Introduction
LGBT is an acronym used to describe people from diverse sexual orientation or gender identity, people that are gay, lesbian, bisexual, or transgender. LGBT people do not constitute a single group nor does each individual “group” constitute a homogeneous unity. However, as higher rates of depression and/or anxiety have been observed in older LGBT people, compared to their heterosexual counterparts (Guasp, Reference Guasp2011) there is a need to raise the profile of mental health issues amongst these groups. The additional letter I is also often included in the acronym LGBTI as intersex people are often included as another gender diverse group. However, there is very little research that includes intersex people and none on older intersex people's mental health so this editorial is restricted to consideration of older LGBT people.
Long-term exposure to discrimination has been identified as a major contributor to the disparity in prevalence of mental health issues between LGBT and heterosexual people (D’Augelli and Grossman, Reference D’Augelli and Grossman2001; Leonard et al., Reference Leonard2012), and there is a growing awareness that this disparity may be exacerbated by the experience of (or the expectation of) discrimination from aged care service providers, as older LGBT people begin to access these services (McFarland and Sanders, Reference McFarland and Sanders2003; Stein et al., Reference Stein, Beckerman and Sherman2010; Guasp, Reference Guasp2011).
Prevalence of mental health issues amongst older LGBT people
To date, one of the most comprehensive studies of the mental health of older LGB people is the Stonewall Report: Lesbian, Gay and Bisexual People in Later Life (Guasp, Reference Guasp2011). Comparing the results of 1,050 heterosexual and 1,036 LGB people aged over 55 years living in Britain, the study found that older LGB people were consistently more anxious than their heterosexual peers. LGB participants in the study reported that much of their anxiety originated from the belief that their sexual orientation or gender identity would negatively impact upon them as they aged, with the most frequent concern being that they would be discriminated against. The study also found that lesbian and bisexual women were more likely to have ever been diagnosed with depression and anxiety than heterosexual women (approximately 40% life-long prevalence of depression and 33% life-long prevalence of anxiety) and gay and bisexual men were twice as likely to have ever been diagnosed with depression and anxiety compared with heterosexual men.
Several other studies support the mental health findings of the Stonewall Report (Guasp, Reference Guasp2011). A systematic review of literature on mental disorder, suicide, and deliberate self-harm in LGB people (King et al., Reference King2008) found that depression, anxiety, and substance use disorders were 1.5 times more common in LGB people than in analogous heterosexual individuals. King's et al. (Reference King2008) review analyzed 25 international studies that included a total of 11,971 LGB participants. Similar results were observed in the analysis of data from a 2001–2002 epidemiological survey of American adults aged 18 years and over, which found a higher prevalence of lifetime mood and anxiety disorders among participants who identified as LGB, compared to those who identified as heterosexual (Bostwick et al., Reference Bostwick, Boyd, Hughes and McCabe2010). Further, a 2008 beyondblue literature review (Corboz et al., Reference Corboz, Dowsett, Mitchell, Couch, Agius and Pitts2008) of international research investigating depression amongst non-heterosexual people found that lesbian, gay, and bisexual populations reported higher depressive rates than their heterosexual peers.
Fear of discrimination in aged care
Many older lesbian, gay, and bisexual people fear that providers of aged care services will not be able to understand and meet their needs (Guasp, Reference Guasp2011). In line with this, a significant number of LGB respondents to the Stonewall survey reported that they had not accessed health services that they felt they needed in the previous year. Nearly half of the LGB respondents reported that they would be uncomfortable about disclosing their sexuality to home care staff, a third would be uncomfortable disclosing to a housing provider, hospital staff or a paid carer, and approximately one in five would not feel comfortable disclosing their sexual orientation to their GP. And yet, compared to heterosexual respondents, the LGB respondents were twice as likely to expect to rely on external services, including GPs, health and social care services and paid help, on account of the increased likelihood of being from isolated other forms of support (such as family) because of negative attitudes towards their sexual orientation.
Similar themes were identified in an Australian study called My People: A project exploring the experiences of gay, lesbian, bisexual, transgender and Intersex seniors in aged care services (Barrett, Reference Barrett2008). In this study, interviews were conducted with 18 aged care recipients who identified as lesbian (7), gay (8), bisexual (2) or transgender (1). Participants were asked to discuss how their sexual orientation or gender identity affected their experiences of accessing aged care services. Participants reported an expectation that their needs would not be understood, and a tendency to hide their sexual orientation or gender identity when they accessed aged care based on the belief that it would be unsafe to disclose.
The findings of the Stonewall Report (Guasp, Reference Guasp2011) and the My People project (Barrett, Reference Barrett2008) have been observed in other studies that explore the experiences of older LGBT people accessing aged care services. For example, a survey exploring the aging-related needs of 59 older LGBT people (McFarland and Sanders, Reference McFarland and Sanders2003) found that there was a strong reluctance to access long-term care services, assisted living services and adult day care, because it was believed that staff would not be knowledgeable about lesbian and gay aging concerns and issues. Participants also expressed concern that they would be discriminated against if their sexual orientation was known.
Similar themes emerged from a qualitative study of 16 lesbian and gay elders that sought to explore the challenges these people face regarding accessing long-term care (Stein et al., Reference Stein, Beckerman and Sherman2010). This study found that participants felt a fear of being rejected or neglected by healthcare providers, particularly personal care aides, due to their sexual orientation, and a fear of having to hide their sexuality and relationships if admitted to an aged care facility.
An exploratory study involving interviews with 127 LGBT people (not specifically older) on their perceptions of discrimination in aged care facilities (Johnson et al., Reference Johnson, Jackson, Arnette and Koffman2005), found that 75% of participants believed that discrimination against LGBT people did exist in these settings. Thirty-four percentage of these participants also believed that they would have to hide their sexual orientation were they to reside in an aged care facility, and 60% believed that they did not have equal access to social and health care services. Members of the same research team conducted a later study in 2008 (Jackson et al., Reference Jackson, Johnson and Roberts2008) in which heterosexual participants were interviewed about their expectations of sexuality-based discrimination in aged care settings, and almost 70% of participants also believed that LGBT people would be the victims of discrimination in this context.
Each of these studies draws attention to the problem that the fear of discrimination, and of not having LGBT-specific needs met by aged care service providers acts as a barrier to accessing these services when they are required. As encapsulated by McFarland and Sanders (Reference McFarland and Sanders2003, p76) “It is of grave concern that individuals may neglect their health needs out of fear of discrimination. . .If this population continues to remain invisible, afraid, and hidden (they cannot be provided with) adequate services as they age.”
Lifetime experience of discrimination
The assumption that LGBT-specific needs will not be met by aged care service providers originates primarily from previous experiences of discrimination that LGBT people have been subject to. The current generation of LGBT seniors were young and middle-aged adults at a time when their sexual orientation or gender identity could result in imprisonment, or enforced medical “cures.” It is only recently that homosexuality has been decriminalized in most Western countries. In England and Wales, same-sex sexual activity was decriminalized in 1967, but it took until the early 1980s for Scotland and Ireland to follow suit and it was only as recently as 2003 that same-sex sexual activity was decriminalized nation-wide in the USA. While homosexuality was removed from the Diagnostic and Statistical Manual of Mental Disorders in 1973 (DSMII), the current version of the manual, DSM V, continues to pathologize transsexuality and transgenderism as gender dysphoria, contributing to the marginalization of people who identify as either (American Psychiatric Association, in press). Given these past and present institutional forms of discrimination whereby the current generation of LGBT seniors risked the loss of family, friends, and employment if their sexual orientation or gender identity became known to non-accepting people, any fear of encountering further discrimination is understandable.
Stein et al. (Reference Stein, Beckerman and Sherman2010, p431) noted that “Having lived with stigmatization and discrimination throughout much of their lives, (participants in their study) were particularly concerned that prejudicial attitudes would negatively affect their care if they needed to enter long-term care facilities.” Participants in the same study expressed concerns not only about potential discrimination from care providers, but also from other aged care users: “Having lived through the dawning of the gay civil rights era, they were aware that the cohort with whom they would be sharing living quarters in nursing homes might be those who had kept them from exercising their rights in earlier days” (Stein et al., Reference Stein, Beckerman and Sherman2010, p. 431).
Experience of discrimination and prejudice in aged care
A number of studies validate the expectations and fears that older LGBTI people will be subject to discrimination in aged care settings. The Aging and Health Report (Fredriksen-Goldsen et al., Reference Fredriksen-Goldsen2011), was a large American study in which 2,560 older LGBT adults were interviewed about their mental and physical health status and experience of accessing aged care services. More than one in ten participants reported being denied care, or being provided with inferior care because they were LGBT. An earlier Canadian study (Brotman et al., Reference Brotman, Ryan and Cormier2003) investigating the experiences and realities of gay and lesbian seniors accessing health services found that the strongest theme to emerge in interviews with participants was that of “profound marginalization,” and that in the aged care setting this was manifest as almost completing ignoring issues relating to sexuality. Participants in Barrett's (Reference Barrett2008) My People study provided accounts of being administered diminished standards of care as a result of their sexual orientation or gender identity, and some of the older gay male participants reported the withdrawal of physical contact by care staff due to the belief that because they were gay they would also be HIV-positive and staff were fearful they would contract HIV. Another study involving in-depth interviews with older lesbians and gay men to examine their experiences of Australian aged care services (Hughes, Reference Hughes2008) found that several participants had experienced discrimination, and a lack of sensitivity towards their sexual orientation.
The tendency of aged care facilities to overlook matters relating to sexuality, and in particular matters relating to LGB sexuality, is highlighted in a number of studies including a recent Australian study that surveyed 40 chief executive officers of residential aged care facilities in and around Perth, Western Australia (GRAI, 2010). Seventy-nine percentage of respondents in this study strongly agreed that a resident's sexuality was not their concern, and 86% of respondents were unaware of any LGBT residents within their facility. A similar American study (Knochel et al., Reference Knochel, Quam and Croghan2010) surveyed 152 aged care service providers. Ninety-seven percentage of respondents reported that their facility did not offer any services specific to non-heterosexual clients. Another American study that asked care providers and administrators to describe their work with older LGBT adults (Hughes et al., Reference Hughes, Harold and Boyer2011) found that 75% of the 87 respondents had no activities or efforts in place to address the needs of older LGBT individuals. In this way, older LGB people face a double stigma. Not only are they considered asexual, along with older heterosexual adults, but their sexual diversity is assumed not to exist by aged care providers. As highlighted in an article exploring discrimination against older LGBT people by nurses (Irwin, Reference Irwin2007), the notion of older people being asexual, coupled with assumptions of heterosexuality, can make LGBT people feel excluded and undervalued.
Ageism and LGBT
Many older people experience ageism, that is, stereotyping and discrimination against individuals or groups on the basis of their age. Prejudicial attitudes or beliefs can often mean that older LGBT people experience discrimination on at least two fronts. One of the ways that ageism can be expressed is through avoiding and ignoring older people, an experience reflected in a paper by Blando (Reference Blando2001) on aging LGBT people, which highlights that older LGBT people often feel that they are “twice hidden.” They are hidden because they are older and they are hidden because they are members of a sexual or gender minority.
There is also evidence to suggest that ageism is experienced differently within LGBT populations. Several studies suggest that the experience of ageism is more pronounced for older gay men than it is for older lesbian women because of the emphasis placed on youth and physical appearance (Holt, Reference Holt2011). One study involved surveying 74 gay men (mean age = 34.4 years) and 109 lesbians (mean age = 39.9 years) on their perceptions of aging and ageism (Schope, Reference Schope2005). The study found that 84% of the gay male respondents felt that gay society viewed growing older negatively, and over half indicated that gay society saw being an older man as “terrible.” Only a fifth of the lesbians surveyed indicated that lesbian society saw aging negatively. On their attitudes towards aging, it was found that gay men are more agist than lesbian women and that they are generally more fearful than lesbian women of negative evaluations by their peers.
From these findings, Schope (Reference Schope2005) concluded that it is more difficult for aging gay men to sustain a positive self-image than it is for aging lesbian women because not only are they struggling against societal homophobia, but also negative attitudes toward older gay men from within their own community. Expounding on this, Schope suggested that older lesbian women are more protected from ageism within their community because they tend to have more social networks comprising lesbians from different age groups; they are more revered by younger lesbians for their wisdom and perceived political power; they tend to reject age-related and normative beauty standards; and they are generally positively influenced by views and attitudes supported by the feminist movement.
Strategies to address discrimination against older LGBTI people
The My People study (Barrett, Reference Barrett2008) identified strategies that some participants had enacted to negotiate the obstacles they faced as they interacted with aged care service providers. For example, some participants built up a relationship with aged care workers before disclosing their sexual orientation or gender identity. Others would listen for workers’ responses to LGBT issues in the media to gauge a reaction to LGBT people before making a decision on disclosure. Others did not wait before disclosing and were quite open about their sexual orientation or gender identity and sought assurances from service providers that they would not be discriminated against.
These strategies point to a considered and proactive approach to managing potentially negative responses to sexual orientation or gender identity. Research exists to suggest that this approach might have been fostered in some older LGBT people through an enforced necessity to adapt to long-term discrimination (Orel, Reference Orel2004). Many older LGBT people are positive about their gender identity and sexual orientation and, over time have developed the ability to manage the stigma associated with being gay, lesbian, bisexual or transgender and built up self-advocacy skills to cope with homophobia. These skills are believed to better prepare them for successful aging (Barranti and Cohen, Reference Barranti, Cohen, Schneider and Kropf2000).
A “demographic snapshot” of older LGB adults was produced by Crisp, Wayland, and Gordon (Reference Crisp, Wayland and Gordon2008) by drawing on several international studies investigating the health and well-being of these populations (Crisp et al., Reference Crisp, Wayland and Gordon2008). In summarizing research on the strengths identified in these populations, the authors wrote: “Due to the oppression and stigma often associated with homosexuality, these persons often have a great ability to adapt to many life situations such as discrimination, violence, and a lack of recognition for couples” (Crisp et al., Reference Crisp, Wayland and Gordon2008, p6). This adaptability, the authors suggest, puts older LGB adults in good stead to negotiate the aforementioned obstacles if they are encountered in the aged care services arena.
However, it is not the case that all older LGBT people possess these forms of resilience and it is unacceptable to expect that successful aging by members of these groups is dependent on their learned ability to cope with oppression and discrimination. Rather, attention needs to be paid to fostering cultures within which LGBT people (older or otherwise) are not subject to oppression and discrimination. There has been some recent policy reform designed to provide equal rights to people who are LGBT, including some specifically designed to address the rights of older LGBT people. For example in Australia, in December 2012 the LGBTI Ageing and Aged Care Strategy was launched by the Department of Health. Central to the strategy is the classification of older LGBTI people as a “special needs” group in the same way that older Aboriginal and Torres Strait Islander people are. By taking this measure, it brings older LGBTI people's sexual orientation and gender identity to the fore (thereby working against the tendency to ignore older people's sexuality, particularly non-heteronormative sexuality) as well as acknowledging that older LGBT people have unique physical and mental health needs. The impact of this policy reform is not known but there has been some research on the impact of earlier reforms in the United States, Canada, and Britain. The general conclusion is that increased judicial empowerment and the development of regulations designed to recognize and protect non-heterosexual identities does positively alter mainstream attitudes towards LGBT populations (Smith, Reference Smith2005; Keck, Reference Keck2009).
Summary and conclusion
There is a growing body of evidence highlighting the enhanced likelihood of older LGBT people suffering depression and anxiety. Some of this research indicates that the fear of, and the actual occurrence of sexuality and/or gender identity-based discrimination in aged care settings is one source of this anxiety and depression. In addition, older LGBT people bear the burden of being discriminated against not only because of their sexual and/or gender identity, but also because of their age. One of the ways that these two forms of discrimination manifest in the lives of older LGBT people is in an almost complete denial of their rights. Although some older LGBT people have developed strategies to make themselves safe in the face of this discrimination, strategies some researchers suggest have emerged as a form of resilience in response to an adult lifetime of discrimination, this is certainly not the case for all, or even most older LGBT people. While these populations are beginning to gain recognition via a number of useful public policies, guidelines, and through awareness being generated in aged care facilities via LGBTI education programs, such as the national LGBTI Ageing and Aged Care Training Project in Australia, the status-quo is a bleak one for older LGBT people accessing aged care resources and services. There is a considerable gap in knowledge amongst aged care providers about how to recognize and manage the mental health needs of older LGBT people. One of the reasons for this is that there is a lack of knowledge about the mental health experiences of older LGBTI people and how they have managed depression and anxiety throughout their lifetimes. There is a need for research that investigates what these populations want and need in aged care settings, as understood and articulated by them, and for this to be translated into education programs for aged care professionals. Furthermore, every attempt should be made to include older intersex people in this research.
Conflict of interest
None.
