Providing Services for LGBT2SQ Seniors

June 2020 blog post by Devan Nambiar, MSc.

To provide inclusive, affirming services and welcoming health care to seniors, healthcare and social service providers working with aging populations can start by being aware that not all seniors are heterosexual and cisgender. Whether you are a volunteer, personal support worker, physician, nurse or social worker, there is plenty you can do to create a more welcoming environment for lesbian, gay, bisexual, Two-Spirit and queer (LGBT2SQ) seniors. You can start by growing your knowledge.

LGBT2SQ definition and terms
LGBT2SQ stands for lesbian, gay, bisexual, transgender, Two-Spirit, queer and others who are part of sexual and gender minority communities. Note that LGBT2SQ communities are not homogeneous. They are in fact very diverse: the varied, intersectional identities (Johnson, p.x) of each person reflect different lived experiences. Each community member will use the terms that feel appropriate for them. For instance, most seniors will not use the term queer as it was once a slur, but the term has been reclaimed and is in use by younger LGBT2SQ communities. You can learn more about basic LGBT2SQ terms and definitions on the Rainbow Health Ontario website.

As part of establishing open and respectful communication to build your therapeutic relationship, when an LGBT2SQ senior client uses a term you are not familiar with you can ask them to clarify the term. You can then repeat your understanding back to them. Some examples of inclusive language are using the word “spouse” or “partner” instead of “husband or “wife.” When caring for your transgender seniors, simply asking about their pronouns and the chosen name they want to be called by can make an enormous difference in their comfort level.

With terms and definitions, never guess. Always ask and apologize (just once) if you make a mistake.

Why does it matter that some of my clients are LGBT2SQ?
When working with aging LGBT2SQ populations, “it is important to consider the culture, politics, and social norms that [once] existed” (Johnson, 2018). LGBT2SQ seniors are likely in their lives to have experienced overt discrimination and stigma, such as: being disowned by their biological families; imprisonment; loss of employment, forced electro-shock therapy to be “cured” of homosexuality; cumulative grief and loss from the impact of HIV/AIDS; or lack of access to transition-related care. For many LGBT2SQ seniors, living in these norms impacted their self-perception, worsened internalized homo/bi/transphobia and made them hide their sexual orientations or gender identities for fear of discovery. 

In 1952, the official diagnosis of “homosexuality” was sociopathic personality disturbance (IOM, p.251). It was a criminal offense to be LGBT2SQ in Canada until 1969. In Canada, from the 1950s to the 1990s thousands of LGBT veterans and civil servants were part of the “LGBT gay purge” and experienced state-sanctioned homophobic discrimination. They were demoted, denied promotions, transferred and fired because of their sexual orientation. They were even seen as a risk to national security.

Now in their twilight years, LGBT2SQ seniors in Canada face uncertainty of how they will be treated when they are more vulnerable to discrimination while seeking access to social services and health care.

Discrimination’s impacts on LGBT2SQ health  
Some of the specific healthcare needs of LGBT2SQ seniors include being assessed for social isolation, depression and anxiety, poverty, delayed care-seeking and poor nutrition (Eckstrand & Ehrenheld, p.175).

Discrimination, particularly experienced over a lifetime as is the case for many LGBT2SQ seniors, can compound stressors to mental, emotional, sexual, physical and spiritual health. Challenging social factors create minority stress (Johnson, 2020, p.x) for LGBT2SQ people, which becomes internalized and over time creates acute and chronic stress. The external stressors “activate a physiological stress response” (Johns et al.2019) which can affect all aspects of their health. Healthcare and social service providers alike should be aware that negative experiences and the stress that results may impact the level of trust, comfort and safety for LGBT2SQ seniors in a healthcare or social service setting.

The trauma of earlier experiences in their lives such as coming out can also impact the attitude and comfort towards disclosure of sexual orientation or gender identity in later life (Hughes, 2007) for LGBT2SQ seniors. Conversely, the years of “stigmatization in earlier adulthood” (Johnson, 2018) allow some LGBT2SQ seniors to build ‘crisis competency skills’ (IOM, p.272) to survive and thrive with aging.

Creating an affirming and welcoming environment for LGBT2SQ seniors
Ontario’s human rights legislation protects LGBT2SQ people against discrimination, making it important for hospitals, long-term care homes, senior centres, and healthcare centres to have policies around equity that cover sexual orientation and gender identity. Moreover, making your environment and care more affirming can go a long way towards increasing the level of comfort for LGBT2SQ patients in your care.

When providing care to LGBT2SQ seniors, ask open-ended questions so they can inform you about what they need. Use gender neutral pronouns and do not make assumption about their partner or spouse. For instance, some LGBT2SQ seniors were married to opposite sex partners and had children before they came out as LGBT2SQ. It is also essential for clinicians to reflect upon their own values and apply current theories of aging and social gerontology.

There are many more ways to create a more welcoming, affirming environment for your LGBT2SQ senior clients, such as:

1.  Having inclusive intake and registration forms, images, and posters.
   For LGBT2SQ seniors, the opportunity to self-identify in an intake or registration form is a sign of inclusivity and allows clients to self-identify. This simple gesture can help set the tone for respectful communication in your therapeutic relationship. The Registered Nurses Association of Ontariohas more suggestions.

2.  Offer access to gender neutral bathrooms for transgender seniors.Ontario Human Rights Commission on gender identity and gender expression (2014).
3. When seeking next of kin, allow options such as chosen family versus biological family.
   Chosen family is a group of people you are emotionally close to and consider to be your family. For many LGBT2SQ people who have been disowned by their biological family, their family is chosen instead of biological. As a healthcare provider and social service organization it’s important to give chosen family the same respect as you would to biological family. These supportive connections should all be welcomed into meetings regarding care and decision-making as consented to by your client. Respect the clients chosen family and connections when chosen families are listed as the next of kin, the Substitute Decision Maker, or listed in Living Wills or as Power of Attorney.
4. Respecting gender identity and understanding that transitioning is different for everyone.
   RHO and The 519’sMedia Reference Guide: Discussing Trans and Gender-Diverse People includes helpful tips on talking to and about trans identities and transitioning. First, ask for and respect pronouns. If you make a mistake, apologize and move on. Secondly, ask about transition-related surgeries or medical procedures only when they are relevant to the care you’re providing. Most of all, keep in mind that there is not one correct way to transition. Transition is different for everyone, and can include social, legal and/or medical transition.
5.  Demonstrating a comfort level with sexual and gender diversity. 
   This means being comfortable in your own sexuality, gender identity and expression. It also means welcoming and normalizing disclosure of sexuality, gender identity and expression. It’s also important to avoid over or under pathologizing and to show support for any clients who may be exploring who they are (Huygen, 2006).
6.  When conducting a health and social assessment, integrate the lived experiences of LGBT2SQ seniors(Eckstrand & Ehrenheld, p.178).

Fundamentally, creating an inclusive environment is about treating the whole person and not making assumptions. If you establish a therapeutic relationship with open, respectful, culturally sensitive and age-appropriate language, you can build rapport with LGBT2SQ seniors in your care, so they feel comfortable disclosing social and medical information to you.

At Rainbow Health Ontario (RHO), a program of Sherbourne Health, our purpose is to create opportunities for the healthcare system to better serve LGBT2SQ communities. As part of this, we offer training for healthcare providers in clinical and cultural competency and create a variety of resources to support you in caring for your LGBT2SQ clients, all available on our website.