10.5 LGBTQ+ Older Adults
Presented by: Iain Wilkinson, Jo Preston, Sophie Norman
Faculty Member: Jackie Lelkes
Special Guests: Cate Bailey
Broadcast date: 11/05/2021
Social Media
Learning Outcomes
Knowledge
- To understand what the term ‘sexuality’ encompasses.
- To understand why LGBTQ+ older adults face additional discrimination and challenges
Skills
- To develop an awareness of some of the issues that impact on older persons sexuality
- To be able to have an open and non-judgemental dialogue about sexuality with your patients, where appropriate
Attitudes
- To consider biases and prejudices regarding sexuality which may affect how we interact with older LGBTQ+ adults.
CPD Log
Show Notes
Definitions
Sexuality:
Dhingra et al (2016) define the term “sexuality” as ‘the capacity for sexual feelings, including also a person’s sexual orientation, gender identity, intimacy, eroticism, and the social aspects of sex’ which are a basic human right.
Sexuality in Older Adults. Clinical and Psychosocial Dilemmas. Dhingra et al.
Gender:
The UK government defines gender as: a social construction relating to behaviours and attributes based on labels of masculinity and femininity; gender identity is a personal, internal perception of oneself and so the gender category someone identifies with may not match the sex they were assigned at birth.
ONS – What is the difference between sex and gender?
LGBTQ+ is an acronym for Lesbian, Gay, Bisexual, Trans and Queer – and we were informed by the website for the organisation ‘opening doors’ for this definition
LGBTQIAP+ is the acronym in its entirety with..
L – lesbian
G- gay
B – bisexual
T – trans or transgender
Q – queer
I – intersex
A – Ace (an umbrella term for people who experience no or varying levels of sexual or romantic attraction eg people identifying as asexual)
P – pansexual
‘+’ – Recognising that there are other ways to identify sexuality and gender beyond the words explicitly included in the acronym
https://www.openingdoorslondon.org.uk/lgbt-glossary
Main Discussion
Despite an ageing population and the importance of expressing sexual identity amongst the older population being linked to quality of life (Bauer, 2015), there is a dearth of government policy which considers sexuality for older people, which Taylor and Gosney (2011) identify as mirroring ‘the general perception and prejudices of an ‘asexual’ old age, where older people do not desire or engage in sex, with older people who do engage in sex being viewed as disgusting, risky or simply funny’.
This may be compounded for older LGBTQ+ adults, with ageism and heterosexism contributing to stigmatisation.
In the gay community, it has been suggested that a focus on physical appearance, for example, contributes to isolation and ‘invisibility’ of older gay adults. And conversely, there is also the opinion among some of the younger LGBTQ+ community that older members see them solely through a ‘sexual lens’.
In addition to the barriers to the expression of sexual identity older heterosexual adults face, many LGBTQ+ older adults will have lived at a time when homosexuality was illeagal, experienced real stigmatisation on the basis of their sexuality.
- The American Physchiatry association only removed homosexuality from the DSM in 1973.
For older adults who may be coming out for the first time, and expressing their sexuality, there are additional considerations to make compared to those for younger LGBTQ+ adults, eg. children, partners, the opinions of their peers and the legacy of a less accepting society causing fear and shame.
Available at: https://www.ncbi.nlm.nih.gov/books/NBK64800/
https://stand.ie/coming-out-later-in-life/
Ageism and Sexuality. Gewirtz-Meydan et al.
Available at https://link.springer.com/chapter/10.1007/978-3-319-73820-8_10#citeas
When looking at sexuality in older people in terms of intimacy, sexual behaviour and eroticism, we discussed some of this when we discussed sex in older age in series 4 (episode 3)
- Consent and capacity
- Physiological changes affecting sex
- Sex in people who have dementia
http://thehearingaidpodcasts.org.uk/episode-4-03-sex-and-older-adults/
According to Dhingra et al (2016) current research suggests that both older women and men still see sexuality as an important part of their lives, they still have sexual desires and a wish to engage in intimate relationships and sexual activity including kissing, cuddling, foreplay, sexual intercourse, and masturbation despite being faced with potential difficulties.
Taylor and Gosney (2011) identified that research into older persons sexuality is difficult due to the deeply personal nature of an individual’s sexuality, and discussing an individual’s sexuality with them is fraught with difficulties including:
· embarrassment
· self-reporting biases
· poor response rates to research
The research does, however, consistently suggest that increasing age is associated with a decreased interest in sex itself.
For example, Taylor and Gosney cite a Swedish study by Helgason et al (1996) in which a postal study (with a 73% response rate) was conducted with men between the ages of 50-80, which showed that 98% of 50–59 year-olds gave sex at least ‘some importance’ compared with 72% of 70–80 year-olds.
The research also looked at sexual function across four domains (desire, erection, orgasm and ejaculatory functions) and found a decrease in all with increasing age. However, even among the oldest men (aged 70–80), 46% reported orgasm at least monthly’.
There are a myriad of reasons why older people lose interest in engaging in sexual activity which can include their
- Physical health, including sexual dysfunction
- Psychological reasons and/or emotional health
- Boredom and familiarity
However…Sexuality is not just about sex, and your sexuality shapes your whole identity. The AgeUK “safe to be me” document states that one major barrier to good practice among HCPs is the notion that sexuality no longer matters in old age.
“If I didn’t have sex with another woman for the rest of my life, I would still be a lesbian. It’s as integral to who I am as my identity as a mother, the job that I do and the beliefs I hold dear. It’s not the whole of me, but it is a big part!’”
Available at https://www.ageuk.org.uk/globalassets/age-uk/documents/booklets/safe_to_be_me.pdf
Discussing sexuality
- Discussing sexual function, dysfunction and sexual health
It is important that professionals are able to discuss with older people their concerns about sexuality, Gott et al (2004) identifying that this must be a priority within primary care if it is to be proactive in playing a broader role in sexual health management.
Unless health and social care professionals accept that older people are engaging in sex, and are comfortably discussing sexuality then it is unlikely sexual problems will be discussed, diagnosed and addressed.
According to Taylor and Gosney (2011) older people often don’t seek help for sexual dysfunction due to embarrassment or a feeling that their GP may see then as a ‘sex maniac’ or that they are time wasters and younger people would benefit more from support.
Farrell and Belza (2012) demonstrated that 40% of older people (men more than women) do wish to discuss their sexual health but that they felt the onus should be on the health care professional to initiate the discussion.
Gott et al (2004) found a belief amongst practitioners that older people would be offended by discussions in relation to their sexuality, but the biggest barrier was the professional’s own attitude to discussing sexual matters finding that ‘discussions about sexual risk taking were not initiated routinely with this age’ (p.533).
- Discussing sexual identity
Lyons et al (2020) suggest that many older lesbian and gay adults feel uncomfortable disclosing their sexual orientation to health and social care service – a view supported by an Australian study by Hughes (2017) which found that 23% of people who identified as LGBTQ over 50 had not disclosed their sexuality to their GP (cited in Lyons et al. 2020)
the reasons for not doing so including:
· Stress
· Fear of unfair treatment
· Fear of discrimination
· Fear of receiving differential treatment
In fact, compared to younger LGBTQ+ individuals, older LGBT individuals are less likely to seek help from healthcare services in general.
This may be preventing older gay men and lesbians from accessing and utilizing formal services that they may need in order to age well.
This is a group of individuals whose relationships have been ignored or denied when they have been open about their sexuality, and for those who grew up prior to the gay liberation era, a group who lived with stigma and shame related both to overt discrimination by healthcare professionals, and for some, forced medical interventions
Changing the Culture of Long-Term Care: Combating Heterosexism. Schwinn et al. PMID:26882426
Legal rights
Sexual orientation, marriage and civil partnership and gender reassignment are three of the protected characteristics under the equalities act 2010
Civil Partnership Act 2004: means that same-sex couples in civil partnerships must be treated the same as married couples and any policies or practices should reflect this.
https://www.legislation.gov.uk/ukpga/2004/33/notes
The Equality Act 2010 2010 outlaws discrimination when providing any goods, facilities and services on the grounds of someone’s sexual orientation or perceived sexual orientation. This means, for example, that it is unlawful to refuse to house a same-sex couple together in a care home if a heterosexual couple in similar circumstances would be housed together.
The public sector Equality Duty, also requires public and private organisations that deliver public services to act to eliminate discrimination. They have a duty to encourage equality of opportunity and foster good relations between different groups including lesbian, gay and bisexual people.
https://www.gov.uk/guidance/equality-act-2010-guidance
The UK Government estimates that the LGBTQ people comprise approximately 5-7% of the population and that by 2031, based on the ONS, there could be as many as 1 to 1.4 million gay, lesbian, trans and bisexual people aged 60 and over in the UK. (likely to be an underestimate).
Available at https://ilcuk.org.uk/wp-content/uploads/2018/10/OlderLGBTPeopleintheUK.pdf
What issues do we as health and social care professionals need to be aware of and what biases do we need to overcome?
Like many other groups of older people, the LGBTQ+ community are a diverse group not only as a result of cultural, ethnic and racial diversity, but similarly to heterosexual older people, their diversity is based on educational background, socioeconomic class and income.
Older people can experience amongst other things:
· ageism
· social isolation (through loss of family and friends)
· poor health
· poverty
Previous experiences of stigma and discrimination on the basis of sexuality may make the experience of growing older for LGBTQ+ individuals different to that of their heterosexual peers.
Homophobia; defined as ‘the irrational hatred, intolerance, and fear of lesbian, gay and bisexual people’, which can take the form of words and language used (e.g. speaking disparagingly) or be in the form of actions e.g. violence.
Heterosexism; being the assumption that everyone is heterosexual
Changing the Culture of Long-Term Care: Combating Heterosexism. Schwinn et al. PMID: 26882426
Dhingra et al (2016) identified that discussions on older LGBTQ+ sexuality is almost entirely absent from mainstream media and that the bulk of currently available research tends to equate having sex with heterosexual sex, omitting other sexual orientations – an example of heterosexism
Sexuality in Older Adults. Clinical and Psychosocial Dilemmas. Dhingra et al.
Available at: https://www.researchgate.net/publication/311626435_Sexuality_in_older_adults_Clinical_and_psychosocial_dilemmas
Lytle et al (2018) suggests that ‘Crisis competence’ identifies how an individual who has developed a stigmatized identity (e.g. sexual orientation) can develop skills to not only cope with that stigmatization but that they can then use those skills to cope with additional stigmatized identities (e.g. older age) enabling people from the LGBTQ+ community to adjust more positively to ageing than heterosexual adults, with 74% of the older respondents stating that their sexual orientation helped them prepare for ageing. Although 54% or respondents also believed that their sexual orientation makes ageing more difficult.
Stonewall guide on ageing
There is a guide published by Stonewall; ‘Working with older lesbian, gay and bisexual people. A Guide for Care and Support Services’. It is informed by YOUGov research published 2011 ‘ Lesbian, Gay and Bisexual People in Later Life’, which surveyed 2000 people over the age of 55, comparing the experiences of heterosexual and lesbian, gay and bisexual people.
Available at: https://www.stonewall.org.uk/system/files/older_people_final_lo_res.pdf
The guide offers support to organisations/services about how to meet the needs of lesbian, gay and bisexual people, but that often simple changes – like awareness, communication – on an individual basis have a big impact.
Some themes in the document are as follows
- Stonewall research has shown that half of older gay people feel their sexual orientation has, or will have, a negative effect on getting older.
- Three in five are not confident that social care and support services will be able to understand and meet their needs
- 50 per cent are uncomfortable being out to care home staff, 33 per cent to a housing provider, and 20 per cent to a GP
There are recurring themes of fear of discrimination and feeling of heightened vulnerability when surveys are done to assess attitudes of LGBTQ+ people towards residential care.
Some feel they have to hide anything that might reveal that they are gay, such as photographs of their partner, because they are unsure of who is coming into their home. Older gay people may also be anxious about coming out and the response they will receive from a care and support worker or personal assistant.
For care workers;
- Don’t assume that people you care for are heterosexual
- Ask people open questions about their life and who is important to them
- In everyday conversation talk about gay people or issues in a non-judgemental way
- Don’t force people to talk about their sexual orientation if they don’t want to
When asking about a next of kin in a hospital/care setting: Older LGBTQ+ people may have concerns that their same-sex partner or even their friends won’t be acknowledged by staff. Asking open questions such as ’who would you like us to contact in an emergency?’ or ‘do you have somebody at home?’ can encourage open discussion about who to nominate to arrange appropriate care.
- Isolation
Gay people are much more likely than heterosexual people to face the prospect of living alone with limited personal help from their families and therefore are more likely to rely on formal services for support in later life.
- 41 per cent of lesbian, gay and bisexual older people live alone compared to 28 per cent of heterosexual older people
- Lesbian, gay and bisexual older people are less likely to have children and less likely to see biological family members on a regular basis – just a quarter of men and half of women see their children compared to nine in ten heterosexual men and women
There is also concern that age will lead to isolation from the LGBTQ+ community itself
“[I] felt I wouldn’t be welcome in the gay community, complete with walking stick…that was my perception…” (from the SAGE project)
Combating loneliness amongst older LGBT people Exploring findings from the Sage programme in Leeds
- Housing
Older lesbian, gay and bisexual people want many of the same things in later life as heterosexual older people. This includes staying in their own homes for as long as possible and being treated with respect and dignity when they access health and care services.
- Many older gay people have lived through a time when same-sex relationships were outlawed and see their home as a safe space where they can be themselves. The vast majority, 95 per cent, of older gay people say they would prefer to live in their own home for as long as possible and they are nearly twice as likely as older heterosexual people to rely on a range of external services for support.
In a report on housing by the LGBT Foundation (Manchester), 74% of responders said they wanted a home for their old age aimed at them and delivered by a LGBT-specific provider, but 43% had no idea where they would get care and support in the future
https://www.theguardian.com/society/2020/oct/21/uks-first-extra-care-housing-lgbtq-manchester
“I would, by virtue of the need to have carers in my home, be at a particularly vulnerable stage of life. The thought of being in my own home requiring help from someone who brings in with them the prejudices and judgements of the world I experience ‘out there’ fills me with dread”
“I want to get old with friends, especially gay-friendly friends. I want to see more scope for friends to cohabit and care for each other without state support”
The stonewall guide we are referencing here was written in 2015, prior to stonewalls ‘a vision for change’ 2017-2022 stating their position on trans inclusion – ‘acceptance without exception for trans people’
A vision for change, acceptance without exception. 2017-2022, Stonewall.
Available at: https://www.stonewall.org.uk/system/files/a_vision_for_change.pdf
Trans older adults
- Older trans adults have been reported to have higher rates of physical ill-health, disability, obesity and lack of physical activity than older non-trans LGB adults (Fredriksen-Goldsen et al., 2014).
- Higher rates of psychological morbidity are also reported.
- Fredriksen-Goldsen et al. (2014) found older trans adults to be at higher risk of depressive symptomatology and perceived stress than older non-trans LGB adults, and Hoy-Ellis et al. (2017) found that nearly 50 per cent of trans adults aged 50+ had clinically significant depressive symptomatology in a secondary analysis of data from a large community survey in the USA
Regarding trans experiences of dementia:
Page et al. (2016) list a number of potential concerns for trans people who are developing dementia:
- fear of being ‘outed’ as trans as a consequence of needing care;
- losing touch with one’s individual gender identity;
- having to rely on others to express one’s own gender identity;
- being forced into the ‘wrong’ gender identity (maybe reverting to birth gender);
- not being treated with respect and dignity.
From Bristol university: “Ensuring trans people in Wales receive dignified and inclusive health and social care in later life: The Trans Ageing and Care (TrAC) project, 2016-18;”
- The report Identified gaps in HCPs knowledge about trans issues in later life (both medical and legal)
- There were examples of trans individuals having to educate HCPs on relevant issues, or do research themselves in the report.
- Mixed responses from HCPS (mainly GPs) to trans people were documented, but examples of transphobia, being misgendered on medical records, and use of wrong names were reported.
- Recommendations from the project:
- Education of HCPs pre and post qualification
- Standards of care and support being set for trans individuals
- Increased resources for trans groups and networks.
Two really powerful videos made as part of this project (TrAC) are available to view here: https://www.youtube.com/watch?v=ETugXLeRBUE
and here: https://www.youtube.com/watch?v=Bk7XZio686Q&list=RDCMUCsDRRuhpz3oCi5PABiiY5kA&index=19
Resources, organisations and examples of good practice
Manchester city council has put out to tender a scheme to build an “LGBT-affirmative extra-care scheme”. 51% of the 150 places are to be allocated to LGBTQ+ people aged over 55, who need extra physical or mental support.
https://www.theguardian.com/society/2020/oct/21/uks-first-extra-care-housing-lgbtq-manchester
Sheffield County Council has started to talk to the lesbian, gay and bisexual community about their housing needs through a survey.
- identified issues such as isolation and vulnerability experienced by older lesbian, gay and bisexual people which has helped the development of the Council’s housing strategy.
East Sussex County Council runs an LGB and T carer and patient group to test ideas and involve in service developments and training. The group has begun using social media to reach out.
The sage project in leeds – for combating loneliness in older age, age UK + YorkshireMESMAC
- Drop in sessions, volunteer ‘buddies’ for people who might need support in a variety of way eg with engaging with local services, and social events and activities
- Focus on creating safe space has contributed to success – whether that’s a physically accessible space for LGBTQ+ support (at leeds pride) or the support of buddies, and making people feel welcome.
Combating loneliness amongst older LGBT people Exploring findings from the Sage programme in Leeds
The stonewall website also has links to resources re ageing specifically – including practical advice; pensions, wills, disregarding historic convictions for gross indecency which can be a real barrier for some people eg with concerns this might stop them being able to get involved with things like volunteering projects (requiring background checks).
https://www.stonewall.org.uk/category/later-life
https://www.stonewall.org.uk/later-life
OLGA – Older Lesbian, Gay, Bisexual & Trans Association, A community network
An organisation run by and for older LGBTQ+ people, working mainly in the north of the UK
Activities include
- Organising local befriending services for older LGBTQ+ people – hospitals and care homes
- Social activities, meetings, newsletters
- Involved in national EOLC project
- Provide awareness and training sessions to H+S care providers across north of england
Age uk
Info on…
- LGBTQ+ rights
- Support re discrimintation
- Health and wellbeing
- Trans issues
- Social groups
- As of this month, age uk listed on its website the following as running LGBTQ+ social groups for older people
- Age UK also have advice and signposting to relevant organisations regarding dating as an LGBTQ+ person on their website
https://www.ageuk.org.uk/information-advice/health-wellbeing/relationships-family/lgbt/
Opening doors london
UK charity providing activities, events, information and support services specifically for lesbian, gay, bisexual, trans, queer, non-binary or gender fluid (LGBTQ+) people over 50.
- Membership free and open to anyone over 50 who Identifies as lesbian, gay, bisexual, trans, queer, non-binary, gender-fluid
- Also provide training for professionals in health, housing and social care sectors
satisfies the equalities requirements of local Clinical Commissioning Groups, the Care Quality Commission
lesbian, gay, bisexual, trans, queer, non-binary or gender fluid (LGBTQ+)
Switchboard, an LGBTQ+ helpline who provide a ‘listening service’ for LGBTQ+ people via the telephone, email and IM, with the volunteers who run the helpline being LGBTQ+ people themselves.
0300 330 0630
Curriculum Mapping
NHS Knowledge Skills Framework
- Equality and Diversity
- Level 4: Develop a culture that promotes equality and values diversity
GPVTS
- Professional topic guide
- Emerging issues
- The GP’s role in reducing discrimination and enhancing inclusion
- Life stages topic guide
- Service issues:
