This chapter uses a gerontological framework and person-centered care philosophy as lenses from which to evaluate the challenges LGBT elders face in the long-term care continuum, which includes a variety of settings from independent living to skilled nursing. This chapter also reviews and evaluates barriers to inclusion and opportunities for optimal aging that LGBT elders face as they age into the long-term care continuum. In order to comprehensively achieve this, issues related to person-centered care, cultural competence, and cultural humility throughout the care continuum will be identified and evaluated. A strength-based treatment is employed as the reader evaluates what it means to optimally age in a holistic manner: biologically, psychologically, sociologically, and spiritually.

We begin by exploring a brief history of the research and practice related to sexual orientation, gender identity, and the care continuum. We then identify and define options ranging from “aging in place” to long-term care, as well as the barriers and unique opportunities for successful aging in the long-term care continuum. We evaluate reasons why LGBT older adults may hide their sexual orientation or gender identity and spend time defining and treating the differences between sexual orientation and gender identity. We identify best practices for creating a supportive environment for LGBT elders and evaluate a case study on optimal aging.

This chapter presents a brief history of the research and reviews the current state of LGBT elders aging within the continuum of care. National organizations, movements, and policies that impact LGBT optimal aging will be identified, as well as state, local, and regional best practices for support and inclusion. In addition, examples of LGBT-inclusive housing developments throughout the nation, affordability of long-term care , and emerging options for aging in place are discussed. We conclude the chapter by evaluating academic and community stakeholders in service delivery to LGBT elders and the roles they can play in future optimal aging and engagement of LGBT elders.

The long-term care continuum consists of a variety of options that includes living at home completely independently to 24-h care provided in a long-term care facility. The long-term care continuum includes the following:

Assisted Living: Housing for elders or persons with disabilities that provides basic nursing care, housekeeping, and prepared meals as needed.

Reviewing the research relating to the aging, LGBT population is a true learning experience in and of itself. It is not simply an exercise in uncovering scholarship, it is educational in the means of research methodology. The data collection methods are sobering.

As one might imagine, acquiring data and results with any statistical power from a marginalized population is a challenge. The LGBT population did not begin to “come out” until after the 1969 Stonewall Riot and the pioneering efforts of leaders such as Harvey Milk in the mid-1970s. Research from this time and throughout the 1980s and 1990s is, by and large, relegated to urban settings, bars, clubs and anecdotal, and qualitative studies (Johnson et al. 2005; Addis et al. 2009).

Until 1974, the American Psychological Association classified homosexuality as a deviant, pathological condition, and so it was not until after the mid-1970s that research on homosexuality shifted from a deviance model to that of a social-constructivist one (Johnson et al. 2005). The data for members of the transgender population have only recently been upgraded with the release of the DSM V, in 2013. In both cases, data derive from a younger cohort with a different view and values from their elder counterparts (Quam and Whitford 1992).

A quote by Berger and Kelly (1996) personifies just how stereotypes and antiquated data proliferate:

Stereotypes such as these above originate within the lifetime of the current cohort of LGBT elders. They inform the conventional wisdom surrounding sexual orientation and one can only assume gender identity.

Much of the existing literature has relatively few participants, and the data are skewed toward the environments in which they took place. The empirical data track heavily toward higher rates of smoking, alcohol use, and obesity (Hughes and Evans 2003). They tend to support older stereotypes of the LGBT population as immersed in a culture of alcoholism, depression, and poor health habits. Examples of real evidence-based qualitative and quantitative studies on LGBT elders begin to emerge in the 1990s and 2000s when data from national organizations (Human Rights Campaign, National Gay and Lesbian Task Force, SAGE) were mined. Although this represents an improvement, the data were collected from members of the LGBT population who are active, enfranchised, engaged, and more likely to participate in “out and proud” organizations. Much of the existing studies lack statistical power due to small sample size and high potential for participant bias. Therefore, it is unwise to unilaterally rely on research that is still emerging and calibrating. While there are indeed excellent, rich, statistically significant studies that have been completed, further research is needed that supports a person-centered model of care and inquiry.

Emerging scholarship tells us that elders who are isolated are at increased risk for premature death (Pantell et al. 2013). Compounding this, according to SAGE, LGBT elders are at increased risk for isolation. LGBT elders are over twice as likely to live alone with thinner support networks, three to four times less likely to have children, and twice as likely to be single as compared to the heterosexual population. LGBT elders have higher disability rates, struggle with economic insecurity, and have increased mental health concerns manifest from a lifetime of discrimination (SAGE 2010).

The Caring and Aging with Pride Study (2011) gives additional information on why the barriers to inclusion and “othering” of LGBT elders are so real and profound. The study found that 82 % reported having been victimized at least once, and 64 % reported experiencing victimization at least three times in their lives. The report notes: “The most common type of victimization is verbal insults (68 %), followed by threats of physical violence (43 %), and being hassled by the police (27 %). Nearly one in four (23 %) have had an object thrown at them, and one-fifth (20 %) have had their property damaged or destroyed. Nearly one in five (19 %) have been physically assaulted (i.e., punched, kicked, or beaten), 14 % threatened with a weapon, and 11 % have been sexually assaulted.

This discrimination continues into later life. According to a 2005 study of LGBT long-term care residents, LGBT elders fear discrimination from administration, direct care professionals, and other residents (Johnson et al. 2005). These responses varied widely with regard to the variables of age, income, gender, community size, and education level of the respondents but are concurrent with the notion that, even among healthcare professionals and, arguably, younger members of the LGBT community, that LGBT elders are “homogeneous, isolated, lonely, and without hope.” (Johnson et al. 2005 p. 86).

According to the National Gay and Lesbian Task Force, the fear of isolation is real among LGBT elders . For many elders who have experienced marginalization and disenfranchisement over the life span, with advancing age comes an increasing reliance on public programs and social services. There is less independence or ability to retreat from discrimination, reinforcing isolative behaviors, and leading to the negative health outcomes outlined above.

Further, housing discrimination based on sexual orientation and gender identity is prohibited in only 15 states and the District of Columbia: California, Colorado, Connecticut, the District of Columbia, Illinois, Iowa, Hawaii, Maine, Minnesota, New Jersey, Nevada, New Mexico, Oregon, Rhode Island, Vermont, and Washington. There are also six states that prohibit housing discrimination based on sexual orientation (but not gender identity): Delaware, Maryland, Massachusetts, New Hampshire, New York, and Wisconsin. In addition, many cities prohibit discrimination on the basis of sexual orientation, including Atlanta, Chicago, Detroit, Miami, New York, Pittsburgh, and Seattle. While that status of the LGBT population is changing, anti-discrimination is by no means universal (Fig. 21.3).

Even given this newer trend toward LGBT positive aging, empirical data still indicate a fear among LGBT elders of aging into a long-term care environment. When one experiences decreasing voice and choice in the healthcare setting, concerns arise. And what about the relationship between direct care professionals and LGBT residents? According to the US Department of Labor and Human Services, direct care is a low-paying vocation. Personal Care Aides and Nursing Aides earn an average of $10.66/h or $21,320 annually based on a 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 household incomes. Women and immigrants are disproportionately represented among direct care workers, again according to the data. There is an increased prevalence of public assistance programs, 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 increased stressors among direct care professionals. Lower income may mean that a second job is required. Less formal education may mean that lower levels of cultural competence may be expected. Research by Gendron et al. (2013) also underscores these findings. In a population of 158 direct care professionals, a majority represented a minority population, were female, and had a high school diploma or less.

In addition to the social distance between direct care professionals and LGBT elders, there is the issue of the non-person-centered approach of integrating sexual orientation and gender identity. From the introduction of this chapter, we have defined sexual orientation and gender identity as two entirely different constructs. Lesbian , gay , and bisexual classification refers to sexual preference or attractions. A transgender classification entails gender identity, gender expression, or gender classification. Members of the transgender population are not necessarily gay or lesbian and, ironically, often face discrimination by members of the LGB population, in addition to the heterosexual population.

Transgender elders are both underserved and understudied in relation to their LGB counterparts and most certainly in relation to heterosexual elders. According to Perrson (2009), the term transgender denotes a community of individuals whose biological sexual identity of birth is not always congruent with their manifested gender identity. Interestingly, though gender identity and sexual orientation are markedly different biological and psychological manifestations, aging may be seen as a unifier. Isolation, health issues, and personal finances are issues that universally challenge. The transgender population experiences these issues at heightened levels.

One of the most significant barriers to optimal aging that transgender elders face in the long-term care continuum is actual lack of knowledge by healthcare professionals. Transgender elders may present with characteristics of both their birth anatomy and transitional anatomy. They may have unique medication interactions. Unique healthcare screenings may be required based on an individual’s biological sex, surgical status, declared gender, and hormonal therapies. There is significant anecdotal data from members of the transgender population of healthcare professionals refusing the treat “those people.” This purposeful “othering” of transgender male and female elders further exacerbates social isolation and healthcare challenges associated with otherwise normal aging.

This “othering” of transgender individuals is also manifest in social supports. Like members of the LGB population, transgender individuals are often isolated from usual social support systems, such as parents, siblings, children, and spouses. Without identity with the homosexual or heterosexual community, many transgender elders face increased social isolation. While the increase in technological connectivity offers social supports via the World Wide Web, these supports are not adequate for direct care and socialization and may, ironically, perpetuate the physical isolation experienced by transgender elders.

Although great strides have been made over the last few years toward LGB rights, the transgender population continues to face institutional obstacles in employment, health care, and law enforcement.

Two West Virginia transgender women claim their recent DMV visits were especially harrowing as they attempted to update their names and change their driver’s license photos. In separate incidents, both recount officials telling them their appearance looked too feminine for a driver’s license issued to a male and that they would have to dress down for their photos. “(A manager) told me it was a DMV policy that people listed as male could not wear makeup,” said Kristen Skinner. “The manager referred to me as “it” and told me to take off my makeup, wig and fake eyelashes.” Skinner, whose hair and eyelashes were her own and not fake, eventually took the license photo after removing all facial makeup. The 45-year-old IT professional called the experience at the Charles Town office in Jefferson County on January 7 “humiliating.” (retrieved from www.​cnn.​com )

According to the 2008 National Transgender Discrimination Survey, these heightened barriers to successful aging for transgender elders also translate into housing. Given the cost of aging into the long-term care continuum, incidences of homelessness persist among transgender elders. To combat this, in 2012, the US Department of Housing and Urban Development issued a proclamation making housing discrimination based on sexual orientation and gender identity illegal. The ruling also makes it possible for LGBT and T individuals and couples are included in HUD’s definition of “family” and are, therefore, entitled to HUD’s public housing and voucher programs.

Despite these advances, according to SAGE and the NCTE’s 2012 report on improving policy and practice related to transgender elders, much more needs to be done. Long-term care administrators and public/private housing providers are not aware of the new protections for the transgender population; therefore, housing discrimination continues. As a result of amplified “othering” experienced by members of the transgender aging population, it is increasingly difficult to gather the personal, social, and financial resources necessary to combat housing discrimination across the long-term care continuum. This continues to be true even in the private sector, and even if adequate funding for long-term care is available.

What is unique about the “Gen Silent” documentary is that it could have easily left the viewer with an image of the LGBT elder as defeated. Maggie Kuhn, founder of the Gray Panthers, referred to this as the “Detroit Syndrome” in the following passage:

Only the newest model is desirable. The old are condemned to obsolescence; left to rot like wrinkled babies in glorified playpens – force to succumb to a trivial, purposeless waste of their years and their time. (Maggie Kuhn in Sheppard, 1982).

Instead, the viewer is left feeling inspired. Each story shows how, when faced with adversity, LGBT elders are able to recalibrate, refocus, and plot a new course for optimal aging. There are bittersweet moments, indeed. However, the viewer is left with the more contemporary vision of LGBT elders aging well, despite disparities. This is no way implies that the barriers to optimal aging for LGBT elders are not real. It simply showcases that in the face of adversity, LGBT elders can thrive.

According to the American Society on Aging (2014), LGBT elders display remarkable resilience, despite the many obstacles they face. Despite increased levels of poor general health, physical limitations, and mental distress as compared to heterosexuals, LGBT elders are remaining connected throughout the life span. The Caring and Aging with Pride study (2011) of 2,560 LGBT elders ages 50 to 95 finds an emerging cohort of positive aging. While the information is presented in a largely negative manner, it supports the emerging notion. Read differently, the following graphic from the Caring and Aging with Pride study showcases that, two-thirds do not report depression, most engage in wellness activities, 90 % have received some form of healthcare, 80 % do disclose sexual orientation or gender identity to medical professionals, etc. This is not meant to undermine the absolute need for more culturally competent care for LGBT elders , rather it showcases an emerging trend toward positive aging. Continuing this path to improvement, especially in long-term care , is of paramount importance (Fig. 21.8).

According to a 2005 survey in the Journal of Homosexuality, diversity trainings for healthcare professionals, diversity trainings for long-term care residents, and the development of LGBT and LGBT-friendly retirement/care facilities would serve as the best remedies for discrimination. Ninety-three (93 %) of respondents believed that diversity/sensitivity trainings for staff would be of value, while 83 % felt that similar trainings would be of value for fellow residents. Nearly all (98 %) of respondents indicated that LGBT or LGBT-friendly facilities would be well-received.

In the last decade, we have seen a rise in the number of diversity and sensitivity training offered, as well as an increase in the number of LGBT-friendly communities. New communities that cater to the aging LGBT population have opened in California, New Mexico, Massachusetts, and the Blue Ridge Mountains of North Carolina. Federal Fair Housing law dictates that residential communities cannot exclude the heterosexual or non-transgender population but must be open and welcoming to all.

According to Gendron et al. (2013), in a mixed method study of 158 eldercare professionals who participated in an LGBT cultural competence training, 97 % expressed knowledge gain and positive feelings about participating in the training. Even with this professed knowledge gain and the growing resources for LGBT cultural competence training, the literature tells us that more needs to be done, particularly toward understanding the unique differences between sexual orientation and gender identity. Although the data absolutely support significant barriers to optimal aging throughout the care continuum, currents are changing, and LGBT elders are becoming increasingly engaged and self-advocating. Progress will continue with the assistance of social and policy advocates as issues of social isolation and support connectivity and engagement are addressed.,

Keys Facts in Social Isolation (adapted from SAGE)

Policy and Advocacy Solutions (adapted from Improving the Lives of LGBT Older Adults, 2010)