35. Trends, Implications, and Future Directions for Policy, Practice, and Research on LGBT Elders

LGBT elders struggle with the same issues about aging as the broader community and with unique concerns that are not represented by mainstream institutions and laws (Abercrombie and Johnson 2007). This chapter is both a capstone of the previous chapters in this book and a roadmap for discussion of trends and future directions of policy , practice, and research on LGBT elders . The intent is to focus on gaps that remain to be addressed. Legal standing for same-sex couples is a hotly debated issue. Over the past two decades, American voters have voted numerous times on the rights of LGBT persons, and more often than not, the outcomes have not been favorable (Russell 2012). Integration of sexual orientation and gender identity into current legislation pertaining to aging and older persons remains tenuous at best. Comprehensive healthcare and social policies and practices that are inclusive and sensitive to the unique needs of LGBT elders remain elusive. In addition, variation in state and local policy regarding LGBT persons adds another dimension for consideration. Although policy, practice, and research on LGBT elders are limited in comparison with their non-LGBT counterparts, transgender persons are the most marginalized, excluded, and discriminated against of all sexual minorities or gender-variant persons. However, there appear to be hopeful signs that the tide of public opinion is changing with such initiatives as the repeal of DOMA and the election of an openly gay bishop by one of the mainline churches.

It is difficult to imagine that any sector of the aging population as a whole has been ignored or under-investigated, particularly given the plethora of scholarly and practice gerontological literature that has been produced over the past fifty years. Robert Hudson, highly recognized scholar of aging policy for over 30 years, observes, “…LGBT older adults have remained nearly invisible to the community of advocates, researchers, practitioners, administrators, and politicians who associate themselves with the modern aging enterprise” (Hudson 2011, p. 1). Though topics of sexual orientation and gender identity among middle-age and older adults are rarely addressed in health and human service delivery training or in educational degree programs (Fredriksen-Goldsen et al. 2014), more clinicians, counselors, social workers, and human service providers are finding themselves working with LGBT elders . In order to help LGBT persons at any age, it is important to understand LGBT issues and stigma, as well as to become aware of available resources, or the lack thereof (Hillman 2012). According to Fredriksen-Goldsen et al. (2014), “health and human service providers must comprehend the intersectionalities of history, social structures, and cultural factors and how they have shaped the life experiences of LGBT elders. In addition, practitioners must identify the typical and the highly unique, yet normative experiences of LGBT people as they age, recognizing distinct transitions over the life course, such as identity management (e.g., coming out or not), and how they influence service use” (p. 86).

Although older, baby boom, and younger LGBT persons share common themes such as concerns about coming out, difficulties with prohibitive religious beliefs, anxiety about HIV and AIDS, disparities in health care and job 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 when the prevailing social norm was to ignore or subvert homosexual tendencies and to ascribe to traditional family values and relationships. Consequently, they (a) are less likely to receive vital information about HIV education, treatment, and prevention (Makadon and Cahill 2012; National Institute on Aging 2009), (b) have fewer family members available to tend to basic and instrumental needs, (c) are more likely to have endured persecution by the community at large, (d) encounter difficulties forming informal social support groups or romantic relationships because they are less likely to easily identify one another due to concern about revealing LGBT identity, and (e) were raised in a generation in which one was not forthcoming about one’s sexual preferences (Hillman 2012; MetLife Mature Market Institute 2010). Each of these issues influences policy development, service delivery, and research foci for LGBT elders .

Substantial differences with their heterosexual counterparts persist for LGBT elders in important domains such as health care, housing, socioeconomic status, social isolation, equal treatment under the law, and targeted programming. At both younger and older ages, LGBT persons remain “invisible” in healthcare settings (Makadon and Cahill 2012). Clinicians, most of whom receive little or no training regarding sexual orientation and gender identify, rarely if ever inquire about their patient’s sexual history, sexual orientation, and gender identity (Makadon and Cahill).

As with practice settings, a growing body of research literature suggests that LGBT elders are discriminated against by health and social service providers: many have received substandard care because of their LGBT identities (Gratwick et al. 2014). Even when providers of aging services indicate a willingness to become more responsive to the needs of LGBT elders (e.g., relevant staff training), evidence suggests that they rarely follow through (Knochel et al. 2012). According to Gehlert et al. (2010, p. 408), “because the determinants of disparities occur at multiple levels, from the molecular to societal and interact with one another in ways not yet fully understood, they represent a challenge to researchers attempting to capture their complexity.”

The San Francisco LGBT Aging Policy Task Force (2014) identified key areas of concern and associated solutions to address: data collection, cultural competency, health and social services, housing, and legal services (see Table 35.1). In (2012), a summit hosted by Healing Detroit (an African American LGBT initiative) and the LGBT Older Adult Coalition was held to explore the needs and experiences expressed by LGBT elders on their experiences and concerns about aging in the Detroit area. The Coalition attracted a mainly Caucasian audience from the suburbs, while Healing Detroit attracted primarily an inner city African American audience. In exploring similarities and differences faced by each of these groups, Lipscomb and LaTosch (2012) reported that (a) mature LGBTQ persons are isolated by their community, and their peers are self-afflicted; (b) if they relocated to a senior living facility, mature LGBTQ persons are most likely sent back into the closet; (c) the LGBTQ community is youth-oriented to the point that women and men aged 55 and over cannot relate to the present social network; (d) financially and career successful women and men aged 55 and over are becoming increasingly isolated by their education, career climbing, and inadequately developed partnerships and community network building; (e) current LGBTQ women and men aged 55+ have lived an isolated lifestyle that has not condoned discussion of issues such as physical illness, financial troubles, and personal relationships; and (f) the younger cohort of baby boomers includes women and men aged 55+ who are not as economically able for their final years as their same-gender counterparts. Older and retired LGBT persons have concerns (e.g., healthcare affordability, competent care) different from their younger counterparts (e.g., housing, independence).

The most common concern for both inner city African American LGBT elders and their suburban Caucasian counterparts was social isolation created by feeling unwelcome at social activities in an LGBT community geared for younger persons, fear of social ostracism within the mainstream senior social community, and unwelcome senior living communities. The most significant difference between them was African American LGBT elders ’ challenges of living in the city (e.g., unemployment, poverty, systemic racial inequity issues) and Caucasian suburban LGBT elders’ challenges for acquiring culturally competent healthcare and appropriate housing options (Lipscomb and LaTosch 2012). Findings by Lipscomb and LaTosch are consistent with results from other studies (e.g., Espinoza 2013, 2014; Fredriksen-Goldsen et al. 2011; Kim and Fredriksen-Goldsen 2014) and other sources reported in this book.

In addition to health disparities, research findings point to other legal, political, and social issues that significantly impact the health and well-being of LGBT persons (Ard and Makadon 2012). One important and highly visible issue is the heated debate over the legality of same-sex marriage, along with it associated benefits. According to Badgett (2011), the right to marry is associated with greater feelings of social inclusion among LGBT persons, whether married or not. Another issue is that, across the lifespan, LGBT elders may experience violence and mistreatment at higher rates than do heterosexual elders and are at high risk for elder abuse, neglect, and exploitation (MAP et al. 2010). Although his work on elder mistreatment did not address LBGT elders, the national prevalence study by Acierno et al. (2010) identifies that elders most at risk are those who have a lack of social support and who were previously exposed to a traumatic event, situations that are very common for LGBT elders. A third issue is that gay men and lesbians tend to place high value on self-sufficiency and thus may hesitate to accept assistance in old age (SAGE and MAP 2010). Such hesitation may well increase the vulnerabilities to mistreatment cited previously. Finally, in addition to hereditary factors, general socioeconomic, cultural, and environmental conditions; living and working conditions; social and community influences; and individual lifestyle factors constitute social determinants influencing disparities between and among LGBT elders (Makadon and Cahill 2012).

Three major approaches to collaboration are multidisciplinary, interdisciplinary, and transdisciplinary. Multidisciplinarity involves experts, researchers, or service providers from a variety of disciplines working together, but with each approaching the issue at hand through his or her own disciplinary lens. Interdisciplinarity has the goal of transferring knowledge from one discipline to another and allowing experts, researchers, or service providers to inform one another’s work and discuss and compare their individual findings. Transdisciplinarity is collaboration in which experts, researchers, or service providers operate outside their disciplines or specialties (Gehlert et al. 2010). Each represents an improvement over a monodisciplinary approach in that it can capture the multifaceted and complex nature of the causes and consequences of group differences, “with disciplinary scholars operating in concert at more than one level throughout the entire research process” (Gehlert et al. 2010, p. 410). Similarly, service providers gain a better understanding of the multiple needs of LGBT elders and of how to provide services in a more integrated and comprehensive way. Although the approach used to collaborate may be determined by one’s discipline, specialty, or setting, the acknowledgment of different perspectives to service delivery will advance access and quality of service to LGBT elders .

Human and social service, medical, nursing, and health sciences disciplines represent many of the professions that knowingly or unknowingly work with LGBT elders. A major challenge across disciplines is the lack of understanding concerning how to educate people to engage in an interdisciplinary approach for examining the impact of contextual factors on the lives of LGBT elders . Disciplines typically teach and train service providers in isolation, resulting in disciplinary myopia—a lack of awareness and understanding of competencies and expectations of practitioners with whom they will work in delivering services to LGBT elders. Effective communication across disciplines is crucial in order to implement the latest educational approaches and evidence-based strategies to address challenges facing LGBT elders.

Chance (2013) argued that while the Affordable Care Act (ACA) will likely help remedy some of the discrimination that results in the LGBT community’s disparate access to health care, it is ineffective in combating broader LGBT healthcare discrimination. Its reformatory focus is on increasing access to care; however, it fails to address the specific needs of the LGBT community and the stigma that results from lower quality care. Chance believes that the social stigma associated with a patient’s LGBT status is the driver of gaps in access to quality healthcare services, the result of which causes him or her to delay seeking health care when needed or to avoid it altogether. Thus, there is a need to shift the policy and regulatory focus toward improving the quality of health care for LGBT persons, to remedy the LGBT community’s disparate healthcare status, and to require cultural competency training for healthcare providers. Also, Chance proposes that as a national legislative and regulatory effort should be launched amending the ACA to focus on provisions aimed at the discrimination that causes substandard provision of care to LGBT persons as well as cultural competency training to students in medical schools and existing practitioners. The justification to amend the ACA to include provisions requiring applicable agencies to issue rules aimed at increasing implementation and utilization of LGBT-specific cultural competence training is predicated upon the older adults’ participation in Medicare and Medicaid programs and the agencies’ recipients of federal research dollars.

LGBT persons, especially transgendered persons, are subject to arbitrary and discriminatory practices in private insurance coverage, which limit access to safe and competent care. Private health insurance plans often exclude coverage for medically necessary care related to gender transition, which can range from psychotherapy to medication, gender-specific examinations, and surgical care (Auldridge and Espinoza 2013; Feldman and Goldberg 2007). Auldridge and Espinoza concluded that these practices are more devastating for LGBT elders of color who are concentrated in low- and fixed-income statuses. The result is a wide disparity in health care for rich and poor and for Caucasian and ethnic and sexual minority elders.

Cultural differences of LGBT elders are poles apart from other older adults and should be taken into consideration during assessment and in service provision in order to reduce health, housing, and economic disparities (Pugh 2005). An example of a program taking this approach is the Los Angeles Gay & Lesbian Center’s Seniors Services Department (hereafter referred to as the Center). The Center responds to the needs of LGBT elders with a three-pronged service approach that includes opportunities for socialization, supportive case management services, and training to help other service providers develop affirmative, supportive practices with helping these populations. The Center is the largest LGBT community center in the world and includes a comprehensive health clinic, mental health clinic, legal services, senior services, youth shelter and services, substance abuse programs, and community cultural arts (Gratwick et al. 2014). The Center’s continuum of services is akin to the interdisciplinary approach mentioned earlier in this chapter. The Center is integrated in that it provides services to LGBT persons and to their heterosexual counterparts aged 50 and older.

In an exploration of how to work toward an interdisciplinary approach to assisting the LGBT aging community, Abercrombie and Johnson (2007) reported the major themes of a Town Hall meeting on aging in the LGBT community convened in Decatur, Georgia. The goal of the meeting was to answer two questions: (1) What are the LGBT community’s most significant concerns about its aging community members? and (2) What are the approaches and actions that can best improve the quality of life of the growing number of aging LGBT community members? The most significant concerns identified included a fear of aging; concerns about the availability of money, housing, and services; and 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 community, (2) creation of alternative housing and healthcare opportunities, (3) increase education and research, (4) increase planning and advocacy, (5) foster greater collaboration, and (6) more effective communication through new technologies. Attention to such efforts, conducted on multiple levels and through a truly interdisciplinary effort, would allow the reduction of socioeconomic disparities for LGBT elders.

Services and Advocacy for Gay, Lesbian, Bisexual and Transgender Elders (SAGE) and Movement Advancement Project (MAP) (2010) offered broad-based recommendations for building change and improving the lives of LGBT elders . The first recommendation was to provide immediate relief for LGBT elders through increasing funding for and provision of LGBT elder programs, affording immediate access to volunteer-based care, and providing education tools and legal services to LGBT elders. The second recommendation was to create an effective LGBT aging infrastructure through the creation and support of a much-needed advocacy infrastructure by building a strong coalition of allies. The third recommendation was to expand an understanding of LGBT aging issues through advocating for more research on LGBT older adults and generating a national public discussion about LGBT aging issues.

Electronic Medical Records. In addition, the agendas outlined above are the issue of electronic record keeping and the data fields it captures. Documenting patients and clients’ progress is frequently linked to data. Given this situation, it is only logical to gather data on sexual orientation and gender identity (a) to increase providers’ ability to screen, detect, and prevent conditions more common in LGBT persons; (b) to create a better understanding of LGBT persons’ lives; (c) to allow comparison of patient/client outcomes with national survey samples of LGBT persons (Makadon and Cahill 2012); and (d) to enhance the patient–provider interaction and regular use of health care (Healthy People 2020). Supporting the institution of these practices , in 2003, the Institute of Medicine recommended collecting data on sexual orientation and gender identity in electronic health records (EHR) (see Table 35.2 for the core functions of EHR) and recommended the creation of structured data elements to allow for comparing and pooling data to analyze the unique needs of LGBT persons. However, in a study of the use of EHRs in US hospitals, Jha et al. (2009) found that, contrary to a consensus that the use of information technology should lead to more efficient, safer, and higher quality care, no reliable estimates of the prevalence of adoption of EHR existed (see Research Box 35.1).

In Canada, many consider EHR systems to be critical for achieving another goal of interdisciplinary collaboration: improved continuity of care, reduced duplication, and decreased incidents of adverse events. However, a number of potential barriers continue to exist (e.g., creating safe, accessible computer-generated records, the ability of health professionals to generate, add to and share documents) (Deber and Baumann 2005). To surmount these barriers, Deber and Baumann recommend attention to three aspects to promote the initiative they support: How health care is financed, how health care is funded, and how it is delivered. Upon resolution of these conundrums, they contend that attention must be paid to the barriers created by interpretations by provincial governments of legal definitions inherent in the Canadian Constitution and the Canadian Health Act.

The National Academy on an Aging Society published Public Policy & Aging Report (2011) in which they explore several topics related to LGBT elders , including the absence of research and public policies devoted to LGBT populations, the failure of existing general aging policies to incorporate LGBT needs and interests, the need of cultural competency training among service personnel, partnerships between organizations working with LGBT elders and elders of color to advance common policy goals, and the implications of a demographic estimate showing that one in two Americans living with HIV will be aged 50 and older by 2015 (Hudson 2011). Adults over the age of 50 who receive a diagnosis of HIV are more likely to receive a concurrent AIDS diagnosis (51 %) compared to their younger peers (33 %) (Centers for Disease Control 2013). Moreover, the stigma of HIV may be perceived to be greater in the elderly population, leading them to hide their diagnosis or avoid testing. HIV prevention campaigns that exist do not typically target elders (Pratt et al. 2010). It is critical that the spheres of research and practice come together to reliably and appropriately inform each other so that desirable policies affecting the very real issues that LGBT persons face be created, developed, and implemented wisely and well.

Policy. For decades, the lives of LGBT persons have been restricted and dictated by public opinion and exploited by the homophobia and heterosexism that pervades the cultural and political landscape of many institutions (Russell 2012). Public opinion has often been the arbiter of public policy , which, in the main has not been sympathetic to the plight of many LGBT persons, including upholding and expanding their rights under the law. According to Russell, when the political and the personal collide, LGBT persons are often vulnerable political targets. On a more positive note, the passage of the ACA provides new health coverage options that should benefit LGBT elders. Prior to the ACA, one in three lower income LGBT adults in the USA had no health insurance. To remedy that situation, Section 1557 of the ACA prohibits discrimination against individuals based on sex, sex stereotyping, and gender identity. Even in light of the potential benefits of the ACA for many LGBT elders , Heinz and Choi (2014) contend that the sweeping policy is only effective if people are aware of it and if outreach, education, and communication are instituted to ensure that LGBT persons have access to quality, affordable health care, and freedom from discrimination. Until these efforts are realized, LGBT elders will be marginalized and oppressed, victims of a variety of disparities, health care being paramount among them.

Practice . Culturally competent practice with LGBT elders in health and human services is an area of critical need. Various disciplines and professional organizations (e.g., American Psychological Association, America Counseling Association, Commission on Certified Rehabilitation Counselors, Council on Social Work Education) “prioritize multicultural competency as an essential factor in both educational training and practice, with the inclusion of sexual and gender minority groups in definitions of multiculturalism” (Fredriksen-Goldsen et al. 2014, p. 82). The implementation of standards and policy statements by professional organizations in their respective Codes of Ethics has propelled LGBT persons into the forefront as populations that traverse a variety of practice settings and are worthy of appropriate and quality treatment. Fredriksen-Goldsen et al. outline 10 core competencies to improve professional practice and service development to promote the health and well-being of LGBT elders (see Table 35.3) in an effort to provide a blueprint for addressing the increasing needs of this population, their families, and their communities. Those competencies were developed from existing LGBT health and aging literature and, although the focus is on social work competencies, they are applicable to other disciplines. Until these competencies are addressed in part or in whole, the lives of LGBT elders will continue to be compromised by their relegation to less than full citizenship status.

Research. Although more research on LGBT elders is available than in previous years, there remains a general lack of empirical research (Hillman 2012) to inform future research as well as the practice community. In part, two major factors appear to contribute to limited research on LGBT elders: non-self-disclosure of sexual minority status and lack of data collection on sexual minority status by investigators and service providers (Gratwick et al. 2014). Discussed earlier, the Town Hall meeting on aging in the LGBT community, preparing for the future meeting in Decatur, Georgia, identified specific recommendations in the areas of education and research: to educate the LGBT community about aging issues and to educate both the general public and the organizations that should serve the needs of LGBT elders (Abercrombie and Johnson 2007).

HIV/AIDS and its implications for LGBT elders is another arena where research is needed. 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 the disease as a result of early onset (i.e., often in their 50 s) and of multiple comorbid health conditions, elevated mental health issues, substance abuse, stigma driven social isolation, and concomitant loneliness. Many LGBT elders who are living with HIV face the disease without the social support networks that they need to age successfully, despite the fact that they have exhibited significant levels of resilience as long-term survivors. Consequently, there continues to be an increased need for research focused on the medical management of HIV in the older population, including sexual minorities. In addition, medical providers must become better educated in the care of older patients with HIV and risk assessment for 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.

One of the most important issues that must be addressed is the present gap between policy and practice for LGBT elders. Does the gap exist because of a lack of evidence-based practices to inform policy, or because of a lack of policy to chart a course for interventions to be developed? Several common themes are explicit in policy issues, practice, and research pertaining to LGBT persons and aging: (1) discriminatory practices are a health risk; (2) stigma is associated with aging, sexual orientation, and gender identity; (3) service providers are in need of education and training about aging and LGBT issues; and (4) research is needed to understand health and health outcomes for LBGT elders. Without attention to these themes, improvements in the health and well-being of LGBT elders will be sporadic—another in the list of disparities that this growing and deserving population of elders faces.