Elder Care Interprofessional Provider Sheets

LGBT - Older Adults in Long-Term Care Facilities

Linda A. Travis, PsyD, Beatitudes Campus, Phoenix, Arizona
Beverly J. Heasley, RN, BSN, MBA, Elder Mediation Associates, Tucson, Arizona

June 2017

  • Assess overall readiness to care for LGBT in welcoming and safe environments that recognize LGBT history, culture, challenges, and strengths.
  • Understand variations and nuances in the "coming out" processes for LGBT older adults.
  • Honor LGBT partners and families of choice.
  • Respect the diversity within the LGBT community.
  • Know protections and legal rights for LGBT residents in long-term care facilities.

Following decades of experience with discrimination and social stigma, the community of Lesbian, Gay, Bisexual, and Transgender (LGBT)* older adults and their loved ones experience a multitude of unique concerns when contemplating placement in long-term care facilities. Administrators, staff, and clinicians in long-term care facilities may not be adequately trained to address LGBT fears and concerns. Facilities may provide care that compromises the health status of LGBT older adults, increases their sense of vulnerability, and lowers satisfaction with peer and staff interactions. Thus, it is important to improve the quality of long-term care for LGBT older adults. Recommendations for improvement are discussed in this issue of Elder Care.

Assessing Readiness to Care for LGBT Older Adults 

Although many long-term care facilities may genuinely want to admit LGBT older adults, substantial transformations need to be in place before those adults, their loved ones, and the clinicians wanting to refer them, can be assured that there will be "no problems." These transformations should be visible to prospective LGBT residents (e.g., explicit and positive LGBT pictures and language on websites, brochures, and forms), and evident in staff training and development. It is recommended that facilities assess their readiness to care for LGBT residents (Table below), hire external consultants and resources as needed, and highlight key aspects of LGBT culture and history, outlined  below, through ongoing training for all employees.

Understanding LGBT Culture and History 

Coming Out 
The first key aspect of LGBT culture and history is the variation and nuances in "Coming Out." For LGBTs older than the Baby Boomer cohort, safety and survival were closely linked with clandestine social gatherings prior to the 1970s Gay Liberation Movement. Invisibility and silence were adaptive responses to laws, attacks, and pervasive discrimination enacted against LGBT communities.

Long-term care facilities must offer safe and welcoming environments. Pressures to come out or concerns of being "outed" may increase a sense of vulnerability to maltreatment. LGBT may isolate or defer medical care if environments seem dangerous. Facilities are advised to view coming out as a process vs. an event, with disclosures likely expressed over time through stories and pictures rather than overt use of LGBT language.

Families of Choice
Prejudice and negative attitudes do not occur only outside homes. Rather, countless LGBT adults suffer temporary or permanent estrangement from their families of origin. The LGBT community has created important friendship networks offering a strong sense of belonging and mutual support over the lifespan; these networks are termed "families of choice." It is highly recommended that long-term care facilities structure family events and care planning meetings to include LGBT families of choice.

Furthermore, partners of LGBT residents  may feel unwelcome or invisible at long-term care facilities. For example, LGBT couples may not be allowed to cohabitate at some facilities, and care giving groups may not be attentive to LGBT partners. Facilities that eliminate such rules may simultaneously eliminate some of the marginalization experienced by LGBT partners.

One Size Does Not Fit All
The LGBT community is a diverse group. For example, there are differences in the life experiences and expectations among the younger-old and oldest-old LGBT. There are also important considerations for LGBT with additional minority identities involving race, ethnicity, socio-economic status, gender, and acculturation. Religious/spiritual beliefs particularly merit attention in LGBT long term care. Administrators, staff, and clinicians add further to the mix of cultural differences. To facilitate optimal care, facilities should arrange for on-going interprofessional case-based consultation about diversity issues. 

Protections and Legal Rights
The LGBT community encounters unique financial and legal challenges when navigating entry into long-term care. It is recommended that facilities offer specialty referrals for LGBT financial matters and LGBT family law. At admission, aging LGBTs and loved ones should be informed of resident councils, family councils, ombudsman representatives, and other institutional protections.

National LGBT organizations are available to inform the LGBT community of long term care advocacy efforts, marriage benefits in relation to federally sponsored aging programs, and updates on federal, state, and local laws related to discrimination. Key resources are listed below. 

* "Q" for "queer or questioning" is included with younger LGBTQs but is less commonly used and potentially offensive in communication with older LGBTs. However, the "Q" will become more commonplace with aging of younger Baby Boomers.

Creating a Welcoming and Safe Environment for LGBT in Long-Term Care Facilities

  • Websites, brochures, pictures, and artwork include positive and explicit images and communication regarding LGBT older adults, their loved ones, and the LGBT community
  • Non-discrimination policies are clearly displayed throughout the facility
  • All intake and clinical care forms use LGBT sensitive language and include categories such as "relationship status" vs. "marital status" as well as options to disclose sexual orientation identities and transgender choices*
  • Residents' social activity programs include attention to LGBT culture, such as LGBT History Month; Gay Pride Month; LGBT movies, books, newspapers/magazines, current events
  • Family events and care-giving groups are structured and facilitated with attention to unique challenges and stressors for LGBT couples, families of choice, and communities
  • Non-LGBT residents and their families are informed about policies and programming for LGBT residents at intake and at regular intervals while at the long-term care facility
  • Commitment to LGBT cultural competency is assessed in staff hiring processes
  • Administrators, staff, and clinicians receive ongoing training and development regarding LGBT cultural competency; all employees are encouraged to consult about questions or concerns regarding caring for LGBT older adults
  • Administrators, staff, and clinicians are aware of local, state, and national resources to continually expand awareness, knowledge, and skills for respectful and effective LGBT care
  • Administrators, staff, and clinicians inform LGBT residents, couples, and families of choice about varied protections and legal rights pertaining to LGBT long-term care

*Further recommendations may be found in the June 2017 Elder Care Fact Sheet and in the 2006 Guidelines for Care of Lesbian, Gay, Bisexual, and Transgender Patients, published by the Gay and Lesbian Medical Association

References and Resources