People may be well-versed in the changing needs of older adults, but still have no understanding of the diverse needs of LGBTQ+ older adults. This population is often inadequately represented, marginalized, mistreated, and poorly served in the mainstream aging field and in LGBTQ+ rights movements. LGBTQ+ Solo Agers have significantly more holistic health and aging challenges than their contemporaries and often fall through the cracks, resulting in dysfunctional patterns and tragic outcomes. With a clear understanding of LGBTQ+ history, past trauma, positive interventions, and broad proactive planning, these dysfunctional patterns can be disrupted to result in successful outcomes and enhanced quality of life for LGBTQ+ Solo Agers.
LGBTQ+ solo aging, trauma-informed care, inclusive care, marginalized, diversity, equity
Jane had been living authentically as a woman for more than 30 years. She began her transition in her mid-40s, to the dismay of her wife, family, and friends, who distanced themselves and rejected her authentic gender identity. Over the years, Jane worked hard to move past her trauma and surround herself with like-minded friends and chosen family. Then, at age 75, she had an unexpected fall, and, in seconds, everything changed. When arriving at a skilled nursing rehab center, the admissions staff decided that it would be “best for all” to place Jane in a room with “another man.”
Luckily for Jane, she had me (a professional care manager) as an advocate, which made for a happy ending. After an exhausting day, Jane was finally able to get settled in her new room and meet her female roommate. When Jane looked up at me, taking my hand in gratitude, I knew that we needed to do better. As healthcare providers, we need to do more to support the needs of LGBTQ+ Solo Agers who are often misunderstood, mistreated, and poorly served.
Everyone deserves to be treated with dignity and respect when aging. As an aging life care professional, I focus on helping older adults to navigate the many complexities and challenges of our healthcare system. Aging is neither easy, inexpensive, nor simple in today’s rapidly changing world. As one ages, new challenges emerge: There are unexpected obstacles, increasing uncertainty, and complicated decisions to make. These challenges can negatively affect one’s resiliency and focus, making it difficult to stay true to one’s priorities, which often evolve during this stage of life.
At times, older adults experience significant worry and fears surface as their coping skills are challenged and the need for support and guidance becomes apparent. As many often say, “it takes a village” to age well, but a great number of older adults do not have a village—or even a single friend—to help provide the vital support needed during the most vulnerable time of their lives. For many LGBTQ+ older adults, whose needs are often under-addressed in the mainstream aging field, holistic and healthy aging is often even more challenging and stressful due to the fact that they are aging solo.
“What will happen if I become seriously ill?” “Who will take care of me when I need help?” “Where will I go when I can no longer take care for myself?” These simple questions are even harder to answer for many LGBTQ+ Solo Agers. The reasons why can be clarified through a clear, general understanding of how history has impacted LGBTQ+ older adults.
Many LGBTQ+ older adults have experienced monumental changes across their lifetimes. Anyone older than age 60 was born at a time when consensual same-sex activity was illegal in every state; such laws were not repealed until early in the 21st century (Our Family Coalition and One Archives Foundation, 2023). Moreover, not only was discrimination against the LGBTQ+ community tolerated by the federal government, it was officially sanctioned when President Eisenhower signed an executive order banning homosexuals from working in the federal government based on unwarranted security concerns over gay workers (Johnson, 2004).
‘Presently, no federal laws exist that prohibit discrimination based on sexual orientation and gender identity.’
Coupled with these legal prohibitions, some of the most damaging discrimination faced by the LGBTQ+ community came from mental health professionals, particularly through the American Psychiatric Association’s (APA) identification of homosexuality as a mental disorder (Baughey-Gill, 2011). This stigmatic classification was not removed until 1973 (Drescher, 2015).
In June 1969, things began to change for the LGBTQ+ community when police raided the Stonewall Inn in New York City. A series of protests began, lasting 6 days and marking the start of a civil rights and gay liberation movement in the United States that continues to this day (Walsh, 2019).
Presently, no federal laws exist that prohibit discrimination based on sexual orientation and gender identity (Movement Advancement Project [MAP], 2023). This general lack of federal protection often negatively impacts and creates a multitude of challenges for LGBTQ+ older adults when it comes to housing, socialization, and access to care and entitlement programs.
Many LGBTQ+ older adults still struggle with the effects of the past and of coming of age at a time of enormous discrimination, prejudice, ill treatment, and violence. For these adults, who are part of what is often called “the Stonewall Generation,” aging without protections leads to increased uncertainty, fear, and withdrawal at a time when they may be even more vulnerable (MAP, 2023). Moreover, the past labeling of LGBTQ+ identity as a mental disorder has been used by some to validate the inappropriate treatment received by many LGBTQ+ older adults, a situation that was exacerbated during the HIV/AIDS epidemic (SAGE, 2017).
This history of legally and medically sanctioned discrimination has resulted in many individuals remaining less-than-willing to be open about their LGBTQ+ identity, especially to healthcare providers and government agencies (Human Rights Campaign & SAGE, 2021). Past negative experiences also have led to a deep-seated mistrust of government, health, and social service programs among many people, as well as a resistance to and/or fear of programs outside of their immediate support circle.
These issues often contribute to a variety of mental health challenges, including persistent stress, which contribute to holistic health disparities. These issues are frequently worse for people of color, as the combination of racism and prejudice related to their sexual orientation and/or gender identity has created even more ongoing trauma and recurrent emotional triggers (MAP & SAGE, 2017). These needs are often under-addressed in the mainstream field of aging and in the LGBTQ+ rights movement. Consequently, a lack of fairness and inclusion for LGBTQ+ older adults has persisted in the field of aging and is only now being addressed (Human Rights Campaign & SAGE, 2021).
Real World Consequences of Historical Discrimination
Statistics show that LGBTQ+ older adults are twice as likely to live alone, are 4 times as likely to have no children, tend to have shrinking social networks, fear disclosing their LGBTQ+ identity, and face discrimination when accessing housing and supportive programs. Due to these factors, LGBTQ+ older adults are 4 times less likely to access community aging services, entitlement programs, and preventive care and treatment, even when needed, leading to a significantly higher risk for holistic health challenges, financial hardship, and homelessness (MAP & SAGE, 2017). These factors also are known to cause LGBTQ+ older adults to frequently resist stepping outside of their social circle to access services and programs, which is a key reason why LGBTQ+ older adults are often Solo Agers.
Because of their life experiences and those of others they know, LGBTQ+ older adults have profound concerns about aging, a fear of receiving judgment and inferior care from healthcare providers, and fear of financial insecurity in retirement years, including a fear of cuts to essential programs and inadequate retirement savings to support their needs (Espinoza, 2014).
‘LGBTQ+ older adults are four times less likely to access community aging services, entitlement programs, and preventive care and treatment.’
Jim is one of many individuals who have experienced these circumstances and have these fears. Jim had been living with his partner for decades. After discovering at age 70 that he had pancreatic cancer and would require care, Jim was reluctant to reach out for help or supportive services because of his experiences during the HIV/AIDS epidemic. When his care finally became too much for his partner to manage alone, Jim relocated to a hospice center. He became immediately concerned about his friends and his partner visiting, and so began dismissing them—along with his LGBTQ+ identity and life—out of fear of receiving poor care. Jim did not feel safe in disclosing his LGBTQ+ identity to the staff while in hospice care and felt marginalized during staff interactions. Although provided with convalescent support and exceptional direct care, tragically, Jim passed away without the onsite support of his partner or long-term friends. Jim is just one of many LGBTQ+ individuals who have felt compelled to die alone out of fear of mistreatment.
Although many challenges exist for those in the LGBTQ+ community, LGBTQ+ older adults do not need to navigate aging alone. Although frequently without children and/or families of origin for support, many LGBTQ+ older adults build strong, lasting friendships with chosen family that extend into their elder years. With proper planning and communication, these relationships can be a valuable resource for LGBTQ+ Solo Agers.
Demographics and Policy
Sadly, a substantial amount of legislation over the past several years has been overtly anti-LGBTQ+, leading to a significant undoing of much of the progress that had been made between the Clinton and Obama administrations. Even with the return of a Democratic administration, there has not been much progress in restoring the rights of the LGBTQ+ community that were taken away in prior years. Instead, for the past several years, we have seen a fairly consistent negative turn in federal policies regarding LGBTQ+ individuals, with legislation actively promoting discriminatory policies and creating barriers to access critical government services (Medina et al., 2021).
According to MAP and SAGE (2017), more than half of U.S. states lack laws explicitly prohibiting discrimination based on sexual orientation and gender identity in housing and places of public accommodation. Without any protections in place, it is a challenge to prevent discrimination against LGBTQ+ older adults, particularly because healthcare providers have no explicit obligation to do so.
But there is power in numbers, and the growth of the Baby Boomer generation has led to an increase in the number of individuals aging solo. The concomitant increase in the number of LGBTQ+ Solo Agers may present opportunities for their needs to be more effectively addressed in the mainstream field of aging. LGBTQ+ aging has not been at the forefront of the mainstream aging field, but soon, as the number of LGBTQ+ older adults grows, it will have to become a greater priority and focus.
Despite the significant amount of recent negative legislation, some progress has been made and continued advocacy for state plans on aging to become LGBTQ+ inclusive could reap positive changes. In June 2022, H.R. 7993 (IH)—the Ruthie and Connie LGBTQ Elder Americans Act of 2022—was introduced to the House of Representatives the day after SAGE’s first ever National Day of Advocacy (SAGE, 2019). This Act aims to decrease the isolation faced by the many vulnerable and disadvantaged LGBTQ+ older adults, improve their holistic health and wellness, and increase their access to culturally competent services and support through programs provided by the Older Americans Act (Bonamici, 2022). This Act will ensure that LGBTQ+ older adults have greater access to safe, inclusive, and equitable care and supportive services, which should make solo aging and aging as an LGBTQ+ person less stressful and more effective. Moreover, the National LGBTQ+ Task Force recently announced:
"[T]he bipartisan omnibus spending package President Biden signed today contains reauthorization of the landmark Violence Against Women Act. From 2013 to 2019 when VAWA expired, it has prohibited discrimination based on sex, sexual orientation and gender identity by those providing help to victims. While it does so much more, this Act creates the first grant program dedicated to expanding and developing initiatives specifically for LGBTQ domestic violence and sexual assault survivors. Our sister organization, the National LGBTQ Task Force Action Fund, participated in a working group on bill language and advocated for its passage." (Seaton, 2022)
As of October 2022, all state aging plans must address LGBTQ+ and HIV issues and concerns. In addition, more organizations are completing SAGE Care credentialing to form more inclusive services and equitable care situations for LGBTQ+ older adults. Education on trauma-informed care, inclusive care awareness, and cross-cultural training programs are slowly receiving more interest from the mainstream aging field. These changes provide opportunities to break clearly dysfunctional and ineffective cycles and enable the solo aging LGBTQ+ population to age in accordance with their expressed values and wishes. While there is still much work to be done, progress has been made and continues to be made that allows LGBTQ+ older adults to live safely and authentically as they grow older.
Having welcoming safe spaces and an inclusive culture—one that fosters safety and trust—are key to helping LGBTQ+ older adults embrace aging effectively. All aging services providers should have these points incorporated into initial and ongoing staff training programs. This will help prevent marginalization and promote a mindset that LGBTQ+ older adults are just as deserving of compassionate elder care as any other older adult, thus setting the stage for an environment where LGBTQ+ older adults feel safe when seeking supportive services. This can only be done when elder care service providers realize it is a priority and take the time to listen, learn, and form a clear understanding of the needs and concerns of LGBTQ+ older adults.
Establishing an inclusive environment is much more than simply providing a safe space sign or a rainbow flag; it is an organizational effort to support all individuals holistically and effectively without marginalization. Forming an organizational culture that embraces the core values of inclusion is the key to establishing trust with LGBTQ+ older adults, which will enable them to be completely open and honest and so begin proper planning for the future.
Tips for Financial and Health Planning for LGBTQ Solo Agers
Planning is probably the most important step for all older adults. Having set goals and a clear path laid also helps to lessen anxiety and fears for the future. This is best accomplished by having executed documents that expressly outline one’s specific wishes and needs, as this will ensure that future caregivers are acting on expressed wishes rather than having to make their own choices and decisions.
For many of the reasons described above, LGBTQ+ older adults fail to undertake effective retirement or estate planning and so are without properly executed documents to support their expressed wishes when the need comes. Long-term care planning that takes a relational estate-planning approach can be very helpful for LGBTQ+ older adults who are solo aging, as this relies upon forming a multidisciplinary team and allows a more dynamic, detailed care plan to be implemented than do traditional estate planning documents.
‘Forming an organizational culture that embraces the core values of inclusion is the key to establishing trust with LGBTQ+ older adults.’
Beginning this process requires active listening and trust formation. Using inclusive language; asking open-ended questions; not rushing or forcing answers; asking about what is important for the individual; and valuing their time, expressed wishes, and personal concerns are all important. Many questions need to be asked and answered throughout this process by both sides so individuals think clearly about what is important to them now as well as what they may need in the future for care and comfort. Does the individual want to age in place? And is this realistic and/or practical for them? Do they want to house share or is a continuing care community going to be best based on financials, expressed wishes, and/or potential support needs? There is a lot to cover.
The long-term planning process helps the individual to consider options, obtain guidance, and gather a natural team of support and experts (including legal, financial, accounting, and even an aging life care manager) while fostering a sense of control for the individual throughout. Although Solo Agers need to feel empowered, they may also need guidance to help make prudent decisions relating to their care and future living situations. Having a clear, set path for the future and assembling a diverse and knowledgeable team with support in place is a critical mechanism for effective solo aging for LGBTQ+ older adults.
Positive Steps to Support LGBTQ+ Solo Agers
1. Foster trust formation and connection through effective communication and active listening. Always ask open-ended questions and do not rush or force answers if an individual appears uncomfortable. Reassure them that this is on their terms. Trust formation takes time and patience.
2. Acknowledge the past and recognize how it impacts the future. Take time to learn about what is important to the individual and what may trigger a past trauma, thus proactively supporting trust formation. Through active and careful listening, one can limit or prevent re-traumatization. Support positive change on their terms and according to their timeline when possible.
3. Encourage and link individuals to inclusive providers, along with community and multigenerational programs, to help LGBTQ+ Solo Agers find others and safely expand their social and supportive networks. Consider the potential role of self-affirmations, derivative resilience, yoga, mindfulness, meditation, and other forms of complementary programs in supporting holistic and mental health.
4. Stay abreast of current news and events, particularly those that may affect marginalized populations. Being knowledgeable and understanding recent changes and ongoing challenges is important.
5. Examine current programming in your organization and community and modify it to better accommodate all individuals. Highlight inclusion, equity, and diversity! For example, include open support for LGBTQ+ Pride in June, LGBTQ+ National Coming out Day, LGBTQ+ History Month, National Transgender Day of Remembrance, and other special days. Acknowledge and highlight LGBTQ+ history and the positive impact that others have made.
6. Review your organizational policies to ensure that all materials (such as flyers, contracts, forms, email signatures, websites, events, and programs) use welcoming and inclusive language always. Blank spaces are preferable to check boxes, as these allow individuals to identify on their terms.
7. Affirm the importance of cultural competency training for providers, including training about implicit bias, microaggressions, trauma-informed care, and culturally sensitive treatment. Promoting cultural competency training in an organization prevents marginalization and reinforces a mindset that LGBTQ+ older adults are as deserving of compassionate eldercare as any other older adult. Training on how to properly support the needs of LGBTQ+ older adults and Solo Agers is paramount in creating safe and welcoming spaces.
8. An understanding of correct and proper pronoun usage, including the avoidance of gendered language, along with knowing and using the specific pronoun(s) that each individual prefers, will help LGBTQ+ older adults feel supported.
9. Respecting gender identity when providing site-segregated community services is essential. When services include shared rooms that are segregated by sex, the assignment of rooms should always be made based on the client’s gender identity, not their sex assigned at birth.
10. Promote diversity and inclusion whenever possible. Creating welcoming and safe environments is critical to forming trust. Honor choices and show empathy toward all individuals. Remember that equity is not treating everyone the same, it is recognizing and acknowledging individuality. Provide the opportunity and allocate resources to support equal outcomes for all.
11. Consider the cumulative effect and overlapping impact of historical trauma and microaggressions upon mental health. Promptly address and deter any negativity or hate speech. Emphasize that everyone deserves to be treated with respect and kindness, including being given the opportunity to live authentically. Help LGBTQ+ Solo Agers to feel connected.
12. Help them to feel they are a part of the community and provide opportunities for engagement and connection on their terms. Solo aging does not have to be aging alone. Remember that the path of solo aging is always best traveled with a good support system!
Karen M. McPhail, BSN, MSN, RN, CCM, CDP, is a professional care manager with more than 30 years’ experience in the healthcare industry. She is the chief executive officer and chief operating officer of Eldementals, LLC, a concierge-style care management company in the Washington, DC, Metro area, the founder and director of Aging Rainbows, an advocacy organization for LGBTQ+ older adults, and a SAGE National Resource Center on LGBTQ+ Aging education ambassador.
Photo credit: Shutterstock/Mangkorn Danggura
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