should a surrogate different than the legal default, would
include provisions instructing health care pro- be ineffective in that the preferred health care
viders on the preferred gender pronoun and name surrogate would lack the authority to do so.
to use when communicating with or about the Creating legal documents without having mean-
patient. The health care surrogate should be ingful conversations with loved ones and health
empowered to direct health care providers to care providers is equally doomed to failure—if
22 End-of-Life Issues for LGBT Elders 447
no one knows what the plans are and what they about 1.4 million persons living in skilled
mean—the plans are unlikely to be followed. long-term care facilities in the USA (CMS 2013)
Mentioned earlier, tools such as “Five Wishes” The vast majority of long -term care services are
and “Your Conversation Starter Kit” are very provided in the community by family and
helpful in planning and facilitating meaningful friends. For LGBT elders, home and community
conversations about health care wishes. based care falls largely to chosen family.
If caregivers are paid, there should be a formal
written caregiver agreement. Elder law attorneys
craft these agreements to take into account the
Elder Law
care needs, wishes of the parties, tax and
employment laws, and Medicaid laws. No two
Elder law is a growing area of practice, and plan-
individuals and no two families are the same, and
ning for LGBT families is a popular topic for elder
the agreements should be written to specifically
law attorneys. Elder law expands on traditional
reflect the situation. This is especially important
estate planning—work that focuses on who gets
for caregivers of LGBT elders, as biological
what after death—by focusing on issues likely to
family may challenge the payments. Caregiver
occur while the client is still alive. Elder law covers
agreements spell out the caregivers’ obligations
a broad spectrum of issues, including financial
and the terms of payment. The agreement and
security, housing, living arrangements, caregiv-
compliance with it can be a defense against
ing, health care benefits, the possibility of inca-
accusations by family members or others that the
pacity, and the preservation and distribution of
caregiver was financially exploiting the elder.
assets after death. Most adults stand to benefit from
Caregiver agreements are also essential if the
advice and assistance from an elder law attorney.
elder ever applies for Medicaid. On average,
Legal aid programs are able to help some
70 % of nursing home residents qualify for
low-income older adults. According to Legal
Medicaid. When an application is made for
Service Corporation, about 15 % of legal aid cli-
Medicaid benefits, the agency looks at gifts made
ents legal are age 60 and older (http://www.lsc.
within five years and may impose periods of
gov/about/lsc-numbers-2013#2013Ageand
ineligibility based on gifts. A caregiver agree-
GenderofClients). Funding is provided under the
ment documents that payments to a caregiver
Older Americans Act for legal assistance. Local
were payments for services and not gifts.
senior centers, local area agencies on aging, or
Medicaid pays for health care for needy
state offices on aging can direct low-income older
elderly and disabled adults when no other pay-
adults to the attorneys funded under this program.
ment source is available. Medicaid is a
There is a locator for free legal assistance for
needs-based program, meaning a beneficiary
low-income older adults on the National Legal
must establish a financial and medical need to be
Resource Center Web site at http://nlrc.acl.gov/
covered by the program. Medicare by contrast is
Services_Providers/Index.aspx.
available without regard to financial need. The
financial need for Medicaid includes both limits
on income and on assets. Congress created special
Caregiving provisions to protect a married couple from total
impoverishment if one of them needs long-term
Family, chosen, marital, and biological, are the care paid for by Medicaid. These are known as
most common caregivers of elders. There are an Medicaid spousal impoverishment protections.
estimated 10 million Americans in need of The protections exempt the average home, at least
long-term care services (Selected Long Term one motor vehicle, and allow the spouse not
Care Statistics, Family Caregiver Alliance, requiring Medicaid services to retain modest
viewed on 9/24/2014 at https://caregiver.org/ savings. The spousal impoverishment protections
selected-long-term-care-statistics.), and only did not protect married same-sex couples, until
448 D. Godfrey
the Windsor decision ruled parts of the Defense of survivor, and widows benefits are becoming a
Marriage Act unconstitutional (Windsor v. Uni- bigger issue for LGBT elders as a result of the
ted States, 570 U.S.—(2013). Prior to this, the expansion of same-sex marriage and the Windsor
Department of Health and Human Services Cen- decision. This is a rapidly evolving area of law
ters for Medicare and Medicaid Services had and policy, and the Social Security Administra-
issued policy letters saying that states could only tion is expanding the availability of spousal,
protect same-sex couples by finding that not survivor, and widows benefits at a rapid pace.
doing so was an undue hardship. This is still the This is a complex area, married same-sex couples
only option in states that do not allow or recog- should be advised to check with an expert to see
nize as valid same-sex marriage. The Windsor whether they are eligible for spousal benefits
decision extends the spousal impoverishment under Social Security.
provisions to hundreds of thousands of married Most private retirement plans or pensions are
same-sex couples. Same-sex couples should required by federal law to protect spouses by
consult an experienced elder law attorney about requiring a surviving spouse benefit as the
the best options for paying for long-term care and default, unless waived by the non-employee
Medicaid eligibility (possibly before they make a spouse. Federal law imposes strict requirements
decision to marry.) on waiving the spousal benefit; these protections
extend to married same-sex couples. For tradi-
tional defined benefit pensions, this means that
Estate Planning and Inheritance when a married person retires, the retirement
benefit is based on paying a benefit for the life-
An end-of-life concern for many people is who time of both spouses, unless waived; if the wage
inherits what when they die. Inheritance issues earner dies before retiring, the surviving spouse
for LGBT elders are complicated by defaults and is eligible for a survivor pension. For a defined
presumptions in the law favoring martial and contribution plan such as an IRA or 401 k, the
biological family. It is helpful to be familiar with default beneficiary for a married person is the
the basic principles; the details of these issues fill spouse, unless waived. In addition, a surviving
a number of tomes. spouse is given preferential treatment in the
When a person dies, laws or legal plans made federal tax law for an inherited tax deferred
by the person determine who inherits his estate. defined contribution plan (the typical IRA or
An estate includes personal property, money, 401 k plan). Post-Windsor, these provisions
investments, vehicles, furniture, household items, apply to married same-sex spouses, though it
jewelry, the right to receive income, and real may take a few years for all of the account
property. Without a will or estate plan, marital documents to be amended to reflect the changes
and biological families inherit the estate. To in federal law. For LGBT elders with non-marital
overcome the statutory presumptions, an adult chosen family, it is essential that they name
needs a will, trust, or other estate-planning beneficiaries on all retirement plans.
instrument. Estate planning is especially impor- When working with LGBT elders nearing the
tant for LGBT elders, as the statutory defaults do end-of-life, it is important to review beneficiary
not include chosen family. LGBT adults nearing designations on pensions, retirement plans, life
the end-of-life should review their estate plan insurance, bank accounts, and investment
with an attorney to assure that the outcome is accounts. For property that has a formal written
what they want to have happen. form of ownership such as bank accounts,
Social Security provides an essential income investment accounts, and motor vehicles, the
support for 93 % of all American elders. Social ownership after death may be determined by
Security provides spousal, survivor, and widows form of ownership on the documents. There are
and widowers benefits. Social Security spousal, two things to look for: is there more than one
22 End-of-Life Issues for LGBT Elders 449
name on the ownership documents, or, is there a them access to the home. The right to remain in a
designation of a beneficiary, payable on death or leased home is especially valuable in areas with
transferable on death designation in the owner- rent control.
ship paperwork? A home is the largest single asset owned by the
Property owned in the name of more than one average American. The wording on the deed is
person is classified as joint property. Most bank essential to understanding joint ownership of real
accounts with more than one name on them are estate. If the deed to real property lists multiple
set up as “joint-with-right-of-survivorship.” This owners, an expert in real property law in the state
means when one joint owner dies, the other joint that the property is located should be called on to
owner(s) are presumed to own the account. It is review who owns what interests. The two most
also possible for jointly owned property to not be common forms of joint ownership of real estate are
“joint-with-right-of-survivorship”—in which tenants in common and joint tenancy. The death of
case the share of the deceased is an asset of their an owner in a tenancy, in common, results in the
estate. Bank and investment accounts may also estate of the deceased owning the deceased owners
may list a beneficiary, frequently called a “pay- interest in the property. A joint tenancy is also
able on death” (POD) or “transferable on death” known as “joint-with-right-of-survivorship”. The
(TOD) designation. Accounts with POD or TOD death of a joint tenant results in the surviving joint
designations pass automatically as an operation owners inheriting the property automatically.
of law to the named beneficiary at the time of There is a third less common form, called tenancy
death. Life insurance pays to the named benefi- by the entireties, that is a super-strong form of
ciary, no document other than a form supplied by joint-with-right-of-survivorship ownership only
the insurance company, can change the benefi- available to married couples. With the expansion
ciary on a life insurance policy. of same-sex marriage, some couples may wish to
change their form of ownership to tenancy by the
entireties. The exact language that creates each of
Housing and Home Ownership these varies from state to state. It is important to
for LGBT Elders have an attorney familiar with the laws of the state
the real estate is in review the deeds to verify that
A person can own a home in a wide array of legal the outcome is as wished by the owners. LGBT
forms. A critical issue for a person near the elders need to be especially concerned with this, as
end-of-life is to assure that the person(s) they homes purchased individually are not automati-
want to inherit or be able to continue living in the cally inherited by chosen family and homes owned
home have a legal right to do so. Evaluation of jointly, purchased before a same-sex marriage,
this requires looking at the ownership docu- may be in a tenancy in common and not create an
ments. This should be done by an attorney with automatic right to inherit.
expertise in real estate and inheritance laws of the End-of-life is a time that many adults engage
state in which the home is located. It is common in or review estate planning. Estate planning is
for the home occupied by an LGBT couple to be especially important for LGBT elders because of
in the name of one person. This places the sur- the mixture of marital, biological, and chosen
vivor at risk of not being able to remain in the family. Without estate planning, all real and
home without advance legal planning. personal property not owned in a manner that
For a lease, if both parties are not on the lease, transfers ownership at the time of death is
the lease may terminate at the death of the named inherited by marital or biological family—a
lessee, forcing the grieving member of the couple process known as intestacy. The defaults under
of negotiate with the landlord or move. In intestacy may not reflect wishes of LGBT elders.
extreme cases, it can result in the person not on Estate planning varies from simple to very
the lease being locked out of the home until complex depending on the state the person lives
probate court orders can be obtained granting or owns property in, the value of the estate, the
450 D. Godfrey
complexity of the assets, and the goals of the conversation and be a willing listener for those
individual. A consultation with an estate plan- who wish to talk.
ning attorney, familiar with the complex issues The end-of-life and death are a part of life.
faced by LGBT elders, is the best option to The unique factors for LGBT elders are based on
determine what is best for an individual. the complex picture of marital, biological, and
chosen family and the desire to disclose or not
disclose sexual orientation and gender identity.
Attitudes About End-of-Life There is a social media posting that makes the
rounds from time to time that a real friend is the
If this chapter were written in the 1980s or one you trust to go to your house when you die
1990s, HIV-Aids would be a major topic of and delete the files on your computer, shred the
consideration for end-of-life and LGBT adults. pictures and DVDs, and dispose of the special
With advances in care, most persons who test box in the closet. For LGBT adults who have
positive for the HIV virus (HIV+) today are able been protective of disclosing being LGBT in life,
to manage the infection as a long-term chronic having someone they trust to “straighten up the
illness. Over the past 20 years, the prognosis for house” after death can be a great relief. In
an HIV+ adult has changed from a near certain working with LGBT adults on end-of-life issues,
death, to a near-normal life expectancy with it can be very helpful to assure that they have
diligent health care. Treatment for HIV+ infec- someone they trust to sort through their personal
tion is taxing; the drug regimens are complex and artifacts after death.
have side effects. Understanding the complex Some LGBT adults are entirely open and
health care issues helps to understand the goals transparent, but disclosure of sexual orientation
and needs of a person who is HIV+. and gender identity is a conscious choice for
Many of today’s LGBT elders lived through many LGBT adults. It is essential to understand
the darkest days of HIV, and some lost many the degree of comfort with disclosure of an
friends and partners. There are many long-term individual, to be able to assist the individual in
survivors with HIV, and there are many who end-of-life issues. It is essential that aging ser-
lived through the epidemic without being infec- vices professionals develop a degree of trust with
ted. HIV changed the way many LGBT elders an LGBT elder, so that the LGBT elder will
view life and end-of-life issues. When a popu- openly discuss what they want to disclosed, or
lation sees large numbers of its contemporaries not disclosed, and to whom. It is important that
die young, many in the prime of life, it impacts we help carry out those wishes. Do they want a
the outlook on life and death. Just as soldiers rainbow flag at their memorial service? Do they
who return from war after seeing fellow soldiers need someone to clean out the closet? Do not
die are forever changed by the experience, LGBT assume anything. Worrying about disclosure can
elders who lived through the early years of HIV cause great stress for an LGBT elder. If you can
are similarly changed by the experience. Some help relieve this stress, you will ease the
feel guilty that they lived while others died. end-of-life transition.
Some feel thankful to be alive. Yet, many others
were overwhelmed by the sheer volume of illness
and death that they experienced. Some want and Policy Boxes
need to talk about this experience, and others To provide leadership and develop
such as some old soldiers do not want to talk resources and expertise, the US Depart-
about the past. As an aging service professionals, ment of Health and Human Services fun-
the best we can do is politely open the door for ded the National Resource Center on
22 End-of-Life Issues for LGBT Elders 451
Summary
LGBT Aging in 2010. http://www.sageusa.
org/programs/nrc.cfm. LGBT elders live and die much the same as
Why is it important that this initiative everyone else; the things that are different are the
and others continue? personal and family relationships, legal bias, and
presumptions in favor of marital and biological
family, the degree of disclosure of LGBT status,
End-of-life illnesses are very stressful for
and cultural homophobia. Understanding these
everyone involved. Families, who have been
issues is the first step. The challenge for human
polite, accepting, and tolerant of LGBT chosen
and aging services professionals is to create a level
family, can be less polite and rejecting of chosen
of trust with LGBT elders, so that they share with
family in an end-of-life setting. It is not uncom-
you what their wishes are regarding end-of-life, so
mon to hear families who welcomed the
you can empower them to carry out those wishes.
same-sex partner in the house for the past 25
Extra care needs to be taken in planning for
holidays, demand that the partner be excluded
end-of-life health care, long-term care, financial
from the hospital room or funeral. Stress brings
management, and inheritance to assure that the
out the worst in some people and the best in
wishes of LGBT elders are carried out.
others. It is also common to see LGBT elders
previously estranged from marital and biological
family reach out to the family they have avoided
for decades at the end-of-life. This can lead to a Learning Exercise
wide spectrum of experiences calling on all of
the skills of human and aging services Self-Check Questions
professionals.
1. Explain five ways that expansion of same-sex
marriage will change the end-of-life issues for
The Last Act same-sex couples.
2. Describe how homophobia, heterosexism,
Funeral and memorial arrangements are either an and ageism impact LGBT elders at the
end-of-life concern for the dying or for the sur- end-of-life.
vivors. For many elders, planning a funeral is the 3. Fred signed a living will directive form
last act. In virtually every state, the law defaults naming Tom his long-term partner as his
to marital and biological family to make health care surrogate at a community health
arrangements for disposition of the bodily fair and locked the documents away in his
remains. For LGBT elders with a mixture of safe deposit box. What can he can he do to
chosen, marital, and biological family, this can improve the effectiveness of his advance
be a point of conflict. Some families have health care planning?
engaged in extended litigation over funeral plans 4. Barbie and Ken have long been hostile to their
and burial location. Pre-planning funeral daughter Crystal being involved in relationships
arrangements make it clear what the elder wanted with other women. Crystal has terminal cancer.
and is invaluable in the event of conflict. In some Crystal recently married Jane in part because
cases, pre-planning can be overridden by sur- she was afraid that her parents would try to
viving family. The greatest likelihood of the last exclude Jane from making health care decisions
act being what the elder wants happens when the for her and interfere with Jane’s inheritance
elder pre-plans and shares the plans with from Crystal. How does the marriage change the
everyone. picture? What does it not change?
452 D. Godfrey
5. Steve is gay and married Karen in 1965. They (b) They tend to go back into the closet
have raised two children. Steve has had a when in need of long-term care
steady boyfriend, Paul for the past 25 years. (c) They do not have children
Steve’s kids refer to him as Uncle Paul; he 2. Concealing one’s sexual identity can be
has attended family gatherings and holidays hardest for a person who is
with Karen and Steve for the past 20 years. (a) Gay
Karen doesn’t talk about her personal life. (b) Lesbian
She and Steve are best friends. Discuss the (c) Bisexual
ramifications on end-of-life issues for Steve. (d) Transgender
What can be done today to improve the odds 3. A person who identifies as transgender may
that all are involved in end-of-life decisions be
and care? (a) Gay or Lesbian
6. James and Mark have been together for nearly (b) Bisexual
30 years and say they will get married when (c) Heterosexual
the state they live in recognizes same-sex (d) All the above
marriage. Mark is quick to remark that they 4. When a patient is unable to make or com-
“have no dogs, no cats, no kids, nothing that municate health care decisions, the first place
makes noise and has to be cleaned up after.” health care providers generally turn to is:
What are the implications as they age and (a) The patient’s spouse
face possible long-term care? (b) The patient’s parents
(c) The courts
(d) Adult protective services
Experiential-Based Assignments 5. What is the most important step in
person-centered advance care planning?
1. What programs and services are available in (a) Having meaningful conversations with
your community for older LGBT adults? Visit family and health care providers
your local LGBT community center and ask (b) Signing legal documents appointing a
about resources for older members of the health care surrogate
community. Does your local senior center offer (c) Signing a living will
resources or programs for LGBT seniors? (d) Omitting family of origin
2. LGBT adults tend to become invisible in 6. What is the most important legal change that
long-term care settings. Visit local skilled same-sex marriage causes?
nursing facilities or assisted living facilities (a) Eliminates discrimination
and ask about programs to support the needs (b) Allows joint ownership of real property
of LGBT residents and training for staff on (c) Recognition under state and federal law
meeting the needs of older LGBT adults. as spouses
3. Assemble a program on LGBT awareness and (d) Encourages institutional collaboration
offer to present this program to staff at local 7. What is the most protective form of joint
aging services providers. ownership of real estate?
(a) Tenants in common
(b) Tenancy by the entireties
Multiple-Choice Questions (c) Joint with right of survivorship
(d) Inclusive specificity
1. An important generalization to avoid when 8. What legal specialty focuses on issues before
working with LGBT elders is: death
(a) They will only talk to you once they (a) Estate planning
trust you (b) Advance care planning
22 End-of-Life Issues for LGBT Elders 453
Legal Service Corporation (2013). LSC by the numbers. Newport, F., & Wilke, J.. (2013, September 25). Desire
Retrieved on January 24, 2015 from http://www.lsc. for children still norm in U.S. Gallop Organization.
gov/about/lsc-numbers- Retrieved from http://www.gallup.com/poll/164618/
2013#2013AgeandGenderofClients. desire-children-norm.aspx.
Levine, C., & Feinberg, L. (2013, May 1). Transitions in The National Resource Center on LGBT Aging &
care: are they person and family centered [Blog post]. Whitman-Walker Health, (2014). Creating end-of-life
Retrieved from http://asaging.org/blog/transitions- documents for trans individuals: An advocate’s guide.
care-are-they-person-and-family-centered. Retrieved from: http://www.lgbtagingcenter.org/
LGBT older adults in long term care facilities (2010). resources/pdfs/End-of-Life%20PlanningArticle.pdf.
Retrieved from Lambda Legal website: http://www. The White House. (2010, April 15). Presidential memo-
lambdalegal.org/sites/default/files/publications/ randum—hospital visitation [Press release]. Retrieved
downloads/ext_nsclc_stories-from-the_field.pdf. from http://www.whitehouse.gov/the-press-office/
McCorquodale, A., (2013, May 26). Florida counties that presidential-memorandum-hospital-visitation.
don’t recognize domestic partnerships. The Huffing- Tilly, J., et al., (2007). Dementia care practice recom-
ton Post. Retrieved from http://www.huffingtonpost. mendations for assisted living residences and nursing
com. homes. Alzheimer’s Association Campaign for Quality
Narayan, C., (2014, January 24). Kansas court says sperm Residential Care. Retreived on January 24, 2015
donor must pay child support. CNN. Retrieved from from http://www.alz.org/national/documents/brochure_
http://www.cnn.com/2014/01/23/justice/kansas-sperm- DCPRphases1n2.pdf.
donation/.
Mental Health Counseling of LGBT
Elders 23
Tracey L. Gendron, Terrie Pendleton and John T. White
Abstract
This chapter discusses the complexity of mental health among older
lesbian, gay, bisexual, and transgender (LGBT) individuals. Mental health
issues for LGBT older adults can potentially involve the long-term impact
of stigma and discrimination, and the changing view of sexual orientation
and gender identity as pathology to non-pathology. This chapter will
address both the risk and protective factors that are relevant to mental
health counseling of LGBT older individuals, will discuss the history of
research and practice related to mental health, and will provide
recommendations for creating culturally competent evidence-based train-
ing programs for mental health service providers working with LGBT
older adults. As well, the chapter provides an overview of specific issues
relevant to the LGBT community including depression and anxiety and
body image concerns. Interdisciplinary perspectives to service delivery for
LGBT older adults are highlighted.
Keywords
LGBT mental health Mental health counseling Minority stress theory
Depression and anxiety Body image
Overview
Specific psychological issues are presented stigma and discrimination, the changing view of
including depression and anxiety and body sexual orientation and gender identity as pathol-
image and eating disorders. Potential barriers to ogy to non-pathology, and socioenvironmental
accessing mental health services are described as stress that impacts individual psychosocial
well as how mental health counselors can resources. Social stress theory and minority
become culturally competent service providers. stress theory provide well-established frame-
This chapter addresses both the risk and protec- works emphasizing how stress can impact an
tive factors that are relevant to mental health individual’s mental health and well-being from
counseling of LGBT older individuals and spe- extended exposure to discrimination and stigma
cifically highlights issues that are unique for (Aneshensel 1992; Dohrenwend 2000; Meyer
transgender older adults. Finally, recommenda- 1995, 2003). Minority stress is based on the
tions for creating culturally competent premise that, due to stigma and marginalization,
evidence-based training programs for mental LGBT individuals may experience enduring
health service providers working with LGBT psychological stress (Meyers 2003). Research
older adults are provided. has documented the negative impact of minority
stress on the mental health of the overall LGBT
population, including higher rates of mental
Learning Objectives disorders, substance abuse, and self-harm than
heterosexual populations (Cochran and Mays
By the end of the chapter, the reader should be 2000; King et al. 2007; Meyer 1995). However,
able to: research has also demonstrated that good mental
health outcomes were indicated for those indi-
1. Understand the risk and protective factors that viduals that were “out” (i.e., people knowing
are important to the mental health of LGBT about their sexual orientation or gender identity)
older adults. who had a higher sense of social integration and
2. Understand the difference between sexual lower internalized homophobia and transphobia
orientation and gender identity in mental (D’Augelli et al. 2001; Lombardi 2009). As with
health risk factors and outcomes. the heterosexual population, good mental health
3. Understand the history of research and prac- outcomes for older adults are related to
tice related to mental health of LGBT elders. self-acceptance, purpose in life, social support,
4. Understand culturally competent and financial security. Some studies suggest that
evidence-based mental health practice con- LGBT older adults may adjust to aging more
cepts for working with LGBT older adults. successfully than their non-LGBT counterparts,
5. Discuss the importance of understanding the due to increased resilience from dealing with
developmental risk and protective factors of prejudice, stigma, and loss (Gabbay and Wahler
growing up as an LGBT individual to coun- 2002; Orel 2004).
selor competency and effective mental health Although the term “LGBT” is utilized as an
service delivery. umbrella term, gender identity (transgender older
adults) and sexual orientation (LGB older adults)
are distinctive from each other with different
mental health influences and outcomes. There are
Introduction numerous reasons why mental health needs
based on sexual orientation and gender identity
Mental health refers to the state of emotional and differ, including the history of the categorization
psychological well-being and is inextricably of homosexuality and gender identity as diag-
linked with physical health and quality of life. nosable conditions in the American Psychiatric
Mental health of older LGBT individuals is a Association’s Diagnostic and Statistical Manual
complex issue involving the long-term impact of of Mental Disorders (DSM).
23 Mental Health Counseling of LGBT Elders 457
Opinions and feelings about sexual orientation The National Alliance on Mental Illness (2014)
and gender identity are rampant, as are opinions reports that LGBT people are likely to be at
and attitudes about aging. Surprisingly, there is higher risk for depression than their heterosexual
not much empirical literature about aging among counterparts. This statement is also as likely true
sexual minorities; therefore, there are compara- of LGBT elders, as evidenced by The Aging and
tively few studies about the mental health needs Health Report (2010) finding that 31 % of LGBT
of older LGBT people. However, there are a elders reported having depressive symptoms at a
variety of known factors that can impact mental clinical level, with more than half having been
health among LGBT older adults. According to told by a doctor that they had depression. In
minority stress theory (Meyer 2003), LGBT many areas of mental health, people of color and
individuals are at higher risk for psychological transgender people show higher rates of mental
problems because they face chronic stressors as a distress as well.
result of their minority status. This can take the Exposure to stigma, discrimination, and
form of external, objectively stressful events, the resulting victimization based on sexual orienta-
expectation of external stressors, and the inter- tion and/or gender identity, coupled with ageism
nalization of negative societal attitudes regarding and victimization based on age, result in LGBT
their minority status (Meyer 2003). In addition, older adults being vulnerable to depression and
society is facing an uphill battle against ageism anxiety. Evidence indicates that mental health
(fear of older people) and gerontophobia (fear of outcomes are associated with the stress of having
our own aging), as aging anxiety remains per- a stigmatized identity and living in a discrimi-
vasive in the USA. Being LGBT and being older natory environment (Meyer 2007). In addition,
can result in “double jeopardy,” whereby the loss and grief can have an impact on mental
older, sexual minority individual becomes even health, especially if the loss is unacknowledged,
more vulnerable to psychological stressors. which may often be the case with a grieving
Therefore, older LGBT individuals may struggle LGBT older adult (Glacken and Higgens 2008).
with issues such as negative self-image and Anxiety disorders have received relatively
self-hatred, and self-imposed or societal isola- little empirical attention among older adults
tion, and perhaps regret for not coming out ear- compared to the research on mood disorders such
lier or at all (Makadon et al. 2008). Being older as depression. However, generalized anxiety
and LGBT increases obstacles to accessing ade- disorder (GAD) is thought to be the most com-
quate mental health services in a predominantly mon anxiety disorder among older adults (Hybles
youth and heteronormative society (Orel 2004). and Blazer 2003) and is associated with lower
Refer to the case study below as a guide to dis- quality of life and increased risk of medical
cuss what psychological issues can impact an conditions (Mackenzie et al. 2011). The cause of
LGBT older adult. depression and anxiety in the LGBT community,
and specifically among LGBT elders, can be
attributed to a variety of factors that include:
Case Study
Ms. Jones is an elder lesbian whose partner
• Societal oppression as a part of a marginal-
recently passed away. She lives in a rural,
ized group;
conservative community and has experi-
• A societal norm that encourages the minimi-
enced increased incidences of anxiety and
zation of the LGBT experience;
depression since her partner passed away.
• Stress specific to living in and navigating a
What are barriers to successful aging for
homophobic culture;
Ms. Jones?
• Societal pressures to fabricate an untrue self;
23 Mental Health Counseling of LGBT Elders 459
in body dissatisfaction and the development and the relationship between body image and eating
onset of disordered eating, as there are a dis- disorders among lesbian and bisexual women.
proportionate number of men with eating disor- Body Image and Gender Identity. There is a
ders that are gay and/or bisexual (Feldman and dearth of research regarding the relationship
Meyer 2007). Research has demonstrated that between gender identity, body image, and eating
homosexual men are generally more dissatisfied disorders. However, eating disorders and body
with their weight and more likely to desire an dissatisfaction are related to gender and gender
underweight ideal and have more eating distur- roles (Murnen and Smolak 1997). It has been
bances than heterosexual men (Frenchet et al. postulated that the constructs of masculinity and
1996; Herzog et al. 1991; Williamson and Hart- femininity may best explain the relationship
ley 1998). Gay and bisexual men are more likely between gender roles and disordered eating. In
than heterosexual men to view their bodies as other words, those with more feminine charac-
sexual objects and therefore may be more vul- teristics, regardless of gender, are more likely to
nerable to experiencing body dissatisfaction (Si- experience disordered eating or body dissatis-
ever 1994). faction. However, research on gender role and
Sociocultural perspective is a theory that has eating pathology is contradictory and difficult to
been used to describe the presence of body dis- interpret. Although some studies suggest femi-
satisfaction in the LGBT community. Sociocul- ninity associated with higher levels of eating
tural perspective postulates that the social and disorders (Meyer et al. 2001), others reveal that
cultural values that inform the ideas of what higher masculinity was associated with abnormal
constitutes an ideal body image are unobtainable eating behaviors (Pritchard 2008). Limited evi-
by many (Yager 2000). According to the socio- dence exists supporting a possible relationship
cultural perspective, gay and bisexual men are between being transgender and having an eating
subject to similar demands and pressures as disorder. The limited research that does exist
heterosexual women, which make them more hypothesizes that male-to-female transgender
likely to be affected by norms that guide ideal individuals are at great risk of developing an
beauty. On the other hand, researchers have eating disorder.
found that the application of sociocultural per- There is very little research on body image and
spective to lesbian and bisexual women has the eating disorders among older adults and almost
opposite effect; for example, lesbian and bisexual nonexistent research about body image and eating
women may be less prone to eating disorders disorders among LGBT older adults. However,
because they do not share the standards and LGBT older adults may be more at risk for issues
ideals of feminine beauty embraced by hetero- related to body image and eating disorders than
sexual women (Feldman and Meyer 2007). their heterosexual counterparts. With aging come
However, it is a misnomer that a strong feminist biological changes that effect physical appear-
perspective is protection against lesbian and ance: increased weight, slowed metabolism,
bisexual women having body image concerns. graying of hair, and wrinkles. Although there is a
Research on body image and eating disorders developmental phenomenon that promotes a more
among lesbian and bisexual women has pro- adaptive body image with age, body image is
duced unclear results. For example, some studies relatively stable across the life span. Therefore,
demonstrate stronger associations between body older adults often age alone with maladaptive
esteem and self-esteem in homosexual women, body dissatisfaction and disordered eating. A life-
with increased prevalence of disordered eating long pattern of a negative body image can be
(Striegel-Moore et al. 1990; Wichstrom 2006), exacerbated by a fear of aging. Fear of aging
while others have shown fewer dysfunctional includes increasing concern about physical
eating attitudes and behaviors in homosexual appearance and attractiveness. Fear of aging is
women (Lakkis et al. 1999; Strong et al. 2000). predominant in Western culture and equates
Clearly, there is more research needed regarding physical beauty with youth. Fear of aging has also
462 T.L. Gendron et al.
been associated with both body dissatisfactions the current systems and mechanisms of care is
and disinhibited eating (Lewis and Cachelin needed. As healthcare professionals work toward
2001). Given that men subscribe more importance meeting the needs of all older adults, the aging
to physical attractiveness than women, older gay services network will be challenged to provide
men are at greater risk of being less satisfied with competent, fair, and equitable services to the
their bodies and more vulnerable to eating disor- LGBT community. The lives of lesbian, gay,
ders in order to conform to the pressure of physical bisexual, and transgender older adults are often
attractiveness. In a study of gay and lesbian per- obstructed by the barriers they encounter in order
ceptions of aging, Schope (2005) found that gay to attain mental health services in addition to
men feel that gay society views aging as some- other services, including medical care, short- and
thing negative. Interestingly, gay men identified long-term care services, nutritional and physical
the age of 39 as “old” for a gay man. Therefore, fitness programs, senior housing, assisted living,
gay men appear to experience increased difficul- in-home health services, legal services, trans-
ties sustaining positive self-images in the face of portation, recreation, and support groups.
both societal homophobia and judgment from In fact, a study by McIntyre et al. (2011)
within their own community. found that the medical model of care contains
particular access to barriers for LGBT people.
Specifically, study results identified
Research Box
systems-level barriers which include barriers
inherent within the medical model that diminish
Drummond, M. (2006). Ageing gay men’s
individuality, lack of availability of supportive
bodies. Gay and Lesbian Issues and Psy-
services including insufficient financial support
chology Review, 2(2)60–66.
for LGBT mental health services, and lastly
Title of the Research: Aging Gay Men’s
disincentives for trained and culturally competent
Bodies.
LGBT providers. As well, fear of discrimination
Objective: To examine emergent
is a significant barrier to the solicitation of mental
body-based issues for older gay men.
health services for many LGBT older adults. The
Method: In-depth interviews of three gay
stigma of being a target of homophobia, hetero-
males. Results: Emergent themes identify
sexism, or transphobia is of great concern to
that older gay males have concerns about
LGBT elders. It is not uncommon for an older
their body image.
adult to remain closeted about his or her sexual
Conclusion: Older gay men experience
orientation or gender identity out of fear of
challenges in regard to their body image,
insensitivity or lack of understanding which can
which subsequently impacts identity and
contribute to disparities in mental health services
self-esteem.
and treatment (Mays and Cochran 2001; McIn-
“Amidst a highly commodified consumer
tyre et al. 2011).
culture in which the body is central to
Another barrier to mental health services for
youthfulness and vitality, arguably even
LGBT older adults relates to the professionals’
more so in gay culture, aging gay men are
lack of knowledge of the LGBT community,
increasingly confronted with such ageist
their culture, and lifestyle preferences. Profes-
notions.”
sionals, although well intentioned, may be
undereducated, miseducated, or simply not edu-
cated concerning the mental health needs of the
LGBT community. A negative experience with a
Barriers to Service Utilization
health professional, limited availability of
LGBT-friendly professionals, and lack of edu-
The LGBT aging community is a growing and
cation and support can cause LGBT older adults
diverse population, and careful examination of
to shy away from seeking mental health services.
23 Mental Health Counseling of LGBT Elders 463
The lack of knowledge of mental health profes- Confidentiality, quality of services, and ethical
sionals can be particularly salient for older behavior are all important factors when seeking
transgender individuals. It is not uncommon for mental health care and treatment. Historically,
mental health professionals to lack the knowl- many minority communities have been subject to
edge about gender identity that is necessary to an array of unethical and unprofessional behav-
provide effective person-centered care. iors as a result of the structure of the healthcare
As a result, it often becomes necessary for the system. For the LGBT community, concerns
older adult to educate his or her own mental regarding homophobia, transphobia, and dis-
health provider or medical healthcare provider crimination may keep LGBT elders from seeking
about issues related to the transgender experience. services as they often assume that they will not be
As well, the LGBT community may be dis- welcomed. In a study by Browne et al. (2008),
proportionally affected by the ever-rising costs of several departments within a hospital system were
healthcare services, creating another barrier to identified that would particularly benefit from
the acquisition of mental health services. This is increased LGBT sensitivity training including
illustrated by the SAMHSA report (2014) esti- chronic disease (including cancer and diabetes)
mating that one in three LGBT Americans in the and long-term care, and mental health. Gaining
low- to middle-income base lack health insur- understanding of the culture of institutions with a
ance. In addition, SAMHSA (2014) reported that history of discrimination and insensitivity to
nationwide, about one in five gay and bisexual minority populations is essential for the devel-
men and one in four lesbian and bisexual women opment of effective intervention strategies.
are living in poverty and more than 25 % of At present, there are only a few LGBT
transgender Americans report an annual house- inclusive aging providers in the USA who pro-
hold income of less than $20,000. vide specialized services to the LGBT commu-
Creating a safe and welcoming clinical envi- nity. These organizations acknowledge and
ronment is essential to break down barriers that understand the concern of LGBT elders and the
may prevent older LGBT clients from accessing requirement for sensitivity and respect. Services
mental health services. A welcoming environ- and Advocacy for Gay, Lesbian, Bisexual and
ment creates an atmosphere where people feel Transgender Elders (SAGE) is one such organi-
safe and cared for as individuals. A safe and zation. SAGE is dedicated to improving the lives
welcoming clinical environment would provide a of LGBT older adults by targeting services spe-
nonjudgmental, safe space that includes cifically to LGBT older adults.
messages of inclusiveness such as a
non-discrimination policies, culturally competent
intake forms, appropriate educational materials, Counselor Competency
and courteous and respectful staff. It would also
require that providers and their staff be culturally Counselor competency specific to LGBT older
competent and sensitive and willing to engage adults requires understanding of the sexual
the individual “where they are at.” Cultural minority experience, the aging experience, and
sensitivity includes valuing and respecting the effect that those experiences have had on the
diversity and being sensitive to cultural differ- life of an LGBT elder. The importance of training
ences. Another feature of a safe and welcoming for therapists to improve culturally competent
clinical environment includes the ability of the practice with LGBT clients is well noted in the
client to be able to engage in open and honest literature (King and McKeown 2004; Mair 2003).
communication with their provider. This is Mental health therapists require an understanding
essential to the development of an effective of how the psychological development of grow-
therapeutic relationship. Therefore, effective ing up LGBT differs from mainstream hetero-
communication must be stressed on the part of sexual development. Core training on LGBT
both the provider and the client. development and lifestyle is central to recognize
464 T.L. Gendron et al.
and avoid heteronormative bias, to gain aware- • The language utilized by the client specific to
ness of internalized bias in the LGBT client, to their historical context
gain awareness of personal attitudes that could The counselor must be conscious of the
impact the therapeutic relationship, and to con- language and the meanings conveyed by
sider the advantages and disadvantages of language associated with the societal and
self-disclosure of sexual orientation and identity cultural environment. The language uti-
(King et al. 2007). Conversion or reparative lized by the LGBT elder should be seen as
therapy describes a range of psychological treat- indicative of their perception of the larger
ments that aim to change sexual orientation from society.
homosexual to heterosexual. As a culturally • Ageism, fear of aging, homophobia, and
competent practitioner, it is essential to under- transphobia (i.e., attitudes and prejudices
stand the impact of conversion therapy in terms of within the larger society and within the LGBT
its anti-gay impact on the individual and on community)
society. Research has demonstrated that attempts Counselor education regarding the effects
by mental health professionals to pathologize and of ageism, fear of aging, homophobia, and
treat or change sexual orientation are unwelcome transphobia is essential to counselor
and lead to dissatisfactions and lower perceived competency. The counselor’s ability to
helpfulness of therapy (King et al. 2007). relate to, empathize with, and assist the
Counselor competency is especially critical LGBT elder in the navigation of systems
for LGBT older adults receiving mental health that are negatively affecting the individual
services from majority group members (i.e., is an imperative.
heterosexual service providers). The long-term • Empathy and compassion regarding the
effect of living in a minority status leaves the LGBT/minority experience
LGBT elder with more vulnerability to experi- The counselor’s ability to comprehend
encing low self-esteem and internalized homo- and show compassion of the minority
phobia. The counselor must acknowledge the experience will have a profound effect on
synergy of the two minority statuses (age and the professional relationship. What does
LGBT) and assist the client in creating positive the minority experience specific to sexual
self-esteem that defies the negative messages orientation and gender mean to the indi-
from society. vidual’s self-identity? How does this par-
Counselor competency in LGBT elder issues ticular minority experience influence the
requires that the counselor be sensitive to the LGBT elder’s relationship with others and
following: with himself? What are the other minority
experiences of the LGBT elder and how
• The social and historical context presented by have they affected the individual’s
the client development?
The counselor must be cognizant of how • Understanding of the intersectionality
LGBT elders have been affected by the between LGBT issues, race, ethnicity, and
physical and social setting of a society aging
where the cultural normative was hetero- The counselor’s ability to understand the
sexuality and where LGBT elders were intersectionality of LGBT issues, race,
identified as the “Other” (e.g., different ethnicity, and aging is critical to a holistic
and separated from the norm). The his- perception of the LGBT elder. What have
torical context (i.e., politics, culture, reli- been the experiences of the LGBT elder
gion, economics, mood, and attitudes) of because of their sexual orientation, gen-
the time played a dominant role in the der, race, ethnicity, and aging? Have these
individual development of the LGBT factors intersected, collided, or both? All
elder both positively and negatively. of the factors identified have presented the
23 Mental Health Counseling of LGBT Elders 465
LGBT elder with both positive and nega- provision of a safe and trusting environment.
tive experiences. Therefore, a competent counselor will strive to
• Provision of an inclusive environment provide a person-centered approach to care by
Providing an inclusive environment is creating a safe and nonjudgmental therapeutic
central to building trust within the environment that encourages honesty and
counselor/client relationship. An inclusive self-acceptance.
and welcoming environment includes
honesty, flexibility, recognizing and val-
Discussion Box 3
uing differences, open dialogue, and
Is it important to know about the sexual
respectful interactions.
orientation of an older adult client seeking
mental health services? Why or why not?
The implications of empirical data on this
In general, do you think LGBT indi-
topic suggest that the mental health system must
viduals age well? Why or why not? What
do more than sensitize counselors to the issues
risk factors or protective factors do you
that face LGBT older adults. It is critical to pro-
think are important?
vide education and training to create culturally
competent providers skilled at person-centered Discussion Box 4
care. Counselor competency specific to LGBT In your own words, define counselor
older adults must incorporate an understanding competency specific to the needs of LGBT
of the stigma, discrimination, and long-term older adults.
effects of the sexual minority experience cou- What does your definition of counselor
pled with the aging experience for LGBT people competency include? Is your definition
in a society where youth is valued and the aging inclusive?
process is often misunderstood. Profile
Counselor competency with the LGBT com- Ms. G and Ms. B are 70-year-old lesbians
munity, and specifically LGBT older adults, who have been in a loving committed
requires ongoing training and translation. The relationship for 37 years. The couple was
goal of training is far greater than simply sensi- married in 2008 in California. Both Ms.
tizing counselors to issues that LGBT older G and Ms. B report that when they came out
adults face; training must include the voices of 40 years ago, neither of their parents was
the LGBT community through face-to-face happy. Ms. G’s parents made attempts to
interaction in order to gain deeper insight and get Ms. G’s ex-husband to secure sole
understanding of an LGBT individual. Counselor custody of their children due to their
competency for LGBT elders and the larger homophobic attitudes and fear that their
LGBT community requires that the mental health grandchildren would have emotional scars.
system seeks out LGBT professionals with the However, he would not, and instead, they
intent to collaborate with, refer clients to, and shared custody of their children. At age 70,
dialogue about LGBT issues that benefit both Ms. G is a practicing mental health therapist
clients and the larger community. It is imperative and counsels LGBT clients. “During my
that counselors receive appropriate training training, we focused strongly on under-
regarding the LGBT culture and lifestyle and that standing the dynamics unique to the lives of
there is honesty and empathy in their under- minority clients including women,
standing of the long-term effects of living a LGBTQ, and people of color.” Question for
minority status in mainstream society. Ulti- discussion: What elements of Ms. G and
mately, competent counseling requires the Ms. B’s lives support their optimal aging?
466 T.L. Gendron et al.
Critical Research to Mental Health heterosexuals. Cochran et al. (2003) found that
Issues of LGBT Elders the prevalence of panic attacks was greater in gay
or bisexual men than in heterosexual men and
Although very few empirical studies have been that lesbian or bisexual women had a signifi-
conducted on mental health of the aging LGBT cantly greater 12-month prevalence of GADs.
population, studies that do exist have demon- A study by Lombardi (2009) found that older
strated high life satisfaction and positive attri- transgender people reported more stress as a result
butes to aging as an LGBT individual (Berger of lifetime experiences of discrimination. Study
1992). A study conducted by D’Augelli et al. results found that post-transition, older people
(2001) found that mental health in older adult- reported more discrimination and stress, which
hood was influenced by better physical health, continues as a constant experience for people even
better cognitive functioning, higher self-esteem, after they transition (Lombardi 2009).
less loneliness, and a higher percentage of people
knowing about the individual’s sexual orienta-
tion. In addition, suicidal ideation was predicted Related Disciplines Influencing Service
by negative feelings about one’s sexual orienta- Delivery and Interdisciplinary
tion, loneliness, and few people knowing about Approaches
the individuals’ sexual orientation. D’Augelli
et al. 2001 found that vast majority of LGBT LGBT older adults will seek services from an
older adults in their sample reported interdisciplinary team of professionals as they
good-to-excellent mental health and unchanged age within their communities. This cadre of
or improved mental health over the past five professionals will include gerontologists, social
years. Mental health was positively related to workers, psychologists, geropsychologists,
income, indicating better mental health for those administrators, and healthcare and allied health-
with higher income, and was negatively corre- care professionals.
lated with victimization, indicating that people The National Association of Social Workers
who reported more victimization had lower lev- (NASW) states, as one of its dual missions, to
els of mental health. D’Augelli and Grossman “seek to enhance the effective functioning and
(2001) looked at how disclosure of sexual ori- well-being of individuals, families, and commu-
entation and victimization related to mental nities through its work and through its advocacy.”
health in a sample of LGBT older adults aged 60 Social workers assist individuals, families, and
and older. Study results indicated that almost communities in their attempt to reach their full
three-quarters of participants reported some form potential through a myriad of services. Working
of victimization (verbal and/or physical). Poor in a variety of fields, social workers provide ser-
mental health, as indicated by lower self-esteem, vices in schools, churches, hospitals, police
more loneliness, and more suicide attempts were departments, prisons, community mental health
reported by those that had been physically clinics, psychiatric hospitals, not-for-profit and
attacked (D’Augelli and Grossman 2001). for-profit organizations, retirement communities,
Studies have demonstrated that the prevalence nursing homes, substance abuse clinics, court
of mood and anxiety disorders, substance abuse, systems, and in other arenas. In the provision of
and suicide attempts is higher among LGBT social work services to LGBT elders, social
individuals than among heterosexuals (Cochran workers are integral in assisting LGBT elders to
et al. 2003; Lytle et al. 2014). A meta-analysis by find their voice and advocate for themselves.
King et al. (2007) found that sexual minority Social workers can and do provide avenues for
individuals have a 1.5 times higher risk for interdisciplinary service involvement through
depression and anxiety disorders and are 2.5 their participation in many different fields in the
times more likely to attempt suicide than community. For example, a medical social
23 Mental Health Counseling of LGBT Elders 467
to LGBT older adults seeking mental health (a) It requires understanding of the sexual
services? minority experience
2. Identify 5 barriers for LGBT older adults that (b) Becoming a culturally competent mental
may prevent them from accessing mental health provider requires taking a psy-
health services. choanalytic approach
3. Describe 5 essential components of culturally (c) Training and education on LGBT aging
competent training for mental health provid- issues is important for promoting coun-
ers working with older LGBT clients. selor competency
4. Why is body image and eating particularly (d) Both A & C
prevalent among gay men? How does the 6. Counselor competency in LGBT elder issues
view of aging within the LGBT community requires that the counselor understands
impact body image and eating disorders? (a) Social and historical context presented
by the client
(b) Knowledge of the client’s views on
fashion
Multiple-Choice Questions (c) Understanding of the intersectionality
between LGBT issues, race, ethnicity,
1. Which of the following is a cause of and aging.
depression and anxiety in LGBT elders? (d) Both A & D
(a) Low self-esteem 7. Transphobia is
(b) Isolation (a) A lack of understanding of the psychol-
(c) Denial of true self ogy of the transgender individual
(d) All of the above (b) A feeling of unease toward those who
2. George is a 75-year-old gay man who never identify as transgender
came out with his family and friends. Which (c) A clinical terminology no longer used to
of the following would he likely be at an describe men who dress as women
increased risk for? (d) The fear of people who are bisexual
(a) GAD 8. Transgender individuals often experience
(b) Higher blood pressure discrimination in the form of
(c) High cholesterol (a) Employment discrimination
(d) A personality disorder (b) Physical abuse
3. A welcoming environment would include all (c) Verbal harassment
of the following except (d) All of the above
(a) An inclusive gender section (i.e., male, 9. What are the factors that can negatively
female, transgender) impact the mental health of LGBT older
(b) A non-discriminatory policy adults?
(c) Male- and female-only restrooms (a) Self-imposed or societal isolation
(d) Courteous, respectful staff (b) A pattern of out-of-control sexual behavior
4. Which of the following is a barrier to service (c) Ageism
utilization? (d) Both A & C
(a) Open and honest communication 10. Research has demonstrated that good mental
(b) Fear of discrimination health outcomes were indicated for LGBT
(c) Professional’s knowledge of the LGBT individuals
community (a) Who had lifetime partners
(d) Nonjudgmental, safe space that includes (b) Had an active religious affiliation
messages of inclusiveness (c) Who were out about their sexual orien-
5. Which of the following is true regarding tation or gender identify
counselor competency? (d) Both A & C
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Substance Use Disorders
Intervention with LGBT Elders 24
Debra A. Harley and Michael T. Hancock
Abstract
Substance use disorders (SUDs) and mental health problems frequently
co-occur. SUDs are one of the most common psychiatric diagnoses in
older adults. The purpose of this chapter is to discuss SUDs among LGBT
elders. Information is presented on the scope of SUDs, prevalence and
patterns of use, SUDs and aging comorbidity, assessment, diagnosis, and
treatment of LGBT elders. This chapter provides the reader with a baseline
for understanding issues that impact and influence LGBT elders’
substance use. There is no suggestion that LGBT status is synonymous
with addiction or mental illness disorders. Thus, the chapter explores the
extent to which SUDs exist among LGBT elders.
Keywords
Substance use disorders Addiction Mental health Alcohol Drugs
Prescription medication
related to substance used, including mental For LGBT elders, the issue of underdiagnosis
health concerns, for LGBT elders. and gross underestimation of SUDs may be even
greater because they have fewer resources in the
community and within healthcare systems for
Learning Objectives prevention, earlier diagnosis, assessment, and
treatment, and they may not seek services or ask
By the end of the chapter, the reader should be for assistance (Ellison 2012; Jessup and Dibble
able to: 2012). Thus, as the baby boom cohort reaches
retirement age, it encounters a healthcare system
1. Identify issues of SUDs for LGBT elders. ill-prepared to deal with older adults with SUDs
2. Understand the co-occurrence of SUDs and (Doweiko 2015).
mental health concerns for LGBT elders. SUDs are the third most common psychiatric
3. Identify issues related to assessment, diag- diagnosis in older adults (Luggen 2006). The
nosis, and treatment of SUDs in LGBT presence of both substance abuse and mental ill-
elders. ness within a person is known as co-occurring
4. Identify policy concerns for addressing SUDs disorder (COD). Although the majority of LGBT
among LGBT elders. elders are in good mental health, significant per-
centages have symptoms of depression, anxiety,
and AOD abuse higher than the general population
(King et al. 2008; SAMHSA 2012). Limited
information on the actual rates of SUDs among
Introduction LGBT elders suggests that substance use among
this population is highly correlated with poor
Currently, almost half of men and slightly over mental health (Conron et al. 2010) and is a response
half of women over the age of 60 consume to stressors related to violence, discrimination,
alcoholic beverages (Barnes et al. 2010) and internalized homophobia, low self-esteem, loneli-
most do not abuse alcohol. The majority of older ness, stigma, and experiences of victimization
adults are considered social drinkers. In general, based on sexual orientation and gender identity or
alcohol consumption decreases with increasing expression (Frederiksen-Goldsen and Muraco
age (International Center for Alcohol Policies 2010). In comparison with the general population,
[ICAP] 2014). Alcohol and drug use in older LGBT persons are more likely to use alcohol and
adults can be late-onset or one that began in drugs, have higher rates of substance abuse, are less
young adulthood. Nevertheless, SUDs, which likely to abstain from use, and are more likely to
include alcohol, drugs, prescription medication, continue heavy drinking into later life (SAMHSA
nicotine, and caffeine (Diagnostic and Statistical 2012). Lesbians and gay men perceive themselves
Manual of Mental Disorders 2013), among older to be at increased risk of SUDs, have an increased
adults are major and growing problems (Sub- need for treatment, and face barriers to treatment.
stance Abuse and Mental Health Services Moreover, the rates of alcohol consumption among
Administration [SAMHSA] 2008). The extent of lesbians and gay men do not seem to decrease with
the problem may be greater than suspected age as quickly as they do among heterosexuals
because of a misconception that older adults do (Healthy People 2010 2010).
not abuse alcohol and other drugs (AODs); The purpose of this chapter is to identify
consequently, healthcare professionals do not SUDs issues pertinent to LGBT elders. Given
need to worry about SUD in this population. As a that SUDs and mental health frequently co-occur,
result of these misperceptions, healthcare pro- reference is made to both SUDs and mental ill-
fessionals typically are the first to identify SUDs ness throughout this chapter. Information is
in elderly persons and to screen infrequently for presented on the scope of SUDs; prevalence and
substance abuse in their older patients. patterns of use; alcohol, drugs, and aging
24 Substance Use Disorders Intervention with LGBT Elders 475
comorbidity; detection, assessment, and diagno- older account for one-third of all medications
sis of SUDs; and treatment and intervention of prescribed, accounting for only 13 % of the
LGBT elders. Finally, discussion of implications population in the United States. Older women are
for policy is presented. The intent of this chapter at higher risk because they are more likely to use
is to provide the reader with baseline information psychoactive medications, usually associated
for understanding issues that impact and influ- with divorce, widowhood, lower income, poorer
ence LGBT elders’ substance use behavior. health status, depression, and/or anxiety. Elderly
Considerable individual variation exists regard- women take an average of five prescription
ing LGBT elders on the basis of age, gender, medications at a time for longer periods of time
sexual orientation, and gender identity or compared to older men (Basca). Prolonged use of
expression. We stress that being LGBT is not psychoactive medications has been associated
synonymous with having an addiction (Beatty with confusion, falls, hip fractures, loss of moti-
and Lewis 2003) or mental health disorders (see vation, memory problems, difficulties with
Chap. 23 for additional information on mental activities of daily living, declines in personal
health). grooming and hygiene, and withdrawal from
normal social activities in older adults. The use of
opioid analgesics can lead to excessive sedation,
respiratory depression, and impairment in vision,
The Scope of SUDs attention, and coordination (Simoni-Wastila and
Yang 2006). Moreover, adverse drug reactions
Alcohol is the most commonly abused substance are more common among the elderly.
by elderly people; approximately 15 % of older Due to multiple chronic illnesses, an elderly
drinkers have a concurrent drug abuse disorder person may be under the care of more than one
(Ellison 2012). Prescription medication misuse doctor, none of whom may be fully informed
(i.e., non-medical use) and abuse are growing about the complete range of medications the
public health problems among older adults in the patient is taking. As drug regimens become more
United States. Most misused medications are complex, there is increased probability of error
obtained legally through prescriptions. Usually, by the patient as well as a greater potential for
problematic prescription medication use by older drug interactions. The chance of drug interac-
adults is unintentional and falls into the misuse tions is further complicated by an older adult’s
category, though it can progress to abuse if they use of over-the-counter drugs. Many medications
continue to use a medication for only the desir- that once were available only by prescription are
able effects it provides (Addiction Technology now available without one. Older adults take
Transfer Center Network [ATTC] 2009). seven times more over-the-counter drugs than do
Regardless of age, individuals who seek a pre- persons of any other age-group (Kinney 2011).
scription with the aim to use the medication Unfortunately, physicians must rely on patient
inappropriately and who may have already self-report about the type, dosage, and frequency
become addicted present with certain character- of over-the-counter drugs being taken.
istics and behaviors (see Table 24.1). Many prescribed and over-the-counter drugs
Older adults are at high risk of medication can interact with alcohol. Physiological changes
misuse because of conditions associated with that occur with aging that affect drug distribution
pain, sleep disorders and insomnia, and anxiety. and metabolism can contribute to the increased
Elders are more likely than their younger coun- risk of drug–alcohol interactions. Certain medi-
terparts to receive prescriptions for psychoactive cations commonly taken by older adults (e.g.,
medications with misuse and abuse potential aspirin, oral anticoagulants, antihistamines, oral
(e.g., opioid analgesics, benzodiazepines) medication for diabetes, pain medication) can
(Administration on Aging 2012). According to present problems in the presence of alcohol.
Basca (2008), medication for persons age 65 and While the elderly exhibit alcohol and other drug
476 D.A. Harley and M.T. Hancock
(AOD) use, illicit drug use (e.g., marijuana, substance abuse prevention and treatment ser-
cocaine, heroin) is low (Kinney 2011). However, vices (Wilkinson 2008). Although much less is
illicit drug use may be increasing in a small known about bisexual and transgender men and
percentage of the elderly population, such as the women, they may be at increased risk of sub-
baby boomers (SAMHSA 2006). Illicit drug use stance abuse because in addition to being dis-
in elders is linked to long-term drug use. criminated against by the heterosexual
According to Simoni-Wastila and Yang (2006), community, they are frequently further margin-
“older addicts may simply represent younger alized by the gay and lesbian community.
addicts who have survived their drug-use disor-
der” (p. 383).
By 2020, it is estimated about 2.7 million
older adults will present with a drug addiction Prevalence and Patterns of Use
(Colliver et al. 2006). Estimating the number of
LGBT elders among those with SUDs is difficult The patterns of substance use and associated
for the following reasons: Many LGBT persons problems vary among the older adults, as well as
do not disclose their LGBT status, substance the reasons for abusing substances. For some of
abuse programs do not conduct outreach specific the elders, substance abuse is linked to the
or implement LGBT-inclusive services to this stresses of aging. In behavioral terms, the best
population, intake and application forms do not predictor of future behavior is past behavior,
contain questions about sexual identity, and especially true for how someone will handle
LGBT persons have difficulty fully accessing growing old. For example, those who have
24 Substance Use Disorders Intervention with LGBT Elders 477
demonstrated flexibility throughout their lives side effects, and drug interactions between sub-
will adapt well to stresses associated with aging. stances, and affects the evolution of disease and
In addition, individuals with strengths and resil- the patient’s functional status and his or her sur-
iency will adjust more readily to age-related vival (Incalzi et al. 1997; Valderas et al. 2009).
stresses (Kinney 2011). Stresses of aging Addiction rates are high among LGBT popula-
include, but are not limited to the following: tions because of higher rates of depression, a need to
(a) social stresses in which aging is equated with escape from the constant presence of social stigma
obsolescence and worthlessness, the process of and homo/transphobia, efforts to either numb or
receiving medical care and paying medical bills, enhance sexual feelings, to ease shame and guilt
and inadequate insurance coverage, especially related to LGBT identity, and for some LGBT
for preventive services; (b) psychological stres- persons, peer pressure (www.recovery.org/topics/
ses, with the greatest one for the elderly being find-the-best-gay-lesbian-bisexual-transgender-
loss (e.g., illness and death of family and friends, lgbt-addiction-recovery-centers/#). Most LGBT
geographical separation of family, earned elders report societal factors (e.g., discrimination,
income, losses accompanying retirement); hate crimes, historical legal prohibitions on sexual
(c) biological stresses including physical dis- behavior) as the reason for an increased prevalence
ability, depressive illness with a physiological of SUDs. Other anti-LGBT discrimination in situa-
basis such as changes in the levels of neuro- tions that are unique to or particularly difficult for
chemicals, and dementia; and (d) iatrogenic older people includes discrimination in housing,
stresses (harm caused by efforts to heal), which medical treatment, and public accommodations.
are by-products of the healthcare system and its Many LGBT elders are open about their sexuality
insensitivities to elders’ unique physiological and and gender identity, but others remain closeted
psychological changes. Usually, iatrogenic because they feel vulnerable and fear discrimina-
stresses are the result of overprescribing medi- tion, abuse, or social condemnation. In addition,
cation, failing to take into account the way the closeted LGBT elders may experience a certain
elderly metabolize medications, and ignoring that level of stress when they come out later in life.
alcohol is also a toxic drug (Kinney). Kinney These feelings lead to stressors for which they
points out that as people age, they become less might use AOD as a means of coping or to reduce
similar to one another and more individualistic; stress. LGBT persons across the age spectrum
therefore, service providers should pay more experience stigma, minority stress, and
attention to individual differences among elders. anti-gay/anti-trans social prejudice (Stevens 2012).
Attention to alcohol use among older adults is Today’s older LGBT persons came of age
important even when it does not qualify as abuse when there were very few places in which they
because it may cause or aggravate a range of could safely express their sexuality or identity.
health problems (Doweiko 2015; Kinney 2011). One such place was gay bars, which play a central
As people age, they become more sensitive to the role in the LGBT community. Gay bars offer a
effects of alcohol and medication, requiring less place where LGBT persons might go to socialize
of the substance to feel its effects. Also, older without fear of ridicule, to meet potential part-
adults have more physical and mental health ners, to relax, or to learn about one’s sexuality
issues than do younger adults (Ruscavage et al. and its implications for daily life (Doweiko
2006). Medical comorbidity in the older adults 2015). Gay bars serve multiple functions for
requires adequate monitoring, especially because LGBT persons and have been described as a
the addition of substance abuse (resulting in combination of bar, country club, and community
multimorbidity) can complicate accurate diagno- center (http://www.agingincanada.ca/lgbt_older_
ses, including the length of time in order to make adults.htm). Substance abuse, especially alcohol,
one. Multimorbidity makes it difficult to find a is a large part of life of some segments of the
treatment that takes into account contradictions, LGBT community (SAMHSA 2012).
478 D.A. Harley and M.T. Hancock
Alcohol, Drugs, and Aging certain medical conditions, taking certain medi-
Comorbidity cations, or a history of AOD abuse. For example,
alcohol has been shown to be a protective factor
The effects of AOD on older adults are quite against coronary heart disease, heart failure, and
different than on younger adults, the majority of myocardial infarction, particularly in older men
which stem from physiological changes associ- (Djousse and Gaziano 2007; Gronbaek 2006).
ated with the aging process. Adults over the age For postmenopausal women, moderate drinking
of 65 have at least one chronic illness, which can can contribute to an improvement in bone density
increase their vulnerability to the negative effects and a reduction in the risk of osteoporosis (Ra-
of alcohol and/or drug consumption. In addition, puri et al. 2000). In both elderly women and men,
specific age-related changes affect the way an light-to-moderate drinking is associated with a
older person responds to alcohol: (a) decrease in reduced incidence of type 2 diabetes mellitus
body water and increase in fat content, (Djousse et al. 2007). Elders who consume
(b) increased sensitivity and decreased tolerance moderate amounts of alcohol have demonstrated
to alcohol, and (c) decrease in the metabolism of improved cognitive functioning compared to
alcohol in the gastrointestinal tract. Each of these those who abstain or report heavy drinking
physiological changes results in a greater con- (Deng et al. 2006; Stampfer et al. 2005; Xu et al.
centration in the blood system and quicker 2009), and delay in cognitive decline in older
intoxication for older adults (SAMHSA 2008). women (Stott et al. 2008). Other studies support
The effects of alcohol on reaction time in older psychological benefits of moderate alcohol con-
adults may well be responsible for some of the sumption among the elders, including reduced
accidents, falls, and injuries that are prevalent in stress and improved mood and sociability (Bond
this age-group (Doweiko 2015). The interaction et al. 2005; McPhee et al. 2004).
of age-related physiological changes and the Because of age-related physical changes,
consumption of high levels of AODs can trigger moderate alcohol consumption is defined as one
or exacerbate other serious health issues among standard drink (e.g., 1 ½ oz of liquor, 12 oz of
older adults (see Table 24.2). Conversely, small beer, or 5 oz of wine) (National Institute on
amounts of alcohol have been shown to provide Alcohol Abuse and Alcoholism [NIH] 2005) in a
health benefits in older adults who do not have 24-hour period, and hazardous alcohol use is
defined as more than three drinks in one sitting or
Table 24.2 AOD abuse and comorbidities in older more than seven drinks in a 7-day period (Drew
adults et al. 2010). It is important to note that,
Malnutrition depending on factors such as the type of alcohol
Cognitive impairment
and the recipe, one mixed drink can contain from
one to three or more standard drinks (NIH).
Decreased bone density
Although moderate alcohol consumption has
Gastrointestinal bleeding
demonstrated some beneficial effects, elders
Alcohol-related dementia should not increase their alcohol consumption for
Sleep pattern disturbances health reasons. Alcohol consumption among the
Cirrhosis and other liver diseases older adults requires careful monitoring along
Increased risk of hemorrhagic stroke with other lifestyle factors (ICAP 2014).
Mental health problems, including depression and The age at which a person begins to use sub-
anxiety stances and eventually progresses to abuse has
Impaired immune system and capacity to combat implications for effects in later life. Elderly per-
infection and cancer sons with SUDs can be categorized as early-onset
Increased risk of hypertension, cardiac arrhythmia, or late-onset abusers. For early-onset abusers,
myocardial infarction, and cardiomyopathy substance abuse develops before age 65.
Adapted from SAMHSA (2008) Early-onset abusers show higher incidences of
24 Substance Use Disorders Intervention with LGBT Elders 479
Objective: This study aimed to explore the 1. If LGBT elders were included in this
prevalence of psychiatric disorders among study, do you think that the results
older adults in the United States by age would have been the same, different, or
(18–44, 45–64, 65–74, and 75 years and similar?
older) and sex. Covariates of disorders for 2. In what ways could this be redesigned
adults age 65 and over were explored. to explore prevalence of mood, anxiety,
Method: A cross-sectional epidemiologic and SUDs for LGBT elders?
study using data from the National 3. Do you think that criteria for SUDs in
Comorbidity Survey-Replication was used. the DSM-5 would change the interpre-
The participants were representative of a tation of these data?
national sample of community-dwelling
adults in the USA. The World Health
Organization Composite International
Diagnostic Interview was used to assess
Diagnostic and Statistical Manual of Men- Detection, Assessment,
tal Disorders (4th ed.) psychiatric disorders. and Diagnosis
Results: Prevalence of 12-month and life- Detection of substance abuse in the older adults is
time mood, anxiety, and substance use difficult because the signs and symptoms of sub-
disorders was lower older adults (65 years stance abuse and aging are similar. Older adults
and older) than younger age-groups: 2.6 % have more medical problems than do younger
for mood disorder, 7.0 % for anxiety dis- persons, which in the early stages of SUDs often
order, 0 for any substance use disorder, and mimic the symptoms of other health conditions. In
8.5 % for any of these disorders (for any addition, older adults who abuse substances tend
disorder, 18–44 years = 27.6 %, 45– to attribute the physical complications caused by
64 years = 22.4 %). Among older adults, their substance use to the aging process. Similarly,
the presence of 12-month anxiety disorder physicians and family members aid in this
was associated with female sex, lower assumption because they do not inquire about
education, being unmarried, and three or possible substance abuse in elderly persons
more chronic conditions. The presence of a (Doweiko 2015; Drew et al. 2010). Some family
12-month mood disorder was associated members believe that the elders have reached an
with disability. Similar patterns were noted age in life in which they have earned the right to
for lifetime disorders (any disorder: 18– drink and to not have their behavior questioned
44 years = 46.4 %, 45–64 years = 43.7 %, (Kinney 2011). Another reason for difficulty with
and 65 years and older = 20.9 %). detection is that social isolation is often both a
Conclusion: This study documented the reason for and consequence of substance abuse
continued pattern of lower rates of formal (see Chaps. 22 and 31). However, for older adults
diagnoses for elders. These rates likely who are socially active, their peers might
underestimate the effects of late-life encourage drinking well into their later adult years
24 Substance Use Disorders Intervention with LGBT Elders 481
(Brennen et al. 2010). Other ways in which (Naegle 2012). Both the SMART and CAGE are
detection of SUDs are difficult to detect are that psychological screening instruments. It is
they have non-specific presentations and rarely important to note that a screening is not a diag-
demonstrate the traditional warning signs of an nosis, rather a means to identify at-risk AOD use.
addiction (e.g., legal problems, workplace If the screening process suggests the presence
behaviors) (Drew et al.). For elders still in the of a SUD, the next step in the process is to
workforce who have SUDs, missing days from determine the severity of the SUD. This step is
work because of substance abuse problems are known as assessment. A comprehensive assess-
explained away as age-related conditions or stress ment involves collection of data about the
of taking care of a sick spouse or partner (Dow- quantity and frequency of use, and the social
eiko). After retirement, typically elders have more health consequences of drug use, including nic-
time on their hands and, for those who may have otine, prescription, over-the-counter, herbal and
been functioning substance abusers while work- food supplements, recreational drugs, and alco-
ing and able to manage their addiction, may begin hol (Naegle 2012). In addition, a comprehensive
to manifest symptoms in retirement as their sub- assessment should include a through physical
stance abuse progresses (Zak 2010). examination along with laboratory analysis and
Elders tend to hide inappropriate AOD usage, psychiatric, neurological, and social evaluations
making detection more difficult. The SAMHSA (Martin 2012). Given that many elders take
Guidelines (i.e., Screening, Brief Intervention, numerous medications, a basic assessment of
Referral to Treat [SBIRT], http://www.samhsa. their medications may require the shopping bag
gov/prevention/sbirt/) recommends that the first approach in which elders bring in all of their
step in a process of detection is a screening, medications (i.e., a shopping bag filled with
using a test like the Short Michigan Alcohol medication). The assessment of elderly substance
Screening Instrument-Geriatric Version abusers involves a biomedical, psychosocial
(SMART-G) (Blow et al. 1992), which is tailored approach in which it is determined whether the
to the needs of older adults. The SMART-G patient has a biological disease (e.g., depression
contains ten questions about the person’s esti- that is producing the abuse) or whether the sub-
mation about quantity of alcohol consumed, stance abuse has produced a biochemical brain
eating habits, physical response after drinking, disorder (e.g., dementia, delirium). Both the
memory, reasons for drinking, conversations medical complications from the abuse and med-
with medical personnel about one’s drinking, and ical problems exacerbated by drug dependence
the use of rules to manage one’s drinking. If an must be examined. Psychological distress (e.g.,
elderly patient answers “yes” to two or more of anti-gay/anti-trans prejudices) can induce addic-
the items on the SMART-G, it is indicative of an tive behavior, requiring psychological interven-
alcohol problem. Another commonly used tions to address the problem. Elderly LGBT
screening instrument is the CAGE (Ewing 1984). persons may have a complex combination of
The CAGE contains four “yes/no” question functional and social behaviors that exacerbate
about drinking: (a) feeling one should “cut substance abuse and complicate treatment. Thus,
down” on drinking, (b) felt “annoyed” by others the treatment team must elicit basic biomedical
criticizing one’s drinking, (c) felt “guilty” about psychosocial information during the diagnostic
one’s drinking, and (d) needing a drink in the phase and then use these data to construct an
morning as an “eye opener.” A “yes” response of appropriate treatment approach (Geriatric Sub-
two or more is considered clinically significant. stance Abuse-Dementia Education & Training
The patient’s responses are used to discuss the Program n.d.). Finally, assessment should con-
need to cut down on the amount of alcohol sider the spiritual concerns and beliefs of LGBT
consumed. If the patient does not see a need for elders (see Chap. 27). This understanding may
change, a referral should be made to a mental aid in the recovery process and relapse
health practitioner or a geriatric psychiatrist prevention.
482 D.A. Harley and M.T. Hancock
During assessment and diagnosis, the assessor SUDs face several substantial dilemmas: (a) a
must be cognizant of several issues to accurately lack of culturally relevant trained staff and spe-
diagnose SUDs in elderly adults. First, memory cialists, (b) staff members and clients who will
loss, particularly short-term, can sometimes attempt to impose their own ideological beliefs
cause an older person to forget to take his or her on them, (c) programs that do not address issues
medication or to take too much unintentionally. related to sexual identity or gender expression,
Similarly, the elder person may have difficulty and (d) programs that do not address issues
recalling information accurately to answer ques- related to traumatic childhood experiences
tions during an assessment interview. Second, (Cochran et al. 2007). In a survey of substance
the interplay of health issues makes diagnosing abuse treatment providers’ attitudes and knowl-
and treating SUDs in elders more complicated edge about LGBT clients, ATTC (n.d.) found
than for other age-groups (Ruscavage et al. half had no education about lesbian, gay, and
2006). Third, the diagnostic criteria in the bisexual persons, and 80 % had no education
Diagnostic and Statistical Manual were vali- regarding transgender persons. Although half of
dated on young and middle-aged adults. the counselors in the study had worked with
Although tolerance of a substance is one diag- lesbian, gay, or bisexual clients in the past and
nostic criterion for SUDs, it may not apply few had worked with transgendered persons, the
because of physiological changes related to majority reported that they lacked information
aging, which may result in less alcohol intake about many important issues that affect LGBT
with not apparent reduction in intoxication. clients. The counselors reported that they had
Similarly, elders with late-onset substance abuse little or no knowledge of LGBT persons
may not experience physiological withdrawal regarding the following: legal issues (73 %),
when the substance is suspended. Fourth, a cri- domestic partnership (69 %), family issues
terion that describes the negative impact of sub- (54 %), internalized homophobia (48 %), and
stance abuse on work functions may be irrelevant coping strategies (37 %). However, 25–50 % of
for elders who live alone. The result is that abuse substance abuse counselors had positive attitudes
among the elderly may be miscalculated. In about LGBT clients. The counselors recognized
addition, the criterion of giving up activities may that they needed training in these areas to be
be of little use when assessing a retiree who has more effective with all clients, especially for
fewer regular activities and responsibilities to relapse prevention and aftercare planning and to
give up (Menninger 2002). Finally, assessment be aware of the potential stresses in the client’s
usually takes place over several days. Thus, the life related to their sexual orientation or gender
assessment process can be fatiguing for elderly identity.
patients. Other challenges when working with the Although the LGBT population is comprised
elderly population include service providers’ of a unique group of individuals with a special set
biases and belief about aging, substance abuse, of commonalities, as a subpopulation, transgender
and LGBT populations, and denial of substance persons require additional considerations in the
use by the elderly (Martin 2012). treatment process. One vital consideration is the
stage of transition in which the person is engaged.
For example, a person who is in pre-surgery status
and is living the role of the “to be assigned”
Treatment and Intervention gender might encounter a range of policies in an
inpatient treatment setting. Such policies may
The majority of elders with SUDs or mental range from non-acceptance to acceptance with
health problems, especially LGBT elders, do not conditions (e.g., separate living quarters and
receive the treatment they need (Martin 2012). bathrooms or separate rooms with access to
LGBT persons who are in need of treatment for generic bathrooms) (Beatty and Lewis 2003).
24 Substance Use Disorders Intervention with LGBT Elders 483
For LGBT persons, certain questions come up in comorbidities enhances cohesiveness of care and
the treatment process. Some questions deal with reduces conflicts between service providers. The
sexual identity and others with trauma (see argument is for both disorders to be treated as
Table 24.3). “primary” using a combination of different
Treatment protocol and treatment success are modalities such as outreach and case manage-
influenced by several factors including severity of ment, motivational techniques, psychotherapy,
substance use, type(s) of substance used, and and psychopharmacology.
whether substances are used in combination with Motivational interviewing, cognitive-behavioral
other substances. Therefore, the types of drugs therapy, brief therapeutic interventions, and indi-
abused, the location of abuse, and potential trig- vidual, group, and family counseling which are
gers for relapse present differently depending on widely used in the treatment of SUDs have been
the population (Singh and Lassiter 2012). implemented with elders (Martin 2012). Brief
Regardless of age or gender, polysubstance interventions, intervention (i.e., significant people in
abusers present more challenges in the treatment the person’s life collectively confront the person with
process because substances used in combination their firsthand experiences of his or her substance
increase risk factors (Rowan and Faul 2011). use), and motivational interviewing, the least inten-
Emerging evidence-based research supports the sive treatment options, are recommended first with
efficacy of a variety of pharmacological and elderly substance abusers as a pre-treatment strategy
psychotherapeutic interventions for SUDs and or as treatment itself (Cummings et al. 2009; Rus-
major psychiatric disorders in elderly persons. In cavage et al. 2006). Least-restrictive treatment
light of comorbidities being associated with options have been found to be effective; older adults
increased healthcare utilization and significant respond better to age-specific group treatment and
healthcare expenditures among elders, targeted cognitive-behavioral therapy-based programs
prevention and early intervention can offset sub- (Brown et al. 2006; D’Agostino et al. 2006). Some
stantial costs to patients, their families, healthcare elders may be in need of intensive treatment such as
organizations, and the government (Bartels et al. inpatient/outpatient, detoxification, recovery or
2005). In fact, an integrated approach to treatment group home housing, and specialized outpatient
of comorbidities results in far better outcomes. services. The treatment approach should be tailored
Using a multidisciplinary team to treat to LGBT elders’ individual circumstances and needs
(e.g., self-esteem, perceptual, cognitive, sensory, or jeopardizing other clients’ recovery; and (d) if
literacy, and language needs). The Treatment they accept generic treatment, their own recovery
Improvement Protocol (TIP) 26 (SAMHSA 2008) is jeopardized (ATTC n.d.). In light of these
identified several key characteristics of treatment that perceptions, counselors and service providers
contribute to positive outcomes for elders with should work with LGBT elders to determine
SUDs. Given that the protocol is not specific to whether, when, and how to come out or to reveal
LGBT persons, as authors of this chapter we present their sexual identity while in treatment. In addi-
the material to be LGBT inclusive (see Table 24.4). tion, attention must be given to the type of
Equally as important in treatment is psychoeducation counseling (e.g., individual, group) that is more
(i.e., teaching components of behavior change) in appropriate. Thus, counselors and service pro-
which elders receive information and gain knowl- viders are required to have cultural competence
edge about the risks of combining alcohol with related to the LGBT population, aging, and eth-
medications and excessive alcohol use (Brown et al. nic minority groups. For counselors and service
2006; D’Agostino et al. 2006; Doweiko 2015; providers who are not culturally competent in
Martin 2012). Often, LGBT elders with SUDs are in working with LGBT populations, it is best to
need of strategies for increasing social interactions acknowledge it and refer the client to someone
and personal efficacy when refusing substances with such competency.
and/or peer pressure. Because of negative experiences of LGBT
Being honest with oneself and others is a elders have had due to their sexual orientation or
hallmark of efficacious treatment strategies. gender identity and expression, it is important for
However, for LGBT persons, being open about treatment interventionists to ensure that their
their sexual identity presents several dilemmas in treatment facility, office, and organization in
treatment: (a) If they come out, they face possible which they work send a clear message that the
rejection and alienation; (b) if they do not come environment is safe for LGBT persons to dis-
out, they are viewed as untruthful; (c) if they close their concerns. For example, displaying
indicate their differences from heterosexual cli- LGBT-friendly literature in the waiting room and
ents, they are seen as asking for special privileges offices or a “Safe Zone” or rainbow sticker on the
front door of the building or reception area are
symbols universally recognized as safe places. It
Table 24.4 Characteristics for LGBT elder treatment is important first to seriously assess the safety of
positive outcomes the service delivery environment before deciding
Emphasis on age-specific rather than mixed-aged to display such a symbol (Singh and Lassiter
treatment 2012). Deciding to disclose one’s sexual orien-
Emphasis on sexual identity-specific characteristics tation or gender identity or gender expression
Use of supportive, non-confrontational approaches that must be given serious consideration because
build self-esteem although federal and a number of state statutes
Focus on cognitive-behavioral approaches to address protect recovering substance abusers from many
negative emotional states forms of discrimination, LGBT persons are not
Development of skills for improving social interaction afforded the same protections in many areas of
and support the United States (SAMHSA 2012).
Involve support systems, including friends and family of Programs that provide treatment to LGBT
choice persons must be particularly vigilant about main-
Appropriate pace and content for LGBT elders taining client’s confidentiality because the conse-
Capacity to provide referrals to medical, mental health, quences of an inappropriate disclosure can have
aging, and LGBT-specific services devastating consequences and implications for
Counselors and service delivery personnel trained to safety, employment, housing, and social services
work with LGBT elders (SAMHSA 2012). In addition, special support
Adapted from SAMHSA (2008) group meetings (e.g., Alcoholics Anonymous)
24 Substance Use Disorders Intervention with LGBT Elders 485
oriented toward the specific needs of LGBT elders of treatment programs, and as the basis for staff
must give consideration to addressing both age training programs (Healthy People 2010 2010).
and sexual orientation or gender identity issues In addition, AOD screening should be part of all
that are relevant to recovery. Unfortunately, such elders’ annual medical examination. The
12-step meetings are usually only found in large administering of the CAGE by nurses should be
cities (Doweiko 2015). Further, 12-step programs part of the series of questions asked during a
can be unwelcoming of LGBT persons because of doctor’s visit by patients.
traditional religious persecution of sexual minor- When assessing LGBT persons with SUDs,
ities (Shelton 2011). See Chap. 29 for additional treatment programs should incorporate more
discussion on the role of religious leaders in inclusive language into their assessment instru-
addressing LGBT elders. ments and retain staff. Assessments include rela-
Treatment services for LGBT elders with tionships with family of origin, family of choice
SUDs require knowledgeable service providers and friends, level of community or systems sup-
who are skilled in the aspects of aging, with port, social interactions, level of self-esteem,
cultural competence in LGBT issues, able to understanding of self-identity, and work issues
understand the effects of comorbidities, and able (SAMHSA 2012) (see A Provider’s Introduction
to integrate biomedical, psychosocial, and phys- to Substance Abuse Treatment for Lesbian, Gay,
iological risk factors for addiction. Service Bisexual, and Transgender Individuals). For
planning and delivery should follow a logical and transgender persons, it is important to address
sequential progression to increase more positive them based on the gender with which they identity.
outcomes. Inclusion of various service profes- Similarly, assessment instruments should be sen-
sionals from across disciplines on the treatment sitive to the age of the individuals and the presence
team for LGBT elders is one way to potentially of coexisting conditions in order to accurately
improve the quality of service. measure the extent of the problem.
Although some efforts have been put forward
regarding practice on SUDs for LGBT elders, an
impact policy is needed to prioritize and fund
Policy on SUDs prevention and intervention as a healthcare con-
cern. Screenings for mental health concerns,
Substance abuse services need to address including substance abuse, should receive equal
deep-rooted age discrimination and heterosexist focus as an emphasis just as is physical disorders
philosophies that continue to permeate main- and diseases among the elderly (e.g., cancer,
stream services. Advocates in the United States arthritis, cataract). Although Medicare covers
assert that policies should allow LGBT elders to treatment for mental health issues, copayments
access the most appropriate clinical service on can be prohibitive for elders with lower incomes.
the basis of need and that age and sexual orien- The Positive Aging Act, an amendment to the
tation or gender identity must not be exclusion Public Health Service Act, is a policy alternative
criteria (SAMHSA 2012). Although, historically, that could address SUDs in elders. First, the act
SUDs were thought to be more prevalent in could demonstrate ways of integrating mental
younger LGB populations, much of the research health services for elders into primary-care set-
and many treatment programs and protocols tings. Second, it could support the establishment
continue to ignore LGBT elders. A critical need and maintenance of interdisciplinary geriatric
exists for LGBT-specific standards of care and mental health outreach teams in community set-
treatment protocols that are generally acceptable tings where older adults reside or receive social
or sanctioned by national accreditation organi- services (Gage and Melillo 2011). In addition,
zations. Such standards could be used as the because doctor shopping is a common occur-
basis for certification of clinical staff or licensing rence among the elders, a need exists for
486 D.A. Harley and M.T. Hancock
(3) What is the purpose of a substance abuse 9. What is a unique challenge of residential
screening is to do which of the following? substance abuse treatment that is specific to
(a) Identify a treatment protocol transgender adults?
(b) Identify at-risk behavior (a) Age at which they come out
(c) Make a diagnosis (b) Post-reassignment surgery status
(d) Determine the existence of a family (c) Pre-reassigned surgery status
history of substance abuse (d) Unwillingness to provide information
4. Which of the following is how comorbitity 10. How many “yes” responses to questions on
of substance abuse and mental illness be the CAGE or SMAR-G are indicative of a
defined and treated? substance abuse problem?
(a) Both as secondary conditions (a) One
(b) One as a primary and the other as a (b) Two
secondary condition (c) Three
(c) Both as primary conditions (d) All
(d) One as a primary condition and the other
as a symptom
Key
5. Which of the following usually result in
iatrogenic stress?
1-C
(a) Overprescribing of medication
2-A
(b) Ignoring that alcohol is also a toxic drug
3-B
(c) Failing to take into account the way the
4-C
elderly metabolize medications
5-D
(d) All of the above
6-D
(e) None of the above
7-A
6. How are LGBT persons viewed if they do
8-B
not reveal their sexual orientation or gender
9-C
identity while in treatment?
10-B
(a) Secretive
(b) Introverted
(c) Selfish
(d) Untruthful
Resources
7. Which of the following is ignored as a
growing concern of LGBT elders in sub-
CSAP Substance Abuse Resource Guide:
stance abuse treatment?
Lesbian, Gay, Bisexual and Transgender
(a) HIV
Populations: http://www.health.org/referrals/
(b) Dementia
resguides.asp?InvNum=MS489
(c) Illicit drugs
LGBT Populations: A Dialogue on Advanc-
(d) Substance-specific syndrome
ing Opportunities for Recovery from Addic-
8. Why are LGBT elders with comorbidities
tions and Mental Health Problems: www.
less likely to seek treatment?
samhsa.gov/recovery/doc/LGBTDialogue.pef
(a) More medical problems than younger
National Association of Lesbian & Gay
people
Addiction Professionals (NALGAP): www.
(b) Internalized stereotypes
nalgap.org
(c) Religious reasons
Preventing Alcohol and Other Drug Problems
(d) Legally cannot be questioned about
in the Lesbian and Gay Community: www.
substance use
prta.com
488 D.A. Harley and M.T. Hancock
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College Report CR 165. (2011, June). Our Borenstein, A. R., & Larson, E. B. (2005). Alcohol
and cognitive performance: A longitudinal study of
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SAMHSA: A Provider’s Introduction to Addictive Behaviors, 24, 254–264.
Substance Abuse Treatment for LGBT Indi- Brown, S. A., Glasner-Edwards, S. V., Tate, S., McQuad,
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substance abuse providers and LGBT community
Part V
Family and Community
LBGT Elders in Rural Settings, Small
Towns, and Frontier Regions 25
Debra A. Harley
Abstract
Rural areas have a higher percentage of older adults than the rest of the
USA and are expected to experience the greatest increase in this age
group, as many rural areas are becoming retirement communities. This
chapter presents a trans-disciplinary examination of issues relevant to
LGBT elders in rural settings (RS), small towns (ST), and frontier regions
(FR). Information is presented on the characteristics of these areas, a
profile of LGBT elders in these settings, issues of isolation and survival
strategies, healthcare concerns and disclosure, and issues about integrated
services and policy. For many LGBT elders, geographic location, in
tandem with social, cultural, and economic issues, is a significant factor
that influences how LGBT individuals experience aging.
Keywords
Rural Small town
Frontier Geographic location Remote
communities
American Indian population, and a higher per- poverty among landless farmers, indigenous
centage of population who are not proficient in peoples, women, and children. The developing
English. Residents of FR are described as having world is still more rural than urban, with 55 % of
distinct cultural characteristics, including the total population living in rural areas. In fact,
self-reliance, conservatism, a distrust of outsid- several parts of the developing world have as their
ers, religion, work orientation, family values, and majority population elderly people in rural areas
individualism (Nayar et al. 2013). (Kumar et al. 2001). At least 70 % of the world’s
Residents of frontier counties have low very poor people are rural; South Asia has the
exposure rates to environmental hazards such as greatest number of poor rural people and
ozone and particulate matter. In addition, these sub-Saharan Africa the highest incidence of rural
residents have a significantly lower proportion of poverty. About 34 % of the total rural population
obese individuals, lower physical inactivity, and of developing countries is classified as extremely
diabetes. However, more adverse behavioral risk poor. Across regions in the developing world,
factors include significantly lower access to families live on less than US $1.5—US $2.00 a
healthy foods and recreational facilities, higher day (Rural Poverty Report 2011). The comparison
liquor store density, and significantly higher of rural poverty in the USA and in developing
motor vehicle fatality rates than non-frontier countries is compositionally (i.e., the character-
counties (Nayar et al. 2013). In addition, frontier istics of the residents) and contextually similar
regions are described as having high rates of (i.e., characteristics of rural areas).
substance abuse and suicide (Minugh et al. 2007; In a study of the rural–urban divide in health
Wagenfeld 2000). services utilization among older Mexicans in
Rural America is currently undergoing major Mexico, Salinas et al. (2010) found that older
demographic and social transitions. There is an Mexicans living in most rural areas were signif-
outmigration of younger individuals and an icantly less likely to have been hospitalized in the
increase in ethnic minority groups, especially previous year and visited the physician less often
from Mexico, South America, and Asia with the than their urban counterparts. One possible
vast majority being Mexican or Hispanic (Glas- explanation for this outcome is having health
gow and Brown 2012; Jensen 2006; Phillips and coverage. However, certain health factors such as
McLeroy 2004). However, non-Hispanic whites diabetes, previous heart attack, hypertension,
are still a majority group (about 79 %) (Johnson depression, and functional limitations predicted
2012). Compared to natives in rural areas, new frequency of physician visits and hospitalization,
immigrants are more likely to be aged 18–64 but they did not explain variations between rural
rather than children or elders. The majority of and urban older Mexicans. In Mexico, the
these immigrants are married, less well educated, healthcare system is work-based (i.e., associated
but they are not necessarily unskilled. In addi- with the formal labor market of employment).
tion, more new immigrants work in agriculture Although the Mexican government provides free
than do natives, are underemployed, more likely state-run health services for uninsured persons or
to be in poverty or near poverty than their urban those unable to pay, resources are limited.
counterparts, and are likely to report good health Another possible explanation for the low number
but may not have access to health insurance of doctor visits by rural older Mexican residents
(Jensen 2006). is that the elderly people tend to remain in their
Similar to rural areas in the USA, rural poverty traditional locations (e.g., ST, villages). Given
in the developing world (e.g., sub-Saharan Africa, the elevated levels of poverty and lack of ser-
Asia, India, the Pacific, Latin America, the vices in rural areas, older Mexicans are at greater
Caribbean, the Middle East and North Africa) is risk for experiencing negative health conse-
very high, with a strong concentration of extreme quences associated with material disadvantage.
25 LBGT Elders in Rural Settings, Small Towns … 497
Lack of access to quality care is the primary household income. In a similar study among
modifiable risk factor for mortality disparities in midlife and older lesbians and gay men in the
rural Mexico (Salinas et al. 2010). desert of California, Gardner et al. (2014) found
Research suggests that in the USA (Centers that almost one-third maintain some fear of
for Disease Control 2013) and in developing openly disclosing their sexual orientation. Third,
countries, longevity is associated with healthcare LGBT persons face potential isolation due to the
access over the entire life course (Gu et al. 2009). lack of a visible gay community and fewer
In general, older adults report high levels of opportunities for social connection (Bostwick
quality of life; however, rural older adults age 65 2007; Hastings and Hoover-Thompson 2011).
and over have lower social functioning than their Fourth, rural elderly lesbians are among the
urban counterparts. Moreover, older African poorest of the poor, with those with disabilities
Americans and Hispanics have lower levels of experiencing the most severe poverty (Brault
quality of life across several dimensions (Ba- 2012; Fowles and Greenberg 2011) (see
ernholdt et al. 2012), including socialization, Chap. 32).
fellowship, mobility, and self-care. Clearly, the Fifth, psychosocial and economic stressors are
world’s elderly population living in these areas is exacerbated in rural areas due to lower levels of
more vulnerable to greater socioeconomic and education, limited opportunities, lack of avail-
health marginalization (Kumar et al. 2001). ability of services, lack of transportation, and
isolation (Fowles and Greenberg 2011). One area
in which these factors are evident is the higher
Profile of LGBT Elders in Rural Society rate of mental health issues as compared to urban
counterparts (Ziller et al. 2010). Many LGBT
Rural elderly LGBT persons present unique elders living in RS and who experience mental
characteristics. The literature suggests several illnesses do not seek care. Research indicates a
details are known about LGBT elders in rural number of barriers to finding LGBT-friendly
communities. First, LGBT persons are shunned mental health providers and programs in rural
from rural society and experience heightened areas (Willging et al. 2006a). For example, fears
stigma because of its traditional values, funda- of harassment or violence prevent LGBT pro-
mentalist religious beliefs, and strong conserva- viders from working with LGBT persons to
tive ideals found within these communities. In create networks and resources (Willging et al.
tandem with these characteristics and a sense of 2006b). Moreover, most information about
cultural heterosexism in rural communities, LGBT persons’ mental health is related to
LGBT elders remain ``closeted'' because of fear of counseling or psychotherapy and limited infor-
harassment of violence (Harley et al. 2014). mation about those with serious mental illness or
Second, the anonymity often found in large cities those who require service other than therapy
is nonexistent in rural areas. The closeness and (Bostwick 2007). However, given the disparities
interdependence in rural areas and ST often blur in both mental health research and services of the
boundaries of privacy; the behavior of residents LGBT population in general and certain LGBT
is easily known and information is shared populations, including rural populations, an
through local venues throughout the community. appropriate inference is that LGBT elders in rural
In a secondary analysis of data from the MetLife areas are underdiagnosed. Sixth, many LGBT
Mature Market Institute (2010a) “Still Out, Still persons have limited access to health care, are
Aging” survey, which compares supports for uninsured, underinsured, and lack financial
LGBT persons (i.e., baby boomers) aging in rural resources for essential and preventive health care
versus urban areas, Lee and Quam (2013) found (Baker and Krehely 2012; Hunter 2005). Finally,
that rural individuals reported lower levels of LGBT persons living in rural areas face the same
outness, guardedness with people including sib- issues (e.g., poverty, lower quality of housing,
lings and close friends, and lower levels of scarce health and mental health resources, need
498 D.A. Harley
life-supporting activities on their own. Comer- responsible for providing voluntary care. How-
ford et al. (2004), in a studied of fifteen elderly ever, gender subscription is less prevalent in
lesbians (average age of 60) in rural Vermont and volunteering among LGBT populations. For
found social isolation, took on an added dimen- example, lesbians in RS pride themselves on
sion as a function of the fear of being rejected being independent and able to do whatever type
because of sexual orientation and fewer lesbians of work to take care of themselves. Thus, in doing
available for support within the population as a carpentry, older lesbians may be seen as doing
whole. In this study, social isolation was medi- “man’s work.” Even if others in rural communi-
ated by wellness and mobility factors, as the ties do not label them as lesbians, they will view
participants were able to leave their communities them as not being lady-like. Given the over-
to socialize and gain support of lesbians in other whelming traditional and conservative values in
areas. Although the participants were able to RS, older lesbians are seen often as hardy women.
enlist heterosexual neighbors to help with
living-related tasks, they did not rely on them for
emotional support. Isolation and Survival Strategies
Comerford et al. (2004) also found that the
majority of the women felt comfortable with their Elderly LGBT persons living in rural areas may
sexual identity as long as it remained private but become more isolated from their families of
became less so when their identity became public origin than others. Because elderly lesbians and
due to fear of potential consequence. In addition, gay men are more likely than their non-lesbian
these women promoted intentional construction of and non-gay counterparts to be single, childless,
informal support networks as a central aspect of and estranged from family members, they must
living as a lesbian because lesbians of their gen- often rely on friends and “informal families of
eration frequently lacked family support. Comer- choice” (Baker and Krehely 2012, p. 19). As they
ford hypothesized that as lesbians in rural areas age, LGBT elders may lose their visibility within
age, they may need additional help to access the lesbian community (having little to no voice
transportation services, existing networks, and to in the political agenda of the LGBT community),
develop new sources of social support. The use of which can exacerbate their endemic loneliness in
technology (e.g., Internet, Web-based programs, rural communities. They may be excluded or
tele-technology) to provide connection and social marginalized by the younger LGBT community
support is recognized as helpful; however, Internet to form community discussions and issues per-
access does not always exist for various rural and tinent to them and absent from the mainstream
urban areas (Lewis and Marshall 2012). Many LGBT political agenda. The experience of age-
adults over age 65 are vulnerable to digital ism in the LGBT community may compound
exclusion. Also, not all elderly people are com- psychological, victimization, and despair issues.
puter literate (Clark and Leipert 2007). For frontier Many experience the loss of a long-term partner
regions, availability and access to technology and may have to hide the grieving process from
remain remote. Similar outcomes are found among others so as to hide the relationship (Hunter
elders in Europe (Burholt and Dobbs 2012). 2005). Thus, as LGBT elders in rural commu-
In the rural culture, volunteerism is a strong nities become more isolated, they eventually
component and can enhance social support (Clark transform into the “truly invisible” (Comerford
and Leipert 2007). Volunteers are a vital force in et al. 2004, p. 420).
rural communities and an investment in the peo- For LGBT elders who manage to thrive in
ple of the community. Rural culture enacts gender rural communities, a number of specific strate-
differences in how social supports are maintained gies are used, including finding a network to help
and accessed, with women being primarily cope with adversity and to gain access to certain
500 D.A. Harley
strengths as (a) being more accepting of others, Unique Needs of Rural LGBT Elders
(b) not taking anything for granted, (c) being and Concerns About HealthCare
more resilient or having a stronger inner strength, Service Delivery and Disclosure
(d) having greater self-reliance, (e) being more
careful in legal and financial matters, and One of the greatest challenges of the twenty-first
(f) having a chosen family (MetLife 2010b). century is ensuring the quality of life of an
Earlier studies on the advantages of being an unprecedented large and growing elderly popu-
aging sexual minority reveal that these individ- lation (Kumar et al. 2001). Older adults in the
uals are not reliant on family, not limited to male general population and among LGBT groups
or female roles, have more awareness of planning tend to be the most frequent users of healthcare
for the future, and have mature psychological and services in the USA. In the case of access and
spiritual dimensions of life (Kimmel 1978; Lucco utilization, limited attention has been given to
1987). In fact, Kimmel described how early health care among elderly LGBT persons.
family stressors, especially around the coming However, LGBT people of all ages are much
out process, may provide LGBT elders with more likely than heterosexual adults to delay or
“crisis competency” or resilience that insulates not seek medical care (de Vries et al. 2011).
the person again in later crises (p. 117). Research Lesbians experience many life circumstances
suggests that LGBT elders who had managed not differently than do their heterosexual counter-
to internalize stigmatizing messages, homopho- parts, including seeking, accessing, and using
bia, and heterosexism were better able to face the human services (Hash and Netting 2009; Maccio
challenges that come with later life. In addition, and Doueck 2002). For older LGBT adults,
these individuals reported higher self-esteem, health concomitants of aging may be exacerbated
were more self-accepting, were better connected by factors associated with gender and sexual
with family members, were actively engaged in orientation (de Vries et al. 2011). Specific chal-
social supports and community and social cau- lenges exist for older bisexual persons, including
ses, and could assess their lives as having been being unwelcome in the gay and lesbian com-
worthwhile and purposeful (Smith and Gray munity, being ignored or oppressed by gays and
2009). lesbians, and feeling like they need to present
Conversely, Subhrajit (2014) suggests that themselves as gay or lesbian in order to be
due to institutionalized heterosexism, social iso- accepted by gays and lesbians (Crisp et al. 2008).
lation, and ageism within the LGBT community For bisexual persons, added discrimination is
itself, many LGBT elders may retreat into the another barrier. Life within a context marked by
closet, thus reinforcing isolation. Some cope by fear and secrecy can have long-lasting, multiple,
passing for being heterosexual. Research sug- and frequently significant impact on many LGBT
gests that disclosure decreases with increasing elders (Comerford et al. 2004).
age (Gates 2010; Rawls 2004). Moreover, as According to the behavioral model, access to
LGBT persons grow older, they enter a world of health care is determined by system factors
services that may be unfamiliar. Any discussion (availability and supply of healthcare providers)
of isolation related to LGBT elders must be and by consumers’ predisposing (biological and
understood in context. Elder and Retrum (2012) social characteristics thought to affect an indi-
remind us, “it is useful to consider that each vidual’s propensity to use health services),
person has a different history and subsequent enabling (though to affect an individual’s ability
propensity for isolation depending on his or her to obtain health services), and need (thought to
behaviors and choices throughout life” (p. 17). have the biggest impact on whether an individual
Isolation may be voluntary or involuntary. The seeks health care) characteristics (Xu and Bor-
way in which a person becomes isolated is var- ders 2003). Xu and Borders contend that one
iable and multifaceted (see Chap. 29). phenomenon that has the potential to further
502 D.A. Harley
undermine the accessibility of health services in Table 25.1 Fears of discrimination from healthcare
rural areas is migration or “outshopping” (seek- providers
ing physician services outside of their local Hostility
market area) for health services. For LGBT Rejection
elders in rural areas, migration may be seen as a Invisibility
better choice to ensure confidentiality and to Deny care
reduce discrimination. Despite being more likely
Reduced care
to have usual source of care (USC), which is one
Stigmatization
of the factors that increases the use of preventive
care services and decreases risk of having unmet Anti-gay violence/safety
health needs (Newacheck et al. 2000), rural Inadequate/substandard health care
adults are somewhat less likely to receive certain Refrain from touching a patient who is lesbian
preventive care services than are urban adults Careless management of private information and
(Ziller and Lenardson 2009). In addition, rural identity disclosure
residents have more travel time and distance to a Inappropriate verbal and/or nonverbal responses from
healthcare provider, which can adversely affect providers and office staff
their ability to access a provider, especially Refusal of service providers and healthcare systems to
among those needing specialty care (Chan et al. recognize extended families within the gay community
2006). Adapted from Saulnier (2002)
In interviews with late middle-aged and older
lesbians in a rural area, Butler and Hope (1999) concealing a fundamental part of themselves
found that their fears included panic when they (e.g., identity) can often interfere with successful
thought about ever having to go to a nursing treatment because they are not able to bring the
home because of heterosexual assumptions of the entirety of who they are into treatment (Lucksted
whole institution, being punished for being a 2004).
lesbian, being old and fearful of having to deal In a study of interactions between
with extremely hostile prejudice of the radical community-based aging service providers and
political right, and denying themselves the health LGBT older adults, Hughes et al. (2011) found
care they needed because of lack of affordability. very few services specific to the needs of older
In fact, older lesbians may feel that revealing LGBT adults and very little outreach to this
their identity is not important if it means community. Knochel et al. (2012) surveyed
receiving inferior healthcare services (Hunter leaders of Area Agencies on Aging, in which half
2005). In a study of lesbians deciding who to see of the existing agencies in the USA participated,
for health and mental health care, Saulnier (2002) in order to understand their services, training,
found that lesbians encountered a continuum of and beliefs about serving LGBT older adults.
provider reactions that shaped their decisions: Results showed that few agencies provided
(a) homophobia, (b) heterosexism, (c) tolerance, LGBT outreach services, one-third had trained
(d) lesbian sensitivity, and (e) lesbian affirmation. staff around LGBT, and four-fifths were willing
See Table 25.1 for a list of fears of discrimination. to offer training. Moreover, those agencies that
Based on the limited available studies on provided, or were willing to provide training,
LGBT persons with serious mental illness, were typically urban-based.
research findings suggest that they are subjected Sexual minorities encounter two unique
to poor treatment, particularly in the public obstacles: homophobia and heterosexism. Navi-
mental health system (Bostwick 2007). LGBT gating healthcare, social, and human services can
persons feel compelled to hide their sexual ori- be further complicated by the degree to which
entation or gender identity in an effort to protect lesbians self-disclose to others (Maccio and
themselves from ridicule, abuse, or maltreatment Doueck 2002). Providers along the healthcare
from service providers and peers. In addition, continuum of caregivers ranging from doctors to
25 LBGT Elders in Rural Settings, Small Towns … 503
elders’ successful aging by reducing financial 28 % of the participants in their study currently
security, health/health care, and community use programs or services available in their com-
support. The lifetime of discrimination faced by munity. When LGBT elders were asked what
older LGBT elders and the resulting effects on services and programs they believe are most
financial security is compounded by major laws needed, they identified senior housing, transpor-
and safety net programs (e.g., Social Security, tation, legal services, social events, and support
Medicaid, tax-qualified retirement plans, retiree groups, with all groups (i.e., lesbians, bisexual
health insurance benefits, veterans’ benefits, women, gay men, bisexual men, and transgen-
inheritance laws) that fail to protect and support der) endorsing the first four being the most nee-
them equally with their heterosexual peers ded. In rural settings, LGBT elders face barriers
(Baker and Krehely 2012). in accessing each of these services. Participants
Persons who require multiple services from in Averill’s study (2012) identified areas in
different service providers tend to receive which work is needed to counteract a “patchwork
appropriate services when the services are well service network” because of a lack of organized,
coordinated and integrated. For LGBT elders in coordinated efforts (see Table 25.2).
rural areas, the need for services to be integrated Healthcare reform is anticipated to improve
is increasingly important because of such factors access to health care and health outcomes for
as limited availability or proximity to services, LGBT populations in rural areas. “The Afford-
costs of services, and transportation, which are able Care Act is the most significant and
often the result of policies established regarding far-reaching reform of America’s health system
eligibility for services, which are discussed since the creation of Medicare and Medicaid in
below. the 1960s” (Baker and Krehely 2012, p. 21). The
Affordable Care Act (ACA) introduces new
protections and options for consumers in the
Integrated Services and Policy Issues private health insurance market, expands access
to more comprehensive benefits and services,
Several factors affect service provision for LGBT focuses on improving the nation’s health,
elders in rural areas. First, the ability of rural emphasizes lowering healthcare cost, and
elders to access necessary care in the community removes barriers for preexisting health condi-
they consider home is important. Second, elders tions. The ACA is viewed as a historic
benefit from the best possible care when con-
gruency exists between standards of practice and
Table 25.2 Needed organized and coordinated efforts
licensure (Hartman and Weierbach 2013). for service delivery
Finally, as elders require care beyond the role of
Accurately document which agencies offer what
the healthcare provider, it is essential that the services
provider collaborate with professionals who are
Various eligibility requirements
qualified through professional standards of
Funding sources that support programs
practice and credentials to meet the needs of
elders (Robert Wood Johnson Foundation 2011; Kind of strategic planning to sustain programs in the
future
IOM 2011). When elders seek services, the
Plans for linking to other services and programs in the
expectation is that the service provider will meet
region
their needs, and moreover, they trust that the
How specific information about health and social
service provider has the knowledge, skills, and services is disseminated, communicated, assessed for
abilities to meet their needs (Hartman and We- adequacy, evaluated for effectiveness, and revised in
ierbach). This expectation is the same among response to analysis and critique
LGBT elders, and the service provider should How necessary personnel levels can be maintained or
reciprocate in meeting this expectation. expanded
Fredriksen-Goldsen et al. (2011) found that only Adapted from Averill (2012)
25 LBGT Elders in Rural Settings, Small Towns … 505
opportunity to change the way people concep- especially in rural areas, interdisciplinary, mul-
tualize how the healthcare industry provides care tidisciplinary, transdisciplinary, and integrated
and promotes wellness, and is seen as the approaches to training service providers are
strongest foundation for closing LGBT dispari- needed to reduce the discrepancy between ped-
ties (Baker and Krehely 2012; National Coalition agogy of training and the execution of producing
for LGBT Health 2012). For all LGBT groups, competent professionals across the disciplines
the ACA also undergirds efforts to (a) expand (Harley et al. 2014).
cultural competency in the healthcare workforce The way in which services are delivered to
to include LGBT issues, (b) improve data col- LGBT elders in rural areas in the USA, Canada,
lection to better identify and address health dis- the United Kingdom, and other parts of the world
parities, and (c) recognize the increasing is interchangeable to a certain extent. However, it
diversity of America’s families. Despite these is important for relevance and utility that
improvements, ACA is not without challenges to context-specific knowledge be identified and
healthcare services in rural areas. Approximately applied to advance the quality of life of rural
an additional 8.1 million rural residents are pro- LGBT elders within the rural setting and service
jected to be insured through Medicaid or state delivery system that is specific to their country
health exchanges due to implementation of ACA (Clark and Leipert 2007). This is not to say that
(UnitedHealth Center for Health Reform & cross-cultural exchanges are not valuable.
Modernization 2011). The challenges of imple- Building a strong coalition of allies with exper-
menting ACA in rural areas may include, but not tise to address the complexities of LGBT elders,
limited to: (a) the increase in the number of both nationally and internationally, is warranted.
persons entering the insurance rolls may amplify SAGE and MAP (2010) assert that allies can
existing pressures on an already overextended bring resources, expertise, policy know-how,
rural healthcare workforce, (b) the health pro- political connections and influence, and the ear of
fessional shortage in certain specializations may the mainstream aging community to the LGBT
further hinder timeliness of service, and (c) hos- aging agenda. Moreover, collaboration between
pitals will be challenged to find new avenues to LGBT aging and mainstream aging entities is a
improve care and reduce cost in the health reform natural partnership because many heterosexual
era (Choi 2012). See Chap. 19 for further dis- elders are also affected by the same issues and
cussion of the impact of ACA for LGBT elders. barriers as LGBT elders. Policy to potentially
The delivery of healthcare services to LGBT achieve a process to improve the health of all
elders should involve understanding the residents in rural communities is offered in the
“person-in-environment” or “person-in-situation” strategic planning section of Rural Health People
(Wheeler 2003). Healthcare providers must 2020 (Bolin and Bellamy 2012, see Policy Box
understand that LGBT elders cannot be under- 25.1).
stood apart from multifaceted contexts (e.g.,
familiar, social, political, spiritual, economic, and
Policy Box 25.1
physical). With a person-in-environment frame-
Strategic Planning for Rural Healthy
work, healthcare providers must be uniquely
People (RHP) 2020
equipped to assess both the medical and psy-
Convene RHP 2020 Advisory Board to
chological aspects of elders and intervene in a
include representatives from funding part-
culturally competent manner, especially critically
ners, rural health providers, state rural
given the complex psychosocial issues underly-
health agencies, and national rural health
ing unmet healthcare needs, life style-related
agencies (including LGBT-specific ser-
medical conditions and treatment non-adherence
vices and programs).
challenges that pose significant barriers in LGBT
Assess the extent to which the previous
elders receiving optimal health care. To facilitate
RHP 2010 achieved its objectives.
an understanding of the needs of LGBT elders,
506 D.A. Harley
Although some rural LGBT elders are heal- you observe an inclusive or welcoming
thy, well adjusted, and socially active, many environment for LGBT elders?
others are not. Underutilization of services is 2. Volunteer to assist an LGBT elder in a rural
more than a function of limited availability and area with transportation, chores, escort to a
access; it is also a manifestation of founded fears social event, and so forth.
concerning receiving poor quality of service 3. Help to establish an advocacy network for
because of their sexual orientation and sexual LGBT elders in a rural community.
identity. Overall, LGBT elders in rural settings
are known to be at risk across numerous cate-
gories and to experience challenges that are Multiple Choice Questions
compounded to a greater extent than their urban
counterparts. Given the vulnerabilities of this 1. The elderly in rural areas are more likely
population, recent changes in health reform, and than urban elders to have which of the
the repeal of the Defense of Marriage Act following?
(DOMA), the impact on the quality of life of a. High income
LGBT elders in rural areas remains to be seen. b. Live poverty
c. Own their own car
d. Graduate from college
2. Which type of healthcare workforce does the
Learning Exercises elderly require?
a. General practitioner
b. Skilled in tele-care
Self-Check Questions c. Trained in geriatric care
d. Understand aging of in-migration in rural
1. RS in the USA make up a substantial portion areas
of the country. Do the majority of people live 3. Which of the following influences how
in rural or urban areas? LGBT elders in rural areas engage with
2. FR are characterized by geographic isolation supportive healthcare or social services?
and low population density. As a result of a. Stigma around their sexual identity
being dispersed over wide areas, upon what b. Age of the service provider
type of physician do residents rely the most? c. Guidance received from social networks
3. Some LGBT elders in rural areas are open d. The number of older persons receiving
about their sexual orientation and identity; services
however, many are not. What are the major 4. What are LGBT elders in rural areas doing
reasons for them concealing their identity? when they withhold disclosure about one’s
4. What challenges does the Affordable Care sexual identity, refrain from seeking assis-
Act have for rural communities? tance for health needs, and avoid association
5. Why is it considered difficult to maintain with LGBT communities?
privacy in rural communities? a. Exhibiting denial
b. Relinquishing avoidance behavior
c. Exercising cohort identity
Field-Based Experiential Assignments d. Employing survival strategies
5. Why can “outshopping” for health services
1. Visit a local gathering spot or community be of benefit LGBT elders in RS?
center in a rural setting and one in an urban a. Reduce out-migration of older persons
area and compare and contrast them. What b. Increase confidentiality and reduce
did you observe about participants’ interac- discrimination
tions? How diverse were the participants? Did
508 D.A. Harley
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Haworth Press.
Law Enforcement and Public Safety
of LGBT Elders 26
Randy Thomas
Abstract
This chapter discusses the issues associated with law enforcement and the
LBGT community. It describes the structure of law enforcement in the
USA, the role that law enforcement plays in the criminal justice system
and the current relationship between law enforcement and the LBGT
community. This chapter also focuses on the victimization of LBGT
elders, the criminal justice response, and the need for better outcomes.
Information is presented on the legal structure that impacts law
enforcement response and the need to understand the interaction between
LBGT elders and the criminal justice system. This chapter will also look at
law enforcement training and possible prescriptive actions needed to
improve to elder LBGT victimization.
Keywords
Law enforcement Criminal code LBGT community Law enforcement
policies Law enforcement training
Utah Police Officer on Leave for Refus- to work this weekend’s Utah Pride Parade.
ing Gay Pride Parade Assignment “If you refuse to do an assignment, that’s
A Salt Lake City police officer has been put going to be a problem inside the police
on leave due to allegations that he refused department,” police spokeswoman Lara
Jones said Friday of the officer’s need to
follow orders. Internal affairs are investi-
gating the officer’s refusal, while he is on
paid leave Jones confirmed. She would not
discuss the officer’s reason for refusing the
R. Thomas (&) assignment, but said “the vast majority of
Exodus International, Orlando, USA
e-mail: Cdr251@gmail.com
The complexity and diversity of the law which LGBT individuals are viewed as “crimi-
enforcement function in the USA is not often nals” rather than victims. Specifically, this is
understood. Media and television entertainment found in an aggressive enforcement or moral’s
frequently present a false picture of the nature of offenses such as solicitation and indecent expo-
policing at every level. Popular shows such as sure. Often this is done in the context of com-
Law and Order: SVU and Cops (one a creative munity policing.
product, the other a reality show) never truly
present the complexity of the average offi-
cer’s day. The dramatic depictions never address
the fact that there are over 17,000 law enforce- Defining “To Protect and Serve”
ment agencies in the USA at the local level
(United States Department of Justice 2011). Before addressing specific issues of the LGBT
Television most often creates the impression that community and law enforcement, it is important
every agency is similar to those in New York or to clarify the concept of “protect and serve” and
Los Angles and has vast resources and expertise the reality of providing police services. While the
to apply to every case. In fact, over half of the entire concept of protect and serve makes an
law enforcement agencies in the USA have less ideal short statement to put on the side of police
than 10 personnel (United States Department of vehicles, it does not explain who gets “protected”
Justice 2011). We are a nation that prides itself or “served.” The words do not provide sufficient
on the ability to provide law enforcement ser- guidance or detail as to the complex nature of
vices, even at the lowest level of government. responding to community calls for service.
This fragmentation of policing makes it diffi- Though the primary focus of law enforcement
cult to draw wide inferences about police–com- is to respond to reports of suspected criminal
munity interaction. This situation is further activity, in many communities law enforcement
complicated by the fact that there is no national is the only public service agency with a 24-hour,
standard addressing the delivery of police ser- 7-day a week response capability. Other public
vices in an individual community. The very agencies that have this ability are often limited in
definition of what constitutes a criminal act is their mandate to respond (e.g., emergency med-
determined by each state. Therefore, the statutory ical services, fire departments). It is often the
construct that establishes the legal environment case that the public contacts law enforcement to
for law enforcement is state-specific and can vary respond to incidents that are clearly not related to
to a large degree from state to state. Differences any criminal offense, an example being civil
in state and local perceptions and experience disputes. This type of response represents the
affect how officers approach the LGBT commu- “serve” function.
nity. Recent legal issues such as defining sexual Since the 1980s, with the rise of community
behavior, marriage equality, and discrimination policing, the “protect” part of the law enforce-
directed toward LGBT individuals have demon- ment function has changed significantly. Com-
strated and highlighted cultural differences in munity policing was based on the recognition
every state. The relationship between sexual that law enforcement had become “removed”
orientation and the code of laws of individual from the environment that they were serving.
states only compounds the difficulty in discuss- These efforts were an acknowledgment that law
ing police behavior and the LGBT community. enforcement had a larger role to play in creating
Unfortunately, and all too often, the legal safe communities that addressed the concerns of
structure has defined the LGBT community in all members of a community. It was not simply
terms of behavior that has been codified as responding to calls from the public.
criminal. Although the courts have overturned The actual outcomes of this approach have not
many of these criminal statutes, they can often always been effective; however, they do show that
create an environment for law enforcement in law enforcement has made an effort to promote a
516 R. Thomas
more inclusive service approach. This approach domestic violence. Many states have domestic
has not always reduced the tension between cer- violence statutes that do not recognize same-sex
tain segments of society and the police. A recent relationships in the statute (Network for Public
Executive Session on Policing conducted by the Health, n.d.). Law enforcement then must rely on
Harvard Kennedy School and the National Insti- general criminal statutes pertaining to assault.
tute of Justice focused on the concept of “rightful The ability to provide victim services such as
policing,” an approach that challenges concept of orders of protection is not available because of
simply enforcing the laws but on the importance this deficit in the law. The lack of legal recog-
of the perception citizens have of their contact nition of relationships can hamper law enforce-
with the police. Simply put, it is critical that this ment attempts to craft a solution that holds an
contact be respectful and legitimate, an important offender accountable and protects the victim.
concept when addressing the concerns of the LGBT domestic violence is a significant problem
LGBT community (Meares 2015). Critical to all and one that most often confronts law enforce-
this discussion is an understanding of whom law ment. The ramifications of reporting domestic
enforcement is protecting and serving with respect violence by a victim can be extremely negative.
to the LGBT population. In a research brief pre- Doing so can result in family rejection, isolation,
pared by the National Center on Elder Abuse and a lack of concern by the community at large.
(National Center on Elder Abuse 2013), it has Coupled with a lack of services and a legal
been estimated that 9 million Americans identify structure that supports the victim, it is fair to
as LGBT, and of those, 1.5 million may be over assume that reporting will be very low.
65. These data provide a clearer picture of who Of special concern is the treatment of trans-
may be in need of both service and protection. It is gender persons. The most frequently occurring
probably safe to assume that these numbers may issue is the profiling of transgender persons as
underestimate the size of LGBT persons because “sex workers.” Other issues may be targeting
of reluctance to disclose their sexuality. While these individuals by asking for identification and
valid victimization rates for this group are difficult “policing” of public bathrooms designated as
to ascertain, LGBT elders have responded to male or female. Sometimes, this law enforcement
studies indicating that they have been victimized behavior may be coupled with racial profiling
due to sexual orientation and gender identity. The that treats these individuals as potential “sus-
National Center on Elder Abuse emphasizes that pects.” A difficult issue for law enforcement is
such incidents take place in both community and how to handle transgender persons if they are
facility settings and that the LGBT population has arrested. The most common practice is to place
been largely ignored in research (Walsh et al. them in cells based upon genitally determined
2011). This situation is further compounded by sex rather than their gender identity. While this
barriers to reporting abuse, such as homophobia, places them at great risk of abuse by fellow
fear of authorities, and legal issues (Cook-Daniels detainees, it should be understood that this cre-
1997). ates a practical challenge for jail/corrections
LGBT elders have been subjected to various administrators (Amnesty International 2005).
forms of abuse (see Chap. 17). The most pre- The Atlanta (GA) Police Department adopted a
valent is verbal abuse based upon their sexual policy outlining how to interact with transgender,
orientation and gender identity. Financial intersex, or gender nonconforming individuals
exploitation of gay elder men is also an issue (APD.SOP.6180). It requires that officers treat
(Meyer 2011). However, this situation is clearly these persons in a manner appropriate to their
seen in the one form of victimization that almost gender identity even though it may be different
always creates a law enforcement response— than that assigned at birth. It also addresses
26 Law Enforcement and Public Safety of LGBT Elders 517
concerns with how this will be recorded on The History of Police and the LGBT
written documents and does so in way that meets Community
the requirements of the agency and the individual
(Atlanta Police Department 2014). The relationship between the police and the
In 2014, the United States Department of LGBT community has historically been an
Justice began a program addressing the issue of adversarial one. The criminalization of same-sex
law enforcement and transgender persons, par- behavior has put law enforcement in the position
ticularly women (The Crime Report 2014). It will of enforcing laws that specifically target the
be a program that will provide transgender cul- LGBT community. This creates a climate in
tural training to local agencies across the country. which LGBT persons are not protected from
The core dilemma for law enforcement is criminal behavior of others (Amnesty Interna-
developing policies that address such issues as tional 2005). Also, this creates conflict whereby
how to address transgender persons, and how are same-sex conduct can result in an individual
they recorded on a report and the housing in being treated as either a criminal or a victim,
detention. All require not only sensitivity by the depending on the circumstances and the law
officer but administrative procedures that enforcement response to a specific incident.
acknowledge the issue but still meet the legal and Police interaction with individuals is often
data collection requirements of the criminal jus- determined by the officer’s biases and the
tice system (Police 2013). department’s organizational attitude toward a
Of significant importance is the lack of vic- particular group. This is reflected in the quoted
timization data for elders. That fact, coupled with newspaper article at the beginning of this chap-
the hidden issue of LGBT elder abuse, makes ter. The Amnesty International Report (2005)
any discussion of law enforcement response discusses police targeting of LGBT individuals
difficult. It must be understood that law and selective enforcement of moral offenses such
enforcement can be “data driven.” Any evalua- as lewd conduct and solicitation. For example, a
tion of police services often relies upon crime common occurrence is a transgender person
statistics. The primary vehicle for this discussion walking down the street being stopped and
is the reporting mechanism used nationally by questioned about solicitation. This targeting
most law enforcement agencies, the National creates a large barrier to addressing positive
Incident Based Reporting System (NIBRS). It change and reflects current practice and policy of
utilizes standardized definitions of criminal many law enforcement agencies.
behavior and captures data with respect to the This targeting of moral offenses also reflects a
level of crime by type, victim, and offender concept in Community-Oriented Policing that
characteristics and the relationship between targets “quality of life” issues. This approach is
them. This issue becomes critical when attempt- designed to create a safer community by aggres-
ing to evaluate the impact of crime on the LGBT sively enforcing laws against minor offenses such
community. It is almost impossible to determine as public drunkenness, loitering, vandalism, or
victimization levels given the manner in which public urination. The prime example of this style
the data are captured. Consequently, it is difficult of policing is found in the New York Police
for law enforcement to make a data-driven case Department. Although many contend that this has
that there exists a problem of crime directed led to a significant reduction in overall crime in
toward the LGBT community and almost New York, it has also led to accusations of tar-
impossible to focus on elders. This is most geting minority populations (Amnesty Interna-
important when law enforcement is developing tional 2005). Therefore, it is also an accurate
problem-based enforcement services. Much more observation that these quality of life offenses can
needs to be done in this area. also be used to target the LGBT community.
518 R. Thomas
the USA. In 2009, Congress passed the Matthew resulted in changing the content of training. The
Shepard and James Byrd, Jr. Hate Crimes Act other issue will be the need to provide for
(NOLO 2015). The key provisions of the act that accountability in police interactions with the
impact local law enforcement are focused on community. Both areas are critical to creating
providing technical, forensic, and prosecutorial and sustaining an effective change in law
support to agencies when they investigate a enforcement.
violent crime that may be motivated by sexual In the USA, police officers receive their
orientation, gender identity, or a violation of training through a system that contains initial
local hate crime laws. It also provides for finan- entry, in-service, and advanced courses. While
cial support for expenses associated with the there are no national standards for law enforce-
investigation. On the surface, this is a very ment training, each state or local government
positive step in furthering a better system for establishes a system of police officer standards
responding to crimes against LGBT persons. and training designed to meet their needs. The
However, it does require a local law enforcement length and content of training varies widely, with
agency to apply for the assistance. It also may be a requirement to receive in-service training after
difficult to build a prosecutable case if the state entering the force not always applied.
statutes do not address hate crimes or the hate Law enforcement training academies are var-
crime definition does not include LGBT persons. ied in how they are structured. In some states,
they are operated by the state and train all law
enforcement candidates, and in others, they are
operated by individual agencies or regional
Creating an Effective Police academies meeting the needs of several juris-
Response dictions. In others, they are part of a technical
school system and students fund their own
The law enforcement community has long been training and there is no agency sponsor-
recognized the need to address the issue of ship. Although every state sets the training
diversity. Mentioned earlier, many agencies have requirements for law enforcement certification
created specialized units to create a better and curriculum content, it is often very frag-
response. Training standards have been adjusted mented system in terms of quality. The average
to include policing diverse communities, and length of initial entry training is 761 hour (about
many communities have developed policies and 19 weeks), and the longest training time is about
procedures that recognize concerns of minorities. 965 hours, with some as short as 604 hours.
With the majority of law enforcement agencies Many academies require an additional field
having so few officers (US Department of Justice training experience ranging from a high of
2008), specialized units are located only in large, 1678 hours to a low of 225 hours. The majority
resource-rich agencies. What then, are the ideal of training time is spent in two areas–firearms
responses to improve services to the LGBT and self-defense. Both of these areas are con-
community and in particular the elderly sidered low-frequency events with high risk
population? (driving is often considered in this area as well)
Tailoring the response. The initial challenge (United States Department of Justice 2009).
is to design a police response that pertains to Special topics. Important to any discussion of
most agencies, regardless of size. First, there has LGBT issues training will often fall under com-
to be a problem statement or description that will munity policing or special topics. In most acad-
provide the framework for change. The central emies, the average number of hours for cultural
issues will be training and accountability. All diversity topics is eleven and content devoted to
significant changes in law enforcement have hate/bias crimes is four (United States
520 R. Thomas
response to these individuals. Admittedly, the 6. How effective are hate crime statutes in pro-
law enforcement response to the LGBT com- viding protection to LGBT individuals?
munity has historically focused on the enforce-
ment of offenses that target their sexual
orientation rather than crime perpetrated against Experiential Exercises
them. While many of these offenses have either
been overturned by the courts or are no longer 1. Identify a law enforcement agency that has a
enforced, this legal approach clearly puts these specialized unit addressing LGBT persons
individuals in the category of offenders and and interview the officers assigned to this
ignores the fact that they are often victims of unit.
crime. This problem is exacerbated by a lack of 2. Develop a training program for law enforce-
understanding by law enforcement officers of the ment that focuses on LGBT issues.
complex lives these people may live. 3. Develop a model policy for law enforcement
Finally, there is a lack of understanding on the response to LGBT concerns.
part of many citizens of the fragmented system of 4. Identify a LGBT victim and conduct an
policing in the USA, a problem further compli- interview that details their experience with
cated by the fact that the criminal code varies law enforcement.
from state to state and that enforcement of these
laws is part of a system response that includes
prosecutors and the courts. Over 17,000 law Multiple-choice Questions
enforcement agencies make it difficult to craft a
response addressing the needs of every agency. 1. The primary function of law enforcement is
The response to the challenge of providing public to provide_____?
safety to the LGBT elder community lies in the (a) Service
need to recognize that a growing problem exists (b) Protection
to craft a solution that fits an individual com- (c) Enforce the laws
munity and then to implement it in such a way (d) Enforce private actions
that institutionalizes that solution. 2. Law enforcement owes a duty to_____?
(a) An individual
(b) The criminal justice system
(c) The courts
Learning Exercises (d) The community
3. One of the major issues confronting any
Self-check Questions study of law enforcement is_____?
(a) Fragmentation
1. What types of challenges do law enforcement (b) Policy
agencies face when responding to the con- (c) Training
cerns of LGBT elders? (d) Community studies
2. What makes the victimization of LGBT 4. Enforcement of criminal statutes is based
elders difficult? upon______?
3. What statutory constraints impact responding (a) State statutes
to the victimization of LGBT elders? (b) Federal guidelines
4. What does research tell us about the concerns (c) Individual officer decisions
of LGBT individuals when dealing with law (d) Community pressure
enforcement? 5. There are over _______ local law enforce-
5. How does the criminal code make it difficult ment agencies?
for law enforcement to adequately protect (a) 14,000
LGBT elder victims? (b) 15,000
26 Law Enforcement and Public Safety of LGBT Elders 523
NOLO: Law for All. (2015). Hate crimes act (Mathew inside-criminal-justice/2014-05-can-cops-learn-how-
Shepard Act). Retrieved February 25, 2015, from to-protect-trans-women.
http://www.nolo.com/legal-encyclopedia/content/hate- The Network for Public Health Law. Domestic violence
crime-act.html. and same-sex relationships fact sheet. (n.d.). Retrieved
Ontario Association of Chiefs of Police. (2013). Best January 20, 2015, from https://www.networkforphl.
practices in policing and lgbtq communities in Ontario. org/_asset/lmb0yo/Master-List-of-SameSex-Domestic-
Retrieved February 25, 2015, from http://www.oacp. Violence-Protections-Updated-1262012.pdf.
on.ca/Userfiles/Files/NewAndEvents/OACP% United States Department of Justice, Office of Justice
20LGBTQ%20final%20Nov2013.pdf. Programs. (2011). Census of state and local law
Police. (2013). Dealing with transgender subjects. enforcement agencies, 2008. Retrieved June 10, 2014,
Retrieved February 25, 2015, from http://www. from http://www.bjs.gov/index.cfm?ty=pbdetail&iid=
policemag.com/blog/training/story/2013/01/dealing- 2216.
with-transgender-subjects.aspx. United States Department of Justice, Office of Justice
Stiffler, S. (2010). Police LGBT liaison units: how Programs. (2009). State and local law enforcement
effective are they? Retrieved January 16, 2015, from training academies, 2006, (Revised 4/1/09). Retrieved
http://www.edgeboston.com/news/national///102392/ January 16, 2015, from http://www.bjs.gov/index.
police_lgbt_liaison_units:_how_effective_are_they?. cfm?ty=pbdetail&iid=1207.
The Crime Report. (2014). How cops can learn how to Walsh, C., Olson, J., Ploeg, J., Lohfeld, L., & MacMillan,
protect trans gender women. Retrieved February 25, J. (2011). Elder abuse and oppression: Voices of
2015, from http://www.thecrimereport.org/news/ marginalized elders. Journal of Elder Abuse and
Neglect, 23(1), 17–42.
The Role of Religious and Faith
Communities in Addressing 27
the Needs of LGBT Elders
Debra A. Harley
Abstract
Religious and faith communities occupy unique and specific roles and
functions in society. Although information is presented on specific views
about LGBT persons of certain religious affiliations, it is not the intent of
this chapter to present a philosophical discussion of the concepts of
religion and spirituality, nor to promote the views of any particular faith or
denomination. The purpose of this chapter is to present information on the
impact, role, and perceptions of faith communities in the lives of LGBT
elders. Specifically, information is presented on the attitudes and
perceptions of the “church” toward LGBT persons, the value placed on
religion and spirituality by LGBT persons, and the ways in which
religious leaders can provide care and support to LGBT elders.
A discussion of implications of the role of religious leaders in policy
development that affect LGBT persons is also presented.
Keywords
Religion Spirituality Faith communities Religious leaders Politics
exorcism. The stressors of aging faced by many sinful, to make claims that inevitably LGBT
LGBT elders are compounded by the trauma persons will receive divine punishment and
inflicted by religion and society around their damnation, and to monitor and control the
sexual orientation and gender identities (Mahru behaviors and identities of LGBT persons
2014). (Halkitis et al. 2009).
The purpose of this chapter is to present This section examines the general function of
information on the impact, role, and perceptions religions, acknowledging that the purposes of
of religion, spirituality, and faith communities in religion are extensive and grounded in philo-
the lives of LGBT elders. First, information is sophical constructs, cultural contexts, and
presented on the historical and contemporary sociological assumptions. Beliefs about the
functions of religion, spirituality, and faith function of religion have evolved over time. For
communities. The attitudes and perceptions of example, Karl Marx and Frederick Engels
the church toward LGBT persons and behaviors asserted that the function of religion was to dis-
are examined. Next, the value placed on religion guise the realities of the underlying economic
and spirituality by LGBT persons and how they system and reduce or cover up the suffering of
express or practice those values and their expe- the laboring masses. The structural–functional
riences are discussed. In addition, the chapter approach to religion has its roots in Emile
includes ways in which religious leaders can Durkheim’s work on religion, Elementary Forms
provide care of and support to LGBT elders. of the Religious Life (1917). Durkheim believed
Finally, political implications of the role of reli- that religion is the celebration of, and to a certain
gions and religious leaders are discussed. extent, self-worship of human society. According
Wherever possible, information is included from to Durkheim, religion provides three major
a cross-cultural perspective. Throughout this functions in society: (a) social cohesion to help
chapter, the term homosexual/homosexuality is maintain social solidarity through shared rituals
used in the context of biblical reference, a term and beliefs, (b) social control to enforce
that is antiquated in contemporary times. religious-based morals and norms to help main-
tain conformity and control in society, and
(c) meaning and purpose to answer existential
The Functions of Religions, Spirituality, questions (Carls 2012). Critics of the structural–
and Faith Communities functional approach to religion argue that it
overlooks religion’s dysfunctions (e.g., to incite
Until the fifth century, the only persons who violence, war, terrorism, hate crimes).
were punished for same-sex behavior were Lenkeit and Lenkeit (1997) expanded on the
“passive men”. Subsequently, Emperor Justinian work of Durkheim and classified the value of
interpreted same-sex intimacy as “against nat- religions to society into eight categories (see
ure,” and, therefore, a religious misdemeanor Table 27.1). The disciplinary function of religion
punishable by God that resulted in double pun- is in many ways disproportionately applied to
ishment from God and law. In essence, the law LGBT persons. As a disciplinary function, reli-
became the weapon of the church (Dreyer 2008a, gion provides a paradigm for moral behavior and
p. 749). Mainstream religions of Christianity, the promise of both natural and supernatural
Judaism, and Islam have been described as being punishments for perceived breaches of conduct.
at best negative and at worst destructive toward Further efforts to explain the functions of reli-
LGBT persons (Lynch 1996). Religion has been gions are offered by Goldberg’s (2010) list of
used to legitimize the ostracism of LGBT per- functions: (a) transmission—to impart to each
sons. Sacred religious texts have been referenced generation a sense of identity through shared
consistently as authoritative means of verifying customs, rituals, stories, and historical continuity;
that LGBT patterns of attraction and intimacy are (b) translation—to help individuals interpret life
528 D.A. Harley
events, acquire a sense of meaning and purpose, communities filled with people experiencing
and understand their relationship to a larger difficult and complex situations involving sexu-
whole, socially and cosmically; (c) transaction— ality, they are turning to their clergy and religious
to create and sustain health communities and leaders for guidance and help in the belief that
provide guidelines for moral behavior and eth- these same leaders are trained in, and capable of,
nical relationships; (d) transformation—to foster dealing with this vast range of concerns”
maturation and ongoing growth, helping people (p. 485). Given the sexual issues and the growing
to become more fulfilled and more complete; and conflicts, awareness, and acknowledgement
(e) transcendence—to satisfy the longing to around them and across the spectrum of religious
expand the perceived boundaries of the self, denominations, religious leaders remain ill pre-
become more aware of the sacred aspect of life, pared to deal with them (Turner and Stayton).
and experience union with the ultimate ground of When people in their congregations bring ques-
being. These viewpoints on the functions of tions, concerns, or dilemmas, many religious
religion may or may not be representative of past leaders realize that they have inadequate infor-
or current functions or representative of different mation, understanding, or training to be good
cultural aspects. Religiosity and scriptural liber- counselors or to address the interwoven spiritual
alism (the degree to which one interprets the nature of congregants’ concerns. Turner and
scriptural literally), associated with traditional- Stayton contend that “religious leaders are in a
ism, also influence faith communities’ views of unique position to transform, inform, and influ-
LGBT persons and behaviors. ence society’s understanding of sexuality and
Turner and Stayton (2014) contend that reli- religion—through the pulpit, pastoral care of
gious leaders face a wide variety of sexual needs individuals and families, and involvement in
and concerns, sexual expressions, and sexuality local communities, the media, and policies”
issues within their faith communities. Sexuality (p. 485). Unfortunately, sexuality and sex edu-
issues range from reproductive technologies to cation are not a part of seminary education and
sexual abuse to sexual orientation and gender religious training. See the case of Alex, an
identity and expression. “Not only are faith example of an older gay man coming to his
27 The Role of Religious and Faith Communities … 529
religious leader for guidance on a situation often the first point of contact for concerns of
around his sexuality. their faith community members.
homosexuality has explored heterosexual atti- believes that, “regardless of context, discrimina-
tudes toward homosexuals with a focus on the tion against any person arising from apathy,
relationship between prejudice, right-wing, insensitivity, ignorance, fear, or hatred is incon-
authoritarianism, and dimensions of religiosity. sistent” with the fundamental belief of b’tselem
Much of religion has been used to create and Elohim, “for the stamp of the Divine is present in
cultivate hostility against LGBT persons. each and every one of us” (Rabbi David Saper-
Stances of faiths on LGBT issues in Islam are stein cited in Appell).
difficult to summarize because of its enormous Homosexuality is discussed seven times in the
geographic, linguistic, and cultural diversity. To a Christian Bible: Genesis 19, Judges 19, Leviticus
large extent, attitudes depend on how individual 18, Leviticus 20, Romans 1, Corinthians 6, and 1
Muslims and Islamic sects interpret the Holy Timothy 1 (Dwyer 2007). These passages serve
Quran and other theological sources. Neverthe- as the foundation for most of the abuse projected
less, a majority of Muslims express very negative on LGBT persons in some churches (Atchison
attitudes toward LGBT persons. However, only a 2013). In response to these biblical references,
few passages in the Quran and several hadiths adherents claim that God condemns homosexu-
(sayings attributed to the prophet Muhammad) ality or homosexuals. In response, Dwyer wrote
refer to sex between two males. Specifically, the the book, Those 7 References: A Study of 7
story of Lut (or Lot as he is known in Jewish and References to Homosexuality in the Bible.
Christian Bibles) is mentioned, but the Quran does Dwyer’s rationale was to allow LGBT persons
not call for a specific punishment for this behavior. who have been abused by the “misuse” of
While most Islamic institutions have not explicitly scripture to have a voice about a different inter-
addressed transgender issues, they do make ref- pretation of God’s voice to be heard in these
erence to cross-dressing, those transgressing tra- passages in ways that had been silenced for many
ditional gender roles, and sex-reassignment for a long period of time. In her reflections about
surgery (Human Rights Campaign, n.d.). the seven references, Atchison (2010) asserts that
The beliefs about and responses to LGBT often the Bible is used (and misused) in two
issues in Judaism vary across Orthodox and extreme interpretations to oppress and harm
Reform Judaism. The Torah clearly states that members of sexual minority groups. The Bible is
the act of homosexuality is prohibited. The Torah used either blindly as “The Word” and the use of
refers to homosexuality as Toaviva-abomination certain texts as a self-flagellation (referring to self
(i.e., abhorrent to God) (Amsel, n.d.). The Tal- and others of their community as “sin”), or with
mud says that in the act of homosexuality, the complete dismissal of the whole book and
person is “straying” from one of the primary Christianity itself, allowing Christian fundamen-
goals in life—to procreate and populate the earth. talists to unanimously dictate what is righteous
It is in the straying that homosexuality is pro- and what is good.
hibited. That is, it is not the “unholiness” of the Atchison (2013) suggests that for people who
homosexual relationship, but rather, the violation teach and preach about the seven references, it is
of one’s purpose on earth (Amsel). For Jews, the necessary to understand that, the Bible, although
law of the Torah is the all-encompassing and relevant for today, was written in a particular
governs every single part of living, general, historical context, making it often difficult to
societal, and personal (Shaffer, n.d.). Conversely, apply something written for a particular ancient
Reform Judaism has a long history of working audience to a contemporary lived experience.
for the full inclusion of LGBT persons in Jewish This view is consistent with that of Dreyer
life (Appell, n.d.). According to Appell, Reform (2006a) who espouses that theologians and exe-
Jews “are guided by the very basic belief that all getes cannot ignore the changes that have
human beings are created b’tselem Elohim (in the occurred in social life from biblical times,
Divine image)” (p. 1). The Reform Movement through the ages, to our modern and postmodern
27 The Role of Religious and Faith Communities … 531
worlds. A postmodern view is that sexuality is tension for participants and led some to abandon
not a homogeneous entity, rather the result of an religion altogether. The authors also found that a
infinite variety of ever changing factors. LGBT changing Irish society is characterized by
persons feel that they are “being” a sexual increased diversity, openness, and respect for
minority and God made them this way. minority rights including LGBT rights. Some
Different religions and denominations have denominations welcome the inclusion of all
varying attitudes toward sexual orientation and persons, including those who are LGBT (e.g.,
sexual identity; experience may vary greatly Episcopalian, United Methodist, Unitarian Uni-
depending on the nature of the religious commu- versalist), at the same time that others overtly
nity. The experiences of LGBT persons in faith condemn them (e.g., Christian fundamentalist,
communities are as diverse as the type of practices Baptist). The current policy (as of 2012) of the
and ceremonies in which they engage. “Religion United Methodist Church’ states, “We implore
has been a source of both solace and suffering for families and churches not to reject or condemn
many LGBT Americans” (Human Rights Cam- lesbian or gay members and friends. We commit
paign 2014). For some LGBT persons, neither ourselves to be in ministry for and with all per-
their sexual orientation, their religion, nor the sons”. Although the United Methodist Church
intersection of the two is a problem, while others bans discrimination at the congregational level
struggle with the attitudes of those around them, and recognizes the “scared worth” of all persons,
religious leaders, or their own internalized atti- church doctrine also states that homosexuality is
tudes toward sexual orientation or sexual identity incompatible with Christian teachings and bans
(Pace 2013). Many LGBT persons have been financial support of all LGBT-based groups.
raised in an organized religion but have been More progressive factions among clergy and
forced to leave those communities because of laity have defied church doctrines in an effort to
condemnation. However, in recent years, there has reclaim the Bible’s call for social justice as it
been a shift in a growing number of organized applies to marriage and ordination (Human
religious groups in the United States to issue Rights Campaign 2014).
statements officially welcoming LGBT persons as In Canada, The United Church has developed
members. As an example, some religious organi- policies about sexual orientation and transgender
zations have taken supportive stands on issues that and gender identity, affirming all human being
affect LGBT persons (e.g., freedom from dis- regardless of sexual orientation. The timeline of
crimination, right to marry, ordination of openly policy decisions on sexual orientation of The
gay clergy) (Human Rights Campaign 2014). United Church of Canada includes the following:
Religion-based bigotry, “the attitudes of pre- (a) in 1984, affirmed acceptance of all human
judice hostility or discrimination toward gay beings as made in the image of God, regardless
people that are falsely justified by religious of sexual orientation, acknowledged that the
teachings or belief,” causes enormous harm to church has condoned the rejection of lesbians
LGBT persons (Faith in America 2010). Nega- and gays, and called the church to repent; (b) in
tive social attitudes about sexual orientation and 1988, declared that “all persons, regardless of
gender identity can cause harmful consequences sexual orientation, who profess faith in Jesus
in the lives of LGBT persons, creating the “fear Christ and obedience to him, are welcome to be
of going to hell” depression, low self-esteem, or become full members of the church;” (c) in
feelings of worthlessness, self-doubt, and inter- 1992, began creating resources for same-sex
nalized homo/bi/transphobia (Barton 2010; covenants; and (d) in 2003, called on the Gov-
Mahru 2014). In a study of LGBT persons in ernment of Canada to recognize same-sex mar-
Ireland, Reygan and Moane (2014) found that riage in marriage legislation (http://affirmunited.
while participants lived in an increasingly plu- ause.ca). More recently, The United Church of
ralistic Irish society, the negative dividend of Canada passed policies on gender identity and
religious homophobia created intrapsychic the participation and ministry of transgender
532 D.A. Harley
(92 %) said that society has become more between one’s sexual orientation or gender
accepting of them in the past decade. The par- identity and one’s religious identity may lead to
ticipants attribute this change to various factors dissonance because full acceptance of one aspect
ranging from people knowing and interacting of the self implies full rejection of another (Gold
with someone who is LGBT to advocacy on 2010). Ways that religiosity may shape sexual
behalf of high-profile public figures to LGBT identity and ways in which LGBT persons’
adults raising families. However, LGBT persons engage in worship practices are altered by their
report that many religions are not accepting of experience within hostile or affirming religious
them. They describe the Muslim religion (84 %), communities. Some LGBT persons elect to
the Mormon Church (83 %), the Catholic Church eschew organized religion entirely, while others
(79 %), and evangelical churches (73 %) as self-define as atheists. Yet others may reject
unfriendly. Fewer than half of LGBT participants public religious life but may express their reli-
indicated that the Jewish religion and mainline gious and spiritual commitment by engaging in
Protestant churches were unfriendly, and private acts of devotion, meditation, and prayer.
one-in-ten described them as friendly, with the LGBT persons who remain committed to par-
remainder indicating that they were neutral. ticipating in organized religious life may choose
Overwhelmingly, research on religion and to ignore or minimize the relevance of anti-gay
sexual minorities has focused on lesbians and doctrines and sentiments within their faith com-
gays. There is limited to no attention given either munity (Halkitis et al. 2009).
to bisexuality or transgenderism and religion A study by Halkitis et al. (2009) included 498
and/or spirituality. Donnelley (2008) states that participants ranging in age from 18 to 75. Of
while many of the religious issues identified for these participants, only 24.5 % (n = 122) reported
LGBT persons apply to transgender persons, the that they held a membership in a religious insti-
pattern of attitudes toward transgender persons is tution such as a church, synagogue, or mosque,
significantly different than toward LGB persons. and those who indicated membership tended to
For instance, issues for transgender persons of be older than non-members. The majority of
faith can be different: there are fewer trans-persons participants were raised in religious households.
than LGB persons, and the law covers trans and Although it is unclear whether the findings that
LGB persons differently. All of these factors older LGBT persons tended to hold membership
suggest that differences in approach may be nee- in organized religion is a reflection of a devel-
ded for trans and LGB issues (Donnelley). opmental effect, they may suggest that as LGBT
persons age, they will have a need for organized
communities in which they can express their
Research on LGBT Elders’ Religious religious and spiritual beliefs. Moreover, these
and Spiritual Beliefs and Practices individuals will have a particular need for wel-
and Experiences coming and affirming religious communities,
ones that can help them negotiate the challenges
Both the religious beliefs and the way in which associated with aging (Halkitis et al.).
individuals worship is a matter of choice, per- As people get older, their support networks
sonal preference, and familial teaching. For many often shrink. Rose (2012) found that spiritual and
LGBT persons, participation in organized reli- religious experiences were an important source
gion may be detrimental to their mental health of support and strength for many LGBT elders.
because of negative messages about their sexual Conversely, it was also a source of pain, due to
orientation and gender identity that are commu- religiously linked experiences of stigma, usually
nicated through religious teachings, institution- in childhood or young adulthood. For all of the
ally imposed sanctions against openly LGBT participants in Rose’s study, sexual orientation or
members, and the prohibition against gay reli- gender identity set them apart in some way from
gious leaders (Lease et al. 2005). The conflict the heterosexual mainstream of their generation
534 D.A. Harley
and required them to define themselves spiritu- involvement in religious and spiritual practice
ally. Those participants had a variety of indi- corresponds to better health-related outcomes
vidual experiences, but most were in the regardless of age (Beery et al. 2002; Brennan
mainstream of American traditions (e.g., church, 2004; Newlin et al. 2008), and may provide
synagogue, other religious institutions). Accord- social support and a sense of well-being, which
ing to Rose, the individuals grew up during a promotes better overall mood (Mitchell and
time when the majority of American society held Weatherly 2000).
religious and social conservative views about A Gallup Poll on LGBT populations and
homosexuality, bisexuality, and gender religious affiliation in the USA found that LGBT
non-conformity. Moreover, “to acknowledge persons are significantly less likely than
one’s identity, was, for the majority of study non-LGBT persons to be highly religious and
participants, to find oneself in a world where significantly more likely to be classified as
religious leaders, social arbiters and, often, one’s non-religious. Religiosity among national adults
own family, would almost universally condemn found that 24 % of LGBT identify as highly
you” (p. 12). religious, 29 % as moderately so, and 47 % as
For many of the LGBT elders in Rose’s not religious compare with non-LGBT at 41, 29,
(2012) study, the spiritual community provided a and 30 %, respectively. A comparison by gender
place to perform service to others. The majority reveals that male gay, bisexual, and transgender
of participants indicated substantial involvement persons compared with non-gay, bisexual, and
with their spiritual or religious community. transgender were classified 25 % versus 36 % as
LGBT elders played various roles and performed highly religious, 26 % versus 28 % as moder-
important functions in their faith community ately, and 49 % versus 35 % as not religious
including the role of deacons, celebrants, taking (Newport 2014). Some LGBT persons find that
care of the place of worship or fellow congre- no specific religion’s teachings are fully in
gants, and mentor of younger members. In accordance with their personal identity and
addition, LGBT elders provided spiritual and worldview, but take comfort from the idea of a
personal support and advice to others struggling spiritual presence in the world. Others find that
with issues of identity or with personal crises. spirituality fits more easily into their identities
These LGBT elders highly valued their spiritual than religion, although many do also maintain a
community and regarded it as a place for them to strong belief in the teachings of particular faiths
fulfill the tasks of adulthood that they might not (Pace 2013). A national survey of American
have had the opportunity to do if they were congregations from 2000 to 2010 (conducted in
disconnected from it. All of the LGBT elders in 2000, 2005, 2008, and 2010) identified sub-
the study stated that in one way or another, stantial changes including a net overall result of
having a religious or spiritual practice, commu- fewer persons in the pews and decreasing spiri-
nity, or perspective helped them cope with life tual vitality (Roozen 2011) (see Table 27.2).
stressors, coming out, health issues, and changes Similarly, a Pew study (Taylor 2013) found
in life circumstances. that LGBT adults are less religious than the
Similarly, Espinoza (2014) found that 40 % of general public. Approximately 48 % reported no
LGBT elders say that their support networks religious affiliation compared to 20 % of the
have become smaller over time, as compared to public at large. Of those LGBT adults with reli-
27 % of non-LGBT older people. Among LGBT gious affiliation, one-third said there is conflict
elders who consider the church or faith commu- between their religious beliefs and their sexual
nity as part of their support networks, 26 % are orientation or gender identity, and 29 % said they
African American, 8 % are White, and 8 % are have been made to feel unwelcome in a place of
Hispanic/Latino. (See Chaps. 6, 7, 8, 9, and 10 worship.
for discussion of the role of religion in the lives The results from each of the studies discussed
of ethnic populations). Research shows that above reveal that while societal views about
27 The Role of Religious and Faith Communities … 535
If indeed “one of the main tasks of the church is that the World Wide Web offers ease and ano-
to help heal people’s wounds, this should include nymity with which persons can obtain advice and
those wounds caused by outdated social codes reassurance. Although LGBT adults are heavy
that express prejudice against sexual orientation users of social media (80 %) as compared to the
and behaviors that differ from heteronormative general public (58 %), older LGBT persons are
conventions” (Dreyer 2008b, p. 1237). less like to do so (Taylor 2013).
Many LGBT elders have encountered negative The Need for LGBT-Affirmative Congrega-
experiences and have been hurt deeply by reli- tions. Generally, LGB persons have three options
gion. Thus, they may have strong initial suspi- when dealing with religious and spiritual issues:
cions of religious leader and their motives. In (a) reparative or conversion therapy—attempts to
interactions with LGBT elders, it is the respon- help the person change their sexual orientation,
sibility of religious leaders to convey a (b) the use of therapy to help the person live a
non-judgmental presence during visits or in celibate life, and (c) abandonment of their reli-
counseling and to affirm them as they are and gious beliefs and work through the issues related
assure them that they are safe (Mahru 2014). to the anticipated loss of meaning and support in
Pastoral engagement with sexual minorities is their lives (Hoffman et al. 2006). Despite being
affected by religious leaders’ disposition, which is proven as ineffective and outdated, conversion
related to their religious views. Thus, therapy is highly regarded among religious
self-reflection on and awareness of religious leaders as a way to change a person’s sexual
leaders’ own personal disposition, theological orientation. Hoffman et al. offer another option
views, and values will prepare them for engaging an affirming or welcoming model for those who
openly and respectfully with those whose belief do not believe that their sexual orientation is
system may differ from theirs (Dreyer 2008b). sinful or wrong and wish to maintain their reli-
According to Dreyer (2005, 2006b), the mental, gious beliefs. LGBT-affirmative congregations
physical, and spiritual well-being of all people of and spiritual communities may be more in line
faith is the concern of pastoral caregivers. Thus, with the biblical teachings of both justice and
Dreyer (2008b) advocates for practical theolo- love. In this vein, Dreyer (2008b) suggests sev-
gians to expose all harmful attitudes toward oth- eral LGBT-affirmative considerations for reli-
ers, including LGBT persons. Whereas therapists gious leaders. First, religious leaders who adopt
and counselors have an ethical obligation to such a theology and philosophy will be more
refrain from imposing their views on clients and advantageous when engaging LGBT persons,
to be non-judgmental about clients’ belief sys- and an open view of the scripture will be con-
tems, many religious leaders may find it difficult ducive to finding a way that the Bible does not
to do so. The issue of maintaining a value-free damage, reject, or condemn individuals. Second,
approach may be even more difficult for religious openness to the voices of the marginalized is
leaders from “a tradition where religious propo- conductive to a pastoral and therapeutic respon-
sitions are presented as undeniable truths, and sibility to listen to and understand the experience
especially when dealing with sexual minorities of the other from the inside. Finally, the will-
where social and religious morality and values are ingness of religious leaders to struggle with the
significant issues” (Dreyer 2008b, p. 1244). Bible and with other voices rather than adhere to
Anonymous pastoral care (APC) is one option a set of prescribed answers is helpful when
for assistance in concerns pertaining to sexuality dealing with the complex personal, social, and
(Van Drie et al. 2014). APC eliminates the risk of religious sectors of LGBT persons.
rejection or judgment by their religious leaders. In 2006, the Social Issues and Resources
APC is especially positioned to counsel LGBT Panel of the Presbyterian Church in Ireland put
persons because of socially contested sexual forward General Assembly Resolution
issues such as lesbianism, gayness, bisexuality, (GAR) guidelines (http://www.presbyterian
and transgenderism. Van Drie et al. (2014) assert ireland.org/getmedia/c89505dc-f8a9-4640-ad20-
538 D.A. Harley
Beyond preaching and teaching that sexual from using hiring policies that discriminate
minorities represent a violation of God’s will, against LGBT persons. Those religious leaders
many religious leaders and groups have worked stressed that it is unjust for any person or cor-
in the political arena to oppose legislation and poration to use their religious beliefs to trample
policies that provide human rights and equality the rights and beliefs of others and stipulated that
for LGBT persons (Thistlethwaite and Cook such actions run contrary to the “Golden Rule”
2011). Thistlethwaite and Cook argue that while articulated in every world religion.
it is important to support the First Amendment Grzymala-Busse (2012) argues that religion
rights of faith communities to voice their beliefs, has had clear and significant impacts in several
it is equally important “to oppose their effects to domains of politics. These include voting and
impose their theology on a pluralistic democracy political behavior; as institutional players, lob-
and deny justice and equality to millions of byists, and coalition partners; in the origins of
LGBT Americans” (p. 1). The quest is to expand institutions and the long-term outcomes through
and reframe the debate that will allow for moral specific ideas and norms regarding appropriate
equality to be as important as legal and social institutional solutions; on attitudes toward and
equality. polices of social welfare; and through the influ-
One area of considerable debate surrounds the ence of regime type and durability by legitimizing
separation of church and state. In the United and lending support to secular regimes, or con-
States, on one side of the political debate (the versely, withdrawing that support and opposing
Religious Right) are organizations that identify particular secular incumbents and governing
themselves as family focused and for traditional structures. These domains demonstrate that
values, and believe that their religious views “organized religion and the secular state are in
should be that of all Americans. On the other side constant interaction, if not conflict”
(the Left) are organizations that support separa- (Grzymala-Busse, p. 433). Religious loyalties
tion of church and state and oppose the imposi- continue to structure political thought and action
tion of religious views about homosexuality and because, as suggested by Grzymala-Busse, once
gay marriage as espoused by the Religious Right. religion is introduced into politics, it becomes
Although religious groups have the right to hire very difficult to disinvite it. In 1991, Demerath
whomever they want and to restrict to whom they described the presence and impact of religion in
will offer services, many view that they should politics and policy development and this percep-
not have a right to accept government funding to tion is as relevant today. According to Demerath,
operate programs and then refuse to offer ser- “Not only do its absolutist criteria clash with the
vices to certain classes of people such as LGBT politics of compromise, but religion tends to be
persons. For faith-based organizations to do so is emotionally ‘hot and accompanied by it own
tantamount to government-sponsored discrimi- experts who are frequently difficult to control …
nation on the grounds of sexual orientation and very few state officials relish publicly opposing
gender identity. religious considerations once they have been
Prominent religious leaders of the Christian activated” (p. 30). The comingling of religion and
Right openly influence public policy that restricts politics regarding polices on LGBT persons has
and denies LGBT rights (White 2006). In July of proven to be a battle between individual freedom
2014, over 100 religious clergy, theologians, and and personal choice and imposition of mandated
faith leaders sent a letter to President Obama doctrines and narrow interpretations of the Bible
urging him not to include religious exemptions in for everyone (Americans United for Separation of
an executive order prohibiting federal contractors Church and State, n.d.).
540 D.A. Harley
Espinoza, R. (2014). Out and visible: The experiences ad Lynch, B. (1996). Religious and spirituality conflicts.
attitudes of lesbian, gay, bisexual, and transgender In D. Davies & C. Neal (Eds.), Pink therapy: A guide
older adults, ages 45–75. New York, NY: Services for counselors and therapists working with gay,
and Advocacy for LGBT Elders. lesbian, and bisexual clients (pp. 199–207). Bucking-
Faith in America. (2010). Addressing religious arguments ham, England: Open University Press.
to achieve LGBT equality. Retrieved November 9, Mackinlay, E. (2006). Spiritual care: Recognizing spiri-
2014 from www.faithinamerica.org/2010-2/2p- tual needs of older adults. Journal of Religion,
content/uploads/2010/11/FIA_ Spirituality and Aging, 18(1–2), 59–71.
ConfrontingReligiousArguments.pdf. Mahru, J. (2014). Pastoral care and LGBT seniors.
Gold, J. M. (2010). Counseling and spirituality: Integrat- Berkeley, CA: Center for gay and lesbian studies in
ing spiritual and clinical orientations. Upper Saddle religion and ministry. Retrieved October 26, 2014
River, NJ: Merrill. from www.clgs.org/files-clgs/CLGS_
Goldberg, P. (2010, June 21). Toward a broader under- LGBTSeniorsFinal.pdf.
standing of religion’s functions. Retrieved October 31, Martin, D. B. (1996). Arsenokoites and malakos: Mean-
2015 from www.huffingtonpost.com/phillip-goldberg/ ing and consequences. In R. L. Brawley (Ed.), Biblical
toward-broader-understa_b_545314.html. ethics and homosexuality: Listening to scripture
Grzymala-Busse, A. (2012). Why comparative politics (pp. 117–136). Louisville, KY: Westminster.
should take religion (more) seriously. Annual Review Mitchell, J., & Weatherly, D. (2000). Beyond church
of Political Science, 15, 421–442. attendance: religiosity and mental health among rural
Guasp, A., & Dick, S. (2012, January). Living together— older adults. Journal of Cross Cultural Gerontology,
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Retrieved November 13, 2014 from www. Musick, M. A., House, J. S., & Williams, D. R. (2004).
socialwelfare.bl.uk/subject-areas/services-client- Attendance at religious services and morality in a
groups/minoritygroups/stonewall/160499living_ national sample. Journal of Health and Social
together_2012.pdf. Behavior, 45, 198–213.
Gubi, P. M., & Jacobs, R. (2009). Exploring the impact Newlin, K., Melkus, G. D., Tappen, R., Chyun, D., &
on counselors of working with spiritually abused Koenig, H. G. (2008). Relationships of religion and
clients. Mental Health, Religion and Culture, 12, 191– spirituality to glycemic control in Black women with
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Ladyzhenskaya, L., Pitrelli, K., et al. (2009). The U.S. significantly less religious. Retrieved October 26,
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Hoffman, L., Knight, S. K., Boscoe-Huffman, S., & England. Retrieved October 26, 2014 from www.
Stewart, S. (2006). Religious experience, gender, and pacehealth.org.uk/files/2013/6551/5626/Religion_
sexual orientation. Retrieved November 11, 2014 and_LGBT_issues.pdf.
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media/ Ano, G. G. (2005). Spiritual struggle: A phenomenon
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544 D.A. Harley
Abstract
To understand and address the unique challenges faced by lesbian, gay,
bisexual, and gender diverse seniors requires an awareness of what drives
workplace diversity initiatives, and cultural competence on the multiple
differences represented by the limiting acronym, LGBT.
Keywords
LGBT elders Workplace Public policy Law
This brief chapter on the issues facing lesbian, workplace that somewhat evens the playing field.
gay, bisexual, and transgender (LGBT)1 seniors In theory, companies cannot afford to lose the
in the workplace is a reflection based upon my best and brightest workers because their work-
40-year career working as an educator on LGBT place is unwelcoming. To attract and retain highly
concerns. I’m not an academician, and so this qualified people and to maintain a competitive
chapter is somewhat different from other chapters edge, most companies seek to create conditions in
in this book. which the diversity of their workforce is cele-
When approaching this topic, you work with brated and fully tapped. That should mean that
the assumption that there is a war for talent in the older lesbian, gay, bisexual, and transgender
people are seen as having the potential to be
1
While I will occasionally use the acronym LGBT in among the company’s best and brightest
writing and speaking, I believe it is preferable to write and
say the words lesbian, gay, bisexual, and transgender.
employees, thus increasing the odds of
These four words represent four distinct communities, profitability.
each with its own concerns. The LGBT acronym enables That said, the working conditions for LGBT
people not to say the words, diminishes the difference in employees of all ages can vary in the same
issues, and is often confusing to the reader or listener. “Is
it a sandwich?”.
company, depending upon the mentality of
middle management. When the middle manager,
influenced by any number of variables such as
B. McNaught (&) religious beliefs, familiarity with gay and trans-
Brian McNaught & Associates, Ft. Lauderdale, gender people, race, and gender, among other
Florida, US
e-mail: brian@brian-mcnaught.com
factors, does not ascribe to his or her company’s
values, the lesbian, gay, bisexual, and transgen- lesbian, gay, bisexual, and transgender workers
der worker is vulnerable to increased risk of means being aware of the rapidly paced changes
harassment. in language and attitudes in LGBT communities.
When considering harassment, or other hostile When I first began working on this issue, the
working conditions, the reader needs to allow for focus was on gay people. It then became about
the possibility of the worst behavior in the lesbian and gay people. Bisexuality was soon
workplace, such as physical and emotional added to the topic. Then, transgender issues
abuse, but he or she is encouraged to focus more became part of the discussion. Not long ago, the
on problems created by unconscious incompe- organization that was originally called the
tence. Excluding examples of termination, hiring National Gay Task Force changed its name to
discrimination, and overt hostility, the majority include letters in the acronym to accommodate
of LGBT people in the workplace complain the issues of people who identify as queer,
about feeling isolated because of their sexual questioning, intersex, and asexual. Further, the
orientation or gender identity or expression. Fear new preferred term for transgender people is
of isolation is what keeps many LGBT people in gender diverse, and the new preferred term for
the closet. The isolation is created by the lack of transitioning (the process of physically becoming
social interactions with colleagues, especially one’s true self) is realignment. Although I have
conversations having to do with personal life. been familiar with these issues for decades,
One of the challenges in creating a clear pic- I need to constantly update my educational
ture of workplace issues for lesbian, gay, bisex- resources on the topic because of these changes
ual, and transgender seniors is that the culture is in language and attitudes.
changing so quickly that the picture will never be What began as a workplace concern in the
complete or reliable. For instance, marriage United States, with me introducing the topic as a
equality is now the law of the land, some poli- business issue in 1985, is now being discussed
ticians insist they will continue to resist it. throughout the world because of the
Though progress is being made in state-by-state multi-national identity of most major corpora-
passage of non-discrimination ordinances, there tions. Creating an office culture that is welcom-
are now efforts to pass statewide legislation that ing to LGBTQQIA people is not just important in
grants religious liberty to employees to discrim- New York, but also in Mumbai. Wall Street
inate on the basis of their personal beliefs. banks brought me to India, Japan, Hong Kong,
Eventually, the Federal Employment and Singapore to train their employees on gay
Non-Discrimination Act (ENDA) will be passed, and transgender issues. That work has rapidly
but probably not for many years. The current fear expanded throughout those countries and many
of gender diversity on the part of many members others. Understanding LGBT senior workplace
of Congress keeps the legislation locked up. That issues requires familiarity with the cultures of
will change, or the legislation will change, and it those individual countries, especially as they
will be passed, but it will still not cover housing relate to age, sexual orientation, and gen-
and public accommodation, which might have an der expression diversity.
impact on a discussion of LGBT workplace Gay and transgender discrimination has
issues. If a gay senior faces discrimination in become an issue of importance to the United
housing, is it possible for him or her to live near Nations. The Roman Catholic Church is said to
the workplace? be softening its approach because of the state-
We are aware of the quickly changing culture, ment by Pope Francis, “Who am I to judge?”
which in the Western world is becoming more Gay issues are now part of the discussion on
comfortable with the full range of sexual orien- where the Olympics will be held. Economic
tation and gender expression, and we are aware sanctions are being imposed on countries that
of the increase in protective legislation. But, discriminate against gay people. The words
understanding the challenges faced by senior “lesbian, gay, bisexual, and transgender” were all
28 No Money, No Work, and You’re Old 547
used by President Obama in his State of the They do not start conversations with gay or
Union address in 2015. transgender people because they fear making a
Another component of the discussion is the mistake, and so they keep quiet. The silence is
very important shift in approaching the trans- interpreted as hostility or at least disapproval.
gender topic. The number of people in a society Education through diversity training creates more
who identify as transsexual or as transgender is competent and confident allies and lowers the
very small, but the number of people who are chances of unwelcoming behaviors. In addition to
discriminated against because of the diversity of continuing education, a company that wants to
their gender expression is huge. Heterosexual diminish the chances of discriminating against
men who are considered effeminate and hetero- LGBT seniors needs to nurture an LGBT
sexual women who are considered masculine can employee resource group that will help the com-
experience more discrimination on the job than a pany stay ahead of the game, in properly adjusting
masculine gay man or a feminine lesbian. What to the changes in the culture, the rules, and the
is considered acceptable behavior or expression issues.
for males and females varies widely from culture The following essay is an updated newspaper
to culture. Hand holding by heterosexual men is column/Internet blog that I wrote, which was
common in India but not in Great Britain. reprinted by groups working with lesbian,
One more consideration when analyzing bisexual, and transgender seniors.
workplace concerns for lesbian, gay, bisexual,
and transgender people is the differences between
the individuals. Some LGBT people are highly
qualified and are likely to be accommodated Essay on LGBT Seniors—No Money,
easily. People who bring in money are highly No Work, and You’re Old
valued despite their age. If the senior gay person
in question is black, Latino, female, foreign, The dream is recurring. I’m in a panic because I
Muslim, economically challenged, or has a dis- don’t have a job, and I question if I’ve ever
ability, he or she will generally fair less well than worked. I’m sure that I’m too old to find mean-
a gay white Christian male, at least in the United ingful employment, but I need money. I eventu-
States. If the transgender person in question is ally become conscious that I’m dreaming, and I
transsexual, and passes easily because he or she remind myself that I’ve had a personally
fits neatly in the male or female box and is rewarding career and that I don’t need to work.
physically attractive, he or she will fare much Perhaps the dream is prompted by my struggle
better than the person, who after realignment, with the idea of retirement, or having been fired
does not look attractive or is easily identifiable as for being gay at age 26, or almost always working
a man or woman. Cross-dressing men have a for myself, or maybe it is because it took many
much more difficult time than cross-dressing years before my father and mother accepted that
women, partly because of sexism, and partly educating others on lesbian, gay, bisexual, and
because they sometimes do not pass easily as a transgender (LGBT) issues was a real job. It is a
female. If the person’s appearance is considered bad dream that takes me a while to shake.
by others as “peculiar,” it is more likely that he or Yet, for many people my age and younger,
she will suffer discrimination in the workplace. there is no waking from the bad dream, and there
Realtors tell us that the primary factor in selling is no shaking off the emotional toll it takes.
a house is location, location, location. My mes- Being unemployed and needing money are the
sage to companies is that the only reliable way to most pressing issues of their lives. They fear
create a workplace that feels safe to lesbian, gay, running out of money before they die and ending
bisexual, and transgender people of all ages is up being dependent on others to survive.
education, education, education. Most people The people who live these nightmares most
want to be supportive but do not know how. often are older workers who, regardless of their
548 B. McNaught
sexual orientation or gender identity, have wat- general population to be unemployed and four
ched the depletion of their savings and the times as likely to live at the poverty level.
diminished value of their skills. They have either According to the State of Georgia Department
lost, or fear they soon will lose, their jobs because of Labor (2012), 4.7 % of the workforce is 65
of profit loss, automation, or their inability to years of age or older. Pew Research (Drake
keep pace with information technology. 2013) speculates that by 2022, 31.9 % of people
If these unemployed older people are lesbian, 65–74 will still be working. In the private sector,
gay, bisexual, or transgender, their situation may 6.48 per cent of those people will be LGBT
feel more precarious. In addition to feeling less seniors, according to the Williams Institute on
needed, they may also feel less wanted. If they are Sexual Orientation Law and Public Policy (2011)
closeted, they may be seen as lacking the fortitude of 65 in order to make ends meet. A significant
to face the challenges of the ever-changing percentage of those people are LGBT. Questions
workplace. Closeted LGBT people, I suspect, that need to be asked are, will these LGBT
are rarely unknown and often disparaged as seniors have legal protections against discrimi-
unable to lead. If they are out of the closet, they nation on the job, and what unique challenges do
may fear that being out will be a factor in their not they face because of their sexual orientation or
being kept or re-hired. Despite how many cor- gender diversity?
porate promises are made about not discriminat- Many older people would like to retire, but
ing on the basis of sexual orientation or gender what if their nest egg has been depleted because
identity, many people feel that the promise only the value of their house has depreciated, they have
counts in the war for talent when the gay or had unexpected health care costs, or their pension
transgender employee is seen as exceptional in was cut—they have no alternative but to find
what he or she does. Additionally, most states work. But what work? How does the 55-year-old
allow for such workplace discrimination. gay man find work after his money-making
Until the ENDA passes Congress and is “companion” dies and leaves the bulk of his
signed into law by the President, LGBT people assets to his children and grandchildren? The
can be discriminated against in employment in single lesbian near retirement is not seen as being
several states. Even if ENDA passes, gay and as needy of steady income as the man who has
gender diverse-people can be denied housing and dependents. If she is let go in downsizing, how
public accommodation. Attempts to pass laws does she find work to make up the lost income?
that guarantee religious liberty make employ- And, what happens to an older person who is
ment rights for LGBT people even more tenuous. transsexual? Where does the average, senior,
Discrimination against gay, lesbian, bisexual, transgender person find work unless he or she is
and gender diverse people in the workplace extraordinary at what he or she does?
ranges from physical violence to silence. The old career development resource book,
Depending upon the location of the workplace, What Color is Your Parachute (Bolles 2015), and
and the age, race, gender, religious affiliation, every similar book published since, tells us that our
and education of fellow employees and manag- best chance of finding a job is knowing someone
ers, the workplace harassment can be unrelenting who can help. Job hunters are encouraged to make
and unchecked, or more a matter of subtle social lists of the people they know who might be able
isolation because of cultural incompetence. and willing to pull strings or make introductions.
Without protective legislation, LGBT people, What good connections do older LGBT people
including seniors, suffer higher rates of unem- have? What if they have pulled back from straight
ployment and income inequality. family and friends because they wanted to be out
Transgender people are particularly affected and proud? Are their gay or straight friends com-
by a lack of protections. Ninety percent of this fortable putting their reputations on the line by
group reports discrimination in the workplace. making a call or giving them a letter of recom-
These individuals are twice as likely as the mendation? Will the names of younger lesbian,
28 No Money, No Work, and You’re Old 549
gay, bisexual, and transgender employees be on Outside the workplace, unemployed gay and
the list of possible connections? Do younger transgender seniors, like their heterosexual peers,
LGBT employees relate to, or even like, their older can find support in their search for work from
counterparts? Are corporate LGBT Employee AARP, the American Association of Retired
Resource Groups (ERGs), headed by younger People. AARP has a 17 % success rate in finding
workers, aware of the struggles of Baby Boom gay work for its members. But unemployed older
and transgender employees, and do they see such LGBT people can also get training and guidance
issues as worthy of their attention, and of inclusion from SAGE, Services and Advocacy for LGBT
in their limited budget? Elders, a national organization with regional
In the corporate world, finding allies who affiliates. They have a 25 % success rate in
understand and support the specific issues of helping senior clients find employment.
older LGBT persons is critical to having their That still leaves 75 % of the LGBT seniors who
needs championed. While older workers, in have sought help from SAGE, and the many more
general, can feel alienated by the attitudes of who have not heard of, or tried to get such help,
younger workers, it can be particularly disen- living daily in the nightmare that only occasion-
franchising for a senior gay worker. To hear gay ally visits me in my dreams. If young lesbian, gay,
worker to hear the offensive word “queer” used bisexual, and transgender activists are looking for
as a proud self-description by younger LGBT the next cause to take on after marriage equality,
employees, and to see that there is no awareness the bread and butter issues of LGBT seniors is an
on the part of youth of the many sacrifices that issue needing immediate attention.
have been made to create such a welcoming work
environment for them, can prompt senior work-
ers to pull away from ERGs. Younger workers
can be seen as ungrateful upstarts who are Learning Exercises
competing for the jobs needed to secure the older
worker’s sustainability. Older employees can be 1. What factors go into helping LGBT seniors
seen as stubborn and out of touch with cultural remain in the workforce? Who is likely to do
advances and as obstacles to promotions. so and why?
If older LGBT workers hope to secure the 2. What factors prevent LGBT seniors from
support of younger LGBT workers, attention entering the workforce? How can these be
must be given to changing attitudes. Older surmounted?
transgender workers are sometimes seen by 3. What factors do you take in consideration
many younger transgender job seekers, not as in addressing the needs of the older
pioneers, but as sad vestiges of the time when LGBT employee or those seeking
people felt forced to pick one gender over the employment?
other. Today’s youth are far more fluid in their
queer identity and feel less the need for full
transition surgery. Closeted older, lesbian, gay, Experiential Exercises
and bisexual workers can be seen by some
younger LGB employees as roadblocks to the 1. Describe your experience working with an
success of equal treatment in the workplace, older lesbian, gay, bisexual, transgender
especially in regional offices and foreign coun- employee. Was there a particular situation
tries. Focusing attention on the issues facing that occurred within the workplace setting
LGBT seniors requires corporate ERGs to ask that you remember? If yes, why?
seniors questions about the challenges they face 2. If you know a senior who is working and
and about how best to be allies. LGBT, ask him or her to describe a situation
550 B. McNaught
in his or her work where he or she was treated Drake, B. (2013). Number of older Americans in the
well and where he or she was treated poorly. workforce is on the rise. Facttank: Pew Research
Center. Retrieved 20 February 2015 at http://www.
pewresearch.org/fact-tank/2014/01/07/number-of-
older-americans-in-the-workforce-is-on-the-rise/.
References Georgia Department of Labor. (2012). Workforce statis-
tics. Retrieved on 25 February 2015 at www.dol.state.
Bolles, R. N. (2015). What color is your parachute? A ga.us/.
practical manual for job-hunters and
career-changers. New York: Random House LLC.
LGBT Intersection of Age and Sexual
Identity in the Workplace 29
Debra A. Harley and Pamela B. Teaster
Abstract
LGBT older workers represent a diverse and growing segment of the
workforce. Often, older LGBT workers must contend with unfair laws and
discriminatory policies in the labor force. They must overcome the typical
barriers to employment such as lack of modern skills, stereotypes, and
disincentives of fringe benefits. Federal, state, and local governments and
private business must examine their policies that adversely affect LGBT
workers and aging workers. Collectively, LGBT workers are subjected to
legalized discrimination, which can result in job loss or demotion. LBGT
workers endue an unfair burden because of their sexual orientation and
gender identity or expression. America is at a policy crossroads and is
being tested for its response to legally sanction discrimination and
violation of the civil right of LGBT workers. The future of the American
work force may well be determined by its response to LGBT workers.
Keywords
LGBT elders Workplace Public policy Legislation Discrimination
Status of Older Job Seekers to the labor market (Johnson and Park 2011;
and Older LGBT Workers Maestas and Li 2006; Li 2010). The reemploy-
ment rate for older displaced workers ages 55–64
The economic downturn beginning in 2007 has was only 39 %; for those 65 and over, the rate
led to an increase in labor force participation for was 22 % (Bureau of Labor statistics 2010). For
may older workers. For those ages 55–64, the older job seekers, long periods of unemployment
upward trend was driven almost exclusively by are cause for serious concern because of the
the increased labor force participation of women; effects on mental health as well as job readiness
the male participation rate was flat to declining. (Heidkamp et al.). The problem of job opportu-
However, among older adults ages 65 or over, nity also has a geographic component, because
the rate increased for both females and males unemployment is associated with declining local
during 2007–2008 (Copelan 2014). As a growing and regional economies (Report of the Taskforce
segment of the population, older workers face on the Aging of the American Workforce, 2008).
challenges in finding and maintaining employ- In addition, for older workers who are not suc-
ment. In part, this is due to competing with cessful in finding new jobs, many are forced to
younger, more technologically savory workers as accept steep cuts in pay (Johnson and Momma-
well as having to stay in the labor force for erts 2011).
longer periods of time for a variety of reasons Older job seekers encounter obstacles due to
(e.g., unexpected expenses, death of a spouse or employers’ reluctance to hire them. They harbor
partner, supplementing retirement accounts, the following negative perceptions, believing that
financing health care). On positive note, older older workers are (a) more expensive, including
workers continue to work because of the removal wages, health insurance, and the cost to train
of barriers that traditionally prevented them from them; (b) less productive than younger workers
working in their later years (e.g., increased life and deliver lower quality work; and (c) less flex-
expectancy, better health outcomes, employment ible in adapting to change in the workplace
opportunities that require less physical labor) (Walker 2007). On the supply-side challenges
(Johnson 2004). Increasingly, various segments (i.e., woeker characteristics), older job seekers
of the labor market are recognizing the value of encounter skill limitations combined with limited
and demanding that they employ older workers access to training programs, limited job searching
(Society for Human management, 2010). skills, and health- and disability-related chal-
The unemployment rate among older workers lenges that often accompany aging (Heidkamp
is lower than the national average for all workers et al. 2012). Overall, older job seekers face a
(Heidkamp et al. 2012). Older workers are gen- plethora of real and perceived challenges that may
erally less likely to lose their jobs than younger contribute to poor outcomes: a weak demand from
workers because their tenure on the job provides employers, possible age discrimination, and out-
them with some protection. Munnell et al. (2006) dated skills in a technological job market.
found that the lower probability of job loss for Older LGBT workers experience high rates of
older workers was based on the correlation discrimination in the workplace, and unfortu-
between age and tenure, but controlling for ten- nately, state and federal laws often fail to protect
ure, age does not protect workers from dis- them. Over the past seventy years, Presidential
placement. In fact, Munnell et al. found that the executive orders requiring workplace protections
probability of displacement actually increases from discrimination, including federal contrac-
with age. Research also suggests that older tors, have not been overturned by courts, Con-
workers who lose a job have a more difficulty gress, or subsequent Presidents. Under current
than their younger counterparts in reconnecting federal law, it is entirely legal to fire someone
29 LGBT Intersection of Age and Sexual Identity in the Workplace 555
based on sexual orientation or gender identity. Workplace Issues for LGBT Workers
Furthermore, LGBT workers lack adequate legal
protection from employment discrimination LGBT persons, their advocates, and their allies
(Badgett, Burns, Hunter et al. 2013a). agree that some progress has been made for
The LGBT Workforce. MAP, SAGE, and the LGBT persons in the workplace. Most of the
Center for American Progress (2013) reported progress made has been through diversity pro-
that the US workforce includes an estimated 5.4 grams. However, general acceptance of LGBT
million LGBT workers. The LGBT workforce is persons in the workplace may lead to compla-
diverse but has common characteristics. The first cency about the need for continued progress.
characteristic is that LGBT workers are geo- A challenge is continuing harassment or dis-
graphically dispersed: 93 % of same-sex couples crimination based on sexual orientation and
live in all US counties. As many as 4.3 million gender identity. Surprisingly, persons’ blatantly
LGBT persons live in states without state laws offensive comments based on sexual orientation
providing employment protection based on sex- or gender identity are tolerated in workplaces that
ual orientation or gender identity or expression. would never tolerate such comments based on
Second, LGBT workers are racially and ethically religion or race (Madell 2012a). Another chal-
diverse, 33 % of whom are persons of color, lenge is the inability to address family needs in
compared to 27 % of non-LGBT individuals. the same ways that non-LGBT couples can. For
Third, a significant number of LGBT workers are example, the majority of companies does not
raising children, thus heightening the importance offer domestic partner benefits (Madell 2012a).
of making family benefits available. In addition, if Although organizations highlight polices and
the norm of non-LGBT grandparents who are benefits for LGBT employees from corporate
raising children holds true for LGBT grandpar- headquarters, a lack of education and information
ents, it is reasonable to assume that a substantial exists beyond that which is provided in offices
number of older LGBT workers are raising located outside main branches (Madell 2012b).
grandchildren (i.e., grandparents raising grand- This limited scope of education beyond the cor-
children). A fourth characteristic is that varying porate office has implications for LGBT persons
levels of education exist among LGBT workers. in companies with global offices. Given that
Data are mixed—some suggest that individuals attitudes and practices toward LGBT persons are
with lower educational levels are more likely to cultural, countries have practices that range from
identify as LGBT, while other data indicate a total acceptance and integration of LGBT persons
higher probability that persons in same-sex cou- to placing them in prison to putting them to death
ples have at least a bachelor’s degree than their (Madell 2012b). Many workers in organizations
opposite-sex counterparts. Similarly, transgender do not know how to behave toward LGBT per-
persons had much higher educational attainment sons, and so they just ignore them (Madell
than the population as a whole (National Trans- 2012b). For example, non-LGBT workers may
gender Discrimination Survey 2011). Fifth, the not invite LGBT coworkers out after work. Given
literature consistently suggests that LGBT work- that networking and decision-making often take
ers experience unemployment at an equal or place in social settings, LGBT workers are com-
higher rate than do other workers, with trans- pletely left out of this process.
gender persons’ unemployment rates twice that of Another persistent problem in companies is
the US populations as a whole. Rates for trans- the lack of accountability processes to ensure that
gender persons of color are as high as four times managers and supervisors create the right culture
the national unemployment rate (MAP, Human of acceptance of LGBT workers (Madell 2012b).
Rights Campaign, & Center for American Pro- Consequently, some managers or supervisors fail
gress). Finally, LGBT workers in the USA are at to pass along the right message or model
higher risk of poverty than are other workers. LGBT-supportive behavior to their employees.
556 D.A. Harley and P.B. Teaster
Yet another challenge for LGBT persons is For LGBT persons, however, this bargain remains
deciding whether or not to come out in the broken, resulting in bias, fewer workplace bene-
workplace. Due to discrimination and concern fits, and higher taxes, despite the passage of fed-
for safety, many LGBT persons remain closeted. eral and state laws aimed expressly at prohibiting
Finally, the overarching challenge to LGBT discrimination against LGBT workers.
persons in the workplace remains the continued Increasingly, it is important to examine the
lack of legal protection (Wyatt 2015). Under- role of unions in advocating for the rights of
standing these challenges from the perspective of LGBT workers. In 2012, the American Federa-
LGBT persons is paramount if workplace culture tion of State, County, and Municipal Employers
is to change in any meaningful way. (AFSCME) set forth a resolution calling for
equality for LGBT workers (http://www.afscme.
org/members/conventions/resolutions-and-
amendments/2012/resolutions/lesbian-gay-
Changing Workplace Culture bisexual-and-transgender-workers). The global
for LGBT Elders counterpart to AFSCME is Population Services
International (PSI), a global union federation of
Workplace inequality and discrimination are health care, municipal, community, and govern-
harmful to all LGBT employees. Mentioned ment workers that champions human rights,
earlier, the impact on LGBT elders is intensified advocates for social justice, and promotes uni-
by economic reasons that have lead to them versal access to pubic services in over 150
remain in the workforce longer or re-enter the job countries. PSI asserts that LGBT workers’ rights
market upon retirement. Even with federal laws are actually trade union rights, and trade union
such as the Age Discrimination in Employment rights are human rights. Thus, “trade unions are
Act, age-based workplace discrimination per- committed to fight against discrimination and for
sists. Compared to younger persons, older job an inclusive non-violent society” (http://www.
applicants are more likely to be passed over for world-psi.org/en/issue/lgbt). Understanding the
interviews and more likely to be paid less. For connection between workplace rights, safe work
older LGBT workers, the effects of age-based environments, and economic development and
discrimination may be compounded by discrim- work productivity is becoming increasingly
ination on the basis of sexual orientation, gender important in understanding how to meet chal-
identity, or gender expression (Cray 2013). Dis- lenges faced by LGBT persons in the workplace.
crimination in employment has long-term impli- Supportive-LGBT workplace policies and
cations for LGBT elders. Over the course of their workplace climates are linked to positive out-
work history, many LGBT elders have experi- comes for LGBT workers ranging from greater
enced years of job instability and unequal pay, job commitment to greater openness about being
which can contribute to financial insecurity well LGBT (see Table 29.1).
after retirement and for the rest of an elder’s life MAP, Human Rights Campaign, & Center for
(Grant et al. 2010). In addition, underemploy- American Progress (2013) identified barriers to
ment, extended unemployment, and lower wages equal and fair treatment of LGBT and other
can contribute to elevated poverty rates among workers concerning a lack of legal protection,
LGBT elders (Badgett et al. 2013c). which makes it harder to find and keep a good
At the core of the American work ethic is that job, and fewer benefits and more taxes that put
if people work hard and meet their responsibili- LGBT workers and their families at risk (see
ties, they should be able to get ahead. This “basic Table 29.2). In 2013, 278 businesses and
bargain is embedded in laws that promote equal employers submitted a brief to the US Supreme
access to jobs and that protect workers from unfair Court in which they argued that unequal treat-
practices” (MAP, Human Rights Campaign, & ment of LGBT workers and their families under
Center for American Progress 2013, p. 1). federal law harms business by the following:
29 LGBT Intersection of Age and Sexual Identity in the Workplace 557
Nondiscrimination Protections, Make (2013) FMLA and pass LGBT-inclusive family and
opined that “given health disparities and high medical leave laws (Make). Fourth, pass
rates of family poverty in the LGBT community, LGBT-inclusive and job-protected paid leave
LGBT workers have a critical need for laws at all levels of government, especially
LGBT-inclusive laws and polices that strengthen important to LGBT workers who are unable to
job security and provide time off for personal afford unpaid time off work. Fifth, government at
health and family caregiving needs” (p. 2). To all level should serve as a model employer by
better support the health and family needs of instituting strong nondiscrimination protections
LGBT workers, Make offered needed policy and and LGBT-inclusive workplace leave policies for
legal changes. First, expand marriage equality. government employers. Sixth, federal, state, and
The ruling of the Supreme to strike Section 3 of local governments should pass employment
the Defense of Marriage Act was a victory for nondiscrimination laws that prohibit discrimina-
LGBT equality. Although the federal govern- tion on the basis of sexual orientation and gender
ment now recognizes same-sex marriages, many identity or expression. These laws can provide
LGBT persons live in states without marriage LGBT workers with recourse against harassment
equity. The second recommendation is to and discrimination and protection to those who
broaden the definition of spouse under the otherwise fear disclosing their family relation-
Family Medical Leave Act (FMLA). For private ships and caregiving responsibilities (Make). The
sector workers, the FMLA defines spouse last two recommendations involve building and
according to the marriage laws of the state in strengthening collaborations between the LGBT
which a worker resides, which often excludes community and workplace leave coalitions, so
many same-sex couples. A third recommendation that they work with businesses to identify model
is in response to the ineligibility of many LGBT employers and to develop spokespersons for
workers for FMLA leave because of the size of LGBT-inclusive leave laws and police (Mark).
their employer, the number of hours worked, or Identification of options for helping older
length of time a worker has been employed. In LGBT workers either find or maintain employ-
addition, the FMLA’s definition of family is ment requires discussion among and input from
narrow. The federal government and states various government and business entities.
should pass legislation to expand access to Many LGBT older workers may need assistance
29 LGBT Intersection of Age and Sexual Identity in the Workplace 559
(c) Most LGBT workers have large 8. Why is it important to address instability in
families employment and job discrimination for
(d) Most LGBT workers are past their LGBT workers?
prime (a) To avoid workplace violence
2. Which of the following types of businesses (b) Implications for financial insecurity
have implemented LGBT-inclusive policies? well after retirement
(a) Small businesses (c) To reduce the high cost of treatment for
(b) Government agencies HIV/AIDS
(c) Fortune 500 (d) Implications for family planning
(d) Universities 9. Which of the following groups report the
3. FMLA defines spouse by which of the highest rate of discrimination and harassment
following? in the workplace?
(a) Federal government (a) Lesbians
(b) The state (b) Gay men
(c) DOMA (c) Bisexuals
(d) Business model (d) Transgender persons
4. The federal Nondiscrimination Employment 10. People who may want to be supportive of
Act includes which of the following LGBT persons in the workplace, but do not
exemptions for businesses? know how, may remain silent. The silence
(a) Companion may be taken for which of the following?
(b) Public accommodation (a) Hostility
(c) Religious (b) Approval
(d) Transgender (c) Avoidance
5. Which of the following is a rationale of why (d) Mining one own business
businesses have added LGBT-inclusive
policies?
Key
(a) Low cost
(b) Higher revenue
1-A
(c) Economic benefit
2-C
(d) All of the above
3-B
(e) None of the above
4-C
6. Which of the following prohibits discrimi-
5-D
nation in employment?
6-B
(a) American Association of Retired
7-A
People
8-B
(b) Age in Discrimination in Employment
9-D
Act
10-A
(c) Age and Wage Fairness Act
(d) Older Persons Fair Employment Act
7. LGBT workers who work hard and meet
their responsibilities and are denied fairness Resources
in hiring and promotion are aside to be vic-
tims of which of the following? A Better Balance: www.abetterbalance.org.
(a) A broken bargain American Association of Retired People
(b) An unofficial promise (AARP): www.aarp.org.
(c) A misunderstanding American Federation of State, County, and
(d) An unintentional act Municipal Employers: www.afscme.org.
29 LGBT Intersection of Age and Sexual Identity in the Workplace 561
Equal Employment Opportunity Commission Research Institute Notes, 35(4), 2–4. Washington, DC:
(EEOC): www.eeoc.gov. Employee Benefit Research Institute.
Government Accountability Office, (2012, April). Unem-
Human Rights Campaign: www.hrc.org/ ployed older workers: Many experience challenges
resources/entry/lgbt-employee-resources. regaining employment and face reduced retirement
Human Rights Campaign—Corporate Equality security. Washington, DC: Author. Retrieved Febru-
Index 2015: Rating American Workplaces on ary 28, 2015 from www.gao.gov/assets/600/590408.
pdf.
Lesbian, Gay, Bisexual and Transgender Grant, J. M., Koskovich, G., Frazer, M. S., Bjerk, S. &
Equality: www.hrc.org/campaigns/corporate- SAGE. (2010). Outing age 2010: Public policy issues
equality-index. affecting lesbian, gay, bisexual, and transgender
Lambda Legal: www.lambdalegal.org. elders. Washington, DC: National Gay and Lesbian
Task Force Policy Institute. Retrieved February 27,
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The public workforce system: Serving older job
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Badgett, M. V. L., Burns, C., Hunter, N. D., Krehely, J., 500.
Mallory, C., & Sears, B. (2013a, February 13). An Human Rights Campaign. (2011b). Workplace discrimi-
executive order to prevent discrimination against nation: Policies, laws, and legislation. Retrieved
LGBT workers. Retrieved March 2, 2015 from http:// February 28, 2015 from http://www.hrc.org/
www.americanprogress.org/issues/lgbt/report/2013/ resources/entry/Workplace-Discrimiation-Policy-
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Badgett, M. V. L., Durso, L. E., Kastanis, A., & Mallory, older workers, 1992–2002. Monthly Labor Review,
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CA: The Williams Institute. Retrieved February 28, in job loss, job search, and reemployment. Washing-
2015 from http://www.WilliamsInstitute.law.ucla.edu/ ton, DC: The Urban Institute.
wp-content/uploads.Business-Impact-of-lgbt- Johnson, R. W., & Park, J. S. (2011). Can unemployed
supportive-workplace-policies.pdf. older workers find work?. Washington, DC: The
Badgett, M. V. L., Durso, L. E., & Schneebaum, A. Urban Institute.
(2013c, June). New patterns of poverty in the lesbian, Li, X. (2010). Extending work lives of older workers: The
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Williams Institute. market. [Abstract] (Dissertation). The Pardee Rand
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562 D.A. Harley and P.B. Teaster
Abstract
As people age, social support systems are essential, especially for LGBT
persons who might be at greater risk of social isolation. Each person has a
different experience and subsequent propensity for isolation. For many
LGBT elders, social inclusion continues to be aspirational, with limited
authentic and sustained progress having been made in this area. In this
chapter, the influencing issues of socialization and inclusion/exclusion of
LGBT elders are examined. The unique circumstances across the life span
for LGBT elders that may either help or hinder opportunities for
socialization and inclusion are discussed. Social inclusion to successful
aging of LGBT elders is reviewed to gain insight into some of the
explanations of their withdrawal from social and recreational functions.
The significance of family involvement is explored. Finally, policy on
social inclusion of elders is presented.
Keywords
Socialization Inclusion
Isolation Exclusion Recreation Senior
citizen centers
may lead to ineffective and potentially harmful 2. Identify contributing factors to social isola-
strategies; (b) still mainly defined as the accep- tion of LGBT elders.
tance and achievement of the dominant societal 3. Understand social inclusion challenges to
values and lifestyle, which may lead to moralistic successful aging of LGBT elders.
judgments; (c) often narrowly defined and mea- 4. Identify the extent to which LGBT elders are
sured; and (d) often limited to the measure of able to remain active and contribute to causes
one’s participation in community-based activi- and points of interest.
ties. For many LGTB elders, social inclusion 5. Understand the role of family involvement in
continues to be aspirational, with limited socialization of LGBT elders.
authentic and sustained progress having been 6. Identify areas in which policy is needed to
made in this area. It is not being a sexual promote inclusivity of LGBT elders in vari-
minority or being an elderly person that is the ous mainstream settings and services.
main cause of social exclusion of LGBT elders;
instead, it is the way in which society responds
discriminately to them. The purpose of this Introduction
chapter is to discuss influencing issues of
socialization and inclusion/exclusion of LGBT As a movement, social inclusion has origins in
elders. First, information is presented on a three paradigms. The first of which is in 1970s’
framework of isolation affecting elderly adults, French ideas of social solidarity conceived by
which highlights the unique circumstances across Lenoir (1974) (Burchardt et al. 2002), which
the life span for LGBT elders who may either referred to people who have slipped through the
help with or limit opportunities for socialization net of the social insurance system and are sub-
and inclusion. Second, the role of socialization, sequently administratively excluded by the state
recreation, and inclusion in the lives of LGBT (Boardman 2010). The second paradigm is the
elders is presented to identify the extent to which specialization paradigm that is dominant in the
LGBT elders are able to remain active and have a USA and UK and that is frequently associated
sense of contributing to causes and points of with discrimination. In the USA, the American
interest. Third, unique social inclusion challenges counterpart to the social model, Minority Group
to successful aging of LGBT elders are reviewed Model, emerged in the late 1970s and was
to gain insight into some of the explanations of influenced by the Civil Rights Movement. The
their withdrawal from social and recreational third is the monopoly paradigm, which is com-
functions. Fourth, the significance of family monly used in Western Europe to strengthen
involvement is explored. As individuals age, group monopoly (Rimmerman 2013) to include
their roles in the family take on a different marginalized groups. Other manifestations of the
meaning; thus, understanding family involve- social exclusion concept include a link to pov-
ment with LGBT elders is important. Finally, a erty, financial well-being, consumption, and
review of the impact of policy on social inclusion income adequacy (Buckmaster and Thomas
of LGBT elders is presented. 2009); a lack of recognition of fundamental
human and civil rights; and the existence of an
underclass (Rafaelic 2012). From a sociological
Learning Objectives perspective, “social inclusion and exclusion
function as apparati that problematize people on
By the end of the chapter, the reader should be the margins, and by extension, contribute to their
able to: governance and control” (Allman 2013, p. 2).
Isolation of elders occurs when conditions
1. Understand the concepts of social necessary for maintaining a functional social
inclusion/exclusion. network break down (Walker and Herbitter 2005).
30 Isolation, Socialization, Recreation, and Inclusion of LGBT Elders 565
Individual and societal factors contribute to the However, such support may be lacking for
degree to which elderly people become isolated. LGBT elders (Espinoza 2013). In comparison
Individual factors include living arrangements, with their heterosexual peers, LGBT elders are
mobility, ethnicity, socioeconomic status, gender, significantly more likely to be isolated, twice as
and sexual orientation and gender expression likely to live alone, half as likely to be partnered,
along with a host of subjective factors such as half as likely to have close relatives to call for
attitudes and expectations. Societal factors help, and more than four times more likely to be
include prejudices, discrimination, homo/bi/ childless (Movement Advancement Project and
transphobia, community characteristics, and SAGE 2010). Moreover, the relationship
American society’s emphasis on individual between diminished social and caregiving sup-
self-sufficiency and remaining independent at all ports with a range of health problems that can
costs. In addition, the degree to which elders have serious consequences for older adults can
receive social support from family and friends, result in premature institutionalization, which
participate in activities, and have access to infor- contributes to even greater social isolation for
mation influences the degree to which they LGBT elders. Once institutionalized, LGBT
experience isolation (Walker and Herbitter 2005). elders may experience isolation not only from
The lack of social support is a contributing factor external connections, but also within the facility,
to abuse of older adults by Acierno et al. (2010). especially if homophobia and heterosexism and a
See Chaps. 16 and 17 for further discussion on lack of awareness of the needs of LGBT resi-
elder mistreatment and victimization. dents among staff and peers exist. Depending on
As people age, social support systems are his or her behaviors and choices throughout life,
essential especially for LGBT persons who might each person has a different experience and sub-
be at greater risk of social isolation and offer sequent propensity for isolation (Elder and Re-
elders social interaction and connectedness, trum 2012). To facilitate an understanding of
reduce social isolation and loneliness, and can terminology used throughout this chapter, a
assist with daily tasks of living (Espinoza 2014). glossary of terms is presented in Table 30.1.
Framework for Isolation in LGBT Elders spiritual and religious programs that would
respect their sexual and gender identities. The
Isolation in later life occurs within certain con- researchers concluded that rural older adults may
textual psychosocial and social factors (see be socially isolated and may need interventions
Table 30.2). Biordo and Nicholson (2009) dis- to maintain physical and mental health,
tinguished between voluntary and involuntary strengthen social relationships and support, and
isolation and developed a typology that identifies to increase their participation in the community
individuals’ isolation along a continuum. Indi- to promote QoL. See Chap. 25 for further dis-
viduals are either (a) integrated (i.e., not iso- cussion on elders in rural areas.
lated), (b) become isolated slowly over time, When asked to describe their living arrange-
(c) recently isolated due to an acute event, or ments and support systems over time, LGBT
(d) lifelong isolates. Thus, social isolation is a adults aged 45–75 overwhelmingly indicated that
loss of place within one’s group(s). It should be they are more likely than their non-LGBT peers
noted that a solitary lifestyle is not an accurate to live alone, have smaller support networks over
indicator of isolation (Elder and Retrum 2012). time (40 % compared to 27 % for non-LGBT
A solitary lifestyle is one in which an individual elders), and are less satisfied with the information
enjoys spending a significant amount of time that they receive related to support systems. For
alone and enjoy pursuing activities indepen- ethnic minority groups, African American LGBT
dently. Oldham and Morris (1995) describe the elders are more likely than their peers to report
solitary personality type as being alone, remain- that people from their faith communities are part
ing independent, maintaining autonomy, being of their support networks. In comparison with
self-contained, and being uninfluenced by praise 21 % of their non-LGBT peers, approximately
or criticism among others. In a study of quality of 34 % of LGBT elders live alone and 48 % of
life (QoL) in rural and urban adults aged 65 and LGBT elders live with spouses or partners
older, Baernholdt et al. (2012) examined associ- compared to 70 % of their non-LGBT peers.
ations between three dimensions of QoL: social Older lesbian and bisexual women (59 %) are far
functioning, emotional well-being, and needs and more likely than their gay male counterparts
health behaviors. The results suggest that while (43 %) to live with a partner or spouse and less
older adults reported high levels of QoL, they likely to live alone (25 and 38 %, respectively)
had lower social functioning with older African (Espinoza 2014). These national data are similar
Americans and Hispanics scoring lower than to earlier data of LGBT elders in San Diego in
Whites on two QoL dimensions. Many of the which 41 % were either married, in a domestic
participants expressed a need for educational, partnership, or had a significant other (Zians
cultural, and recreational programs, as well as 2011).
One area of concern is the ability of LGBT
elders to access adequate social care as they age.
Table 30.2 Contextual factors for isolation in later life Social care is defined as the broad-based system
Income of informal social network resources (i.e., family,
Mobility friends, church) and the network of
Societal factors
community-based formal services (e.g., home
health care, senior citizen centers) (Cantor and
Social networks
Brennan 2000). To age independently and
Social supports
maintain quality of life, the social care network is
Individual history considered an important component
Physical environment (Brennan-Ing et al. 2014, see Research Box
Social engagement and integration 30.1). In Cantor and Mayer’s (1978) text on
Adapted from Elder and Retrum (2012), British Columbia Hierarchical Compensatory Theory, when older
Ministry of Health (2004) adults need assistance, they turn first to
30 Isolation, Socialization, Recreation, and Inclusion of LGBT Elders 567
last wishes, or financial security. Finally, the lack (Cornwell and Waite 2009; Ortiz 2011; Rosen-
of legal recognition of same-sex partners in most bloom 2009). For ethnic minority LGBT elders,
jurisdictions excludes informal networks and social isolation might be heightened because they
partners from making caregiving decisions might be isolated from their racial and ethnic
(Breenan-Ing et al. 2014), despite recent devel- communities as LGBT older adults as well as from
opments with the repeal of Defense of Marriage the mainstream LGBT community as people of
Act (DOMA). Regardless of these challenges, color (Fredriksen-Goldsen et al. 2011).
the early assertion of Dorfman et al. (1995) holds
true that in some situations, “support from
Research Box 30.2
friends is actually more desirable because it is
Kim and Fredriksen-Goldsen (2014).
given freely and without obligation,” as opposed
Objective: To examine the relationship
to help and support from relatives, which can be
between living arrangement and loneliness
considered more stressful “due to increased
among LGB older adults using the loneli-
expectations and demands” (p. 40). In regard to
ness model. The potential correlated
individuals living away from urban and suburban
including social resources and personal
areas, the ability to access social networks is
constraints were taken into consideration.
even more challenging for LGBT elders because
Method: The data from a national sur-
of the nature of their rural geographical settings
vey of LGB adults aged 50 and older
(see Chap. 25).
(N = 2444) were used. Types of living
One of the underlying factors determining the
arrangement include living with a partner
prevalence of those considered as isolated is their
or spouse, living alone, and living with
living status (i.e., live alone) (Elder and Retrum
someone other than a partner or spouse.
2012). In a study of living arrangement and
Results: Compared with LGB older
loneliness among LGB elders, Kim and
adults living with a partner or spouse, both
Fredriksen-Goldsen (2014) found that compared
those living alone and those living with
with LGB older adults living with a partner or
others reported higher degrees of loneli-
spouse, both those living alone and those living
ness, even after controlling for other cor-
with others reported higher degrees of loneliness
relates. The results of a multivariate
(see Research Box 30.2). It is estimated that 17 %
regression analysis reveal that social sup-
of Americans over 65 years of age are isolated
port, social network size, and internalized
because they live alone. For LGBT elders, 53 %
stigma partially account for the relationship
feel isolated from others (Fredriksen-Goldsen
between living arrangement and loneliness.
et al. 2011). Moreover, these individuals face
Conclusion: Living arrangement was
one or more barriers related to geographical
found to be an independent correlate of
location (e.g., rural), language, physical or mental
loneliness among LGB elders. Targeted
disability, economic instability, losing a partner
interventions are needed to reduce loneli-
and/or close friends, losing an important role such
ness in part by enhancing social resources
as employment, having a small social network,
and reducing risks of internalized stigma.
and having poor-quality social relationships.
Eliminating discriminatory policies against
Community-level risk factors for isolation include
same-sex partnerships and partnered living
feeling safe to leave one’s home, access to trans-
arrangements is recommended.
portation, availability of local events conducive to
meaningful activities as defined by the older per- Questions
son, and lacking or having limited opportunities
for social interaction and access to resources. 1. Do you think that the results would be
Societal-level risk factors consist of ageism, rac- different when examining the same
ism, sexism, or homophobia, and discrimination variables for transgender elders?
30 Isolation, Socialization, Recreation, and Inclusion of LGBT Elders 569
socialization may become curtailed for a number found that 47 % of all respondents experienced
of reasons at a time in their lives when many difficulty in finding opportunities for friendship
people find themselves able to engage in social or or social connection. Of these respondents, 31 %
recreational activities. Brennan-Ing et al. (2014, reported moderate difficulty, 12 % serious, and
p. 41) surveyed LGBT elders to learn about their 4 % severe. There was no difference in response
social care needs and reported that respondents based on gender or ethnicity.
expressed an “interest in a wide range of edu- Overall, LGBT elders have positive feelings
cational and recreational services, including of belonging to the LGBT community; however,
computer and technology classes, and culinary distinct differences also exist. Specifically, les-
programs.” The use of the Internet is on the rise bians are more likely to feel more positive about
by seniors in general, as many Baby Boomers belonging to the LGBT community than do
enjoy relative ease of access and use of tech- bisexual women. Older gay and bisexual men
nology. However, for many LGBT elders, access tend to have similar feelings of belonging, while
and use of technology is not easily accomplished. transgender elders are less likely to have such
One respondent expressed concern over financial positive feelings (Fredriksen-Goldsen et al.
barriers getting in the way of accessing culture 2011). The extent to which LGBT elders per-
and arts programs. Others wanted spiritual pro- ceive acceptance and inclusion both in the
grams but stressed that such programs must not community at large and in the LGBT community
discriminate based on differences inherent in may be a function of social selection, which is
LGBT elders. Recreational sports and programs the tendency for individuals sharing certain
such as yoga, exercise classes, and card games characteristics and specific cultural backgrounds
were requested as well. Although many cities and to live in similar neighborhoods and participate
communities allow LGBT elders to participate in in similar activities (Bread and Petitot 2010).
their programs, the same fears experienced with In an examination of urban space from a
regard to housing and assisted living, for exam- non-heterosexist perspective, Nusser (2010)
ple, tend to hold true in this arena. Many LGBT explored how LGBT persons experience every-
elders fear being discriminated against, made fun day space in the city, particularly the places in
of, or alienated by the staff or their heterosexual which they feel the most (i.e., spaces preferred)
peers in the chosen activities. If LGBT older and least comfortable (i.e., spaces avoided) being
adults do in fact underutilize service and avoid a sexual minority. The study explored two
participation in activities, the result is a sort of research questions: (a) How do relationships
self-imposed exclusion and isolation in addition between the design, management, and spatial
to that which imposed upon them by society. characteristics of spaces communicate values
Participants in the Brennan-Ing et al.’s (2014) about sexual orientation and gender identity? and
study also expressed their desire for alternative (b) How could planners and designers create
venues for meeting people. One man stated, “I more inclusive spaces? Nusser contends that
don’t know where to go to meet other gay men while urban design and service planning has
my own age in a healthy setting, rather than the always interacted with issues of sexuality, “the
bar” (p. 42). An older lesbian commented that failure of the literature to address these practices
there are limited social environments for those explicitly has led to the silencing of minority
who are aged 50 and older. The “bar scene” is for sexualities in planning discourse and the severe
younger women, and fund-raisers that combine marginalization of many queer people in cities”
socialization are too expensive for participants. (p. 1). Although reference is not made specifi-
Older gay men and older lesbians both seem to cally to LGBT elders, presumably the con-
face similar challenges with socializing and fluences of the urban planning process produce
meeting potential romantic partners, citing age- similar marginalization. Not all heteronormative
ism as a significant barrier. In a needs assessment space is anti-LGBT; however, most spaces in the
of LGBT seniors in San Diego, Zians (2011) USA are heteronormative. LGBT persons in
30 Isolation, Socialization, Recreation, and Inclusion of LGBT Elders 571
Cambridge and in two US cities were inter- lack social support or support systems, they are at
viewed to ascertain their observations about much greater risk for a host of psychosocial
LGBT and anti-LGBT spaces. Nusser found that adjustment issues. MAP and SAGE (2010)
LGBT spaces were perceived as highly enclosed identify four major obstacles to social support
and had rigid boundaries imposed discrete and community engagement for LGBT elders:
entrance (informal entrance in the USA), (1) lack of support from and feeling unwelcome
attached parking lot, near public transportation, in mainstream aging programs, (2) lack of sup-
and near LGBT-tested places. Anti-LGBT spaces port from and feeling unwelcome in the broader
had activity concentrated in the interior, which LGBT community, (3) lack of sufficient oppor-
were enclosed, and exposed entrances were at the tunities to contribute and volunteer, and
lowest elevation of the space. (4) housing discrimination adds to the challenge
Socialization and inclusion promote positive LGBT elders face in connecting to their com-
feelings about belonging to communities in munities. In response to these obstacles, MAP
general and to the LGBT community for older and SAGE offer a series of recommendations to
LGBT adults. Although self-disclosure about overcome these barriers (see Table 30.4). Each
ones’ sexual orientation and gender identity can barrier adds to an LGBT elders’ sense of
lead to rejection and victimization, “it can also rejection.
provide opportunities for community and social Unwelcoming mainstream aging programs.
support that can be crucial to older adults’ Senior citizen centers and other aging programs
wellbeing” (Fredriksen-Goldsen et al. 2011, (e.g., civic groups) and churches often do not
p. 16). The willingness to be “out” and partici- consider the possibility that participants may be
pating in the community can provide LGBT LGBT. Some of these settings discriminate based
elders with access to resources and support sys- on omission of inclusive services, while others
tems about which they may have been unaware. do so intentionally through denial of services and
For many LGBT elders, the key is to find ways to harassment. Many LGBT elders distrust service
deal with the “social and legal convention” in providers and avoid local agencies, conse-
society to “discriminate against, ridicule, and quently, missing out on services and sense of
abuse” them “within the foundational institu- community of their peers. Only a small number
tions” of the family, workplace, health care, of agencies that provide services for the aging
social service programs, and recreational settings citizens engage in outreach programs designed to
(Grant et al. 2011, p. 6). A persistent challenge welcome LGBT elders (e.g., see New York City
for LGBT elders is to find support systems that Department for the Aging, www.nyc.gov/html/
are nonjudgmental. dfta/html/services/lgbt.shtml). Often, these
agencies also are not “prepared to address inci-
dents of discrimination toward LGBT elders by
Social Inclusion Challenges other older people” (MAP and SAGE 2010,
to the Successful Aging of LGBT Elders p. 48). MAP and SAGE reported that barriers
encountered by LGBT elders at mainstream
Although many LGBT elders live alone, living centers include (1) denial of services, (2) harass-
alone does not mean that they are living in iso- ment from providers and heterosexual elders, and
lation, are facing stresses, or are lonely. In this (3) having specific needs ignored. It is because of
day and time, communication technologies are these types of barriers that many LGBT elders
more widely used than ever and may expand conceal their sexual identity when participating
opportunities for elders to communication, in activities offered by mainstream aging
therefore decreasing social isolation and loneli- programs.
ness (British Columbia Ministry of Health 2004). Unwelcoming LGBT community. Even though
Furthermore, not all LGBT elders lack social the LGBT community is diverse, ageism
support. However, when older adults living alone abounds, especially among gay males. LGBT
572 D.A. Harley et al.
elders feel unwelcome by younger generations of opposite-sex partner to avoid being labeled gay
LGBT persons, ignored because of their age, or lesbian. Such stigma and distrust most cer-
marginalized as they grow older, and experi- tainly can contribute to bisexual elders’ concern
enced diminished social support. Gender differ- about aging, identity, and social isolation (Hill-
ences in socialization exist between LGBT man 2012). Hillman suggests that some trans-
elders. For example, older gay men report a gender elders align themselves with the LGBT
greater sense of rejection from their younger community, whereas others do not because of
counterparts than do lesbians, owing in part to a discrimination from among the gay community
“loss of social valuation as physical and sexual itself. Moreover, with the availability of options
changes affect what has been a source of for support groups via the Internet, it is unclear
self-esteem” (MAP and SAGE 2010, p. 490). what proportion of transgender elders use or even
Research suggests that older lesbians tend to have access to this informational system (Hill-
retain a higher level of socialization through man). On a positive note, the movers and shakers
political involvement and mentoring of younger in the LGBT movement are allotting more time
lesbians. Younger gay men tend to be more and effort toward issues related to their elder
dismissive of older gay men, in part because of constituents, especially as the Baby Boomers
their emphasis on physical attributes (MAP and advance into old age (Diverse Elders Coalition
SAGE). In addition, many gay men feel that very 2012).
little is done by the LGBT movement to engage Lack of sufficient opportunities to contribute.
LGBT elders in social events. Elder lesbians, on LGBT elders are often overlooked as potential
the other hand, report that their social networks volunteers and providers of support to others.
were more resilient and “showed less fluctuation Given their vast experiences, LGBT elders have
in response to changes with aging” (p. 49). the potential to make enormous contributions as
Bisexual elders face the challenge of general advocates. Doing so can provide them with a
distrust toward them by some segments of soci- sense of purpose while decreasing social isola-
ety, which may include heterosexual, gay, and tion. The reasons elders volunteer include altru-
lesbian individuals, who believe that bisexual ism, filling leisure time, enhancing social
persons simply choose to be open to both male contacts, a need for affiliation, a sense of duty, to
and female partners out of convenience and that feel competent, or to contribute to the function-
these individuals may simply choose an ing of their communities. Unlike younger age
30 Isolation, Socialization, Recreation, and Inclusion of LGBT Elders 573
groups, elders rarely volunteer to gain work rate of inflation and cost of living. Limited life-
experience or employment-related contacts time earnings place LGBT elders at high risk for
(British Columbia Ministry of Health 2004). poverty in old age. Older Americans who lack
Adults who have opportunities for continued affordable housing must spend a large portion of
work and/or volunteer activities have better their budget on housing, leaving less money for
mental and physical health, vitality, quality of essential needs (Funders for Lesbian and Gay
life, and, indirectly, physical activity (Cullinan Issues 2004). LGBT elders rank housing as their
2006; King and King 2010). number one priority (Plumb and Associates
Three large volunteer programs exist (i.e., 2003–2004).
RSVP, Foster Grandparent Program, Senior LGBT elders face special challenges in the
Companion Program) under the Senior Corps area of housing. For example, health issues and
umbrella, which is administered by the federal disabilities often decrease their ability to con-
government. Participation tends to be hampered tinue living independently and to age in place.
by “income eligibility, service scope, and time For many LGBT elders who are not partnered,
requirements” (MAP and SAGE 2010, p. 50). who do not have children, or who are estranged
MAP and SAGE recommend that national vol- from or closeted to members of their family,
unteer programs should reach out to elder LGBT supports are absent. Furthermore, LGBT elders
citizens. Another avenue for contribution is are hesitant to access home health care or other
self-advocacy. “Sage and other organizations assisted living services because of the fear of
working with LGBT older adults have long rec- inviting judgmental or hostile care providers into
ognized that the greatest resource available to their homes, and “having a stranger come into
LGBT older adults is often themselves” (2010, their home—maybe the only place that the elder
p. 50). Considering that many of today’s LGBT was truly able to be out and express their sexual
elders have participated in civic action in support identity—can be as terrifying as living commu-
of LGBT people at some time in their lives, they nally with people who will presume that they are
can bring to the table a great deal of knowledge, straight” (Plumb and Associates 2003–2004,
experiences, and problem-solving skills, to men- p. 18). Although they need them, studies reveal
tion a few. SAGE (2010) cites that the following that LGBT elders access essential services (e.g.,
LGBT aging organizations were started by older senior citizen centers, food stamps, meal plans,
adults: Gay and Gray in the West (Denver, CO), visiting nurses) much less frequently than the
the Silver Haired Legislature (Missouri), Old general population (MAP and SAGE 2010).
Lesbians Organizing for Change (OLOC), and the A discussion of housing as a challenge for
Leadership Academy of Lavender Seniors of the LGBT elder is incomplete without discussion of
East Bay (San Leandro, CA). the major demographic transition toward urbani-
Housing discrimination. Discrimination in zation, which has influences on the health and
housing is a growing concern for sexual minor- quality of life of older persons. The type of
ities of all ages; however, for LGBT elders, the neighborhood in which LGBT elders live suggests
problem is often magnified because of economic that communities more conducive to “active
reasons. In addition to being denied housing, aging” and “aging in place” can influence health
including residency in mainstream retirement (e.g., accessible and affordable health and
communities, LGBT elders might find them- healthcare services, opportunities to stay active),
selves facing homelessness due to economic participation (e.g., accessible public transporta-
reasons. Homelessness among older adults in tion, information services, recreational programs,
general and LGBT elders in particular is social connections, volunteer opportunities, pla-
increasing because many are finding themselves ces to worship, a sense of being valued and
either outliving their retirement income and respected), and security (e.g., home and commu-
having not saved enough for retirement, or their nity safety, transportation safety, affordable
social security income not keeping pace with the housing) (Beard and Petitot 2010). This ecological
574 D.A. Harley et al.
perspective of aging (Lawton and Nahemow LGBT persons is that friendships in the work-
1973) assumes an interface between a person’s place have increased because LGBT persons are
functional capacity, adaptation, and his or her more open about their identity.
physical and social environment. These compo- In a study of the intersection of family, com-
nents link to related concepts of urban design and munity, and disclosure in the lives of gay and
service planning for disability and aging (e.g., lesbian elders, LGBT elders regarded traditional
universal design, accessibility, walkable commu- family members such as siblings, children, par-
nities) (Alley et al. 2007). ents, aunts, and cousins as part of their familial
makeup. When questioned about support net-
works, all participants expanded their definitions
of family beyond biological ties to include friends,
Family Involvement community members, and ex-partners. These
digressions from the family of origin revealed the
The definition of family has changed to varying creation of a “chosen family.” All participants
degrees to be more inclusive of different com- indicated their sexual identity as influential on
positions. Over the course of a century, a their familial experiences (Irizarry 2011).
movement toward modified family structures Several demographic trends may exacerbate
based on individual choice and circumstance has social isolation and loneliness of LGBT elders.
occurred. Clearly, LGBT elders have a family of According to the British Columbia Ministry of
origin (biological). In addition, they may have an Health (2004), the family structure of the Baby
established family (partnership/marriage). Fre- Boom generation differs dramatically from the
quently, LGBT elders have a chosen or created current generation of elders. For example, het-
family comprised of people selected for inclu- erosexual Baby Boomers have married later, had
sion, such as close friends, other LGBT persons, fewer children, have a higher divorce rate, and
and trusted neighbors. Rarely does the chosen increased longevity than did previous genera-
family include blood relatives. Many LGBT tions. Lesbian and gay couples who have bio-
elders found it necessary to create an alternative logical children or who have adopted children
family for reasons such as being closeted, being have fewer offspring than did previous genera-
rejected by the family of origin, or because of tions. The result may be that more childless
logistics that made contact with and support from elderly people are living alone. Further, the trend
blood relative difficult. Thus, LGBT elders often toward smaller family size in the family of origin
exist in a familial structure that is chosen, whose for Baby Boomers may reduce the capacity of
research overwhelmingly focuses on as a social kin networks to provide formal support to LGBT
support system (Fredriksen-Goldsen et al. 2011; elders. Also, the Baby Boom generation is highly
Muraco et al. 2008; Orel 2004). mobile, which may mean that few family mem-
Given the limited family supports of many bers live in close proximity.
LGBT elders, Espinoza (2013) examined the role The impact of how family is defined in the
of friendship for LGBT people as they age general population and among LGBT popula-
through an interview with two longtime leaders tions has yet to be determined. However, it is
in LGBT aging (Jesus Ramirez-Valles and Gina likely that the conceptualization of family has
D’Antonio). The two leaders suggested the fol- changed in both meaning and scope among dif-
lowing: (a) Social spaces in which LGBT per- ferent cultures, across generations, and within
sons live should be welcoming as they age, LGBT and non-LGBT groups. Therefore, as a
(b) LGBT culture prefers young people, and result, the development of policy on social
(c) the likelihood of losing social connections inclusion may be influenced by more
and friendships happens at moments when they non-traditional interpretations and expectations
are often most needed, such as facing chronic of what people envision as important to their
illness. One aspect that has changed for aging inclusion and social well-being.
30 Isolation, Socialization, Recreation, and Inclusion of LGBT Elders 575
appropriate to counter against exclusion. On the the LGBT elder, the family, the support networks,
one hand, it is not to necessarily create new and the community should identify the essence of
programming, but rather to expand existing ser- the problem and have a clear and accepted inter-
vices and link them for greater inclusivity. On the pretation (Austrian Government n.d.).
other hand, it is necessary to develop program The final approach is to plan for sustainability.
interventions for socially isolated and lonely Strategies that will help LGBT elders and com-
LGBT elders because the one-size-fits-all munities deal more effectively with problems,
approach to policy and program design is barriers, and challenges in the future, as well as
contra-indicated (Children’s, Women’s and solving current problems, are essential to ensure
Seniors Health Branch, British Columbia Min- that LGBT elders build capacity and develop
istry of Health 2004). For LGBT elders at high protective factors to enable them to self-manage
risk for social exclusion, reduction in the frag- through life-course events (Austrian Government
mentation of services systems is particularly n.d.). A planning process for sustainability must
important in relation to transitions from adult- include establishing benchmarks, adopting formal
hood to old age or to retirement. Moreover, tai- qualified targets that are attainable, measurable,
loring services for LGBT elders can be and time specific, focusing on long-term policy
concentrated to specific locations (e.g., rural, goals, and integrating long-term social inclusion
urban, ethnic community). This approach lends objectives in broader reform efforts (e.g., bud-
itself to increasing buy-in from LGBT elder getary reform) (Austrian Government n.d.).
participants. A fourth approach is giving high Many social inclusion principles for older
priority to early intervention and prevention. The adults, especially LGBT elders, are aspirational.
strategy is to head off isolation and exclusion by In the USA, Canada, Austria, and European
understanding root causes (e.g., poverty, dis- Union, programs or services such as visiting
ability, transportation) (Austrian Government, n. senior programs (i.e., to provide friendship to
d.). Identifying root causes of isolation for LGBT elders who are homebound or living alone) are
elders and the connection between different types managed through an existing service agency as
of disadvantage allows interventions to be part of an outreach component (Adelman et al.
designed to either prevent the occurrence of 2006; British Columbia Ministry of Health
exclusion or provide more effective support to 2004). The Children’s, Women’s, and Seniors
LGBT elders who are vulnerable before exclu- Health Branch British Columbia Ministry of
sion and isolation become entrenched. Health (2004) acknowledges the potential harm-
A fifth strategy is to use evidence and inte- ful effects of social isolation for elders and sug-
grated data to inform policy. “Progress toward gests that policy implications can be separated
social inclusion must be accompanied by better into two categories: areas for further research and
information, faster learning and better use of developing future interventions (see Policy Box
knowledge to improve outcomes” (Australian 30.1). Clearly, future research is needed across
Government n.d., p. 4). We are living in an era in multiple areas of exclusion and social isolation
which programming and policy are influenced by for LGBT elders including disability and eth-
evidence-based practices. Interventions should nicities. In addition, transgender elders are
draw on the practical experience of service and probably the most neglected segment of LGBT
support networks, existing research and the persons in research and service provision. Con-
evidence-based practices, monitoring and evalu- sideration needs to be given to contextualize
ating strategies as they develop, and focus on these implications for all LGBT elders.
outcomes (summative), as well as documentation
of progress. The monitoring and evaluating of
Policy Box 30.1 Policy Implications
interventions should be designed in a way which
Future work is about social isolation
builds on this evidence-base. The use of clear
and loneliness of LGBT elders.
indicators and reporting from the perspective of
30 Isolation, Socialization, Recreation, and Inclusion of LGBT Elders 577
Adapted from Children’s, Women’s and 1. What are the ways in which older lesbians
Seniors Health Branch, British Columbia and older gay men differ in how they are
Ministry of Health (2004). perceived by younger lesbians and gay
males?
2. What are some of the societal factors that
contribute to the degree in which the elderly
become isolated?
Summary 3. In comparison with heterosexual elders, how
do LGBT elders differ in their social support
Social isolation and loneliness contribute to systems?
negative effects on the health, premature func- 4. What are some contextual factors for isolation
tional decline, and mortality of LGBT older in later life?
adults. Other factors such as income level, edu- 5. How does social isolation differ from a soli-
cational attainment, geographical location, and tary lifestyle?
578 D.A. Harley et al.
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Part VI
Counseling and Human
Services Delivery
Counseling LGBT Elders
31
Steven D. Johnson and Anthony Fluty Jr.
Abstract
Although little empirical information exists on what constitutes effective
psychotherapy specifically for LGBT elders, gay affirmative treatment
approaches are increasing among practicing clinicians. LGBT elders as a
specific population have certain unique issues that should be considered
by clinicians when providing psychotherapy and counseling. While not all
issues pertain to every individual, concerns about coming out, internalized
oppression, sexual minority stress, and stereotyping are issues that should
be considered by clinicians when counseling LGBT elders. Having an
understanding of these issues promotes culturally competent practice.
Using a gay affirmative approach in counseling allows the clinician to
utilize different theoretical psychotherapeutic approaches when working
with LGBT elders. Cognitive-behavioral therapy, person-centered therapy,
and existential therapy lend themselves to effective counseling strategies
when combined with a gay affirmative approach. Other theoretical
approaches may also be equally effective with LGBT elders. Besides
individual counseling, LGBT elders may benefit from group therapy,
couples counseling, or pastoral counseling if indicated.
Keywords
LGBT seniors Gay affirmative therapy Cultural competence Gay
psychotherapy
Overview
While there are unique issues for this population, psychotherapy with LGBT individuals has
one should keep in mind that not all issues per- evolved significantly in the last few decades.
tain to every individual. As with all counseling, Until the 1970s, psychotherapy with this popu-
understanding the client’s unique journey is lation had focused on treating a mental distur-
paramount in developing an effective treatment bance. It was not until 1973 that homosexuality
strategy. This chapter will outline issues specific was removed from the diagnostic and statistical
to LGBT elders, describe individual theories for manual of mental disorders (DSM) as a psycho-
counseling these issues, and discuss other treat- logical disorder (Krajeski 1996). Even with this
ment modalities to help students and clinicians significant change, anti-gay sentiment continued
become culturally competent when counseling for many mental health clinicians, with treatment
LGBT elders. still focused on reparative and conversion-type
therapies (Lebolt 1999). While professional
organizations such as the American Psychiatric
Learning Objectives Association, the American Psychological Asso-
ciation, and the National Association of Social
By the end of the chapter, the reader should be Workers have clearly mandated these conversion
able to: therapies to be counter-therapeutic and likely
harmful, they unfortunately still exist and are
1. Identify and understand unique issues for regarded by some as an option for therapeutic
LGBT elders for clinical practice. treatment (Bieschke et al. 2007).
2. Understand specific counseling theories of While this is a small proportion of the type of
cognitive-behavioral therapy and their appli- therapy conducted today with the LGBT com-
cation with LGBT elders. munity, there still is a significant gap between
3. Understand specific counseling theories of historic ideas of “curing” the gay client and
person-centered therapy and their application current beliefs about what types of psychothera-
to LGBT elders. pies are most efficacious for LGBT individuals.
4. Understand specific counseling theories of Likewise, most graduate training programs in
existential therapy and their application to behavioral health still lack a comprehensive
LGBT elders. inclusion of LGBT issues across their curricula
5. Understand how to implement effective (Biaggio et al. 2003). Yet, many psychothera-
counseling strategies with LGBT elders based pists and counselors work with LGBT individu-
upon the above theories. als who present for psychotherapy to deal with a
variety of issues, including those specifically
related to being a sexual minority.
Introduction
Cultural Competence with LGBT
To date, limited empirically validated information Elders
exists on what constitutes effective psychotherapy
for LGBT elders. The life-span psychological and What is Cultural Competence? In 2007, NASW
mental health issues of LGBT individuals as a saw the need to formally identify the important
whole have continued to be practically absent role that diversity plays in client service. With the
from the mainstream psychological literature, profession embracing this understanding, NASW
with even less being written about LGBT elders published Indicators for Cultural Competence in
specifically (Bieschke et al. 2007; David and Social Work Practice. In it, cultural competence
Cernin 2007; Mabey 2011; Quam and Whitford is defined as “the process by which individuals
1992; Ritter and Terndrup 2002). However, and systems respond respectfully and effectively
31 Counseling LGBT Elders 587
to people of all cultures, languages, classes, races, matter what stage of coming out a client might be
ethnic backgrounds, religions, and other diversity experiencing, this process is still something
factors in a manner that recognizes, affirms and developmentally unique to the LGBT community
values the worth of individuals, families, and (Smith 1997). While coming out issues may or
communities and protects and preserves the dig- may not be the focus of psychotherapy, clinicians
nity of each” (NASW 2007, p. 12). Keeping this should consider this unique phenomenon during
definition in mind, let us explore how it might be their initial assessment with LGBT clients, just as
applied to counseling LGBT elders. one would likely assess for Post-Traumatic Stress
Senior adults in general face many challenges Disorder in returning combat veterans.
as they grow older, including health, finances, There have been several developmental theo-
and decreasing support, as well as possible age- ries that describe the coming out process in the
ism and discrimination (Gratwick et al. 2014). In context of identity formation. Typically, these
counseling elders, it is important to keep these developmental models refer mostly to lesbians
concerns in mind as well as possible other con- and gay men (Ritter and Terndrup 2002). It
cerns unique to older adult LGBT individuals. would be beneficial for clinicians to be familiar
Coming out, internalized oppression, sexual with these theories when working with LGBT
minority stress, and stereotyping are unique elders or other clients who are coming out. Grace
issues counselors may encounter when working (1992), a social worker, proposed a five-stage
with senior sexual minorities. model of gay and lesbian identity formation that
included acknowledging and understanding the
unique challenges faced by lesbians and gays in a
homophobic society. Grace noted that environ-
Issues Specific to LGBT Elders mental barriers of a homophobic society create
oppressive effects reflected in the development of
lesbians and gays (Grace 1992).
Coming Out Grace’s (1992) first level of identity develop-
ment in his coming out model is emergence. In
Coming out is a unique developmental milestone this stage, individuals sense that they are differ-
for LGBT individuals. It involves disclosing ent, yet realize they must conform to heterosexist
one’s minority sexual orientation to others. Far norms. They work at passing for being hetero-
from being a singular event, coming out may sexual, although they may begin to experience
often be filled with both significant highs and same-sex attraction. Next, Grace identifies stage 2
lows. Self-acceptance of one’s LGBT sexual as acknowledgment. In this stage, feelings of fear
orientation is usually a significant part of the and shame may increase prior to accepting one’s
coming out process. Often seen as a process that sexual orientation. This stage typically occurs
may take many years to complete, coming out during adolescence, but may occur later in life for
can be a time of doubt, distress, and discomfort some. “Fear of acknowledging their same-sex
for many LGBT individuals (Beckstead and feelings leads many to deny, rationalize, or bar-
Israel 2007). Fortunately, for some, however, it gain in order to limit conscious awareness of their
can be a time of growth, connection, and emerging sexual identities” (Grace 1992, p. 42).
self-acceptance (Riggle and Rostosky 2012). Stages 3 and 4 may be different for lesbians
Psychotherapists working with LGBT clients and gay men. For lesbians, Grace identifies the
should bear in mind that most of these clients third stage as first relationships, followed by the
will have a coming out narrative to share fourth stage of finding a community. For gay
(Johnson 2012). Clients may be in different men, this is typically reversed. Gay men,
stages of coming out from denial or unawareness according to Grace, will first explore the gay
about their sexual orientation to feeling like they community before finding their first relation-
are completely out to family and friends. No ship. The final stage is self-definition and
588 S.D. Johnson and A. Fluty Jr.
society as a whole. Helping LGBT elders replace discrimination against sexual minorities. Thus,
negative schemas and develop new beliefs about for some LGBT elders, sexual minority stress
their sexual identify may foster a healthier may have become a chronic condition that may
self-identify. have affected their mental health and well-being
(Meyer and Frost 2013). When working with
LGBT elders, clinicians should keep in mind the
Sexual Minority Stress cumulative effects of sexual minority stress and
assess for this phenomenon in individual and
Besides dealing with ageism and other stressors, group therapy.
many senior LGBT individuals also may have to
cope with sexual minority stress. Sexual minority
stress theory posits that in addition to general stress Stereotyping
experienced by all people, LGBT individuals
experience unique, chronic stressors (both inter- Stereotypes are generally considered to be
nally and externally) and are continually forced to “beliefs about the characteristics, attributes, and
adapt and cope with societal stigmatization behaviors of members of certain groups” (Hilton
(Meyer 2003). Internal stressors include percep- and von Hippel 1996, p. 240). Hilton and von
tion of stigma associated with being LGBT, Hippel (1996) note the connection between ste-
internalized heterosexism, self-concealment, and reotypes and prejudice and how this affects per-
emotional inhibition. External stressors include ception of certain social groups. The LGBT
such things as experiences of harassment, dis- community is a social group that has been the
crimination, bullying (see Chap. 18), and target of many stereotypes (Clausell and Fiske
anti-LGBT violence (Szymanski et al. 2008). 2005). LGBT elders grew up in an era where gay
Minority stress theorists have asserted that these stereotypes were often prevalent. Many elders
stressors can lead to mental health problems for may have been victims of negative stereotyping
LGBT individuals (Meyer 2003; Szymanski themselves. For some individuals, these stereo-
2005). types may have included bullying and teasing,
Minority stressors can include visible issues that negatively affecting the individual’s self-concept.
are well-documented in the news media. These Negative stereotypes can lead to self-doubt and
stressors can also take on more subtle forms that negative thoughts about self. Believing negative
do not gain public attention. For example, Szy- stereotypes can lead to internalized oppression
manski et al. (2008) point out that bisexuals and even self-loathing (Smith and Gray 2009).
experience unique minority stressors in that they Assessing and processing for how negative ste-
are often stereotyped as being promiscuous and reotypes may have affected an individual may be
untrustworthy or they are viewed as being gay or essential in successful counseling and psycho-
lesbian persons who refuse to embrace their real therapy. Particularly with LGBT Elders, loss of
sexuality. Persons who identify as bisexual may independence that results in having to depend on
also be seen as unwilling to give up their heter- professional caregivers may elicit fear of dis-
osexual privilege and, therefore are subject to crimination and stereotyping. Counselors should
discrimination from the gay and lesbian com- assess for these concerns, particularly if there has
munity as well as the heterosexual community been a new life transition such as moving to new
(Israel and Mohr 2004). community to be closer to family or perhaps a
Many LGBT elders have lived through years skilled care facility that might involve the stress
of oppressive climates (Mabey 2011). Discrimi- of coming out again.
nation against LGBT individuals was the norm In summary, there are unique issues that
with strong messages from local, state, and might arise when working with LGBT elders.
national legislative policies that condoned Having an understanding of these unique issues
590 S.D. Johnson and A. Fluty Jr.
will better help clinicians to plan appropriate LGBT individuals also shifted from conversion-
interventions for their clients. However, clini- type therapies, still common in the 1980s and
cians should always be cautious in assuming 1990s, to acceptance-model therapies. In 2000,
what will be significant in working with each the American Psychological Association adopted
individual LGBT elder. In other words, clinical 16 positive and affirming guidelines for psycho-
judgment should always supersede assumptions therapy with LGBT individuals (American Psy-
of what issues might be significant to the LGBT chological Association 2000). This perspective
older adult presenting for counseling. Clinicians has helped shift the focus of treatment toward a
should always remember that each individual gay affirmative approach that seeks to understand
case is unique and not stereotype based on pop- the effects of discrimination, rejection, conceal-
ulation characteristics. ment of identity, and internalized oppression that
many LGBT individuals experience (Meyer
2003).
In an attempt to define what was being called
Individual Counseling gay affirmative therapy, one researcher con-
ducted a literature review asking the following
As mentioned previously, little empirical questions: “(1) Does gay affirmative therapy
research exists in the psychotherapy literature on exist? (2) Can gay affirmative therapy be
what counseling techniques are most helpful for defined? (3) Are there any distinguishing features
LGBT individuals in general. Even less exists implicit in gay affirmative therapy? and (4) What
that is specific for LGBT elders (Bieschke et al. issues emerge which have wider implications for
2007; Ritter and Terndrup 2002). This is due, in counseling clients who are gay?” (Harrison
part, to the fact that until the early and 2000). To explore these questions, he reviewed
mid-1980s, most of the psychotherapy literature 33 journal articles and summaries of conference
still focused on curing clients of homosexuality papers dated between 1982 and 1995. He con-
(Stein and Cabaj 1996). Empirical outcome cluded from his thematic analysis that gay affir-
studies for the effectiveness of psychotherapy in mative therapy included a non-pathological view
general is improving for some psychotherapy of homosexuality and knowledge by the therapist
modalities, but overall, nothing specific exists for that is appropriate for working with gay clients
this particular population. However, there has (Harrison 2000). He noted that some articles
been an increase of scholarly publications on gay expanded the definition to include the role of the
affirmative therapy. therapist as challenging oppression in self and
others, identifying societal discrimination, and
advocating for social change.
Gay Affirmative Therapy Langdridge (2007), writing from the United
Kingdom, also noted that this “more developed”
What exactly is gay affirmative therapy? And or “strong” affirmative therapy is different from
how has it come to be viewed by many profes- what is usually considered gay affirmative ther-
sionals as the appropriate therapeutic modality apy, or in his words “ethically affirmative ther-
for working with LGBT individuals? To under- apy.” Langdridge argued that ethically
stand how the counseling and psychotherapy affirmative therapy is nothing more than ethically
community have arrived at this point, a quick appropriate therapy involving LGBT clients.
overview of the historical path will be useful. Thus, true LGBT affirmative therapy to Langd-
When homosexuality was removed as a dis- ridge must include not only the understanding
order from the DSM, thoughts of homosexuality and acceptance but also the “positive affirmation
began shifting from pathology to a naturally to directly ameliorate the effects of heterosex-
occurring lifestyle. Psychotherapy treatment for ism.” (Langdridge 2007, p. 30). Langdridge also
31 Counseling LGBT Elders 591
pointed out that while many refer to their thera- individuals continually process information from
peutic work as gay affirmative therapy, no one their external and internal environments. For
specifically identified significant theoretical or example, ending a romantic relationship could
technical modifications to clearly define unique elicit many feelings associated with the event.
characteristics of gay affirmative therapy. This These feelings and subsequent behaviors will be
reinforces Harrison’s (2000) conclusions that determined by what the individual believes about
what exists in the literature is actually a gay the situation.
affirmative approach to therapy rather than a gay Essentially, in the therapy session, clinicians
affirmative therapy. help clients explore patterns of thinking that can
Even though no conclusive research exists on lead to negative feelings and actions. Individuals
what constitutes effective psychotherapy with learn to modify their patterns of thinking to
LGBT clients, many in the mental health field improve coping (Beck 1995). CBT is a type of
have identified the importance of psychothera- psychotherapy that is different from traditional
pists using gay affirmative therapy or a gay psychodynamic psychotherapy in that the thera-
affirmative approach with their clients. In the pist and the patient will actively work together as
Handbook of Counseling and Psychotherapy with a team to help the patient recover from agreed
Lesbian, Gay, Bisexual, and Transgender Clients, upon problems. CBT deals with the here and now
Ruperto Perez, one of the book’s editors, defines and is a practical therapy that often makes use of
gay affirmative therapy as “the integration of in-session teaching as well as homework
knowledge and awareness by the therapist of the assignments. CBT is a short-term psychotherapy
unique development and cultural aspect of LGBT that typically completed in 8–12 sessions.
individuals, the therapist’s own self-knowledge, In CBT, clinicians help patients address neg-
and the translation of this knowledge and ative life views or schemas. For LGBT elders,
awareness into effective and helpful therapy skills these might include negative thoughts about being
at all stages of the therapeutic process” (Bieschke gay or transgendered (internalized oppression).
et al. 2007, p. 408). Although this definition lacks These long-term negative beliefs may inhibit the
a unique theoretical framework, it clearly aligns individual from fully enjoying life and experi-
with most counseling philosophies. In the fol- encing healthy relationships. The CBT model
lowing sections, we explore how to apply gay would have the patient to identify specific situa-
affirmative therapy or a gay affirmative approach tions causing distress. The therapist would then
to several common therapeutic modalities that help the patient identify any negative or irrational
lend themselves to treating LGBT elders. thoughts about sexuality or gender identity per-
taining to the specific situation. By examining
these thoughts, the therapist and client determine
Cognitive Behavior Therapy which beliefs are rational or irrational and may be
contributing to negative emotions. By continuing
Cognitive-behavioral therapy (CBT) is a form of this process, the therapist helps the client identify
psychotherapy that focuses on examining the patterns in thinking that create negative schemas.
relationships between thoughts, feelings, and By substituting counter thoughts for irrational
behaviors. It has its roots in Rational Emotive thinking, the client is able to adopt new ideas that
Therapy (Ellis 1962) and later work on cognitive lead to corrected schemas and improved mood.
therapy by Aaron Beck. The basic proposition of This is one example of negative or automatic
CBT is that cognitions or beliefs strongly deter- thoughts that a therapist might encounter when
mine our feelings and actions. In other words, working with LGBT elders. Others might include
how an individual’s situation is perceived is a distorted thoughts about self-worth, physical
defining feature of how an individual feels and appearance, relationships, family, and acceptance
behaves (Beck et al. 1979). This is significant, as in the heteronormative community.
592 S.D. Johnson and A. Fluty Jr.
When working with LGBT elders who may unconditional positive regard, and congruence.
have held negative beliefs about themselves for Empathy is a consistent appreciation of the sub-
years, clinicians may find challenging such jective experience of the client. Beyond reflective
beliefs to be especially difficult. However, listening or mirroring, empathy is carried out in a
because CBT is done in the context of a collab- personal, nonjudgmental way to truly understand
orative relationship, building a therapeutic alli- the client’s internal frame of reference. Beyond
ance with the client may aid positive therapeutic the therapist’s empathetic understanding is the
success. Homework task is an essential element importance in appreciating the complete world of
of CBT. These might include reading assign- the client. This creates a way in which the ther-
ments, thought monitoring and challenging, or apist gets closer and closer to the true meaning
behavioral tasks. Ultimately, the goal of CBT is and feelings of the client, thus fostering a deeper
for clients to become their own therapist and be therapeutic relationship based upon respect for
able to apply CBT techniques on their own (Beck and understanding of the other person (Corsini
1995). and Wedding 2005).
Unconditional positive regard is another fun-
damental aspect of person-centered therapy.
Person-Centered Therapy Therapists must demonstrate total acceptance of
the client’s right to his or her feelings. Sometimes
Person-centered therapy is primarily based upon described as prizing the client in a total rather than
the relationship between the therapist and the conditional way, Rogers felt unconditional posi-
client. According to Carl Rogers, the founder of tive regard was necessary for an authentic thera-
person-centered therapy, all individuals have the peutic relationship and for the self-actualizing
ability to resolve their problems and actualize tendency to the full development of one’s
their full potential (Rogers 1951). potential (Rogers 1986). This may be particularly
Person-centered therapy is a non-directive psy- important for LGBT elders who may not have
chotherapy meaning the client, not the therapist, experienced unconditional acceptance.
sets the agenda for the therapy sessions. The Congruence involves a genuineness of the
therapist is responsible for creating an empa- therapist to express feelings being experienced
thetic, caring, and genuine environment in the with the client. Rather than assume a professional
therapy sessions. To this end, the therapist must distance, the therapist attends to any persistent
demonstrate the core therapeutic values of con- feelings created in the therapeutic relationship and
gruence, unconditional positive regard, and expresses them authentically to the client. By
empathy creating a foundation of trust in the being transparent or genuine, the therapist
therapeutic relationship (Rogers 1957). increases the likelihood that the client will change
Person-centered therapy gained popularity and grow in a constructive manner (Rogers 1957).
during the 1960s and 1970s (Knopf 1992).
According to Knopf (1992), Rogers was
Case Vignette 32.2
open-minded and accepting of the gay lifestyle.
Ryan has set up an initial appointment to
He was known to have lesbian, gay, and bisexual
see you in an outpatient-counseling center.
colleagues working with him prior to the
During your initial assessment with Ryan,
declassification of homosexuality from the DSM.
you learn that he is a female-to-male
There are close parallels with current gay affir-
transgendered client. Ryan is 61 years old
mative therapy and the strong tenets of accep-
and works as a marketing consultant for a
tance contained in person-centered therapy.
local Fortune 500 company. He is feeling
Therapists wishing to use person-centered
depressed because of a recent breakup with
therapy with LGBT elders should begin with
his partner. He is seeking counseling to
mastering the three tenets of empathy,
31 Counseling LGBT Elders 593
Human beings have a strong desire to create allow them to experience a healthy level of
meaning. Conversely, the lack of meaning can be anxiety versus neurotic anxiety. For LGBT
one of great existential concern. In existential elders, these issues may be something that they
therapy, clients are faced with finding unique have avoided thinking about due to other life
meaning for their lives in a world where meaning stress(es). Being able to process thoughts and
is self-defined. Discovering a sense of meaning is feelings about death with LGBT elders offers a
essential in creating a hierarchy of values. Values productive time of reflection. Existential therapy
provide a blueprint for life conduct. Our life offers LGBT elders a way to address the large
values tell us not only why we live, but also how questions of their existence.
to live. Helping LGBT elders establish meaning Cognitive-behavioral therapy,
may be an essential part of the therapeutic pro- person-centered therapy, and existential therapy
cess. The last stages of identify development are broad in scope and work well when com-
involve an integrated sense of self, finding bined with a gay affirmative approach for a
meaning in being part of the gay community, and variety of issues. Below is a chart containing
also finding meaning in other areas of life. suggestions on what approach might work well
Yalom’s fourth existential theme is death. for certain issues (Table 31.1).
Awareness that death is inevitable contrasted It should be noted that cognitive behavior
with a strong desired to live can create inner therapy, person-centered therapy, and existential
conflict. Each human being must face his or her therapy were discussed in this chapter as
own mortality. Likewise, each human being approaches the authors thought would fit well
creates defenses against facing death. People with issues LGBT elders might face along with
tend to busy themselves with daily distractions so compatibility with a gay affirmative approach.
that they do not have to think about what ulti- There is no research to support that these specific
mately awaits them. In a sense, they are in denial therapeutic approaches might work better than
about death. In existential therapy, clients strive other therapeutic modalities. Other psychothera-
to find a balance between the ultimate reality of peutic approaches such as psychodynamic ther-
death and total denial of its existence. If the apy, gestalt therapy, interpersonal therapy, and
individual cannot create balance, internal psy- behavioral therapy may also be effective when
chopathology may occur. Clinicians working combined with a gay affirmative approach when
with LGBT elders will encounter individuals working with LGBT elders. Clinicians should
struggling with this existential crisis. Being able always use their clinical judgment when selecting
to talk openly with clients about how they have a treatment modality and planning psychothera-
created meaning and their thoughts about death peutic interventions.
Couples Counseling
Other Counseling Modalities
Same-sex couples seek counseling for issues
While individual psychotherapy may be benefi- similar to those affecting all couples. Communi-
cial for many LGBT elders, other treatment cation problems, infidelity and affairs, substance
modalities may also be effective for certain issues. abuse, and decision-making about staying
596 S.D. Johnson and A. Fluty Jr.
together or separating are issues faced by all cli- were born (i.e., their spiritual traditions of ori-
ents (Cabaj and Klinger 1996). Besides these gin). This may be especially true of those whose
common issues, however, LGBT couples have religious traditions are highly rigid or funda-
unique issues that impact their relationships. mentalist (Blando 2009). However, for some
According to Green (2004), most same-sex cou- LGBT elders, organized religion and spirituality
ples face similar issues, including (1) coping with have been and continue to be a source of comfort
societal homophobia and heterosexism; (2) defin- and support (Halkitis et al. 2009; Rostosky et al.
ing a relationship despite the lack of a societal or 2012) especially if the religious organization to
legal model for same-sex relationships; (3) creat- which they belong is seen as gay-affirming
ing social networks that provide emotional sup- (Sowe et al. 2014). If a client presents in coun-
port and establishing families of choice; and seling with issues surrounding religion and
(4) maintaining flexible gender roles (thus spirituality, it would be germane for the clinician
avoiding over-dependency in female couples or to address those issues as thoroughly as possible
emotional disengagement and competition in within the scope of their training. At times, it
male couples). may be best to refer the client for pastoral
Additional issues that may face same-sex counseling if the issues fall beyond what the
couples are coming out issues. Stages of coming clinicians feel they are able to provide. Pastoral
out may differ for each person in the relationship counseling may be provided by individuals spe-
thus creating tension for the couple as to how cifically trained in religious counseling tech-
“out” they are to other people. In other words, if niques. While each counseling situation is
one member is out to family and friends and the unique, pastoral counseling might be indicated
other is not, this may create tension in the rela- for LGBT elders with strongly self-identified
tionship. Additionally, family dynamics may religious backgrounds, individuals having a type
cause problems for same-sex couples. If the of religious crisis, or those contemplating exis-
families of origin are not supportive, same-sex tential or end-of-life issues (Halkitis et al. 2009).
couples may have to negotiate discrimination not Clinicians should be sure to discuss pastoral
only from society, but also from their families. counseling with the client before making a
Being in a relationship that is not validated by referral to be sure they both agree that it is
one’s family can add to sexual minority stress therapeutically appropriate.
(Connolly 2004).
With the legalization of same-sex marriage,
some same-sex couples may be facing adjust-
ment issues surrounding their newly defined Summary
relationships. While in the past they may have
had to downplay or disguise their relationship, Although little empirical information exists on
they are now able to openly share their rela- what constitutes effective psychotherapy for
tionship publicly. This may cause some issues of LGBT elders, positive strides have been made in
adjustment for the couple. Couples counseling moving from treatment focused on reparative or
may include ways to adjust to this new dynamic conversion-type therapies to gay affirmative
(Segal and Novack 2008). treatment. LGBT elders as a specific population
have certain unique issues that should be con-
sidered by clinicians when providing psycho-
Pastoral Counseling therapy and counseling. While not all issues
pertain to every individual, concerns about
Many older LGBT people may have felt coming out, internalized oppression, sexual
oppressed by and now subsequently feel alien- minority stress, and stereotyping are issues that
ated from the religious traditions into which they should be considered by clinicians when
31 Counseling LGBT Elders 597
counseling LGBT elders. Having an under- 7. How might a therapist use existential therapy
standing of these issues promotes culturally when working with a client dealing with
competent practice. internalized oppression?
Using a gay affirmative approach in counsel-
ing allows the clinician to combine different
theoretical psychotherapeutic approaches when Multiple-Choice Questions
working with LGBT elders. Cognitive-behavioral
therapy, person-centered therapy, and existential 1. Cultural competence can be defined as:
therapy lend themselves to effective counseling A. Responding respectfully to people of all
strategies when combined with a gay affirmative cultures, languages, classes, and races
approach. Other theoretical approaches may also B. Affirming the values and the worth of
be equally effective with LGBT elders. Besides individuals, families, and communities
individual counseling, LGBT elders may benefit C. Protecting and preserving the dignity of
from group therapy, couples counseling, or pas- diversity factors
toral counseling if indicated. D. All of the above
2. A unique developmental milestone for LGBT
individuals involving disclosing one’s minor-
ity sexual orientation to others is known as:
Learning Exercises A. Internalized oppression
B. Self-actualization
Explore the Services and Advocacy for Gay, C. Coming out
Lesbian, Bisexual, and Transgender Elders D. Reverse stereotyping
(SAGE) Web site at http://sageusa.org/. Read 3. A gay man meets with a counselor because
one article or select a topic from the Web site that he still feels shameful and guilty about his
you feel would help your understanding of sexuality. These negative feelings toward
counseling LGBT seniors. himself can best be described as:
A. Internalized oppression
Self-check Questions B. Obsessive-compulsive thoughts
C. Gay stereotyping
1. Define cultural competence and how it relates D. Narcissistic injury
to LGBT elders. 4. The first stage of coming out involves com-
2. According to the authors, what are the unique ing out to:
issues faced when counseling LGBT elders? A. Family
Can you think of other issues that you may B. Close friends
encounter when working with this population? C. Intimate partners
3. Why is it important to understand the differ- D. Self
ent stages of coming out? Are these stages 5. A gay affirmative approach in psychotherapy
different for LGBT seniors than younger can be used with:
adults? A. Cognitive-behavioral therapy
4. Discuss the differences between being cul- B. Person-centered therapy
turally competent and stereotyping clients C. Existential therapy
when working with LGBT elders. D. All of the above
5. Do you feel that sexual minority stress is less 6. In cognitive-behavioral therapy, the main
for LGBT elders than younger adults? Why focus of the therapeutic process involves:
or why not? A. Processing childhood events
6. Some might argue that using a gay affirmative B. Changing negative beliefs
approach is appropriate for use with all cli- C. Analyzing dreams and wishes
ents. What do you think this means? D. Answering questions about life’s meaning
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Advocacy and Community Needs
Assessment 32
Robert Espinoza
Abstract
This chapter provides an overview of the current public policy dilemmas
faced by lesbian, gay, bisexual, and transgender (LGBT) older people in
areas such as economic security and employment, health equity and
healthcare access, housing, HIV and aging, data collection and research,
and major federal legislation meant to protect older people in this country.
It summarizes the current research and literature on LGBT aging and offers
an assessment of the national advocacy capacity of national, state, and local
nonprofit organizations working to support LGBT elders. The chapter
closes with future considerations for strengthening policy supports for a
growing, vulnerable, and neglected demographic of LGBT older adults.
Keywords
Policy Aging Advocacy Legislation LGBT
2. Identify relevant policy that affects LGBT agenda for LGBT elders remains marginal,
older persons. especially when compared to the magnitude of
3. Understand the multidisciplinary infrastruc- the population and its large-scale concerns, or
ture of national, state, and local organizations when contrasted with the much larger national
working to advance policy change for LGBT aging and long-term care field.
elders. This chapter begins by reviewing the policy
research and literature on LGBT older people,
notably the research that was produced from
2010 to the present. The chapter then examines
various policy issues in depth, including the
Introduction Older Americans Act; economic security,
employment, and poverty; affordable housing
In the last decade, the visibility of lesbian, gay, and safe, long-term care; health equity and
bisexual, and transgender (LGBT) older adults healthcare access; HIV and aging; and data col-
has grown considerably, gaining significant lection and research. The chapter proceeds to
traction in federal public policy discussions on describe the multidisciplinary infrastructure of
aging, long-term care, and LGBT rights. The national, state, and local organizations working
broader societal awareness about aging and to advance policy change for LGBT elders and
long-term care can be partially attributed to a proposes a variety of issues that should be
demographic shift that has rapidly changed the resolved through future scholarship, such as
age composition of the US population; estimates developing best practices for integrating LGBT
forecast that the percentage of people aged 65 issues into national surveys and clinical settings
and older will grow from 13.7 % of the US so that LGBT elder advocates can draw from
population in 2012 (or 43.1 million people) to data for future policies and programmatic
21 % in 2040 (or nearly 80 million people) interventions.
(Administration on Aging, Administration for
Community Living 2013). This aging shift has
captured the attention of policy government
officials, nonprofit leaders, health and aging Policy Research and Literature
professionals, and mainstream media. Addition- on LGBT Older People
ally, the increased visibility and acceptance of
LGBT people have enabled a concurrent growth The policy research and literature on lesbian,
in organizations and programs focused on LGBT gay, bisexual, and transgender (LGBT) aging
older people, many of which produce landmark dates back to 2000, though most policy reports
policy analysis and spearhead advocacy to on this subject were produced from 2010 to the
remove the policy barriers faced by LGBT peo- present. In Outing Age: Public Policy Issues
ple as they age. Conservative estimates suggest Affecting Gay, Lesbian, Bisexual, and Trans-
that there are at least 1.5 million LGBT people gender Elders, the first in-depth policy report on
aged 65 and older in this country and that this LGBT elders, Cahill et al. (2000) outline a
number will double in the next two decades variety of political, social, and cultural chal-
(Movement Advancement Project and SAGE lenges faced by LGBT older people, including
2010). Yet despite the policy progress made over the lack of LGBT-friendly social services,
the last five years in regard to LGBT elders unequal treatment in safety net programs such as
(Espinoza 2013b), policy leaders often omit Medicaid and Medicare (among others), ongoing
LGBT elders from major discussions and pro- discrimination in housing and nursing homes,
posals focused on improving the health and and a general lack of policies that protect LGBT
wellness of US seniors. Concurrently, the LGBT people. They note that ageism in the LGBT
aging sector that is positioned to steer a policy community coupled with heterosexism in the
32 Advocacy and Community Needs Assessment 603
aging field has colluded to exclude the realities of people who face additional barriers and consid-
LGBT older people from policy conversations on erations. SAGE (2011b) describes the opportu-
aging, long-term care, health, and LGBT rights. nities offered by the Older Americans Act to
support LGBT elders, citing recommendations
This landmark policy report both lays the
groundwork and anticipates the policy advocacy for this signature legislation to amend its defini-
movement that will emerge on LGBT elders in the tions to specify LGBT older adults; require data
ensuing two decades: Today we stand at the edge collection and reporting on the extent to which
of two tidal waves: a growing wave of GLBT local services and programs serve LGBT older
people aging and entering the social service and
community institutions which care for and advo- people; broaden definitions of “family” to
cate for the elderly; and a tidal wave of reaction include families of choice; and support LGBT
against government, and against government cultural competence training nationwide. The
funding for social service needs. How will GLBT National Senior Citizens Law Center (2011)
people fare as these waves wash over our com-
munities? To date, aging service providers are not profiles the stories of more than 700 LGBT older
ready for the new wave of GLBT elders, policy people and their loved ones in long-term care
makers are running away from it, and until very settings, describing harrowing incidents
recently, frankly, the GLBT community has not throughout the country of verbal and physical
faced this wave either (p. iv).
harassment from staff and other residents, as well
In 2010, the Movement Advancement Project as stories of staff members refusing to use a
and SAGE (Services and Advocacy for GLBT resident’s preferred (gendered) name or to pro-
Elders) revive this LGBT aging policy agenda by vide basic care or services, among other stories
positing that LGBT older adults deal with three of hardship. In its recommendations, the report
overarching challenges: the long-term conse- calls for additional research on the experiences of
quences of stigma and discrimination; the LGBT elders in long-term care facilities and
over-reliance of LGBT older people on “families more LGBT cultural competence training for
of choice” that are not legally protected and are nursing home and other aging professionals, as
often rendered secondary to spouses and biologi- two notable examples. The National Academy on
cal next of kin in public policies, legal protections, an Aging Society (2011) examines a variety of
and within most mainstream aging service provi- current policy topics related to LGBT elders,
sion; and the general unequal treatment of LGBT including the policy barriers faced by older
people in aging services and under the law. The adults with HIV, the role of public policy in
authors surmise that these challenges compound creating culturally competent aging services for
to impair LGBT elders’ financial security, proper LGBT elders, and how the Affordable Care Act
health and healthcare access, and their level of explicitly supports both older people and LGBT
social support.In response, the authors enumerate people, among other issue areas. This report
more than 50 policy recommendations in areas represents the first multi-issue policy report on
such as Social Security, Medicaid, Veteran’s LGBT aging published by a national organiza-
Benefits, visitation and medical-decision-making, tion focused on aging: the Gerontological Soci-
housing and more (pp. 65–68). The report also ety of America. SAGE and the National Center
elicits the support of a few national aging orga- for Transgender Equality (2012) offer more than
nizations, including AARP (formerly the Ameri- 60 recommendations for policy and practice in
can Association of Retired Persons), the American regard to supporting transgender older people,
Society on Aging, and the National Senior Citi- including recommendations related to privacy
zens Law Center, which forecasts how main- and documentation, violence, aging service and
stream national aging organizations will become healthcare barriers, employment and housing
more supportive of an LGBT elder policy agenda discrimination, and more. The reader is referred
in the years that follow. to Chap. 14 in this book for further discussion on
Subsequent policy reports focus on discrete transgender elders. SAGE (2013a) identifies 10
policy areas or subpopulations of LGBT older policy areas that can promote health equity
604 R. Espinoza
among LGBT older people of color, including Conference on Aging, the existing Ryan White
data collection, strengthening Social Security, Care Program, and the current reauthorization of
increasing funding for culturally and linguisti- the Older Americans Act.
cally competent aging supports, and more. The
author notes that though LGBT elders of color
represent an important segment of the demo-
graphic shift that is rapidly diversifying and Policy Issues Faced by LGBT Older
aging the US population, “the available research Adults
shows that they often face heightened health
disparities and are largely rendered invisible in LGBT older people face an array of policy bar-
public policy discussions on aging” (p. 1). The riers in areas related to the Older Americans Act,
reader is referred to Chaps. 6–8 in this book for economic security and employment, health
further discussion on LGBT elders of color. The equity, HIV and aging, affordable housing and
National Hispanic Council on Aging (2014) long-term care, and data collection and research.
focuses on the importance of funding and deliv- LGBT elders are not explicitly accounted for in
ering LGBT-friendly culturally and linguistically most public policies that are meant to support
appropriate services to LGBT Latino older peo- older people, and many LGBT elders face
ple. The needs assessment finds that LGBT unequal treatment under the law as LGBT people
Latino people deal with multiple barriers to and as same-sex couples. LGBT elders concur-
accessing supportive communities when they rently experience differential treatment in
age, including the biases of more conservative accessing aging and health services, housing, and
people of faith, the lack of environments that long-term care—with marginal legal protections
embrace LGBT Latino elders as people with or policy-funded interventions. The data and
multiple identities, and the compounding chal- research on LGBT older people remain thin and
lenges of having survived discrimination rooted underfunded. Nevertheless, policy advocates
in one’s sexual and gender identity, as well as have advanced a variety of protections in recent
one’s racial and ethnic realities. The Equal years, widening opportunities to protect LGBT
Rights Center (2014) argues for stronger elders in safety net programs, aging services, and
LGBT-friendly non-discrimination protections in federal and state public policy.
housing based on a 10-city investigation among
older same-sex couples. The investigation finds
that in 48 percent of the tests, older same-sex Older Americans Act
couples experienced at least one form of differ-
ential treatment when seeking housing in The Older Americans Act (OAA) serves as the
senior-living facilities, such as being provided country’s largest vehicle for funding and deliv-
less information about additional units, or being ering services to older people in the USA; esti-
required to pay additional fees or costs, and mates suggest that its funding scope is more than
undergo a more extensive application process, $2.3 billion annually (National Health Policy
among other hurdles. The Diverse Elders Coali- Forum 2012). The OAA also emphasizes reach-
tion (2014) argues for policy improvements in ing older people with the “greatest social need,”
eight areas related to HIV and aging, including which includes economically vulnerable people
funding HIV prevention programs aimed at older and racial and ethnic minorities. However, the
people, increasing Medicaid expansion across OAA does not include LGBT-specific provisions
states, developing and propagating clinical care that would increase funding for programs, ser-
guidelines for treating older people with HIV, vices, and research related to LGBT older peo-
and more. The report also calls for the inclusion ple. Without these provisions, the national array
and funding of HIV and aging as a significant of service providers and local and state govern-
need in the upcoming 2015 White House ment agencies that comprise the country’s “aging
32 Advocacy and Community Needs Assessment 605
network” are not compelled, encouraged, or security, and spurred higher poverty rates for
mandated to consider LGBT people as a popu- many LGBT older people, notably LGBT people
lation worthy of targeted supports (SAGE, n.d.b). of color who deal with the added burdens of
The reauthorization of the OAA, which takes multiple forms of discrimination (MAP and
place every five years, provides an opportunity to SAGE 2010). These economic conditions are
amend this legislation in ways that address these worsened by the current recession, the general
concerns. In response, national LGBT and aging increase in healthcare costs over the years, the
advocates have proposed that the OAA be pervasiveness of age-related bias (as early as age
amended to specify LGBT older adults as a 40), and LGBT-specific discrimination in the
population of “greatest social need.” Addition- employment process and the workplace (Cray
ally, advocates propose that OAA require that 2013). The federal government does not prohibit
state and area agencies on aging report the extent workplace discrimination based on sexual ori-
to which they serve LGBT older people; that entation and gender identity, while 29 states lack
OAA increase funding for both research and protections for both sexual orientation and gen-
programs focused on LGBT elders; and that the der identity in the workplace (Human Rights
National Resource Center on LGBT Aging, a Campaign 2014a, b). Additionally, many LGBT
technical assistance and training center seeded by older people and their families do not have other
the US Department of Health and Human Ser- assurances such as adequate paid leave protec-
vices (HHS) in 2010 and led by SAGE, be per- tions that would allow them or their primary
manently established in the OAA (SAGE, n.d.b). caregivers to take time off from work to care of
These recommendations have garnered wide- their loved ones when they are ill; paid leave
spread support from leading national nonprofits protections nationwide are sparse; and typically
in the aging field such as the Leadership Council “families of choice” who are friends and care-
of Aging Organizations, as well as from mem- givers of many single LGBT older people, are
bers of Congress and federal agencies (SAGE not protected by leave protections (Make 2013a).
2011a). A proposed 2012 Senate bill and a pro- The reader is referred to Chap. 29 in this book for
posed 2014 House bill on OAA reauthorization further discussion on LGBT issues in the
included these LGBT-friendly recommendations workplace.
(Tax 2014). In July 2012, the Administration for Finally, unequal treatment for same-sex cou-
Community Living (ACL) at HHS issued guid- ples in federal programs such as Medicaid and
ance recommending that LGBT older people be Social Security has left many LGBT older couples
considered by ACL’s grantees as a population of without the financial resources they need to live
greatest social need in local planning efforts financially secure in old age (MAP and SAGE
(SAGE 2014a). In addition to the legislative 2010). The June 2013 Supreme Court decision
remedies outlined above, federal agencies can that effectively struck down the federal Defense of
exercise their authorities to issue regulatory and Marriage Act has spurred numerous improve-
administrative changes that move forward many ments for same-sex couples in accessing impor-
aspects of these recommendations. tant federal benefits, though the breadth of these
benefits continues to evolve as the federal
administration implements this decision across
Economic Security, Employment, programs (Tax 2014). Two notable policy ten-
and Poverty sions are whether federal benefits should be
available to all legally married same-sex couples
A lifetime of discrimination in the workforce and regardless of whether they reside in a state that
in public benefit programs has diminished does not sanction same-sex marriage and whether
retirement savings, exacerbated economic these benefits should extend beyond marriage and
606 R. Espinoza
support couples or dyads in civil unions, domestic In April 2014, the US Department of Health and
partnerships, and/or mutually dependent caregiver Human Services released guidance that legally
relationships (Freedom to Marry 2013; Movement married same-sex couples are eligible for Medi-
Advancement Project and SAGE 2010). The care benefits, regardless of where the couple lives
reader is referred to Chap. 36 in this book for (2014). In May 2014, the Administration for
further discussion on the implications of the Community Living issued guidance to its grantees
Supreme Court ruling on same-sex marriage. that they could include same-sex married couples
To improve the economic security of LGBT in their definitions of “spouse,” “family,” and
older people, policy leaders propose an array of “relative” and that grantees should follow the
policy remedies. Congress could pass the “place of celebration” rule, meaning that
Employment Non-Discrimination Act, which same-sex marriages will be affirmed for ACL
would provide critical workplace protections programs, regardless of the state in which they
related to sexual orientation and gender identity to reside (SAGE 2014a). Finally, a bill has been
millions of LGBT workers (Cray 2013). Addi- introduced in the US Senate—the Social Security
tionally, the President could issue an executive and Marriage Equality (SAME) Act of 2014—
order that prohibits federal contractors from dis- that would extend spousal, survival, and death
criminating on the basis of sexual orientation and benefits under Social Security to married
gender identity (Ford 2014). Federal, state, and same-sex couples in all states (Goodwin and Knox
city governments could enact paid leave laws that 2014).
expand legal recognition to same-sex couples and
broader “families of choice,” allowing LGBT
older workers and their caregivers to support one Affordable Housing and Safe
another in times of illness (Make 2013b). The Long-Term Care
federal government could ensure that LGBT
people, same-sex couples, and their families of Many LGBT older people struggle with securing
choice in all states have access to federal benefits safe and affordable housing. Research shows that
across areas such as Medicare, Social Security, LGBT older people encounter various forms of
Veteran’s Benefits, the Family and Medical differential treatment when attempting to buy or
Leave Act, and more (Lambda Legal 2013). The rent homes and apartments, as well as access
Social Security Administration could exercise its senior housing (Movement Advancement Project
authority to ensure that same-sex couples in and SAGE 2010; Equal Rights Center 2014).
marriages, civil unions, and domestic partner- Additionally, many LGBT elders encounter bias
ships have equal access to Social Security spou- and discrimination from staff members and fel-
sal, survival, and death benefits, regardless of the low residents in independent living and
state in which they reside (Novak 2014). assisted-living facilities, nursing homes, and
The federal administration has made signifi- home care (National Senior Citizens Law Center
cant progress following the June 2013 Supreme 2011). Espinoza (2014) notes that while a crop of
Court decision that invalidated the Defense of affordable LGBT senior housing complexes have
Marriage Act. In June 2013, the Social Security been developed around the country, generating
Administration (SSA) announced that transgender significant media attention and widespread
people could update their Social Security records interest from LGBT older people and their
to reflect their proper gender identities, and in advocates, the availability of these complexes
April 2014, SSA issued updated guidance that a and the limited stock of units cannot meet the
gender transition does not affect the validity of demand of millions of LGBT older people who
transgender people and their spouses (with addi- might want to reside in these residences; advo-
tional review required in some states) (National cates posit that housing solutions for LGBT
Center for Transgender Equality 2013; 2014a). elders must be more innovative and expansive.
32 Advocacy and Community Needs Assessment 607
The author also argues that a lifetime of dis- continues to train hundreds of aging providers
crimination has hampered the economic security nationwide on the issues faced by LGBT elders,
and limited the housing options of many LGBT increasing knowledge and supportiveness for
older people, notably people of color, transgen- LGBT elders among aging professionals
der people, and women. The broader housing (National Resource Center on LGBT Aging
crisis, recession, and foreclosure crisis has only 2014). State advocates have also led LGBT
worsened these housing realities for LGBT sensitivity trainings for housing providers to
elders. reduce bias and discrimination aimed at LGBT
Policy advocates argue for the importance of older people (Wayland 2014).
federal and state-level non-discrimination pro-
tections that include sexual orientation and gen-
der identity and which cover public Health Equity and Healthcare Access
accommodations to account for nursing homes
and other long-term settings (Human Rights Fredriksen-Goldsen et al. (2011) conducted a
Campaign 2014a). To support LGBT senior national study of LGBT older adults that found
housing complexes as well as a range of housing significant disparities in areas related to physical
supports geared at LGBT older adults (i.e., LGBT and mental health, including obesity, high blood
sensitivity training for housing providers, pressure, cholesterol, arthritis, cataracts, asthma,
know-your-rights resources for LGBT elders who cardiovascular disease, diabetes, and other areas.
are seeking housing, and more), federal and state In regard to mental health, the authors found that
governments could increase funding for these more than half of the study’s respondents had been
types of housing developments and supports (U. told by a doctor that they had depression and 39 %
S. Department of Housing and Urban Develop- had seriously thought about suicide. And in many
ment, n.d.). The Older Americans Act, the US of the health areas examined in the study, LGBT
Department of Housing and Urban Development, older people of color and transgender people faced
and the Centers for Disease Control and Preven- higher health disparities. The research shows that
tion could play critical roles in funding and pro- many LGBT older people report avoiding or
moting senior housing communities that offer delaying care for fear of discrimination; as one
more skilled long-term services to LGBT older example, older people with HIV are often more
people, as well as promote independent living likely to be dually diagnosed with HIV and AIDS
communities that allow for aging in place. than their younger counterparts, a medical desig-
Finally, increased funding for LGBT cultural nation that suggests that older people are not
competence training that reaches long-term care seeking proper care to detect HIV, older people are
staff and housing providers around the country not speaking candidly about their sexual health
could help ensure that LGBT elders live in homes with their providers, and/or older people are not
and long-term care facilities that feel more wel- being screened properly by medical professionals,
coming and safe (SAGE 2013b). many of whom might mistakenly assume that
A February 2014 report on housing discrimi- sexual activity diminishes or goes away in old age
nation among same-sex older adults garnered (National Resource Center on LGBT Aging
widespread media attention and visibility on 2011). One systematic barrier to LGBT-friendly
LGBT elders and housing (Equal Rights Center patient-centered health care is that questions about
2014). Around the country, housing developers sexual orientation and gender identity, which
and community advocates have increasingly would identify LGBT patients to doctors, nurses,
spearheaded the creation of LGBT senior hous- and other medical professionals, are rarely asked
ing complexes, including Los Angeles, Minne- in the patient intake process. Conversely, evidence
apolis, Philadelphia, and more (SAGE 2013a). suggests that these questions improve candor and
The National Resource Center on LGBT Aging can lead to important interventions related to
608 R. Espinoza
common LGBT health concerns (The Fenway A 2013 report on health equity (SAGE) out-
Institute and The Center for American Progress, lined various policy proposals to improve the
2013). health of LGBT older people, in particular people
To address national health disparities, the of color who face multiple health and
Affordable Care Act (ACA) put into place a aging-related challenges. The report recommends
number of enhancements for LGBT people and passage of two legislative bills related to the Older
seniors, including new provisions that prevent Americans Act, which would facilitate support
health insurers from denying coverage based on programs geared at LGBT older people, as well as
preexisting conditions such as a person’s sexual culturally and linguistically appropriate supports
orientation, gender identity or HIV status, and for people of color and limited-English-proficient
various supports for people aged 65 and older, people, a percentage of whom are LGBT. The US
including assistance with prescription drug costs Department of Health and Human Services
and increased access to more prevention services (HHS) and its relevant agencies could exercise
(SAGE 2013d). The extent to which ACA has their authorities to fund programs that target
improved healthcare access for LGBT older LGBT older people, while encouraging other
people remains unknown, though the need for grantees and community-based partners to work
improved health coverage is more substantiated. closely with LGBT nonprofits when implement-
The Center for American Progress (2013a) has ing their health initiatives. Because the federal and
found that 34 % of LGBT people were uninsured state marketplaces did not collect data on the
at the beginning of the open enrollment period sexual orientations and gender identities of new
(October 2013) for the ACA’s marketplaces. enrollees, it remains unclear how many LGBT
Twenty-eight percent of LGBT people aged 50– people are included in the roughly 8 million
64 were uninsured in this research (K. Baker, people who enrolled in the ACA marketplace (K.
personal communication, May 28, 2014). Addi- Baker, personal communication, May 28, 2014).
tionally, 82 % of uninsured LGBT people Thus, SAGE (2013b) recommends that the federal
reported discrimination when trying to access regulations on state exchanges explicitly account
their partners’ plans; 67 % had been without for LGBT older people, which could include
health insurance for more than two years, and LGBT data collection on enrollees. Additionally,
60 % reported delaying medical care for the past in May 2014, HHS declared that Medicare could
12 months because they could not afford the no longer arbitrarily exclude transition-related
costs of health care (Center for American Pro- surgery, regardless of a person’s medical condi-
gress 2013b). The reader is referred to Chap. 19 tion. This decision means that transgender people
in this book for further discussion on the impact can obtain this surgery if it is approved by a
of health reform on LGBT elders. Finally, medical provider that accepts Medicare and if they
transgender older people in particular struggle are able to cover the remaining medical costs such
with accessing health care; lifelong discrimina- as deductibles and co-pays (National Center for
tion has limited their job security, their incomes, Transgender Equality 2014b).
and their access to private employer insurance. In
turn, many transgender older people rely largely
on federal programs such as Medicare and HIV and Aging
Medicaid, which have historically contained
arbitrary exclusions for transition-related health Since its onset in the early 1980s, the HIV/AIDS
care, placing the financial burden for these pro- epidemic has disproportionately affected LGBT
cedures entirely on the transgender patient people, notably men who have sex with men,
(SAGE and NCTE 2012, pp. 15–16). transgender people, and people of color. As HIV
32 Advocacy and Community Needs Assessment 609
treatment drastically improved in the mid-1990s, earlier age-related comorbidities; these guide-
HIV/AIDS became less of a death sentence and lines were recently created by a national team of
more of a chronic and manageable illness, pro- HIV experts from different fields and disciplines
foundly altering the age composition of the (American Academy of HIV, Medicine, Ameri-
epidemic into the present (SAGE, n.d.a). By can Geriatrics Society and AIDS Community
2015, one in two people with HIV in the USA Research Initiative of America 2011). The reau-
will be aged 50 and older—and by 2020, this thorization of the Older Americans Act and the
proportion will increase to nearly three in four 2015 White House Conference on Aging provide
people (or 70 %). Research also shows that new critical opportunities to integrate policy changes
infections are on the rise among older people, and recommendations for older people with HIV.
many of whom report not being screened or Finally, if every state opted to expand Medicaid
tested by healthcare providers who mistakenly coverage through the Affordable Care Act
assume that sexual activity ends in older age. (ACA), and every person with HIV was in care,
Additionally, older people are often dually this change would provide coverage to more than
diagnosed with both HIV and AIDS, a clinical 200,000 people with HIV who otherwise might
designation that means the virus has worsened not receive appropriate health care.
to a state of medical and financial crisis (Cahil The visibility of HIV and aging has grown in
et al. 2010). A growing body of medical the last few years. In fall 2013, a Congressional
research indicates that people with HIV in their hearing and briefing examined the policy barriers
early 50s exhibit the same number of comor- faced by older adults with HIV, gathering experts
bidities as people without HIV in their early from around the country (ACRIA 2013). In
70s; the virus, the anti-retroviral treatment, and a 2013, the CDC issued a landmark surveillance
range of socioeconomic factors compound to report tracking HIV among people aged 50 and
spur aging and disability faster and sooner older in five-year increments; this report allows
among people with HIV (American Academy of researchers to better track the course of the epi-
HIV, Medicine, American Geriatrics Society and demic as older people age (Centers for Disease
AIDS Community Research Initiative of Amer- Control and Prevention 2013). In May 2014,
ica 2011). More broadly, few organizations, national advocates representing older people,
government agencies, or health and aging ser- people with HIV, LGBT people, and communi-
vice providers account for the existence or the ties of color held a historic national teleconfer-
growing needs of older adults with HIV, many ence and released an updated policy report on
of whom are LGBT and/or people of color HIV and aging, calling for action on eight policy
(Diverse Elders Coalition 2014). recommendations that would dramatically
Advocates propose a range of policy inter- improve the health and wellness of older adults
ventions to support this demographic, as recently with HIV (Diverse Elders Coalition 2014).
described in a policy report authored by the
Diverse Elders Coalition (2014). The Ryan
White Care Program, which provides essential
services to people with HIV throughout the Data Collection and Research
country, must be sufficiently funded to support
the growing population of older people with Espinoza (2013a) describes the various chal-
HIV. The Centers for Disease Control and Pre- lenges faced by the systematic data collection and
vention (CDC) could dedicate funding for HIV research on LGBT older adults. The large-scale
prevention campaigns aimed at older people, as quantitative data and research on LGBT older
well as better promote its testing guidelines to people remain thin and sparse, which prevents
reach older populations. HHS could implement the knowledge that would substantiate and
and promote guidelines for the clinical care of inform properly designed programs, policies,
older people with HIV, given the number of and interventions that target LGBT elders.
610 R. Espinoza
Questions that capture a person’s sexual orien- To broaden the data and knowledge on LGBT
tation and transgender status are not included in older adults, advocates and researchers propose
most federal surveys, from the US Census to the various policy solutions (SAGE 2013b). The US
broad array of federal surveys on health, retire- Department of Health and Human Services
ment, long-term care, and other matters relevant (HHS) and agencies within HHS such as the
to LGBT elders. This means that statistics on the Administration for Community Living
total number of LGBT older people in this (ACL) and the Centers for Disease Control and
country are conservative estimates at best. Prevention could develop, include, and test
Further, where questions are asked, the related elder-sensitive questions on sexual orientation
sample sizes for people aged 50 and older are and gender identity in their national survey
often too small to form representative findings; instruments. The Office of the National Coordi-
few, if any, questions related to sexual orientation nator for Health Information Technology could
and gender identity are assessed for their clarity include data collection on sexual orientation and
and accuracy among older populations, many of gender identity within its meaningful use stan-
whom might have generational traits that shape dards for electronic health records. State health
their understanding of these research questions as departments could integrate questions on sexual
well as their willingness to respond. Moreover, orientation and gender identity into their patient
the challenges with securing older adult samples intake processes for people entering the
in representative surveys intensify when Medicaid-funded system, similar to recent efforts
researching LGBT elder subgroups. For example, in New York State (Espinoza 2013a, b). HHS
researchers struggle with reaching low-income, could track data on discrimination and mistreat-
racially, and ethnically diverse transgender ment of LGBT older people through the National
older people; most studies on transgender people Ombudsman Reporting System, and ACL could
have older adult samples that are more likely require that state and area units on aging to col-
to be white and have higher income than lect data that measure the extent to which LGBT
their younger counterparts (SAGE and NCTE older people are being served by the national
2012, p. 4). aging network, especially in more conservative,
Along the same lines, questions on sexual less LGBT-friendly areas (SAGE 2013b).
orientation and gender identity are rarely cap- In 2013, the CDC began testing a question on
tured in the patient intake process by most public sexual orientation in its National Health Inter-
and private health and aging entities, despite view Survey and encouraged states to use ques-
evidence that these questions can improve patient tions on both sexual orientation and gender
candor and patient care; further, when properly identity in the CDC’s Behavioral Risk Factor
aggregated and reported, the responses to these Surveillance System (U.S. Department for Health
questions could help illuminate health disparities and Human Service 2013). In 2013, the New
(The Fenway Institute and The Center for York State Department of Health integrated
American Progress 2013). Finally, state and area questions on sexual orientation and gender
agencies on aging are not encouraged or required identity into its statewide patient intake process
to measure the extent to which they outreach and for specific Medicaid-funded facilities, and the
serve LGBT older people in their areas, which New York State Office for the Aging also revised
limits the public understanding on the types of its intake forms to include these questions (Es-
services and supports that LGBT elders receive pinoza 2013a, b). Both developments signal
in different parts of the country (SAGE, n.d.b). opportunities for other federal and state agencies
Research shows that too few state and area to modify their surveys and patient intake pro-
agencies on aging provide outreach to LGBT cesses to include LGBT-specific questions, ide-
communities or LGBT-friendly services through ally with elder-appropriate methodologies that
their agencies (Knochel et al. 2011). collect robust samples of LGBT older people.
32 Advocacy and Community Needs Assessment 611
To protect LGBT elder clients and patients, these organizations are primarily focused on LGBT
questions should be accompanied with protocols aging in their missions and programs, a per-
for collecting data, LGBT cultural competence centage of which are leading policy analysis and
training for professionals, and resources that advocacy. As evidence of the national under-
educate LGBT patients on their legal rights in funding and marginalization of LGBT aging,
aging and long-term care settings (National Funders for LGBTQ Issues has reported that US
Resource Center on LGBT Aging 2013). The foundation giving to organizations and programs
reader is referred to Chaps. 22 and 34 in this serving LGBT older people grew marginally
book for further discussion on healthcare prac- from $1.9 million to $3.5 million between 2007
tices with LGBT elders, and the ethical standards and 2012 (Funders for LGBTQ Issues 2009;
and practices in human services and health care. Funders for LGBTQ Issues 2013). More broadly,
US foundations awarded more than $49 billion to
nonprofits in 2012 (Foundation Center 2013),
meaning that foundation giving to LGBT aging
Related Disciplines is a minute fraction of total foundation giving in
the USA. A sufficiently funded LGBT aging
To better understand the political progress that sector of national and state organizations—
has been achieved for LGBT elders, as well as working in coalition with their partner organi-
what can be accomplished in the future, it is zations in the aging and long-term care field—
important to map the sector of organizations, will be vital to support the growing millions of
programs, and coalitions working on federal, LGBT older people over the next few decades.
state, and local advocacy for LGBT older people.
These organizations work across disciplines and
sectors, yet their policy endeavors are generally National Organizations
focused on policy analysis and joint advocacy
activities such as holding briefings for lawmak- While the sector of organizations working to
ers, offering legal guidance to federal and state support LGBT older people has expanded in the
agencies, and building public awareness and last decade, it remains a small field led by a few
support for LGBT elder policy concerns. While national organizations and a few dozen organi-
extremely successful in the last 10 years, advo- zations working largely at the local level. SAGE
cates argue that the LGBT aging sector must (Services and Advocacy for GLBT Elders),
significantly expand in order to continue which was founded in 1978, remains the largest
achieving large-scale change for future genera- and oldest national organization focused pri-
tions of LGBT older adults. marily on LGBT older people, coordinating
direct services for LGBT elders, providing
training to aging providers on LGBT cultural
LGBT Aging Organizations, Programs, competence (through its National Resource
and Coalitions Center on LGBT Aging, seeded in 2010 by the
US Department of Health and Human Services),
While the visibility of LGBT aging has increased spearheading federal and state policy improve-
dramatically since 2007, as well as the number of ments with national and state partner organiza-
nonprofit actors working to address the lives of tions, and producing online consumer resources
LGBT older people, this sector continues to be for LGBT elders related to health, legal, and
comparatively small when compared to the financial planning, caregiving, and more (SAGE,
broader aging and LGBT rights fields and to the n.d.f). Old Lesbians Organizing for Change
national nonprofit sector. Only a few national (OLOC) is a national network for lesbians aged
organizations and less than 50 state and local 60 and older; its signature programming includes
612 R. Espinoza
Policy Task Force in San Francisco; the LGBT warns that the underfunded LGBT aging field is
Older Adult Coalition in Detroit, MI; and the limited in its ability to focus on large-scale leg-
LGBT Elder Initiative in Philadelphia, PA. These islative reforms and culture change.
networks have overseen LGBT elder needs
Adams (2011) writes: At the same time, the
assessments, brought together advocates to pro- experience of LGBT aging advocates also high-
duce policy reports and recommendations, and lights some of the likely limits to progress during
organized meetings and educational seminars on difficult times, as forward movement is shaped and
issues affecting LGBT older adults in their restricted by who has the capacity to engage in the
advocacy process, what issues stronger and larger
communities (Bajko 2013; LGBT Elder Initia- institutions are effective at advancing, and in a still
tive, n.d.; The LGBT Older Adult Coalition, n. underdeveloped space like the LGBT aging field,
d.). what remains beyond the reach of even the field’s
How did this LGBT aging sector come to be, strongest leaders (p. 18).
and what can it accomplish in the future, as the
needs of LGBT elders grow larger? Adams
(2011) describes the historical context, possibil-
ities, and limitations behind the relative growth Issues to Be Resolved Through
of the LGBT aging sector since 2005, when the Research and Other Scholarship
White House Conference on Aging first included
LGBT delegates in its decennial gathering. A 2011 report on LGBT health from the Institute
Between 2007 and 2011, Adams notes that of Medicine calls for additional research on
SAGE, the largest organization in this field, grew various issues related to later adulthood, includ-
from a $1.5 million annual budget to nearly $7 ing broader demographic and descriptive
million, and its local affiliates grew from six to research (i.e., the number and percentage of
21. Adams argues that early leaders in the LGBT elders who are LGBT, across their full diversity);
aging field succeeded in developing necessary family and interpersonal relations, including the
local services for LGBT older people in different role of families of choice; experiences with
parts of the country, as well as in identifying the health services, including barriers to access and
various policy barriers affecting LGBT elders, quality of care; physical and mental health; and
but they struggled with developing the type of sexual and reproductive health, including HIV
institutional capacity (e.g., organizations, net- and aging. The report also calls for more research
works, coalitions) that could move political and on transgender and bisexual elders (Institute of
cultural change at the federal and national levels Medicine 2011, pp. 283–284). More research in
and that could connect the dots among local these areas could inform the types of program-
groups to form a national grassroots movement. matic interventions needed to support the full
The author acknowledges that the election of an breadth of LGBT older adults. Additionally, the
LGBT-friendly Presidential administration in research could yield insight into the specific
2008, the increased awareness of elders brought policy barriers faced by LGBT older people
on by the aging of the Baby Boom generation, across the spectrum; for example, further
and the pivotal support of a handful of private research on bisexual older people would identify
foundations all contributed to a climate in which a host of policy opportunities to support aging
organizations such as SAGE could build its among this population.
infrastructure and policy apparatus. It also cre- Further research should also assess the proper
ated a climate where more organizations could implementation of various policy proposals,
prioritize LGBT older people, at least through including how to properly ask elder-appropriate
discrete programs and initiatives. Nevertheless, questions related to sexual orientation and gender
the author emphasizes the urgency of policy identity in both surveys and clinical settings—in
change that can open up many more government ways that preserve confidentiality, yield accurate
funding streams to LGBT elder programs and information, and shield LGBT respondents from
614 R. Espinoza
prejudice, stereotypes, and discrimination from numbers and LGBT visibility has sparked the
health providers and social service staff collect- imagination of policy advocates who have pro-
ing these data (Espinoza 2013a, b). duced a vast literature documenting the many
Elder-friendly questions in surveys and clinical policy barriers faced by LGBT older people. In
questions should be routinely tested and vali- general, LGBT elders lack the community sup-
dated, and best practices on these questions port, economic security, and proper health and
should be widely shared across sectors that healthcare access to age successfully. They face
interact with LGBT older people. Policy pro- an array of concerns, from health and economic
posals also request that agencies within the security, to data collection and housing, to
national aging network, such as state and area reforming major legislation such as the Older
units on aging, report the extent to which they American Act and much more. Recent advances
conduct outreach to LGBT communities, as well in regard to marriage equality for same-sex
as track the number of LGBT older people they couples have shifted the economic supports for
serve (SAGE, n.d.b). Recognizing the possible legally married LGBT older adult couples, but
biases of staff members within the aging net- these federal benefits related to marriage consti-
work, and the limited resources afforded to aging tute only a small fraction of the inequalities and
services in many areas of the country, further hardships faced by the broader LGBT older adult
research should understand the feasibility of population, in particular transgender people, poor
revising local intake forms to better capture these and low-income people, and people of color.
data, as well as how to provide data on LGBT Is the current LGBT aging sector sufficiently
people in cost-effective ways. Around the coun- resourced to meet this demand? Many advocates
try, aging providers and LGBT community fear that it is not. The LGBT aging sector needs
organizations are developing and implementing to grow in its scope and strength, and the broader
programs and services that are meant to support aging and long-term care must become increas-
the health, community, and financial security of ingly responsive to LGBT issues in order to
LGBT older people (Barrios-Paoli and Thurston address the profound aging of America.
2011). Research should assess the impact and Recently, progress has been made as mainstream
effectiveness of these programs, with advice on aging organizations have begun to lend their
which programs could yield the best outcomes support and resources to partnerships and coali-
with the most efficient resources and which tions that are focused on repairing the policy
programs can be properly replicated throughout inequities of LGBT older people.
the country. The LGBT aging field could benefit Yet any forward movement in public progress
from a slate of evidence-based practices that also raises more questions. If the LGBT aging
address the various subpopulations that comprise field is able to convince the aging network to
LGBT elders, as well as the range of later track the extent to which they serve LGBT older
adulthood issues outlined in the 2011 IOM report people, what’s the best and most inexpensive
on LGBT health. way to accomplish this goal, given that we live in
an economic era of restrained financial resour-
ces? If health and aging providers become
increasingly aware about the existence of LGBT
Summary people in their clientele, how should we equip
these thousands of practitioners with the tools
LGBT older people are at the center of a demo- and training to work with this growing demo-
graphic shift that is rapidly changing the US graphic? Policy implementation and enforcement
population. As the Baby Boom generation con- is as important as policy advancement, especially
tinues turning age 65, millions of LGBT people when dealing with vulnerable populations.
will become more visible in the aging and The LGBT aging field has made significant
long-term care field. This increase in elder strides in moving the aging field to the point
32 Advocacy and Community Needs Assessment 615
where it can ask these more difficult questions— (d) All of the above
now it needs the large-scale private and public (e) None of the above
support to move the national dial in support of 2. Which of the following is the largest orga-
LGBT elders nationwide. nization in the LGBT aging sector?
(a) PFLAG
(b) SAGE
(c) AARP
Learning Activities (d) EEOC
3. Which of the following is a barrier to
Self-check Questions accessing supportive communities for LGBT
Latino people as they age?
1. What role do LGBT elders play in (a) Biases of more conservative people of
self-advocacy? faith
2. What are the barriers to inclusion of LGBT (b) Lack of environments that embrace
elders in discussion on aging policy? LGBT elders as people with multiple
3. What are the challenges faced by systemic identities
data collection of LGBT elders in research? (c) Compounding challenges of having
survived discrimination rooted in their
sexual and gender identity
Experiential Exercises (d) All of the above
(e) None of the above
1. Conceptualize ways in which you can advo- 4. Which of the following legislation contains an
cate on behalf of LGBT elders. array of barriers in affordable housing, HIV and
2. Develop an interdisciplinary approach in aging, economic security, and employment?
which LGBT elder can plan and implement (a) Older Americans Act
self-advocacy strategies. (b) Senior Citizen Protection Act
3. Start a letter writing campaign to state legis- (c) Elders Anti-Victimization Act
lators and policy makers to promote fairness (d) LGBT Aging Act
and equity for LGBT elders. 5. When seeking housing in senior-living
facilities, LGBT people often experience
which of the following treatment?
Multiple-Choice Questions (a) Subsidized funding
(b) More information about additional units
1. Which of the following contributed to a cli- (c) Required to pay additional fees or cost
mate in which organizations such as SAGE (d) Undergo an abridged application process
could build it infrastructure and policy 6. Which of the following usually impair
apparatus? LGBT elders’ financial security, healthcare
(a) Election of an LGBT-friendly Presi- access, and level of social support?
dential administration in 2008 (a) Broad definition of family
(b) Increased awareness of elders brought (b) Affordable Care Act requirement of
on by the aging Baby Boom generation routine medical tests
(c) Support of a handful of private (c) Reliance of families of choice that are
foundations not legally protected
616 R. Espinoza
outreach and communication strategies from the Foundations (2007). New York, NY: Funders for
Center for American Progress. Washington, DC: CAP. LGBTQ Issues.
Centers for Disease Control and Prevention. (2013). Funders for LGBTQ Issues. (2013). 2012 tracking report:
Diagnoses of HIV infection among adults aged Lesbian, gay, bisexual, transgender and queer grant-
50 years and older in the United States and dependent making by U.S. Foundations. New York, NY: Funders
areas, 2007–2010. HIV Surveillance Supplemental for LGBTQ Issues.
Report 2013. Retrieved from http://www.cdc.gov/hiv/ Goodwin, L., & Knox, O. (2014). Murray bill would force
topics/surveillance/resources/reports/#supplemental. Social Security to pay same-sex spouses survivor
Cray, A. (2013, August 6). ENDA provides protections benefits. Yahoo News. Retrieved from http://news.
for older LGBT Americans. Retrieved from http:// yahoo.com/murray-bill-would-force-social-security-
www.americanprogress.org/issues/lgbt/news/2013/08/ to-pay-same-sex-spouses-survivor-benefits-
06/71553/enda-provides-protections-for-older-lgbt- 220923730.html.
americans/. Human Rights Campaign. (2014a). Housing for LGBT
Diverse Elders Coalition. (2014). 8 policy recommenda- people: What you need to know about property
tions for improving the health and wellness of older ownership and discrimination. Retrieved from http://
adults with HIV. New York, NY: DEC. www.hrc.org/resources/entry/housing-for-lgbt-people-
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618 R. Espinoza
Debra A. Harley
Abstract
Aging is frequently marked by chronic conditions and disability involving
physical, psychological, and sensory disorders. Individuals with adult or
later onset of chronic illness or acquired disability (CIAD) tend to
experience more adjustment difficulties than those with early onset.
Although most elderly adults remain healthy throughout the aging
process, many LGBT elders do have chronic conditions and disabilities
that affect their health and successful aging. This chapter reviews
disabilities and chronic conditions that affect LGBT elders, challenges
they face in dealing with disabilities and chronic illness, and implications
of health care and health policy.
Keywords
Disability Chronic illness Late onset Acquired disability
The purpose of this chapter is to discuss dis- existing conditions (Fredriksen-Goldsen et al.
abilities and chronic conditions that affect LGBT 2011).
older adults. Information is presented on the The prevalence of disability among LGBT
definitions of disability and chronic illness; the elderly is approximately 50 % (Fredriksen-
status of aging, health, and disability; character- Goldsen et al. 2011; Fredriksen-Goldsen et al.
istics and challenges of chronic illness and dis- 2013). Wallace et al. (2011) found that LGB
ability among LGBT elders; targets for adults aged 50–70 had higher rates of physical
intervention; and health care and policy issues. disability compared to their heterosexual coun-
terparts. Further inspection of these results based
on the gender reveals that about 31 % of lesbians
Learning Objective and 24 % of gay men report a disability as
defined as a condition that substantially limits
By the end of this chapter, the reader should be one or more basic instrumental activities of daily
able to: living (IADL). Heikkinen (2003) asserts that on
the one hand disability in old age has identified
1. Understand the concept of disability. non-modifiable risk factors such as age, gender,
2. Understand co-occurring disabilities and and genetics. On the other hand, disability in old
chronic conditions in the elderly. age has modifiable risk factors such as
3. Understand how LGBT elders are impacted age-related diseases, impairments, functional
by disabilities and chronic conditions. limitations, poor coping strategies, sedentary
4. Understand health disparities, interventions, lifestyles and other unhealthy behaviors, as well
and healthcare policies for LGBT elders. as social and environmental obstacles, many of
which stem from earlier phases of life and the
prevalent socioeconomic conditions. Moreover,
diseases, particularly multiple chronic illnesses,
are the main causes of old-age disability. LGBT
Introduction elders with disabilities must also contend with
ableism; like homophobia and transphobia, it is
Individuals with adult or later onset of chronic pervasive in society.
illness or acquired disability (CIAD) tend to The information in this chapter is not intended
experience more adjustment difficulties than do to stereotype elders as sick, depressed, cogni-
those with early onset. It is hypothesized that tively or physically impaired, or fragile. Never-
those with early onset and longer duration have theless, because most elderly adults remain
had more time to adjust to a disability. Individ- healthy throughout the aging process and reside
uals with CIAD are faced with significant chan- in their homes (Zians 2011), many other older
ges in their social and familial relationships, adults, especially LGBT elders, develop chronic
vocational functions, and life roles while dealing conditions and disabilities that affect their health
concurrently with psychosocial distress, physical and successful aging. Successful aging is iden-
pain, loss of role identity and status, prolonged tified with three important components:
medical treatment, and gradually decreasing (a) avoiding disease, (b) staying engaged in life,
performance of self-care and daily activities and (c) maintaining high cognitive and physical
(Bishop 2012; Falvo 2014). In addition, mental functioning (Zians 2011). Nevertheless, the lit-
health plays an important role in physical health; erature is consistent in the acknowledgment that
poor mental health can increase risk of devel- with increasing age comes increased likelihood
oping chronic health conditions or aggravate of disability.
33 Disabilities and Chronic Illness Among LGBT Elders … 621
Across the life span, disability is typically The physical environment offers the potential to
defined in terms of difficulties in one or more assist an individual to intrinsic disability (i.e.,
physical activities of daily living (PADLS) (e.g., ability to perform an activity regardless of con-
bathing, dressing, feeding, and toileting) or in text) through the removal or modification of
one or more IADLs (e.g., walking, housekeep- environmental barriers. Thus, for persons with
ing, shopping, using the phone, taking medica- disabilities the goal is to enhance an individual’s
tion, climbing stairs, reaching, and lifting or actual ability (i.e., ability to perform an activity
carrying large objects) (Heikkinen 2003; Wallace when supported by the physical or social envi-
et al. 2011). Loss of the ability to care for oneself ronment) (Chappell and Cooke 2010; Verbrugge
appropriately results in further loss of indepen- and Jette 1994). The challenge for many older
dence and can lead to the need for care in an adults with disabilities and chronic illness is that
institutional setting (Centers for Disease Control aging-in-place (remaining at home) may be
and Prevention [CDC] 2013). Moreover, Hei- compromised by environmental hazards and
kkinen contends that the general pattern of an barriers, common in the homes of older adults
increase in disability with advancing age is fairly (Chappell and Cooke). Table 33.2 identifies
consistent across industrialized countries, even modifications often needed for older adults to
though there may be significant differences in the remain at home as they age. In addition, fear of
prevalence of particular disabilities and under- discrimination and stigma drives many LGBT
lying factors. elders to avoid services that might enable them to
Just as development is not static or finite, stay in their homes and avoid premature institu-
neither is disability. The effects of chronic illness tionalization (Funders for Lesbian and Gay
and disability may differ depending on individual Issues 2004).
attributes and on different stages of development, Without traditional support systems that allow
impeding the development of certain skills them to age-in-place, many LGBT elders end up
associated with a particular stage of life. For relying on nursing homes or other facilities to
example, for older adults, illness or disability can provide long-term care (MAP and SAGE 2010).
present physical or cognitive limitations in
addition to those commonly associated with the
Table 33.2 Modifications necessary for elders to
aging process. An individual grows old gradu- age-in-place
ally and does not suddenly become old when he
Automatic door openers or door handles instead of
or she turns age 60, 65, or 70 (Chappell and doorknobs
Cooke 2010). Disability is a process of contin-
Flashing lights connect to doorbell for those
uous adaptation to changes across the life span hard-of-hearing
(Sheets 2010). Eventually, disability limits Frequently used items in a lower location/easier to reach
autonomy, introduces dependence, reduces
Handrails in showers, bathtubs, and around toilet area
quality of life, and increases risk of assisted
living or custodial care and premature death Wider doorways, hallways, and circulation paths
(Fried et al. 2004; Heikkinen 2003). No carpet and fewer transitions in flooring
One of the essential functions to an individ- Lower counters, tables, and cabinets
ual’s everyday life is mobility. In fact, mobility Step-free entry into shower
is considered central to an understanding of Enhanced ringer on phone
health and well-being among older populations. Handrails on walls
Limited or lack of mobility significantly narrows Large print dials
an older person’s world and ability to do things
Brighter lighting
that bring enjoyment and meaning to life (Cen-
ters for Disease Control and Prevention 2013). Exterior ramps
33 Disabilities and Chronic Illness Among LGBT Elders … 623
outcomes, and other individual variations among important for several reasons: (a) advances in
older persons, elders are frequently identified as medicine, public health, rehabilitation, and
vulnerable because of comorbidity (multiple technology have increased life expectancy for
chronic conditions), frailty, and disability. Fried persons with disabilities; (b) LGBT elders have
et al. assert that these clinical entities are distinct limited access to culturally sensitive and
but causally related in that both frailty and LGBT-affirmative service; (c) older adults are
comorbidity predict disability, disability exacer- remaining in the workforce longer; (d) LGBT
bates frailty and comorbidity, and comorbid elders are among the poorest of the poor, espe-
diseases may contribute, at least additively, to the cially women; (e) LGBT elders have higher rates
development of frailty. No distinction is made of health disparities; and (f) quality of life is
between the older population and older LGBT compounded by the intersection of age, sexual
adults for these clinical entities. Over two dec- orientation or gender identity, and disability
ades ago, Fine and Asch (1988) asserted that (Harley 2015). Increasing numbers of older
almost all research on adults with disabilities adults living to reach old age (including LGBT
seemed to assume the irrelevance of sexual ori- elders) have changed the demographics of dis-
entation and presume that having a disability ability (Sheets 2010). The case of Gloria below is
eclipses social experience. To date the majority an illustration of a lesbian who acquired a dis-
of research on aging and disability and chronic ability earlier in life and additional chronic ill-
illness continues to ignore LGBT elders. nesses as she aged.
For LGBT persons with disabilities, a disability
is likened to living in the “second closet”
Case Study of Gloria Gloria is a
(Benedetti 2011). Thus, only estimates of the full
67-year-old African American lesbian. She
extent of LGBT health disparities are possible
was diagnosed with multiple sclerosis at
due to a consistent lack of data collection. The
age 36. Gloria worked as a college pro-
main areas of disparity are access to health care,
fessor until her disability forced her to
HIV/AIDS, mental health, and chronic physical
retire at age 57. Subsequently, she was
conditions (MAP and SAGE 2010).
diagnosed with arthritis in her hands and
Understanding chronic conditions and dis-
knees at age 48 and recently with macular
ability among LGBT elders is increasingly
33 Disabilities and Chronic Illness Among LGBT Elders … 625
in cognitive, ambulatory, self-care, and sensory elders. The prevalence of physical and mental
functions compared to married and unmarried health problems is elevated among LGBT elders
men in opposite-sex relationships. However, men even taking into account differences in age dis-
in same-sex relationships were slightly more tribution, income, and education; however, those
likely to report difficulties with independent liv- LGBT elders with lower incomes and lower
ing. On the other hand, women in same-sex education are at more heightened risk
relationships reported higher levels of almost all (Fredriksen-Goldsen et al.).
disability types compared to their married and Much of the sparse research that has been done
unmarried counterparts in opposite-sex relation- on LGBT elders with disabilities has looked at
ships, including any disability and difficulty in either physical or mental disabilities. There is a
ambulatory, self-care, sensory, and independent clear lack of focus on LGBT older adults with
living functions. The prevalence of cognitive dif- developmental disabilities. This is especially dis-
ficulty for women in same-sex relationships was concerting for two reasons. First, many persons
less than that of women in unmarried opposite-sex with developmental disabilities have the same life
relationships, but more than that of women in expectancy as the general population. Second,
married opposite-sex relationships. In summary, while most people begin to experience the effects
these data provide evidence of national disparities of aging in their 40s, some persons with a devel-
in disability between older adults in same-sex opmental disability may require a greater level of
relationships compared to older adults in support at a younger age than the general popula-
opposite-sex relationships. And, this relationship tion. The later reason requires more attention be
is especially strong and consistent for women given to factors associated with aging such as
(Populations Association of America). changes in social roles, activity levels, behavior
Overall, mental health of LGBT elders is good patterns, and response to occurrences in the envi-
(70.8 on a scale of 0 = very poor to 100 = excel- ronment and health conditions (Connect Ability
lent). In rating satisfaction with their life, lesbi- 2010). Some characteristics of aging may mask
ans report (71.8), bisexual women (65.6), gay symptoms of a developmental disability and vice
men (71.7), bisexual men (65.6), and transgender versa. For example, an older adult with Alzhei-
older adults (62.7). Thirty-one percent of LGBT mer’s may exhibit a lack of insight or an inability to
elders report some type of depressive symptoms, articulate what he or she is experiencing, both of
with 53 % having been told by a doctor that they which are characteristic of cognitive impairment
have depression. Transgender older adults have associated with a developmental disability and
the highest rate of depression (48 %), and les- Alzheimer’s disease.
bians (27 %) and gay men (29 %) have the LGBT elders with disabilities and chronic
lowest, and 24 % of LGBT older adults have conditions may find themselves facing issues of
been told they have anxiety (Fredriksen-Goldsen coming out or coming out again as needs for
et al. 2011). Two of the most alarming mental social services increase (Sue and Sue 2013). It is
health issues for LGBT elder are loneliness and important for them to understand and be prepared
social isolation (see Chap. 30). Both of these for the potential negative responses they may
issues can lead to negative health consequences receive as they complete the application process
or be the result of chronic illness and disability. for services. For example, the answers that they
Older bisexual women and men exhibit higher provide on an application may inadvertently
rates of loneness than lesbians and gay men. The expose them to discrimination. Thus, LGBT
rates of neglect experienced by LGBT elders are elders’ application for services because of a
similar to the general elderly population, and disability may be overshadowed by a service
their rates of mistreatment tend to be higher (see provider’s preoccupation and bias with their
Chaps. 16, 17, and 21 in this text). Across the sexual orientation or gender identity. Discussion
categories of physical and mental health, trans- Box 33.1 provides some examples of implica-
gender older adults fair worst than other LGB tions for practice.
33 Disabilities and Chronic Illness Among LGBT Elders … 627
or restricting them from living together. More health care, or denial of appropriate services. The
blatant cases of differential treatment include distribution of discrimination by service provid-
housing providers making degrading remarks, ers against LGBT elders is even more so against
being less than inviting, or being hostile. transgender elders. In a survey of 320 area
Although this study did not include transgender agencies and state units on aging, Knochel et al.
persons, discrimination is also a widespread (2011) found that more than one in four reported
problem against them, regardless of their sexual that transgender older adults would either not be
orientation, which typically results in being welcomed by local service providers or the
denied a home or apartment, being evicted agency was unsure of how welcome they would
because of being transgender or gender be. The Institute of Medicine (2011) verifies that
non-conforming, and homelessness (Grant et al. major research gaps in transgender aging, elder
2011). Other studies found that gay or lesbian abuse, substance abuse, risk and best practices
home seekers were subject to unfavorable treat- for long-term hormone therapy, sexual health,
ment 27 % of the time (Michigan Fair Housing and cancers as areas in which more transgender
Centers 2007), and when emailing the same researches are needed. Often, both fear and
housing provider to inquire about housing reality of discrimination lead to underutilization
availability, opposite-sex couples were more of services (Tobin 2011). Table 33.4 contains
likely to receive a response than same-sex cou- examples of discrimination and victimization
ples (Davis et al. 2013). See Chap. 21 for addi- experienced by LGBT elders and that create
tional discussion on housing concerns of LGBT obstacles to accessing and utilizing necessary
elders. health and social support services. In addition,
Many older adults with disabilities rely on racism affects the health and healthcare experi-
assistive animals (e.g., service animals, support ences of ethnic minority LGBT elders differently
animals, assistance animals, therapy animals) to than their non-minority counterparts (see
perform tasks or provide support that alleviates at Chaps. 5–8, and 10 in this text). The combination
least one of the functional limitations or effects of of ageism and homophobia or transphobia serves
a disability. Persons with an assistive animal who to demean, devalue, and denigrate older LGBT
are refused rental housing or required to pay an adults and pathologize their lives. Furthermore,
additional fee or deposit essentially deny persons
with disabilities access to housing. Despite legal
Table 33.4 Obstacles to LGBT elders accessing health
protection, persons who use assistive animals are and social support services
frequently denied required accommodations
Ageism
(Equal Rights Center 2012). The Equal Rights
Center found that housing providers or leasing Hostility
agents either do not know the reasonable Harassment
accommodation policies in place for their prop- Homophobia
erties, or do not obtain and provide this infor- Tansphobia
mation for a potential tenant with a disability on Lack of affordability
request. Threats of being “outed”
Healthcare and Other Services. Often, pro-
Denial or provision inferior services
viding healthcare services, counseling, and other
Threats of physical violence
social services to LGBT elders is challenging
because of stigma and discrimination from ser- Violation of confidential information
vice providers. According to the American Panic over dealing with heterosexual assumptions
Medical Association (2009), the failure of phy- Verbal insults and inappropriate nonverbal responses
sicians to recognize patient’s sexual orientation from service providers and staff
and gender identity and patients non-disclosure Refusal of healthcare systems to recognize extended
can result in serious medical problems, inferior families within the GBT Community
33 Disabilities and Chronic Illness Among LGBT Elders … 629
the discriminatory behavior of practitioners may developed by The Joint Commission (2011) for
result in inaccurately assessing LGBT elders hospitals and medical settings can be imple-
presenting problems, refraining from providing mented by various human and social service
appropriate services and referrals, increasing entities (see Table 33.5).
LGBT elders dependency on caregivers and The intent of identifying health disparities and
service providers, and offering inappropriate other service needs of LGBT elders is to illu-
treatments (Crisp et al. 2008). minate and define them in a way that advances
Another area of critical concern for LGBT the formulation of public policy and legislation
elders with disabilities is the need of support (Gamble and Stone 2006). Too often, policies
systems, both informal (e.g., family and friends) have discriminated against LGBT persons, failed
and formal (e.g., institutional care). Overreliance to recognize them as deserving of equal protec-
on informal support system often results in tion under the law, and erected barriers to seek-
emotional stress, physical fatigue, and financial ing and securing needed services for health and
burden for those individuals. Reliance on insti- mental health. The overall objective of policy
tutional supports can result in increased depen- should be to decrease, eventually eliminate dis-
dency for LGBT elders. An overlapping and criminatory practices, and level the playing field.
critical concern for LGBT elders with disabilities The following section discusses policy implica-
and chronic conditions is decision making about tions for LGBT elders with disabilities.
end-of-life issues (see Chap. 22). In the absence
of a living will or healthcare directive, older
LGBT adults may rely on members in their Policy Issues
informal network to make decisions. These
members may be denied access to an elder at the The disparities in disability between LGBT
end of the life due to provisions in the Health elders and their heterosexual counterparts in
Insurance Portability and Accountability Act tandem with their status as an already vulnerable
(1996), one intention of which was to provide population should raise concern for practitioners
greater safeguards concerning medical records. and policymakers alike (Population Association
Most importantly, LGBT elders with disabil- of America 2014). As the overall population
ities and chronic conditions need to achieve ages, the numbers of the most vulnerable (e.g.,
recognition as a distinct minority group with persons with disability, the elderly, women living
needs unique from their heterosexual counter- alone, minorities) will grow as well. Clearly, an
parts. The assumption of heterosexuality by ser- older population with health, disability, and
vice providers serves to not only relegate LGBT mobility issues will drive the demand for home
elders to secondary status because of age, dis- modifications, housing options that facilitate
ability, sexual orientation, and gender identity, delivery of services and help prevent premature
but also to dismiss the reality that they exist. This entry into assisted living facilities and nursing
belief informs the delivery of health care, social homes, flexible housing zoning polices, and
services, and social programs (Kimmel 2014). In aggressive enforcement of the requirements of
fact Kimmel et al. (2015) use very explicit the Fair Housing Act and the ADA to help LGBT
adjectives to describe the perceptual impact on elders age-in-place (Lipman et al. 2012). Of
LGBT elders by implicit heterosexual assump- course, a critical concern is how to pay for the
tions in various service arenas. These descrip- services to help LGBT elders with disabilities
tions include how assumptions “limit” the and chronic conditions age-in-place.
language used in intake forms and communica- Developing policy that is responsive to the
tion, “prevent” discussion, “interfere” with, needs of LGBT elders with disabilities and
“preclude,” “marginalize,” and “alienate” LGBT chronic conditions does not always require the
seniors. In an effort to counteract these negative reinvention of services. Rather, modifications can
and aversive assumptions, the guidelines be made in existing policy used to respond to
630 D.A. Harley
barriers imposed on persons with disabilities and stamps, housing, and protection and advocacy)
disadvantaged groups (e.g., WHO 2011). For can improve access. For persons with disabilities,
example, emphasis should be placed on early community-based services are a critical part of
intervention with the provision of services as the continuum of care (WHO 2011).
close as possible to individuals’ residence or An area in which policy issues and social
community. For established services, the focus concerns are lagging behind is in addressing
should be on improving efficiency and effec- older adults with HIV. Over time, AIDS has
tiveness by including LGBT-sensitive program- shifted from being dubbed the “gay” disease to
ming and improving quality and affordability. In equally affecting heterosexuals and dispropor-
less-resourced settings, the focus should be on tionately affecting women and people of color.
accelerating the supply of LGBT-appropriate People are living an almost typical life span if
services, complemented by referrals to second- diagnosed and treated early. A growing number
ary services. Integrating LGBT services specific of older adults are getting HIV because they do
to elders with disabilities into primary and sec- not believe that they are at risk. In fact, older
ondary healthcare settings can improve avail- adults are more vulnerable to HIV infection than
ability if these settings have practitioners who are younger people due to biological changes asso-
sensitive to and competent in working with this ciated with aging (e.g., thinner mucosal mem-
population. In addition, referral systems between branes in the anus and vagina) (Tietz and
different modes of service delivery (e.g., inpa- Schaefer 2011). In terms of policy, Tietz and
tient, outpatient, home-based care), levels of Schaefer assert that the problem is that virtually
health service provision (e.g., primary, second- no comprehensive, federal HIV prevention ini-
ary, and tertiary care facilities), and types of tiatives have been funded to target older adults in
human and social service assistance (e.g., food light of HIV being one of many treatable chronic
33 Disabilities and Chronic Illness Among LGBT Elders … 631
conditions affecting this population. Therefore, resilience and challenges and barriers that impact
several recommendations are presented for the their health outcomes. Not all aging is negative.
Centers for Disease Control regarding HIV and They must address the pervasiveness of ableism,
older adults. First, the CDC needs to extend its homophobia, and transphobia. Certain health
age cap (ages 16–64) for recommended annual behaviors are more prevalent among older LGBT
HIV testing to include adults over age 64, espe- adults as compared to their heterosexual
cially since many are sexually active. Second, counterparts.
develop HIV prevention models aimed specifi- As a group, LGBT elders are one of the least
cally at older adults and should include a social understood in terms of their chronic health con-
messaging component to end the HIV and ditions and aging-related needs. The types of
anti-gay stigma often seen in nursing homes, chronic conditions among LGBT elders vary
senior centers, and other senior programs. As according to gender. The severity of disability
part of its reauthorization, the Older Americans also affects the person’s level of independence,
Act (OAA) can make legislation more responsive mobility, their ability to age-in-place, and social
to older adults living with and at risk for HIV. inclusion.
Defining older adults with HIV as a population of Overwhelmingly, research on adults with
greatest social need within the OAA will allow disabilities has not focused on LGBT elders.
the Administration on Aging to dedicate critical Understanding LGBT elders within the context
resources for community planning and social of disability has implications for the development
services, research and development projects, and of services and programs and policy. LGBT
personnel training in the field of aging (Tietz and elders with disabilities have different attributes
Schaefer). and characteristics that interact with age than
Although there are existing aging services, their differently able peers, and deserve no less
public policy, and research initiatives intended to than having their differing and unique needs
support older adults in times of need, most are understood and served.
inaccessible to LGBT elders and their loved
ones. In addition, available services and pro-
Research Box 33.1
grams are geared toward the general population
Objective: To comprehensively examine
and do not take into consideration the unique
disability among LGB adults through the
circumstances facing LGBT elders with disabil-
use of population-based data.
ities and chronic conditions (Fredriksen-Goldsen
et al. 2013). Moreover, policy and legislation for Method: Estimated prevalence of disabil-
persons with disabilities do not include specific ity and its covariates and compared by
reference to LGBT persons with disabilities. sexual orientation by using data from the
Washington State Behavioral Risk Factor
Surveillance System collected in 2003,
2005, 2007, and 2009. Multivariate logistic
Summary regression was used to analyze the rela-
tionship between disability and sexual
Almost half of the LGBT elders over age 50 have orientation after controlling for covariates
a disability. LGBT elders are at an elevated risk of disability.
of disability, chronic conditions, and mental Results: The prevalence of disability is
distress. Some of the disabilities and chronic higher among LGB adults compared with
health conditions of LGBT elders are a result of their heterosexual counterparts; LGB
the aging process and others are related to adults with disabilities are significantly
stressor experienced as a result of a lifetime of younger than heterosexual adults with
stigma and discrimination. Similar to other disabilities. Higher disability prevalence
groups, LGBT elders possess both strengths and
632 D.A. Harley
(c) Americans with Disabilities Act 9. Which of the following presents more
(d) Rehabilitation Act of 1973 adjustment difficulties to disability or chronic
3. Activities such as walking, dressing, feeding, illness?
and toileting are known as which of the (a) Early onset
following? (b) Midlife onset
(a) Physical activities of daily living (c) Later onset
(b) Instructional activities of daily living (d) None of the above
(c) Instrumental activities of daily living 10. Which of the following refers to older adults
(d) Disability continuum of daily living remaining in their home?
4. Which of the following groups among LGBT (a) Aging-in-place
elders have the highest overall rate of (b) Assistive living
disability? (c) Structural support
(a) Lesbians (d) Group home
(b) Gay men
(c) Bisexual men
Key
(d) Bisexual women
5. What are the two most alarming mental
1-b
health issues for LGBT elders?
2-d
(a) Bipolar disorder and loneliness
3-c
(b) Loneliness and social isolation
4-a
(c) Social isolation and depression
5-b
(d) Depression and anxiety
6-b
6. At what age does the Centers for Disease
7-c
Control cap it recommendation for annual
8-d
HIV testing?
9-c
(a) 55
10-a
(b) 64
(c) 67
(d) 70
7. What is the rate of Alzheimer’s disease
Resources and Websites
among LGBT elders as compared to the
general elderly population?
Center for Disability and Aging: www.acl.gov/
(a) Lower
Programs/CDAP/OIP/ADRC/index.aspx
(b) Higher
National Coalition for LGBT Health (Being
(c) Unknown
LGBT with a Disability): www.lgbthealth.
(d) About the same
webolutionary.com/content/being-lgbt-disability
8. Which of the following do LGBT elders
National Council on Independent Living:
identify as the number one priority for
www.ncil.org
action?
National Organization on Disability: www.
(a) Social support systems
nod.org
(b) Food stamps
Services and Advocacy for Gay, Lesbian,
(c) Transportation
Bisexual and Transgender Elders (Disability:
(d) Housing
www.sageusa.org/issues/disability.cfm
634 D.A. Harley
US General Services Administration: www. Espinoza, R. (2011). The diverse elders coalition and
gas.gov LGBT aging: Connecting communities, issues, and
resources in a historic moment. In R. B. Hudson (Ed.),
US Government Disability Resources: www. Public policy & aging report: Integrating lesbian,
Disability.gov gay, bisexual, and transgender older adults into aging
and practice (pp. 8–13). Washington, DC: National
Academy on an Aging Society.
Falvo, D. (2014). Medical and psychosocial aspects of
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Part VII
Conclusion
Ethical Standards and Practices
in Human Services and Health Care 34
for LGBT Elders
Abstract
Understanding and working with a population as diverse as LGBT elders is
not possible without a grounding in ethics and its application to real-world
problems faced by the older adults and their families. Principles of
autonomy, beneficence, nonmaleficence, justice, fidelity, and veracity are
critical for professionals to understand when confronting dilemmas that
LGBT elders face. In this chapter, the authors use a case study to illustrate a
real-world example of ethical and moral action. The purpose of this chapter
is to provide a grounding in ethical principles and frameworks, as well as
discuss pertinent codes of ethics, in order to make the case that an
understanding of ethics is essential when dealing with the complex
dilemmas that LGBT elders face.
Keywords
Autonomy Beneficence Nonmaleficence Justice Fidelity Veracity
Codes of ethics
The purpose of this chapter is to provide the asked for her, he was far less jovial than he was
reader with a grounding in ethics and ethical usually. Dr. Fields, this is Bill Smock. I have a
gentleman here who wants to speak with you—
principles and frameworks in order to make the about possible elder abuse. Can you talk with him?
case that an understanding of ethics is essential He is sitting here in my chair getting his hair
when dealing with LGBT elders. trimmed. Bill had her attention. And of course she
had time and of course she would take the call.
The man explained that he thought that his
mother was being exploited by his nephew, a
Learning Objectives young man who had just never been able to hold a
job. The man explained that his mother would
By the end of the chapter, the reader should be become really agitated when the nephew’s name
was mentioned, particularly if asked about the
able to: increasingly frequent loans that she had made to
him. The man confessed that he did not want to put
1. Understand basic principles of ethics. his nephew in jail, but that talking directly with
2. Understand how ethics are applied to health him (and his mother) had only emboldened the
nephew. And he mentioned that his mother was
and healthcare situations. more than a little confused, confined to her home,
3. Understand ethical codes for law, social and more and more relied on her wheelchair rather
work, and medicine as they apply to human than her walker. And there was one more thing to
services and health care for LGBT elders. add about his mother—she had come out ten years
ago to the family. Really and all along, she was a
4. Identify future areas for the intersection of lesbian.
ethics, human services, and health care for Ann Fields sighed. The information seemed like
LGBT elders. a case study that she might write for her students
someday, but the wrinkle was that she was not a
direct services provider and that her dear friend
Bill was intervening immediately and on his cli-
ent’s behalf. At the end of the conversation, she
recommended that the man call Adult Protective
Introduction Services (APS), and she provided the number for
him. Then, she called an APS worker who was
also a friend, and told him to be on the lookout for
In order to introduce and frame this section, we the report. She hoped that she had done the right
will start with an illustrative case, one that things, and she also hoped that the right things
actually occurred (with names changed to protect would be done, whatever they turned out to be.
Contextual factors would make this a more com-
confidentiality). We will refer to it and expand on plicated case than some. And, Ann also knew that,
it throughout the chapter. due to confidentiality, she would not know any-
thing more about the report.
It was an unremarkable day at the office for Ann
Fields, researcher, the only notable difference being The case above is emblematic of the very real
that her hair had been cut and colored (she liked to and urgent importance of ethical and moral
say “clipped and dipped”). Having her hair cut
always made her feel better, but likely that had more action. A number of these issues are at work in
to do with the strong bond that she had forged with the case illustration above. The son’s ethical and
her hairdresser, Bill, of over 10 years. The two dis- legal duty was to report the suspicion (his state
cussed everything, including her research work on was an “any person” state), and his ethical
elder abuse. Over the years, she had come to realize,
as depicted in the stage play and movie, Steel responsibility was to protect his mother from
Magnolias, how much intimate interaction occurred being harmed. At the point he made the call to
between a hairdresser and a long-time client. She Ann Fields, it was her moral responsibility to
had even mentioned to Bill that the next effort that assist a fellow human being seeking help, and her
she would make on raising the visibility of the issue
of elder abuse would be to contact the hairstyling relationship to Bill had often been one she
association in their state to see what they might be characterized as being one of a brother and sister.
able to add on their website about the topic. At the point the son reported the suspicion to
On that typical day at work, Bill telephoned her APS (if he in fact did), other ethical codes also
using her office phone (not typical). When he
34 Ethical Standards and Practices in Human Services … 641
would come into play—those most typically of communicative ethics focuses on the importance
the professions of social work, law, and medi- of negotiation and communication in ethical
cine, all of which will be discussed below. The conflict resolution (Moody 1992), utilitarian
purpose of this chapter is to provide the reader theories emphasize the greater good for all,
with a grounding in ethics and ethical principles consequential theories, on the other hand, focus
and framework in order to make the case that an on outcomes and context (situational ethics),
understanding of ethics is essential when dealing while ethical relativism considers the impact of
with LGBT elders. We first anchor this chapter different cultures on notions of what is morally
on ethics by providing the reader with a basic right or wrong (Pozgar 2012).
understanding of ethics and its importance. Then, Ethical principles. Ethics can also be looked at
we discuss how human services codes of ethics in terms of principles distilled from various the-
and those of law and medicine both complement ories to help inform and guide ethical conduct and
and confound helping LGBT elders. behavior. Principlism, as an ethical framework,
provides a universal set of principles or rules of
conduct most commonly recognized in general
What Is Ethics? discourses of ethics, namely beneficence, non-
maleficence, justice, and autonomy (Beauchamp
What ought to be in a given circumstance (s). and Childress 2012). Simply put, beneficence
exhorts us to do good to others, nonmaleficence
The Oxford English Dictionary (1996) pro-
urges against doing harm to others, and while
vides a simple definition of ethics as a system of
justice reminds us of the importance of fairness in
moral principles or values that govern or provide
distributive justice, respect for autonomy focuses
rules of conduct. Ethics is the sphere within the
on self-determination and requires us to recognize
discipline of philosophy that explores morals,
and acknowledge the right of individuals (and
values, and virtues of human conduct, not as they
groups) to make their own choices and decisions
are but as they ought to be (Pozgar 2012). Ethics
(Pozgar 2012; Beauchamp and Childress 2012)
are universal principles that provide a basis to
(see Table 34.1).
guide, regulate, prescribe, or understand behavior
These principles have been applied to the field
on both micro- (individual) and macro- (group,
of aging, although some have voiced reservations
culture) levels. However, ethics is not law, and so
about issues of interpretation and application
does not carry legal force, and is not bind-
(Moody 1992; Polivka and Moody 2001). Hol-
ing. (Darr 2011). These principles aid in making
stein and Mitzen (2001) and Holstein et al. (2011)
distinctions between good versus bad, right ver-
argue that principlism fails to consider the heter-
sus wrong, and in determining what may be
ogeneity of older adults, while others have argued
considered acceptable or unacceptable, or what
that strict or rigid applications of these principles
ought to be in a given circumstance. Ethics is
may result in undesirable results. For example, an
more than feelings, or what is legal, moral, reli-
overemphasis on nonmaleficence may lead to
gious, socially normative, or acceptable by
paternalism, thereby limiting freedom of action
society. Ethics often find representation in theo-
for competent older adults, and upholding auton-
ries and principles, some of which are presented
omy may detract from recognizing the importance
in brief below.
and responsibilities of membership in social and
Ethical Theories. There are a variety of the-
collective networks (Polivka and Moody 2001;
ories that provide a range of ethical perspectives.
Holstein and Mitzen 2001; Holstein et al. 2011).
Often they detail parameters for actions that are
Thus, these perceived limitations of using prin-
considered ethical and provide a premise for
ciplism, including the emphasis on individuals to
doing so. For instance, normative ethics focuses
the detriment of community, neglect or noncon-
on moral standards of human behavior—that
sideration of factors such as context, circum-
which is good and right (Summers 2009),
stance, and agents to which it is applied, and its
642 P.B. Teaster and A.E. Sokan
tendency to view relationships as adversarial resonance when dealing with older adults and
because of its origins in law and philosophy, have can be used as tools to guide ethical action and
led to the exploration and development of alter- decision-making. Finally, principlism still has
native frameworks more suited to addressing relevance, in as much as the principles of
aging (Hofland 2001). These frameworks are beneficence, nonmaleficence, justice, and auton-
presented below; what they share in common is omy are evaluated, interpreted, and applied with
the focus placed on the perspectives of agents, due consideration for how well they can be
subjects, and context in the consideration of ethics manipulated or adapted to address aging issues
(see Table 34.2). meaningfully. For instance, a consideration of
In addition to the creation of alternative what constitutes ethical standards and practices
frameworks, other avenues have been explored relating to LGBT elders must consider their
for a more meaningful interpretation and appli- personal and group history and experience as it
cation of ethics in aging. For instance, other relates to sexual orientation and/or gender iden-
principles, such as honesty, integrity, compas- tity, and the implications for the provision of care
sion, caring, and privacy, are of particular and other services.
Why Ethics Is Important for Working usually begins with the spouse of the elder, fol-
with LGBT Elders lowed by a son or daughter and continuing to
next of kin. This designation can be particularly
Understanding ethics as applied to elders, par- problematic for older LGBT persons, since the
ticularly the LGBT elder population, is important law in many states does not recognize the marital
for a number of reasons (i.e., decision-making, status of a same-sex partner. Due to divided
habilitation, resource allocation, dementia, end of acceptance of an elder coming out, some family
life), which are discussed below. Older LGBT members are estranged and so may be very poor
adults represent a special population highly surrogates for the incapacitated elder. Also, the
deserving of ethical considerations and treatment. isolation that some older LGBT persons experi-
The aging population, of which LGBT elders are ence may make surrogate decision-making even
a part, presents unique and confounding ethical more challenging, because his or her wishes for
challenges for healthcare and human services health care and service acceptance may not be
professionals. The complexities of an aging discernable or followed. This situation would be
society include ethical considerations heretofore particularly difficult should an LGBT elder
historically unheard of as recently as the 1900s require that a guardianship be initiated due to his
when the average US life expectancy was age 47, or her incapacity (Teaster et al. 2010).
to today, when it is 76 (World Health Organi- The emphasis on autonomy to the exclusion
zation 2014). Several domains pertinent to aging of other ethical principles (Holstein and Mitzen
LGBT individuals warrant ethical attention. 2001; Holstein et al. 2011) is one not as deeply
Decision-Making. Competent elders are often held in other countries (and actually, not by all
capable of making decisions for themselves, even older adults) as it is in the USA. Some countries
until the end of their lives. However, their ability have far different approaches toward treating
to make decisions for themselves can become persons who are dying or persons who are suf-
compromised due to such reasons as medication fering from a terminal illness. For example,
interactions, chronic illness, dementia, general Moody (2001) describes the conundrum faced
weakness, or all of the previous reasons in when a US-based and indoctrinated medical team
combination. Also, because of vulnerabilities that faces the wishes of an Asian family concerning
some elders experience at the end of their lives, the issue of veracity. The US team wants to tell
they may be the focus of unhealthy dependencies the old Asian mother that she has terminal can-
by their care providers (formal or informal) and cer, but the family members, acting within the
so may become the unwitting victims of undue value system of their culture, want to withhold
influence (Nerenberg 2000) when making this information.
decisions. Habilitation. Unlike the majority of their
For elders who are competent and who wish younger counterparts, older adults live in both
to authorize another individual to make decisions community and facility settings, and many will
for their health care, finances, or both, a power of live in both at some point in their lives (Con-
attorney (POA) document must be executed, gressional Budget Office 2013). The meaning of
while the older adult still has the capacity to place and where an elder identifies his or her
make decisions (see Chap. 22). Such a document home reflects important ethical concepts of
executed under undue influence or when an older belonging, respect for persons, autonomy, and
adult no longer possesses the capacity to make justice (Beauchamp and Childress 2012; Holstein
decisions is not a legally executed or binding and Mitzen 2001). For many adults, the home in
document. In addition, should an older adult fail which they intended to live for the remainder of
to appoint a surrogate or become incompetent their days may become inappropriate for them:
without executing a POA, many states have a Upkeep or house payments may become too
statutorily established order of surrogacy, which expensive, the neighborhood is no longer safe,
644 P.B. Teaster and A.E. Sokan
the elder is no longer able to traverse stairs, and another interpretation, guns or canes, is a fre-
little accommodation is possible, or the elder quently debated issue, particularly at the national
experiences dementia and cannot attend to level. Ethical issues of justice (Callahan 1995;
activities of daily living or instrumental activities Moody 1992; Rawls 2009) come to bear when
of daily living. Making decisions concerning resources are allocated. As an example, a goal of
one’s habilitation is life-altering and may be the 2010 Affordable Care Act has been to widen
irreversible, a situation different from when they healthcare coverage for persons who have here-
were a younger adult. tofore been unable to access it. Questions con-
One of the most wrenching decisions that cerning the fairness of compelling persons to
many families face is whether or not to have an purchase health care, despite hardship, strike at
elder leave his or her home and move to either an the bedrock principle of autonomy, one fiercely
assisted-living facility (if resources allow it) or a guarded in the USA.
nursing home (synonymous with death for some In addition to this, the allocation of healthcare
elders) (Kane and Caplan 1990; Powers 2003). resources is the developing conundrum con-
Bed availability and quality of care are ongoing cerning access to technology (Lesnoff-Caravaglia
concerns for care provision in nursing homes 1999). Perhaps nowhere in the USA is the digital
(see, generally, Web sites for the Centers for divide more keenly felt than that which divides
Medicare and Medicaid Services and National generations coupled with those who are well off
Consumer Voice for Quality Long-Term Care). and those who are not. As an illustration, LGBT
For LGBT elders, there is an added concern, elders with the ability to teleconnect via some
which is that of being outed in a care environ- form of computer (e.g., laptop, mobile phone,
ment that may be inhospitable to him or her. iPad) with others are thus able to reduce isolation
Some facilities have staff members who are and its effect on health and well-being. Elders
vicious and abusive, and some such facilities, who are able to live in homes that are becoming
which may provide excellent and loving care, increasingly “smart” may be able to reduce
may be the only one available within a huge injuries at rates far higher than their poorer and
radius, as is often the case in rural areas. Here, older counterparts. Also, elders with means are
ethical dilemmas revolve around limiting free- able to afford better assistive devices such as
doms to protect and preserve safety. This aspi- canes, walkers, mobile scooters, and the like far
ration may not be realized if the care more easily than elders who have limited means
environment does not welcome LGBT elders to acquire them.
(see Chaps. 16, 17, 25, and 28). Dementia. Also, unlike their younger coun-
Resource Allocation. Resource allocation is terparts, older adults, who are disproportionately
yet another arena in which ethics informs how affected by the problem, may develop a type of
healthcare providers and service professionals dementia (Binstock et al. 1992; Post 2000; Pur-
treat the needs of LGBT elders. Even though lita and ten Have 2004). About 4–5 million
approximately 20 % of the population will be people in the USA have some degree of dementia
composed of older adults, policy tends to lag at any given time, a number expected to increase
both scholarship and demographic realities. In over the next few decades due to the aging of the
addition, uncomfortable questions arise as to population. Dementia affects about 1 % of people
deservingness. Whose interests have primacy? aged 60–64 years and 30–50 % of people older
Young children? Adolescents? Young or old than 85 years. Dementia is the leading reason for
LGBT persons? Gay or straight? The allocation placing elderly people in institutions such as
of resources is usually not so blatantly black or nursing homes. Dementia is a serious condition
white. More often than not, simmering below the that results in significant financial and human
surface are issues of who gets what, when, and costs (Alzheimer’s Association 2014). Demen-
where. When resources are scarce, these issues tias are not all alike. In the USA, 50,000–60,000
become even more heated. Guns or butter, or in new cases of Parkinson’s disease (PD) are
34 Ethical Standards and Practices in Human Services … 645
diagnosed each year, adding to the one million the application of ethical principles and approa-
people who currently have PD (National Par- ches to specific issues that such professionals
kinson Foundation, n.d.), while an estimated encounter as well as offers suggestions for ways
5.2 million Americans of all ages had Alzhei- to approach ethical dilemmas.
mer’s disease in 2014, including an estimated
5 million people aged 65 and older and approx-
imately 200,000 individuals under the age of 65 Application of Ethics
(Alzheimer’s Association 2014).
Regardless of type, cures do not yet exist, and Ethics can be applied in a variety of ways. Ethics
the march of such chronic diseases is relentless. can be used as rules of conduct “moral code” for
When persons become deeply forgetful (Post individual behavior, as well as for groups such as
2000), it is all the more important to provide those adopted as professional codes of ethics, as
respectful care to such afflicted individuals who a means to determine rights, duties, and respon-
may be unable to remember that they are lesbian sibilities to others as well as to inform
or for that matter, their very name. It is in these decision-making (Pozgar 2012). Applying ethics
particular positions of vulnerability that afflicted to LGBT elders requires considering not only
LGBT elders must be treated with dignity and what rights accrue to LGBT older adults, but also
respect for personhood, though many former what duties and responsibilities are incumbent on
vestiges may become unrecognizable. health and social services providers in order to
End of Life. Finally, considerations of what is effectively care and serve this population. It is
ethical come to bear at the terminus of a long life. also important to consider what ethical consid-
This is not to say that end-of-life issues do not erations need to inform optimal decision-making
affect younger populations, but living to an old and how current ethical principles can be inter-
age involves the certainty that older adults are preted to reflect LGBT elders’ reality.
nearing the end of their lives, a time when the Interpreting ethical principles through the
complexities that append to living a long life LGBT perspective can help develop an ethical
intersect (Ellingston and Fuller 2001; Gaventa framework or “moral map” for caring for LGBT
and Coulter 2005). End of life can involve elders and the unique ethical dilemmas that may
addressing real pain encountered through chronic arise. Such applications must at the very least
illness and that encountered as a consequence of affirm LGBT elders, address prejudice, recognize
living. Personal pain can be acute when families inequalities and vulnerability, and be flexible.
and friends fail to accept the needs and wishes of One alternate framework, whose precepts
an LGBT elder. Ideally, end-of-life circumstances provide a good starting point for application of
allow for the resolution of a life that is coming to ethics to LGBT elders, is Joan Tronto’s Ethic of
an end, one that requires special attention and care Care (1993). Care is defined as “activity that
if the dying elder is LGBT. It may be very includes everything that we do to maintain,
important to the elder that, despite years of fric- continue, and repair our ‘world’ so that we can
tion, family conflict is confronted and resolved. live in it as well as possible. That world includes
Issues of religiosity and spirituality are also highly our bodies, our selves, and our environment, all
important at this time in life (see Chap. 29). of which seek to interweave in a complex,
The ethical issues presented above that are life-sustaining web” (Fisher and Tronto 1990,
germane to an aging LGBT population are not p. 40, as cited in Tronto 1993, p. 61). According
exhaustive of those that may arise. They are, to Tronto, how we “care” for others is a human
however, illustrative of why an understanding of activity, and because it is an action and practice,
ethics is critical when healthcare and service rather than a set of rules, which is based upon a
professionals confront conundrums of aging flexible standard, what constitutes good and thus
LGBT persons. The following section explores ethical care reflects “the way of life, the set of
646 P.B. Teaster and A.E. Sokan
values and conditions, of the people engaged in providers and LGBT elders by promoting
the caring practice” (Tronto 1993, p. 61). Also, responsibility, accountability, and professional-
four phases of care and the correlating ethical ism in service delivery. They can provide a
principle have been recognized: method, lens, or perspective to guide
decision-making, problem identification, and
Phase 1: Caring about—Attentiveness as the solution, as well as promote the social and moral
ethical quality (dimension) of being values that they consider important (Resnik
able to perceive the needs of others 2011). It is critical, therefore, that these codes
and one self. clearly include ethical principles germane to
Phase 2: Caring for—assuming the Responsi- working with LGBT elders.
bility for responding to the identified
need for care.
Phase 3: Caregiving—ethical requirement of Codes of Ethics
Competence in performing the func-
tions of care. In order to provide guidance for elevating
Phase 4: Care receiving—relates to the members’ behavior and to instill confidence
Responsiveness of recipients of care, (both within and outside the organization), vari-
to care received, and the ability of care ous disciplines as well as government and pro-
to meet/address identified needs. fessional organizations have developed and
subsequently adopted codes of ethics that guide
Applying the ethics of care to LGBT elders the conduct of professional behavior (Plant
requires health and social services providers to 2001). Most codes of ethics, also called codes of
become knowledgeable about the unique needs conduct, explicate an organization’s values,
and challenges these elders face, as a necessary mission, and vision. Additionally and typically
foundation in order to properly discern the needs grounded in the ethical principles and frame-
to be addressed, as well as to determine the scope works delineated earlier in this chapter, an
of responsibility. It requires competence not only organization’s code of ethics provides direction
with regard to the nature of work performed, but to its members on appropriate standards of con-
also cultural competence in issues affecting sex- duct, including how to adhere to them (Adams
ual orientation, gender identity, and how these et al. 2001). Most mature professions have
may interact with aging to determine unique developed codes of ethics or conduct (e.g., social
needs and inform appropriate interventions. work, law, medicine, gerontology). Such guid-
Additionally, by considering the response of ance is critical for the complex situations that can
LGBT elders, the application of the ethics of care arise when working with older members of a
places the LGBT elder in the epicenter of sexual minority. Below, we return to our case
decision-making and action, ensuring a voice in study earlier and discuss codes of ethics for
the issues that affect them, such as the efficacy of social work, law, medicine, and gerontology,
services received. highlighting how they might guide members’
Another way to promote the application of treatment of LGBT elders.
ethical standards and practices with LGBT elders
The man who sat in the chair of the beauty salon
is to embed appropriate ethical principles and did, in fact, make a report to Adult Protective
values in the professional codes of conduct for Services. The report was logged in the state sys-
the different disciplines that work with LGBT tem, and an APS worker was assigned to investi-
elders. These codes are important because they gate the case. The APS worker had a Master’s of
Social Work and belonged to the National Asso-
prescribe agreed-upon standards and expecta- ciation for Social Work.
tions of conduct, as well as consequences for
breach, if that occurs (Pozgar 2012; Resnik Code of Ethics for Social Work. According
2011). Professional codes of ethics protect both to the preamble of the Code of Ethics for Social
34 Ethical Standards and Practices in Human Services … 647
Work, promulgated by the National Association their efforts to identify and clarify their goals.
of Social Work (NASW) (2008), Social workers may limit clients’ right to
self-determination when, in the social workers’
The primary mission of the social work profession professional judgment, clients’ actions or potential
is to enhance human well-being and help meet the actions pose a serious, foreseeable, and imminent
basic human needs of all people, with particular risk to themselves or others.
attention to the needs and empowerment of people
who are vulnerable, oppressed, and living in pov- Goals for LGBT elders may be to remain in
erty. A historic and defining feature of social work the home as long as possible, to direct their own
is the profession’s focus on individual well-being health care, or to discontinue life support in the
in a social context and the well-being of society. event that medical treatment is deemed futile. An
Fundamental to social work is attention to the
environmental forces that create, contribute to, and elderly LGBT person’s self-determination may
address problems in living. have to be limited, for example, if the older adult
were determined to be self-neglecting (see
The preamble of the code stresses that the
Chap. 16).
profession should promote social justice and
Also highly important for working with older
social change with and on behalf of clients whom
LGBT clients is Section 1.05, i.e., Cultural
they serve. The code stipulates that the term
Competence and Social Diversity. The section
“clients” is used inclusively and refers to “indi-
directs social workers to “understand culture and
viduals, families, groups, organizations, and
its function in human behavior and society, rec-
communities” and that “social workers are sen-
ognizing the strengths that exist in all cultures.”
sitive to cultural and ethnic diversity and strive to
Further, “social workers should obtain education
end discrimination, oppression, poverty, and
about and seek to understand the nature of social
other forms of social injustice.” Core values of
diversity and oppression with respect to race,
the NASW include service, social justice, dignity
ethnicity, national origin, color, sex, sexual ori-
and worth of persons, importance of human
entation, gender identity or expression, age,
relationships, integrity, and competence.
marital status, political belief, religion, immi-
Most pertinent to clients who are LGBT is
gration status, and mental or physical disability.”
Section 1 of the code, “Social Workers’ Ethical
Section 1.05 includes the strongest admoni-
Responsibilities to Clients.” Subsections within
tion of the code to respect and understand the
Section 1 include social workers’ commitment to
particular needs and situations of older LGBT
clients, respect for clients’ self-determination,
clients, tenets that reflect the ethical principles of
informed consent, professional competence, cul-
beneficence and nonmaleficence, as well as the
tural competence and social diversity, conflict of
ethics of care discussed earlier. It is notable that
interests, privacy and confidentiality, access to
the code was revised in 2008 to specifically
records, sexual relationships, physical contact,
mention sex, sexual orientation, gender identify,
sexual harassment, derogatory language, payment
and expression (NASW).
for services, clients who lack decision-making
capacity, and interruption and termination of Upon investigation of the report to APS, the social
services. Particularly salient for social workers worker assigned to the case substantiated it for
physical abuse and financial exploitation by the
who are addressing the needs of older LGBT nephew. It had not taken the older woman long to
clients is the guidance that the code provides on admit that her nephew had been threatening to out
self-determination and cultural competency, her in the intimate assisted living facility in which
which defer to the ethical principles of autonomy, she was currently living. The woman was adamant
that she wanted the exploitation to end (she never
nonmaleficence, and justice. According to the quite admitted that the bruises on her arms were
Section 1.02 on self-determination, the result of his striking her) but that she did not
want her nephew to go to jail. But the social
Social workers respect and promote the right of worker knew that exploiting an elder was a crime
clients to self-determination and assist clients in
648 P.B. Teaster and A.E. Sokan
as was physical abuse. She referred the case to the lawyers perform these functions with compe-
local commonwealth’s attorney. tence, promptness, and diligence. These roles and
Code of Ethics for Law. The American Bar performance requirements are pertinent and
Association’s (ABA) rules of professional con- useful considerations when dealing with allega-
duct for members of the legal profession are tions or reports of elder mistreatment (see earlier
codified in Model Rules of Professional Conduct, discussions in Chap. 16).
adopted by the ABA House of Delegates in ABA core values for professional conduct
1983. Commonly known as Model Rules, this address client–lawyer relationships, the roles of
code has nationwide application and has been lawyers as counselor/advisor and advocate, as
modified and adopted by most states as the for- well as transactions with nonclients. For instance,
mat for state-level disciplinary codes or rules of Rules 1.1, 1.3, and 1.6 and Rule address values
professional conduct, with the exception of the of competence, diligence, and confidentiality,
state of California (ABA 1983). The nature and respectively, in client–lawyer relationships:
extent of a lawyer’s professional responsibility Rule 1.1 Competence: A lawyer shall provide
are delineated in the preamble and scope of the competent representation to a client. Competent
Model Rules of Professional Conduct. The pre- representation requires the legal knowledge, skill,
amble emphasizes that the Model Rules provide thoroughness and preparation reasonably neces-
sary for the representation.
a framework to guide practitioners in the ethical
practice of the law and a basis for disciplinary Rule 1.3 Diligence: A lawyer shall act with rea-
sonable diligence and promptness in representing a
action against those who fail to comply with the client.
prohibitions and obligations imposed.
According to Sections 1 and 2 of the pream- As stated earlier, these values are pertinent when
ble, a lawyer has multiple responsibilities—“as a dealing with LGBT elder clients. Competence
member of the legal profession, is a representa- requires that a lawyer be culturally competent in
tive of clients, an officer of the legal system and a LGBT issues, including knowledge and aware-
public citizen having special responsibility for ness of the history of prejudice and stigma, atti-
the quality of justice.” It also spells out clearly, tudes of clients themselves as well as others to
the various capacities in and through which the issues of sexual orientation or gender identity,
lawyer acts a representative of his/her client(s): and how these impact the experience of clients or
issues at stake. Also, the potential to reduce or
[2] As a representative of clients, a lawyer per- ameliorate harm suffered by LGBT elder clients
forms various functions. As advisor, a lawyer
provides a client with an informed understanding through prompt and timely action is anchored on
of the client's legal rights and obligations and the capacity to act with diligence and recognition
explains their practical implications. As advocate, of the need and benefits from doing so.
a lawyer zealously asserts the client's position Because of the history of prejudice and stigma
under the rules of the adversary system. As
negotiator, a lawyer seeks a result advantageous to that LGBT people endure as a result of sexual
the client but consistent with requirements of orientation and/or gender identity, the value
honest dealings with others. As an evaluator, a placed on confidentiality of information in cli-
lawyer acts by examining a client's legal affairs and ent–lawyer relationships is critical. Subject to
reporting about them to the client or to others.
exceptions in subsection (b), such as the protec-
Thus, a lawyer’s functions and roles include tion from harm or death, and commission of
advising, advocacy, negotiation, evaluation, and crimes or fraud, Rule 1.6 (a) provides that,
reporting as clients’ needs and circumstances
A lawyer shall not reveal information relating to
dictate. In addition, the preamble indicates that a the representation of a client unless the client gives
lawyer may serve as “third-party neutral” in informed consent, the disclosure is impliedly
dispute resolutions without a representational authorized in order to carry out the representation
role to parties involved. Section 4 requires that or the disclosure is permitted by paragraph (b).
34 Ethical Standards and Practices in Human Services … 649
Further, subsection (c), which requires that The goal of protection can be linked to the
ethical principle of nonmaleficence (i.e., do no
A lawyer shall make reasonable efforts to prevent
the inadvertent or unauthorized disclosure of, or harm). This section also provides that a lawyer
unauthorized access to, information relating to the may disclose or reveal information about the
representation of a client. client whether it is necessary to protect the cli-
ent’s interests. This is potentially a useful safe-
is also germane to protecting LGBT privacy
guard that may be necessary in effecting
interests, especially in light of the fears of per-
secution, discrimination, backlash, and other communication with and informed action by
other stakeholders or professionals such as social
undesirable consequences following disclosure
workers, healthcare providers, and/or criminal
of sexual orientation or gender identity often
justice system on behalf of the client.
harbored by LGBT elders. For instance, research
Model Rules also provide guidance in terms
indicating that such fears are significant con-
of the roles that a lawyer might play in relation to
tributors to nondisclosure of LGBT status in
an LGBT elder client and how to execute these
health care encounters (Durso and Meyer 2012;
ethically. These roles help shape goals of
Fredriksen-Goldsen et al. 2011).
behavior when working with LGBT elders on
The value of communication also addressed in
issues, such as elder mistreatment. As advisor, in
Model Rules is important because it works in
Rule 2.1, lawyers are required to “exercise
tandem with confidentiality and informed con-
independent professional judgment and render
sent, both of which are tied to the ethical prin-
candid advice” and to consider beyond the law,
ciple of autonomy. Appropriate, timely, honest,
“other considerations such as moral, economic,
open, and clear communication is necessary in
social and political factors that may be relevant to
order to serve LGBT elder clients because it
the client's situation.” Again, this is pertinent
facilitates decision-making and enhances trust
when dealing with LGBT elders because their
and understanding in the client–lawyer
sexual identity and/or gender identity reflect and
relationship.
impact moral, social, and political realities of the
Model Rules also provide guidance for deal-
day with implications for both these LGBT
ing with clients with diminished capacity, which
elders and society in general. Counselor and
may be relevant in some cases involving LGBT
advocate are two other roles addressed in Model
elders with increased levels of vulnerability due
Rules. The conduct of either role can bear on the
for instance to cognition, or other circumstance.
ethical principle of autonomy and respect for
Rule 1.14 states,
persons, because they require considerations of
(a) When a client's capacity to make adequately the rights to self-determination of LGBT elders,
considered decisions in connection with a to make choices and decisions. They also reflect
representation is diminished, whether because the duty of truth-telling and fidelity to clients
of minority, mental impairment or for some
(Darr 2011). As counselor, emphasis is placed on
other reason, the lawyer shall, as far as rea-
sonably possible, maintain a normal the ethical responsibility to obtain informed
client-lawyer relationship with the client. consent and to protect client’s interests (Rule
(b) When the lawyer reasonably believes that the 2.3/4). In the role of advocate (Rule 3), lawyers
client has diminished capacity, is at risk of
are required to exhibit the values of candor,
substantial physical, financial or other harm
unless action is taken and cannot adequately fairness, and truthfulness and to act in good faith
act in the client's own interest, the lawyer may in the interests of the client. In order to do so
take reasonably necessary protective action, effectively, again the importance of LGBT cul-
including consulting with individuals or enti-
tural competence (sensitivity, knowledge, and
ties that have the ability to take action to pro-
tect the client and, in appropriate cases, awareness) cannot be overstated.
seeking the appointment of a guardian ad Finally, the Model Rules also recognize a duty
litem, conservator or guardian. of lawyers for public service, such as through
provision of pro bono services to those of limited
650 P.B. Teaster and A.E. Sokan
means. This reflects the ethical principle of Code of Ethics for Medicine. The American
beneficence (do good) as well as justice (fair- Medical Association’s (AMA) Code of Medical
ness). According to Rule 6, lawyers should pro- Ethics provides nine ethical statements that
vide services—at free or reduced rates “to constitute the professional code of ethics for
persons of limited means” (6.2); or “to individ- physicians. The first professional code of ethics
uals, groups or organizations seeking to secure or for physicians was adopted at the inception of the
protect civil rights, civil liberties or public AMA in 1847 (Darr 2011). Since then, it has
rights… where the payment of standard legal undergone a number of revisions as recently as
fees would significantly deplete the organiza- 2001 (AMA 2015). According to its preamble,
tion's economic resources or would be otherwise this code that sets the standards of honorable
inappropriate” (6.1). Because the life experiences conduct or behavior for physicians was designed
of LGBT elders often reflect a curtailment of primarily for the protection of patients and
their rights and result in socioeconomic dispari- requires that
ties in later life, the provisions of Rule 6 are of
As a member of this profession, a physician must
particular salience to this population, by assuring recognize responsibility to patients first and fore-
extending access to legal representation, regard- most, as well as to society, to other health pro-
less of financial wherewithal to do so. fessionals, and to self.
Although the Model Rules of Professional
A review of the nine ethical statements that
Conduct do not specifically mention issues of
make up the Code of Medical Ethics (the Code)
sexual orientation or gender identity, the
reveals the following core values—competence,
espoused core values lend themselves to the
compassion, respect for human dignity and
ethical treatment of LGBT elders by detailing
rights, honesty, confidentiality, respect for the
acceptable behaviors in client–lawyer relation-
law, professionalism, and duty to patients and
ships, as well as expectations and responsibilities
wider community. Of particular relevance here,
to act as advisor/counselor and advocate in ser-
Principle I requires that—
vice to all clients. Appropriate service in these
roles requires at the very least a willingness to A physician shall be dedicated to providing com-
understand the challenges facing LGBT elders, petent medical care, with compassion and respect
for human dignity and rights.
LGBT cultural competence, and collaboration
with other caregivers, stakeholders, or profes- The requirement of competence and compas-
sions as necessary to assure the interests of sion in providing care touches on the ethical
LGBT elder clients. principal of respect for persons and autonomy.
Competence also requires that the physician
The local commonwealth’s attorney reviewed the
report in front of him, as well as the notes he had seeks knowledge and resources necessary to
made during his conversation with the social support the provision of compassionate and
worker. Cognizant of his ethical role as counsellor appropriate care to LGBT elders. In addition,
and advocate, he wanted to be sure that he left no Principle IV emphasizes the importance of
stone unturned in dealing with the matter. How-
ever, from past experience and anecdotal conver- respect for patient rights, thus ensuring the pro-
sations with other colleagues, he knew that he tection of privacy and confidentiality—important
would need more information before he could considerations when dealing with LGBT elders
determine how to proceed, for example what extra as stated earlier. The ethical responsibility to seek
issues did the question of sexual orientation create,
which should be considered, and how to establish LGBT cultural competence finds support in
evidence of the physical abuse alleged. He recalled Principle V, which states that—
a recent article written by a physician about the
forensics of physical abuse and mental health A physician shall continue to study, apply, and
concerns in vulnerable adults. He wondered if advance scientific knowledge, maintain a com-
there was any benefit to speaking to a health care mitment to medical education, make relevant
provider as he prepared to work on this case. information available to patients, colleagues, and
34 Ethical Standards and Practices in Human Services … 651
the public, obtain consultation, and use the talents understood that the study was appropriate. He
of other health professionals when indicated. passed the information on to his recovering patient.
He always liked helping with the research endea-
As stated earlier (see Chap. 20), provider vor though his clinical practice took nearly all the
awareness and sensitivity improves disclosure in time and focus he had.
health encounters and enhances outcomes
Code of Ethics for the Gerontological Soci-
(Lambda Legal 2010; Durso and Meyer 2012;
ety of America. A Code of Ethics for members of
The Joint Commission 2011). Compliance with
the Gerontological Society of America (GSA) was
Principle V also encourages collaboration with
developed by members of the Research, Educa-
other service and care providers, or working in
tion, and Practice Committee and approved by
multidisciplinary teams, which augur well for
GSA Council 2002. Its stated purpose is to guide
care. The code recognizes the physician respon-
“professional behavior for the members of the
sibility to improve community and public health
Gerontological Society of America,” who are
(Principle VII). This responsibility to “do good”
directed to conduct themselves in a manner con-
in a broader level can serve as the impetus for
sistent with the statements set out in the Code
encouraging more rigorous participation of phy-
(GSA 2002). The intention of the Code is to
sicians in efforts to identify and address elder
“promote discussion and provide general guide-
mistreatment generally and within the LGBT
lines for ethically responsible decisions” (GSA
community. 2002). The statement applies, but is not limited, to
Finally, Principles VIII and IX contain the
members’ relationships with “research subjects,
following provisions:
colleagues, students, employees and society at
large as we carry out our aging related work”
VIII. A physician shall, while caring for a
patient, regard responsibility to the patient (GSA). Pertinent to the research alluded to above
as paramount. is the following set of statements.
IX. A physician shall support access to medical
care for all people. To those we study we owe disclosure of our
research goals, methods, and sponsorship. The
Taken together, these principles have ramifications participation of people in our research activities
for physician behavior in the care of LGBT elders. shall only be on a voluntary basis and only on
research projects approved by an appropriate
It requires that the well-being of LGBT elder institutional review board. We shall provide a
patients be the key consideration in healthcare means through our research activities and in sub-
encounters. To ensure this, the needs and chal- sequent publications and reports to maintain the
lenges faced by LGBT elders and barriers to quality confidentiality of those we study. The people we
study and their proxies must be made aware of the
care, including access to care, must be addressed. It likely limits of confidentiality and must not be
requires recognition of the moral or ethical context promised a greater degree of confidentiality than
of care, for instance the need to balance autonomy can be realistically expected under current legal
with protection, or beneficence with nonmalefi- circumstances in our respective nations. We shall,
within the limits of our knowledge, disclose any
cence; the understanding that care requires a significant risks or limits of possible benefits to
holistic approach that combines medical and social those we study.
factors and thus, the value in seeking out those
outside the medical community who are in posi- Other statements from GSA’s code direct
tions to provide insight and assistance. members to respect the dignity, integrity, and
worth of individuals, families, and communities
The doctor to whom the case was referred was touched by members’ activities, which would
helping a gerontologist at the university in town
include LGBT elders involved in the research
(Dr. Ann Fields, a Fellow of the Gerontological
Society of America) conduct a National Institute of endeavor and concepts addressing the ethical
Justice funded study on testing theories and out- principles of autonomy, beneficence, and fidelity.
comes of elder abuse. He had agreed to put out Additional topics addressed under the code are
some flyers describing the study in his office and to
appropriate treatment of colleagues and factual
mention it to patients for whom he thought and
652 P.B. Teaster and A.E. Sokan
(e) Ethics should consider shared meaning American Medical Association (AMA). Code of
from the perspectives of participants Medical Ethics—American Medical Association.
themselves http://www.ama-assn.org/go/codeofmedicalethics.
9. Which of the following is not a true state- Centers for Medicare and Medicaid Services.
ment about the limitations of applying prin- http://www.cms.gov/.
ciplism to the field of aging? National Association of Social Workers. Code of
(a) It emphasizes individuals to the detri- Ethics. http://www.socialworkers.org/pubs/code/
ment of community code.asp.
(b) It considers the heterogeneity of older National Adult Protective Services Association.
adults Code of Ethics. http://www.napsa-now.org/
(c) It neglects such factors as context, cir- about-napsa/code-of-ethics/.
cumstance, and agents to whom it is National Consumer Voice for Quality Long-Term
applied Care. http://theconsumervoice.org/.
(d) It has a tendency to view relationships as Gerontological Society of America. Code of
adversarial Ethics. http://www.geron.org/code-of-ethics.
(e) Strict application may result in undesir-
able results
10. In working with LGBT elders, health and
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Trends, Implications, and Future
Directions for Policy, Practice, 35
and Research on LGBT Elders
Abstract
LGBT elders remain nearly invisible to advocates, researchers, educators,
practitioners, administrators, and policy makers. The topics of sexual
orientation and gender identity are rarely addressed in health and human
service delivery or educational degree programs, and their relevance to
LGBT elders is further marginalized or omitted from these venues. In this
chapter, we identify trends and anticipate future directions and implica-
tions for policy practice and research on LGBT elders. This chapter serves
simultaneously as a capstone of the previous 34 chapters and as a roadmap
for advancing a research and service delivery agenda to address the
challenges of LGBT elders.
Keywords
Research Future trends Policy Practice LGBT elders
LGBT elders are limited in comparison with their themselves working with LGBT elders. In order to
non-LGBT counterparts, transgender persons are help LGBT persons at any age, it is important to
the most marginalized, excluded, and discrimi- understand LGBT issues and stigma, as well as to
nated against of all sexual minorities or become aware of available resources, or the lack
gender-variant persons. However, there appear to thereof (Hillman 2012). According to
be hopeful signs that the tide of public opinion is Fredriksen-Goldsen et al. (2014), “health and
changing with such initiatives as the repeal of human service providers must comprehend the
DOMA and the election of an openly gay bishop intersectionalities of history, social structures, and
by one of the mainline churches. cultural factors and how they have shaped the life
experiences of LGBT elders. In addition, practi-
tioners must identify the typical and the highly
Learning Objectives unique, yet normative experiences of LGBT peo-
ple as they age, recognizing distinct transitions
By the end of the chapter, the reader should be over the life course, such as identity management
able to: (e.g., coming out or not), and how they influence
service use” (p. 86).
1. Identify future trends in policy, practice, and Although older, baby boom, and younger
research that will impact LGBT elders. LGBT persons share common themes such as
2. Identify the core competencies for practice concerns about coming out, difficulties with
with LGBT elders. prohibitive religious beliefs, anxiety about HIV
3. Discuss existing gaps in policy, practice, and and AIDS, disparities in health care and job
research on LGBT elders. opportunities, fear of discrimination, concerns
about support networks, and legal issues related
to same-sex marriage and partnerships, important
differences exist between these age cohorts
(Hillman 2012). Many LGBT elders came of age
Introduction when the prevailing social norm was to ignore or
subvert homosexual tendencies and to ascribe to
It is difficult to imagine that any sector of the aging traditional family values and relationships. Con-
population as a whole has been ignored or sequently, they (a) are less likely to receive vital
under-investigated, particularly given the plethora information about HIV education, treatment, and
of scholarly and practice gerontological literature prevention (Makadon and Cahill 2012; National
that has been produced over the past fifty years. Institute on Aging 2009), (b) have fewer family
Robert Hudson, highly recognized scholar of members available to tend to basic and instru-
aging policy for over 30 years, observes, “… mental needs, (c) are more likely to have endured
LGBT older adults have remained nearly invisible persecution by the community at large,
to the community of advocates, researchers, (d) encounter difficulties forming informal social
practitioners, administrators, and politicians who support groups or romantic relationships because
associate themselves with the modern aging they are less likely to easily identify one another
enterprise” (Hudson 2011, p. 1). Though topics of due to concern about revealing LGBT identity,
sexual orientation and gender identity among and (e) were raised in a generation in which one
middle-age and older adults are rarely addressed in was not forthcoming about one’s sexual prefer-
health and human service delivery training or in ences (Hillman 2012; MetLife Mature Market
educational degree programs (Fredriksen-Goldsen Institute 2010). Each of these issues influences
et al. 2014), more clinicians, counselors, social policy development, service delivery, and
workers, and human service providers are finding research foci for LGBT elders.
35 Trends, Implications, and Future Directions for Policy, Practice, and Research on LGBT Elders 659
Disparities in Outcomes for LGBT Table 35.1 Concerns and solutions for LGBT elders
Elders and Older Heterosexual Concern 1: Lack of data on gender identity and sexual
Populations orientation among city agencies prevents understanding
of service needs and utilization in the LGBT population
Substantial differences with their heterosexual • Solution: Collect data on gender identity and sexual
orientation whenever other voluntary demographic data
counterparts persist for LGBT elders in important
are collected
domains such as health care, housing, socioeco-
Concern 2: Senior service providers do not have
nomic status, social isolation, equal treatment adequate cultural competence to appropriately serve
under the law, and targeted programming. At LGBT seniors
both younger and older ages, LGBT persons • Solution: Require training to improve cultural
remain “invisible” in healthcare settings (Maka- competency of service providers in working effectively
don and Cahill 2012). Clinicians, most of whom with LGBT elders
receive little or no training regarding sexual Concern 3: LGBT elders lack information and
orientation and gender identify, rarely if ever enrollment support for social services, financial support,
benefits counseling, legal advocacy, and health
inquire about their patient’s sexual history, sex-
insurance access
ual orientation, and gender identity (Makadon
• Solution: Develop and implement an information,
and Cahill). referral, enrollment assistance, and case management
As with practice settings, a growing body of referral program that provides a single place for LGBT
research literature suggests that LGBT elders are elders to receive information, referral, and enrollment
discriminated against by health and social service assistance for a wide range of available social services
and health care
providers: many have received substandard care
because of their LGBT identities (Gratwick et al. Concern 4: Availability of limited supportive services
to aid in the provision, coordination, and planning of
2014). Even when providers of aging services care to address unique challenges facing LGBT elders
indicate a willingness to become more respon- • Solution: Develop and implement an LGBT elder case
sive to the needs of LGBT elders (e.g., relevant management and peer specialist program
staff training), evidence suggests that they rarely Concern 5: Availability of limited support services to
follow through (Knochel et al. 2012). According address the emotional, behavioral health, and social
to Gehlert et al. (2010, p. 408), “because the isolation challenges of LGBT elders
determinants of disparities occur at multiple • Solution: Develop and implement an LGBT elder peer
levels, from the molecular to societal and interact counseling program and an LGBT peer support
volunteer program
with one another in ways not yet fully under-
stood, they represent a challenge to researchers Concern 6: LGBT elders have unique barriers to
accessing information about and services for
attempting to capture their complexity.” Alzheimer’s and dementia care
The San Francisco LGBT Aging Policy Task
• Solution: Create an LGBT-targeted education and
Force (2014) identified key areas of concern and awareness campaign and increase availability of related
associated solutions to address: data collection, support groups
cultural competency, health and social services, Concern 7: LGBT elders struggle with low income and
housing, and legal services (see Table 35.1). In poor financial literacy
(2012), a summit hosted by Healing Detroit (an • Solution: Develop and implement financial literacy
African American LGBT initiative) and the training services targeting LGBT elders
LGBT Older Adult Coalition was held to explore Concern 8: LGBT elders are especially vulnerable to
the needs and experiences expressed by LGBT losing their residential housing as a result of eviction
elders on their experiences and concerns about and physical barriers to aging in place, and the
consequences of losing housing late in life are severe
aging in the Detroit area. The Coalition attracted for most LGBT elders
a mainly Caucasian audience from the suburbs, • Solution: Improve eviction prevention protections for
while Healing Detroit attracted primarily an inner LGBT elders through rental and homeowner assistance,
city African American audience. In exploring (continued)
660 P.B. Teaster and D.A. Harley
Table 35.1 (continued) building; (e) current LGBTQ women and men
legal services, and increased restriction on evictions and aged 55+ have lived an isolated lifestyle that has
increase resources for LGBT elder homeowners not condoned discussion of issues such as
Concern 9: LGBT elders need more access to physical illness, financial troubles, and personal
affordable housing relationships; and (f) the younger cohort of baby
• Solution: Increase availability of and access to boomers includes women and men aged 55+ who
affordable housing by including LGBT elders in are not as economically able for their final years
planning processes, prioritizing developments that
target them, and providing LGBT-focused housing
as their same-gender counterparts. Older and
counseling and rental assistance retired LGBT persons have concerns (e.g.,
Concern 10: Conditions in apartments and single room healthcare affordability, competent care) different
occupancy (SRO) where many LGBT elders live are from their younger counterparts (e.g., housing,
often unacceptable independence).
• Solution: Improve conditions in apartments and SROs The most common concern for both inner city
through improved Department of Building Inspections African American LGBT elders and their sub-
(DBI) policies and enhance work on habitability
urban Caucasian counterparts was social isola-
Concern 11: Many LGBT elders feel unsafe and tion created by feeling unwelcome at social
unwelcome in city shelters
activities in an LGBT community geared for
• Solution: The city should address unsafe and younger persons, fear of social ostracism within
unwelcoming treatment of LGBT elders in city shelters
by providing targeted shelter services and implementing the mainstream senior social community, and
training at existing shelters unwelcome senior living communities. The most
Concern 12: LGBT elders in long-term care facilities significant difference between them was African
face systemic discrimination and abuse American LGBT elders’ challenges of living in
• Solution: Improve legal protections and resources for the city (e.g., unemployment, poverty, systemic
LGBT elders in long-term care facilities racial inequity issues) and Caucasian suburban
Concern 13: LGBT elders face obstacles to and lack LGBT elders’ challenges for acquiring culturally
resources for drafting appropriate life-planning competent healthcare and appropriate housing
documents options (Lipscomb and LaTosch 2012). Findings
• Solution: Promote LGBT life-planning legal clinics, by Lipscomb and LaTosch are consistent with
referral protocols, and sample documents, and develop
resources to aid LGBT elders who wish to complete the
results from other studies (e.g., Espinoza 2013,
planning process 2014; Fredriksen-Goldsen et al. 2011; Kim and
Adapted from San Francisco LGBT Aging Policy Task Fredriksen-Goldsen 2014) and other sources
Force (2014) reported in this book.
In addition to health disparities, research
findings point to other legal, political, and social
similarities and differences faced by each of these issues that significantly impact the health and
groups, Lipscomb and LaTosch (2012) reported well-being of LGBT persons (Ard and Makadon
that (a) mature LGBTQ persons are isolated by 2012). One important and highly visible issue is
their community, and their peers are the heated debate over the legality of same-sex
self-afflicted; (b) if they relocated to a senior marriage, along with it associated benefits.
living facility, mature LGBTQ persons are most According to Badgett (2011), the right to marry
likely sent back into the closet; (c) the LGBTQ is associated with greater feelings of social
community is youth-oriented to the point that inclusion among LGBT persons, whether mar-
women and men aged 55 and over cannot relate ried or not. Another issue is that, across the
to the present social network; (d) financially and lifespan, LGBT elders may experience violence
career successful women and men aged 55 and and mistreatment at higher rates than do het-
over are becoming increasingly isolated by their erosexual elders and are at high risk for elder
education, career climbing, and inadequately abuse, neglect, and exploitation (MAP et al.
developed partnerships and community network 2010). Although his work on elder mistreatment
35 Trends, Implications, and Future Directions for Policy, Practice, and Research on LGBT Elders 661
did not address LBGT elders, the national prev- of LGBT elders and of how to provide services in
alence study by Acierno et al. (2010) identifies a more integrated and comprehensive way.
that elders most at risk are those who have a lack Although the approach used to collaborate may
of social support and who were previously be determined by one’s discipline, specialty, or
exposed to a traumatic event, situations that are setting, the acknowledgment of different per-
very common for LGBT elders. A third issue is spectives to service delivery will advance access
that gay men and lesbians tend to place high and quality of service to LGBT elders.
value on self-sufficiency and thus may hesitate Human and social service, medical, nursing, and
to accept assistance in old age (SAGE and MAP health sciences disciplines represent many of the
2010). Such hesitation may well increase the professions that knowingly or unknowingly work
vulnerabilities to mistreatment cited previously. with LGBT elders. A major challenge across disci-
Finally, in addition to hereditary factors, general plines is the lack of understanding concerning how
socioeconomic, cultural, and environmental to educate people to engage in an interdisciplinary
conditions; living and working conditions; social approach for examining the impact of contextual
and community influences; and individual life- factors on the lives of LGBT elders. Disciplines
style factors constitute social determinants typically teach and train service providers in isola-
influencing disparities between and among tion, resulting in disciplinary myopia—a lack of
LGBT elders (Makadon and Cahill 2012). awareness and understanding of competencies and
expectations of practitioners with whom they will
work in delivering services to LGBT elders. Effec-
tive communication across disciplines is crucial in
Interdisciplinary Perspective order to implement the latest educational approaches
to the Study of Aging and Sexual and evidence-based strategies to address challenges
Minorities facing LGBT elders.
require cultural competency training for health- socialization, supportive case management ser-
care providers. Also, Chance proposes that as a vices, and training to help other service providers
national legislative and regulatory effort should be develop affirmative, supportive practices with
launched amending the ACA to focus on provi- helping these populations. The Center is the
sions aimed at the discrimination that causes largest LGBT community center in the world and
substandard provision of care to LGBT persons as includes a comprehensive health clinic, mental
well as cultural competency training to students in health clinic, legal services, senior services,
medical schools and existing practitioners. The youth shelter and services, substance abuse pro-
justification to amend the ACA to include provi- grams, and community cultural arts (Gratwick
sions requiring applicable agencies to issue rules et al. 2014). The Center’s continuum of services
aimed at increasing implementation and utilization is akin to the interdisciplinary approach men-
of LGBT-specific cultural competence training is tioned earlier in this chapter. The Center is
predicated upon the older adults’ participation in integrated in that it provides services to LGBT
Medicare and Medicaid programs and the agen- persons and to their heterosexual counterparts
cies’ recipients of federal research dollars. aged 50 and older.
LGBT persons, especially transgendered per- In an exploration of how to work toward an
sons, are subject to arbitrary and discriminatory interdisciplinary approach to assisting the LGBT
practices in private insurance coverage, which aging community, Abercrombie and Johnson
limit access to safe and competent care. Private (2007) reported the major themes of a Town Hall
health insurance plans often exclude coverage for meeting on aging in the LGBT community con-
medically necessary care related to gender tran- vened in Decatur, Georgia. The goal of the
sition, which can range from psychotherapy to meeting was to answer two questions: (1) What
medication, gender-specific examinations, and are the LGBT community’s most significant
surgical care (Auldridge and Espinoza 2013; concerns about its aging community members?
Feldman and Goldberg 2007). Auldridge and and (2) What are the approaches and actions that
Espinoza concluded that these practices are more can best improve the quality of life of the
devastating for LGBT elders of color who are growing number of aging LGBT community
concentrated in low- and fixed-income statuses. members? The most significant concerns identi-
The result is a wide disparity in health care for fied included a fear of aging; concerns about the
rich and poor and for Caucasian and ethnic and availability of money, housing, and services; and
sexual minority elders. retaining the ability to maintain as much control
over their lives as possible. The most important
approaches and actions to mollify these concerns
were as follows: (1) mobilization of the LGBT
Innovative Approaches to Improve community, (2) creation of alternative housing
Services for LGBT Elders and healthcare opportunities, (3) increase edu-
cation and research, (4) increase planning and
Cultural differences of LGBT elders are poles advocacy, (5) foster greater collaboration, and
apart from other older adults and should be taken (6) more effective communication through new
into consideration during assessment and in ser- technologies. Attention to such efforts, conducted
vice provision in order to reduce health, housing, on multiple levels and through a truly interdis-
and economic disparities (Pugh 2005). An ciplinary effort, would allow the reduction of
example of a program taking this approach is the socioeconomic disparities for LGBT elders.
Los Angeles Gay & Lesbian Center’s Seniors Services and Advocacy for Gay, Lesbian,
Services Department (hereafter referred to as the Bisexual and Transgender Elders (SAGE) and
Center). The Center responds to the needs of Movement Advancement Project (MAP) (2010)
LGBT elders with a three-pronged service offered broad-based recommendations for build-
approach that includes opportunities for ing change and improving the lives of LGBT
35 Trends, Implications, and Future Directions for Policy, Practice, and Research on LGBT Elders 663
elders. The first recommendation was to provide recommended the creation of structured data
immediate relief for LGBT elders through elements to allow for comparing and pooling
increasing funding for and provision of LGBT data to analyze the unique needs of LGBT per-
elder programs, affording immediate access to sons. However, in a study of the use of EHRs in
volunteer-based care, and providing education US hospitals, Jha et al. (2009) found that, con-
tools and legal services to LGBT elders. The trary to a consensus that the use of information
second recommendation was to create an effec- technology should lead to more efficient, safer,
tive LGBT aging infrastructure through the cre- and higher quality care, no reliable estimates of
ation and support of a much-needed advocacy the prevalence of adoption of EHR existed (see
infrastructure by building a strong coalition of Research Box 35.1).
allies. The third recommendation was to expand
an understanding of LGBT aging issues through
Research Box 35.1
advocating for more research on LGBT older
Jha, A.K., Des Roches, C.M., Campbell, E.
adults and generating a national public discus-
G., Donelan, K.D., Rao, S.R., Ferris, T.G.,
sion about LGBT aging issues.
Shields, A., Rosenbaum, S., & Blumenthal,
Electronic Medical Records. In addition, the
D. (2009). Use of electronic health records
agendas outlined above are the issue of electronic
in US hospitals. New England Journal of
record keeping and the data fields it captures.
Medicine, 360, 1628–1638.
Documenting patients and clients’ progress is
Objective: This study aimed to deter-
frequently linked to data. Given this situation, it
mine the extent to which large hospitals,
is only logical to gather data on sexual orienta-
teaching hospitals, non-teaching hospitals,
tion and gender identity (a) to increase providers’
and private hospitals adopt electronic
ability to screen, detect, and prevent conditions
health records.
more common in LGBT persons; (b) to create a
Method: All acute hospitals that are
better understanding of LGBT persons’ lives;
members of the American Hospital Asso-
(c) to allow comparison of patient/client out-
ciation were surveyed for the presence of
comes with national survey samples of LGBT
specific electronic record functionalities.
persons (Makadon and Cahill 2012); and (d) to
Using a definition of EHR based on expert
enhance the patient–provider interaction and
consensus, the proportion of hospitals that
regular use of health care (Healthy People 2020).
had such systems in their clinical areas was
Supporting the institution of these practices, in
determined. In addition, the relationship of
2003, the Institute of Medicine recommended
adoption of EHR with specific hospital
collecting data on sexual orientation and gender
characteristics and factors that were
identity in electronic health records (EHR) (see
reported to be barriers to or facilitators of
Table 35.2 for the core functions of EHR) and
adoption were examined.
Results: Based on responses from
Table 35.2 Core functions of electronic health records 63.1 % of hospitals surveyed, only 1.5 %
Health information and data
of US hospitals have a comprehensive
EHR system in all clinical units and an
Result management
additional 7.6 % have a basic system in at
Order management
least one clinical unit. Computerized pro-
Decision support vider order entry for medications has been
Electronic communication and connectivity implemented in only 17 % of hospitals.
Patient support Larger hospitals in urban areas and teach-
Administrative processes and reporting ing hospitals were more likely to have
Reporting and population health EHR. Capital requirements and high
Adapted from Institute of Medicine (2003)
maintenance costs were cited as the
664 P.B. Teaster and D.A. Harley
benefit LGBT elders. Prior to the ACA, one in Table 35.3 Core competencies for practice with LGBT
three lower income LGBT adults in the USA had elders
no health insurance. To remedy that situation, Critically analyze personal and professional attitudes
Section 1557 of the ACA prohibits discrimina- toward sexual orientation, gender identity, and age, and
understand how culture, religion, media, and health and
tion against individuals based on sex, sex ste- human service systems influence attitudes and ethical
reotyping, and gender identity. Even in light of decision-making
the potential benefits of the ACA for many Understand and articulate the ways that larger social and
LGBT elders, Heinz and Choi (2014) contend cultural contexts may have negatively impacted older
that the sweeping policy is only effective if adults as a historically disadvantaged population
people are aware of it and if outreach, education, Distinguish similarities and differences within the
and communication are instituted to ensure that subgroups of LGBT elders, as well as their intersecting
identities (i.e., age, gender, race, health status) to
LGBT persons have access to quality, affordable develop tailored and responsive health strategies
health care, and freedom from discrimination.
Apply theories of aging and social and health
Until these efforts are realized, LGBT elders will perspectives and the most up-to-date knowledge
be marginalized and oppressed, victims of a available to engage in culturally competent practice with
variety of disparities, health care being para- LGBT elders
mount among them. When conducting a comprehensive biopsychosocial
Practice. Culturally competent practice with assessment, attend to the ways that the larger social
context and structural and environmental risks and
LGBT elders in health and human services is an
resources may impact LGBT elder
area of critical need. Various disciplines and
When using empathy and sensitive interviewing skills
professional organizations (e.g., American Psy- during assessment and intervention, ensure the use of
chological Association, America Counseling language is appropriate for working with LGBT elders
Association, Commission on Certified Rehabili- to establish and build rapport
tation Counselors, Council on Social Work Understand and articulate the ways in which agency,
Education) “prioritize multicultural competency program, and service policies do or do not marginalize
as an essential factor in both educational training and discriminate against LGBT elders
and practice, with the inclusion of sexual and Understand and articulate the ways that the local, state,
and federal laws negatively and positively impact LGBT
gender minority groups in definitions of multi-
elders, to advocate on their behalf
culturalism” (Fredriksen-Goldsen et al. 2014,
Provide sensitive and appropriate outreach to LGBT
p. 82). The implementation of standards and elders, their families, caregiver and other supports to
policy statements by professional organizations identify and address service gaps, fragmentation, and
in their respective Codes of Ethics has propelled barriers that impact LGBT elders
LGBT persons into the forefront as populations Enhance the capacity of LGBT elders and their families,
that traverse a variety of practice settings and are caregivers, and other supports to navigate aging, social,
worthy of appropriate and quality treatment. and health services
Fredriksen-Goldsen et al. outline 10 core com- Adapted from Fredriksen-Goldsen et al. (2014)
petencies to improve professional practice and
service development to promote the health and elders will continue to be compromised by their
well-being of LGBT elders (see Table 35.3) in an relegation to less than full citizenship status.
effort to provide a blueprint for addressing the Research. Although more research on LGBT
increasing needs of this population, their fami- elders is available than in previous years, there
lies, and their communities. Those competencies remains a general lack of empirical research
were developed from existing LGBT health and (Hillman 2012) to inform future research as well
aging literature and, although the focus is on as the practice community. In part, two major
social work competencies, they are applicable to factors appear to contribute to limited research on
other disciplines. Until these competencies are LGBT elders: non-self-disclosure of sexual
addressed in part or in whole, the lives of LGBT minority status and lack of data collection on
666 P.B. Teaster and D.A. Harley
sexual minority status by investigators and service issues, practice, and research pertaining to LGBT
providers (Gratwick et al. 2014). Discussed ear- persons and aging: (1) discriminatory practices are
lier, the Town Hall meeting on aging in the LGBT a health risk; (2) stigma is associated with aging,
community, preparing for the future meeting in sexual orientation, and gender identity; (3) service
Decatur, Georgia, identified specific recommen- providers are in need of education and training
dations in the areas of education and research: to about aging and LGBT issues; and (4) research is
educate the LGBT community about aging issues needed to understand health and health outcomes
and to educate both the general public and the for LBGT elders. Without attention to these
organizations that should serve the needs of themes, improvements in the health and
LGBT elders (Abercrombie and Johnson 2007). well-being of LGBT elders will be sporadic—
HIV/AIDS and its implications for LGBT another in the list of disparities that this growing
elders is another arena where research is needed. and deserving population of elders faces.
Although HIV/AIDS has evolved into a chronic,
manageable disease due to the success of
anti-retroviral therapy, many persons aging with
HIV are living with considerable consequences of Resources
the disease as a result of early onset (i.e., often in
their 50 s) and of multiple comorbid health con- Center for Population Research in LGBT Health:
ditions, elevated mental health issues, substance www.lgbtpopulationcenter.org
abuse, stigma driven social isolation, and con- LGBT Aging Project: www.lgbtagingproject.org
comitant loneliness. Many LGBT elders who are Movement Advancement Project (MAP): www.
living with HIV face the disease without the social lgbtmap.org
support networks that they need to age success- Public Policy & Aging Report: www.aging-
fully, despite the fact that they have exhibited society.org
significant levels of resilience as long-term sur- Services & Advocacy for Gay, Lesbian,
vivors. Consequently, there continues to be an Bisexual & Transgender Elders (SAGE): www.
increased need for research focused on the medi- sageusa.org
cal management of HIV in the older population, The Fenway Institute: www.thefenway-
including sexual minorities. In addition, medical institute.org
providers must become better educated in the care The National Gay and Lesbian Task Force:
of older patients with HIV and risk assessment for http://thetaskforce.or13
HIV (Brennan-Ing and Karplak 2011). And, as a
part of an older patients’ health assessment,
questions about exposure to HIV should become
normative rather than atypical. Learning Exercises
Self-Check Questions
4. What are the major contributing factors to 4. Which of the following legislation prohibits
limited research on LGBT elders? discrimination bases on sex, sex stereotyping,
5. What concerns have LGBT elders identified and gender identity?
as the most important? (a) Americans with Disabilities Act
(b) Civil Rights Act
(c) Affordable Care Act
Experiential Exercises (d) Medicare
5. Which of the following is a logical reason to
1. Imagine that you have the ability to develop or gather data on sexual orientation and sexual
influence policy pertaining to LGBT elders. identity?
Select a specific area (e.g., health care, housing, (a) Increases ability to screen, detect, and
employment) and outline issues that need to be prevent conditions more common in
addressed, specify potential policy/solutions, LGBT persons
and how you would implement them. (b) Helps develop a better understanding of
2. Research an LGBT elder who has influenced patients’ lives
policy on older LGBT adults. How has he or (c) Allows comparison of patient outcomes
she been able to establish or change current with national survey samples of LGBT
policies? person
(d) All of the above
(e) None of the above
Multiple-Choice Questions 6. Which of the following is the intended pur-
pose of electronic health records?
1. Which type of approach to collaboration (a) Reduce duplication
occurs when experts or practitioners operate (b) Allow clinician to share information
outside their disciplines or specialty? (c) Improve quality of care
(a) Interdisciplinary (d) All of the above
(b) Transdisciplinary (e) None of the above
(c) Multidisciplinary
(d) Intradisciplinary Key
2. The Affordable Care Act has been criticized
for failure to do which of the following for 1-b
LGBT persons? 2-c
(a) Ensure access to health care 3-a
(b) Promote life care planning 4-c
(c) Ensure quality of care 5-d
(d) Promote a full spectrum of services 6-d
3. In addition to health disparities, which of the
following may be a reason for disparities
between LGBT and non-LGBT elders?
References
(a) LGBT elders place high value on
self-sufficiency
Acierno, R., Hernandez, M. A., Amstadter, A. B., Resnick,
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(Eds.), Casebook for counseling lesbian, gay,
Implications of DOMA
and the Supreme Court Ruling 36
on Same-Sex Marriage for Spousal
Benefits
Abstract
The purpose of this chapter is to examine the implications of the Defense of
Marriage Act (DOMA) and the Supreme Court ruling on same-sex marriage
pertaining to spousal benefits. The focus is on same-sex marriage, not
necessarily civil unions or registered domestic partnerships. Given this
ruling; first, this chapter will identify issues of concern emanating from both
sides of the debate on gay marriage that were presented to the Supreme Court.
Second, implications after DOMA in regard to Medicaid and Medicare
spousal protections; Supplemental Security Income (SSI) for the elderly,
blind, and persons with disabilities; military and spousal benefits; immigra-
tion; and private employment issues and benefits are discussed. Implications
for inheritance, power of attorney, and families of choice in hospital
visitations and medical decision-making are dispersed throughout the
discussion. The information presented in this chapter is intended to present
information to help guide thinking and actions of service professionals.
Keywords
The Defense of Marriage Act DOMA Same-sex marriage Gay
marriage
Kennedy wrote that allowed same-sex marriages “transgender people who are in marriages that
“conferred upon them a dignity and status of may be legally considered same-sex can now be
immense import.” Further, Kennedy asserted that confident that their marriages will receive the full
DOMA was written to convey moral disapproval respect and recognition they are entitled to from
of homosexuality and “a stigma upon all who the federal government” (http://www.transgender
enter into same-sex marriages made lawful by the lawcwnter.org/archieves/8493). For transgender
unquestioned authority of the states” (Gay & persons, recognition of their marriage as valid
Lesbian Advocates & Defenders [GLAAD] depends on what state they live in, what medical
2015) (see Table 36.1 for a list of consenting and procedures they have undergone, and whether
dissenting justices). Essentially, the repeal of or not an employer or insurer challenges their
Section 3 of DOMA expanded protections for marriage’s validity (http://www.transgender
legally married same-sex couples, granting them lawcenter.org/archieves/8493). Additional infor-
the same benefits received by opposite-sex mar- mation about transgender persons and marriage
ried couples. Dozens of lower court judges law is available at www.lambdalegal.org/know-
interpreted Kennedy’s opinion to mean that your-rights/transgender/trans-marriage-law-faq
states’ bans violate constitutional rights as well (see Chap. 14 in this text for further discussion on
(GLAAD 2015). transgender persons).
A fact sheer series produced by the Human
Rights Campaign (n.d.) produced the fact sheets
series, After DOMA: What it Means for You, and
Supreme Court Ruling on Same-Sex
begins with the following response:
Marriage: To Be Determined
The Supreme Court victory in USA v. Windsor
striking down the discriminatory federal Defense The process that determines the fate of the legal
of marriage Act (DOMA) affirms that all loving
and committed couples who are married deserve
recognition of same-sex marriage is set in
equal legal respect and treatment from the federal motion. The High Court heard oral arguments in
government. The demise of DOMA marks a April and rendered a decision on June 26, 2015.
turning point in how the US government treats the The Supreme Court decided that freedom to
relationships of married same-sex couples for
federal programs that are linked to being married.
marry a person of one’s choice is a constitutional
At the same time, a turning point is part of a longer right. Prior to this ruling, both proponents and
journey, not the end of the road. There is much opponents of same-sex marriage agree that the
work ahead before same-sex couples living across Supreme Court has set the stage for a potentially
the nation can enjoy all the same protections as
their different-sex counterparts (http://www.hrc.
historic ruling. According to Sherman (2015):
org/resources/entry/doma-get-the-facts). Proponents of same-sex marriage said they expect
the high court to settle the matter once and for all
Ilona Turner, legal director of the Transgender
with a decision that invalidates state provisions
Law Center in San Francisco, indicated that that define marriage as between a man and a
marriage equality is an issue that affects many woman. On the other side of the issue, advocates
transgender persons in the USA. Turner added, for traditional marriage want the court to let the
political process play out, rather than have judges
order states to allow same-sex couples to marry.
Table 36.1 Consenting and dissenting justice on DOMA (p. 1)
Table 36.2 Hospitals’ written policies and procedures on patients’ visitation rights
Inform each patient of his or her right to receive visitors whom he or she designates, including domestic partner
Do not restrict or limit visitation rights based on sexual orientation and gender identity, among other factors
Ensure that all visitors have full and equal visitation rights, consistent with a patient’s wishes
Adapted from http://www.hrc.org/resources/entry/hospital-visitation-guide-for-lgbt-families
couple’s situation is unique and may change Supplemental Security Income (SSI).
from year to year. With the invalidation of The SSI programs pay cash benefits to people
DOMA, the following are a few tax issues that who are at least age 65 and meet financial limits
may affect married same-sex couples. For filing or have severe disabilities and very limited
status (i.e., single, head of household, married income and resources (www.ssa.gov/pgm/ssi.
filing jointly, married filing separately), only htm). It is more difficult for a married couple
married couples can file as married, whether living together to qualify for SSI than when not
jointly or separately. Filing status is determined living together. A married couple (both age
on the last day of the year. For example, persons 65 years or older) living together who meets the
who are married on the last day of the year are Social Security Act disability standard must
considered married for the entire year. It is apply for SSI as a couple. For married couples
believed that the Internal Revenue Service living together, with only one spouse meeting the
(IRS) will instruct married same-sex couples to age of disability standard, the qualifying spouse
file income taxes as married, whether jointly or must apply as an individual. However, the
separately. If the individual is considered married income and resources of the ineligible spouse
in his or her state of permanent residence, that will be considered (i.e., deemed) to constitute the
practice seems to suggest that only people in income and resource of the spouse applying for
states that license or recognize marriages of SSI as stipulated by a formula set forth in SSI
same-sex couples and in the D.C. can expect to regulations. Marital status is based under the
be treated as married by the IRS. However, the statute on “appropriate state law,” and regula-
IRS does not always follow this practice; for tions further specify that the law of the state
example, the IRS recognizes “common law” where the couple principally lives (i.e., domicile)
marriages for federal tax purposes no matter at the time of application should apply. Under
where a couple resides as long as their marriage additional statutory provisions, even if the mar-
was valid where entered (http://hrc-assets.s3- riage is not recognized by the state where the
website-us-east-1.amazonaws.com/files/assets/ couple lives, the couple will nevertheless be
resources/Post-DOMA_FSS_Federal-Taxes_v3. considered married for SSI purposes if a spouse
pdf). can inherit personal property from the other
Social Security. Although the Social Security without a will under the state’s law as would a
Administration (SSA) has yet to issue specific spouse (http://hrc-assets.s3-website-us-east-1.
guidance on eligibility for benefits for same-sex amazonaws.com/files/assets/resources/Post-
couples nationwide, including eligibility DOMA_SSI_v2.pdf).
depending on whether persons live in a state that A married same-sex couple living in a state
bars marriages, a state with some alternative that respects the marriage will be regarded as
status such as civil unions, domestic partner- married for SSI purposes, and the income and
ships, or designated beneficiaries, or living in a resources of both spouses will be taken into
marriage state, SSA should still accept an appli- account to determine SSI eligibility and benefits.
cation for benefits, while these determinations It is uncertain what this means for married
are being made. Nevertheless, in 2013, the SSA same-sex couples who live in a state that does not
announced that it was processing some retire- recognize their marriage. The couple would not
ment spousal claims for same-sex couples be regarded as married under the law of their
(http:///hrc-assets.s3-website-us-east-1.amizo- state of domicile. However, it is possible that the
naws.com/files/assets/resources/Post-DOMA_ couple could be construed as “holding them-
FSS_Federal_Social-Security_v3.pdf). Addi- selves out” as married to the community and
tional information from SSA about benefits for hence subject to the rules for married couples for
same-sex couples and family members is avail- federal SSI purposes. A section of the Social
able at http://ssa.gov/doma/. Security Act provides that, even if there is no
36 Implications of DOMA and the Supreme Court Ruling … 677
recognized marital relationship, if two individu- Medicare is as simple as turning 65 years old, but
als hold themselves out as “husband and wife” to other aspects of the program, such as require-
the community in which they reside, they will be ments and amounts of premiums, eligibility for
regarded as a married couple for SSI eligibility certain types of plans, and timing of enrollment,
purposes. Efforts may be made in may depend on work history, access to other
non-recognition states to apply this “holding out” health care, health status, and income. In several
provision to same-sex partners in evaluating eli- situations, having a spouse may alter the way
gibility for SSI (http://hrc-assets.s3-website-us- benefits are accessed. Additional information is
east-1.amazonaws.com/files/assets/resources/ available at www.medicare.gov or www.ssa.gov/
Post-DOMA_ssI_v2.pdf). pgm/medicare.htm.
Medicaid. Medicaid is a federal-state health Medicare defines the same definitions as
insurance program targeted for very low-income Social Security. According to the Medicare
people who meet certain guidelines. Medicaid guidelines, a person is a spouse if (a) he or she
also provides insurance coverage for long-term has a valid marriage under the law of the state
care for persons who qualify. Each state has it where he or she lives at the time of filing for
own Medicaid program that is partially funded by benefits, or (b) he or she has the same rights as a
the federal government. Although there are some husband or wife for purposes of the distribution
federal requirements that states must follow, each of intestate personal property under the laws of
state has different rules about who qualifies for the state where he or she lives at the time of filing
Medicaid and what is covered. The Affordable for benefits. This definition also applies to mar-
Care Act (ACA) made Medicaid available to all ried same-sex couples who live in a state that
very low-income people regardless of whether recognizes their marriage. For married same-sex
they have a child, a disability, or are elderly; couples living in states that discriminate against
however, under the recent Supreme Court ruling their marriages, federal law likely prevents them
about ACA, not every state has to expand Med- from accessing spousal benefits. If a partner
icaid under the law. In states that choose not to applied for benefits while living in a state that
expand Medicaid, the old eligibility rules will still recognized the marriage or allowed the spouse to
apply. Many states that have marriage equality inherit without a will as a spouse and only moved
did not treat same-sex married couples as married after the commencement of receiving benefits, he
for many Medicaid programs. Given that the or she should continue receiving Medicare ben-
Medicaid program is limited to very low-income efits in the new home state, regardless of the
people, who is considered to be a family member relationship recognition laws in that state because
for the purposes of determining family income benefits are determined by the marital status in
and assets impact eligibility for Medicaid (http:// the state in which application was made for
hrc-assets.s3-website-us-east-1.amazonaws.com/ benefits (http://hrc-assets.s3-website-us-east-1.
files/assets/resources/Post-DOMA_MEDICAID_ amazonaws.com/files/assets/resources/Post-
v3.pdf). Additional information is available at DOMA_Medicare_v3.pdf).
www.helthcare.gov or www.medicaid.gov. Military Spousal Benefits. For members who
Medicare Spousal Protections. Medicare is a are in the active military, reserves, and National
federal health insurance program for adults aged Guards, by statute a spouse is a husband or wife
65 and older, as well as for certain younger as the case may be. In 2013, the Secretary of
people with disabilities. Medicare has four parts: Defense wrote in a memo that:
(a) Part A, hospital insurance; (b) Part B, medical
In the event that the Defense of marriage Act is no
insurance; (c) Part C, Medicare Advantage Plans, longer applicable to the Department of Defense, it
which are private health plans that contract with will be the policy of the Department to construe
Medicare to provide both Part A and Part B the words “spouse” and “marriage” without regard
benefits; and (d) Part D, prescription drug cov- to sexual orientation, and married couples, irre-
spective of sexual orientation, and their
erage. For most people, becoming eligible for
678 D.A. Harley and P.B. Teaster
dependents, will be granted full military benefits celebration” rule, so that spousal status is asses-
(http://www.defense.gov/news/Same- sed according to the law of the state where one
SexBenefitsMwemo.pdff).
married or secured a spousal status. This is the
With the High Court striking down DOMA, standard DOD and the military use, where there
the DOD construes the statutory definition of is no statute specifying a place of residence rule.
spouse as inclusive. Generally, the military con- Unless a “place of celebration” rule is established
siders marriage valid if it was valid in the state for the VA, if a veteran and his or her spouse
where the marriage took place. A state-issued traveled from a state that would not recognize the
marriage certificate is normally all the evidence marriage in order to marry in a state that recog-
necessary to demonstrate that the marriage was nizes the marriage of same-sex couples and lived
considered valid by the state. Generally, mar- in a non-recognition state when their veteran’s
riages entered into foreign countries to foreign benefits took effect, they will likely not be con-
nationals must be approved by the military ser- sidered married for purposes of the VA (http://
vice beforehand. The military determines a hrc-assets.s3-website-us-east-1.amizonaws.com/
marriage to be valid based on the law of the state files/assets/resources/Post-DOMA_FSS_
where the marriage took place; thus, it should not Veteran_Spousal_Benefits_v3.pdf.
matter in what state the couple lived when they Immigration (binational). Immigration is a
married, what state they moved to after the complicated area of law, with many factors spe-
marriage, or where a spouse was stationed cific to each individual. Before the repeal of
around the world. Once a spouse is recognized DOMA, LG persons were advised not to marry
by the military as a spouse, the laws of the state their partner, because for the most common type
in which the couple lives no longer play a role in of non-immigrant visas (e.g., tourist, student), the
whether either spouse is eligible for spousal foreign national entering the USA must demon-
benefits from the military (http://hrc-assets.s3- strate to US immigration officials that he or she
website-us-east-1.amazonaws.com/files/assets/ does not have the intent to remain in the USA.
resources/POST-DOMA_ Now, however, it is anticipated that for those
MilitarySpousalBenefits_v3.pdf). seeking permanent resident status in the USA
Veteran’s Spousal Benefits. Two categories based on marital relationship, in many cases it
of veterans receive benefits from the Department will make sense to marry and file for permanent
of Veterans Affairs (DOA): qualified non-retired benefits. Furthermore, in many cases, an LG
(those who meet eligibility requirements for person can marry his or her partner and sponsor
specific benefits usually related to time-in-service him or her for a green card. Options for families
and discharge characterization) and retirees will vary from case to case, based upon a number
(those who served at least 20 years in the military of factors including whether the partners are
and who formally retired from military service). living together or in different countries; whether
A veteran spouse or surviving spouse is defined the partners are living together in the USA or
as a person of the opposite sex who is a wife or abroad; whether the partners have married;
husband. However, the repeal of DOMA appears whether the partners can marry; and for families
to make these definitions constitutionally invalid together in the USA, whether the non-US citizen
and no longer enforceable. On the other hand, the partner arrived here after having been inspected
statutes that govern veteran’s benefits contain by an immigration officer or whether the partner
problematic provisions for determining when a entered without inspection. Same-sex couples
marriage is valid. Because determination of will also have to meet the general criteria for
marriage validity derives from federal statues, marriage-based immigration. Other consider-
action will likely be required by the courts or ations are specific for immigrants who are in
Congress. A better standard would be a “place of lawful immigration status versus those who are
36 Implications of DOMA and the Supreme Court Ruling … 679
equality state, this scenario holds regardless of residence, a shared social or personal life, and a
the gender of the spouses. This chain of succes- relationship that exhibits a particularly high level
sion may provide a modicum of protection, of closeness and care” (p. 7). In other words,
although not to the same extent as a compre- consideration for surrogacy should not be based
hensive estate plan. Difficulties could arise if a simply on biological relationship as opposed to
same-sex couple marries in a marriage equality family of choice.
state and then moves to a non-recognition state.
There, should one spouse die without a will, the
surviving spouse will likely not receive the
deceased spouse’s assets, and surviving children Families of Choice in Hospital
might not either. The deceased spouse’s assets Visitation and Medical
could then be distributed to his or her relatives, Decision-Making
often contrary to his or her intent (Human Rights
Campaign 2013). The right to make medical decisions is a protected
Consequently, contents on the Web site of the individual right held solely by a patient who is
Human Rights Campaign (2013) urge the LGBT competent and able to make such decisions. The
community to treat such matters formally, with- expanded scope of exclusivity of this right to
out relying on default rules of state law. The Web privacy of patient information and records has
site emphasizes that eliminating DOMA addres- limited a patient’s spouse, domestic partner, and
sed only some life and estate planning concerns other family members’ access (Vergari 2007). In
of married same-sex couples while creating 2010, President Obama issued a presidential
complexities for others. For instance, federal memorandum on hospital visitation that called for
benefits and protections available to same-sex “appropriate rulemaking … to ensure that hospi-
couples may depend on where the couple was tals that participate in Medicare or Medicaid
married or on where they currently live. More- respect the rights of patients to visitors.” The
over, the Web site emphasizes that although recommendation was for the US Department of
overturning DOMA was a major victory for the Health and Human Services (HHS) to develop
LGBT community, it does not reduce or elimi- guidelines for hospital visitation that prohibit
nate the need for comprehensive life and estate discrimination based on race, color, national ori-
planning. In light of the DOMA ruling, it is gin, religion, sex, sexual orientation, gender
critically important that all same-sex couples identity, or disability. Later that year, HHS issued
work with their financial and legal advisers to regulations that prohibit these types of discrimi-
review their life and estate plans (Human Rights nation in hospital visitation and make it clear that
Campaign 2013). In addition, the National Cen- designated visitors should be permitted access to
ter for Lesbian Rights (NCLR 2011) recom- patients regardless of whether or not they have a
mends the person selected as the surrogate legally recognized relationship. In addition, these
decision-maker should be the person most regulations require hospitals to have written
likely to be knowledgeable about the individual’s guidelines and inform patients of their visitation
wishes. In comments submitted to the Centers for rights. A year later, HHS released a guidance
Medicare and Medicaid Services for a model for letter to implement and enforce visitation,
determining medical decision-making and healthcare proxy, and advance directive require-
advance directives for LGBT patients, NCLR ments. In tandem with the presidential memo-
stated the policy should not rely on an arbitrary randum and HHS guidelines, additional
ranking of family members. Instead, “determi- non-discrimination protections are in the ACA’s
nation should be based on proof of a close, non-discrimination provision, Section 1557 (Riou
personal relationship such as proof of shared 2014). For hospitals participating in Medicaid
36 Implications of DOMA and the Supreme Court Ruling … 681
and Medicare, see Table 36.2 for requirement of into believing that their rights extend further than
written policies and procedures regarding they do in specific areas of medical practices,
patients’ visitation rights. particularly misinterpretation of surrogate
The law explicitly grants same-sex couples decision-making. For example, “many LGBT
equal or substantially equivalent standing to patients mistakenly believe that they have been
other family members in 36 states, and D.C. Law granted additional federal rights to make
offers limited recognition of same-sex partners end-of-life decisions for their loved ones when,
through broad language in five states. Same-sex in fact, they have not” (p. 802). Wahlert and
couples are treated as legal strangers in nine Fiester urged that, as policies are being devel-
states. Of LGBT persons covered by laws, 75 % oped and implemented, policymakers must be
live in states with inclusive medical careful not to overstate the ground being gained.
decision-making laws, 4 % live in states with
limited recognition of same-sex couples, and
23 % live in states where same-sex couples are
treated as legal strangers (Movement Advance- Summary
ment Project 2015).
It is especially important for LGBT persons to Certainly, the impending US Supreme Court
take steps to ensure that the people whom they decision concerning DOMA will be a landmark
choose may visit them and make medical deci- civil rights decision concerning the rights of all
sions on their behalf in an emergency situation LGBT persons, especially those who are elderly.
and to protect visitation and decision-making Historically, marriage and its attendant benefits
rights: (a) complete advance healthcare directives have been the purview of states, and as such, the
and visitation authorization forms, (b) talk with a federal government has been loathe to interfere.
primary care physician about preferred visitors However, in the USA v. Windsor, the US
and advance healthcare directives, (c) work with Supreme Court held that “the federal government
local hospitals to file completed forms, and could not refuse to recognize or provide benefits
(d) carry information related to advance health- to people in same-sex marriages that were con-
care directives and visitation authorization forms ducted in states where they were legal” and that
in a wallet or other readily accessible area for withholding federal recognition of same-sex
emergencies (Human Rights Campaign 2011). married couples “places them in an unstable
Additional information on living will, healthcare position of being in second-tier marriages” and
proxy, and other medical decision-making tools “demeans the couple.” Also, the military has
is available at http://www.hrc.org under the tag, liberalized its policy to allow same-sex couples
working for LGBT equal rights. to have rights commensurate to those of
Despite pro-LGBT healthcare different-sex couples. And with the Supreme
decision-making rights recommendations and Court ruling on same-sex marriages, other rights
policy released by the Obama administration, the and benefits should follow. Still, in every domain
Institute of Medicine, and HHS, Wahlert and —Medicare, Medicaid, Social Security, estate
Fiester (2013) warn of a false sense of security planning, surrogate decision-making, and immi-
concerning surrogate decision-making rights for gration—the law is “not quite there” yet, and so
LGBT patients and families in the American caution is urged. At the time of this writing, the
healthcare system. The authors proposed that, best defense appears to be a formal and legal one
“new regulations on surrogate decision-making rather than relying on any other mechanism. Of
merely invoke a sense of universal patient rights course, the US Supreme Court ruling that
rather than actually generating them” (p. 802). DOMA is unconstitutional, such cautionary
LGBT patients are vulnerable to being mislead advice may not be needed.
682 D.A. Harley and P.B. Teaster
Resources
B
Beneficence, 639, 641, 642, 650, 652 F
Bisexual, 417, 418, 423, 431, 435 Faith communities, 525–529, 531, 536, 539, 540
Black, 106–127 Family of choice, 44, 54, 57, 189
Body image, 456, 460, 461 Family of origin, 48–50, 54
Bullying, 359–369 Family of procreation, 44, 57
Fidelity, 639, 649, 652
Frontier, 495, 496, 499
C Future trends, 658, 664, 665
Canadian aboriginal two-spirit, 137, 144, 145, 148
Care network, 83, 84, 92–94
Chosen kin, 47, 49, 57 G
Chronic illness, 619, 620, 622–624 Gay, 417, 418, 420, 421, 423, 428–430
Codes of ethics, 639, 641, 645, 646 Gay affirmative therapy, 590–592
Community reentry, 248 Gay marriage, 672
Community reintegration, 242, 255 Gay psychotherapy, 586
Criminal code, 518, 522 Gender identity development, 12
Cultural competence, 192, 401, 403–405, 586 Geographic location, 494
Cumulative advantage/disadvantage, 262, 273, 277 GLBT, 430
D H
The Defense of marriage act (DOMA), 671–676, Health disparities, 110, 121, 122, 125, 126, 398, 401, 405,
678–681 406, 409
Demographic characteristics, 37 Healthcare reform, 377, 382–385
I N
Immigrant/Immigrant population, 201–206, 209, Native pacific islander, 159, 160, 168
261–265, 269, 272–274, 276, 277, 279 Non-disclosure, 398–401
Incapacity, 439, 440, 447 Nonmaleficence, 639, 652
Inclusion, 563, 564, 569, 571, 574–576
Inheritance, 439, 442, 448, 449, 451
Intersection of identities, 83, 88, 89, 95 O
Intersectionality, 179, 183, 240, 245, 256 Older adult, 419, 430, 435
Isolation, 564–566, 568, 569, 571, 574, 576 Organizational intervention, 366, 368
J P
Justice, 639, 641, 642, 647, 649, 652 Peer victimization, 360, 363, 364
Policy, 325, 601–604, 606, 608, 609, 611–614, 657, 658,
661, 664–666
L Politics, 539
Late-onset, 620 Population, 28–35, 37–39
Latino, 199–212, 214, 216 Practice, 657–659, 662–666
Law, 546, 548 Prescription medication, 474, 475
Law enforcement, 514–522 Presumptions, 439, 441, 445, 448, 451
Law enforcement policies, 517 Prisons, 240, 241, 244, 246, 255
Law enforcement training, 514 Public health, 241, 242
LBGT community, 514–521 Public policy, 548, 553
Legislation, 558, 603, 605
Lesbian, 418, 420, 421, 423, 430, 431, 435
LGBT, 28–31, 35–39, 106–127, 200–203, 205–208, 210, Q
212–214, 216, 217, 292, 293, 299, 304, 325, 326, Queer theory, 316
328, 331, 417–423, 425–430, 601–614
LGBT elders, 73, 75, 160, 166, 168, 172, 173, 343–346,
348, 349, 351–354, 549, 552, 553, 556, 657–666 R
LGBT elders health, 376–378, 380 Race, 83, 85, 86, 88, 89, 91, 92, 95
LGBT families, 44–48, 54, 55, 57 Racism, 72, 73, 77
LGBT health disparities, 376, 377, 379, 385 Recreation, 564, 569
LGBT issues, 242 Relational aggression, 359, 360, 362, 365, 367, 368
LGBT mental health, 462, 467 Religion, 525–529, 531–534, 539, 540
LGBT seniors, 588, 597 Religious leaders, 527–529, 531, 534, 537–540
LGBT theories, 4 Remote communities, 495
LGBT veterans, 223–225, 227, 228, 230–234 Research, 657, 658, 660, 661, 663–666
Life course, 262, 273, 274, 277 Rural, 493–499, 501, 502, 504–507
Life span development theories, 4, 7
Long-term care, 418, 419, 421, 425–427, 430, 431
S
Same-sex couples, 200, 207
M Same-sex marriage, 671, 672, 673–675, 679
Mental health, 474, 475, 477, 479, 481, 482, 485, 486 Senior citizen centers, 566, 571, 578
Mental health counseling, 455, 456, 467 Services, 325, 327, 330, 332, 333, 335–337
Microaggression, 361–363, 365 Sexual orientation identity development, 10, 11
Military personnel, 223, 224, 227 Sexuality, 83, 86, 87, 91, 92, 95
Minority stress, 398, 400 Small town, 493–495, 497
Minority stress theory, 456, 458 Social integration, 240, 244
Mistreatment, 343–347, 349, 351–354 Social isolation, 344, 346
Index 691