As long as there have been nursing homes, there have been residents living in them who were lesbian, gay, bi-sexual or transgender (LGBT). This may surprise some, because it is a common assumption that it is possible to identify LGBT individuals by appearances, experiences, or external characteristics. However, nothing could be further from the truth: LGBT elders do not all look the same way or adopt the same mannerisms or ways of dressing. Indeed, they may have past life experiences—such as being previously married or having children or grandchildren—that conflict with common assumptions about LGBT people.
The unhappy reality is that people in nursing homes who are lesbian, gay, bi-sexual, or transgender have almost always been reluctant and even afraid to be identified as such, from fear of how staff, other residents and family members would respond to them. Surveys indicate that four out of five LGBT elders say they don’t trust the health-care system, and in 2010 the federal government noted in its Healthy People 2010 campaign that LGBT people face specific and magnified health vulnerabilities. These vulnerabilities range from LGBT elders avoiding health care providers because of their worries about how they’ll be treated, to the damaging physical and mental health effects of being stigmatized and/or the focus of prejudice and discrimination, which create a hostile and stressful environment. There are approximately 1.5-2 million LGBT Americans over 65, and they have the same needs for long-term care services as other elders. However, in order to be sure we are providing them with the same quality of care that we provide to others, it is essential that we take steps to ensure that they feel genuinely welcome, and while in our care, free from fear or discrimination. Here are some suggestions from the National Resource Center on LGBT Aging:
The first step is learning about all the ways that people with dementia let us know when they have pain. Pain observation tools have been developed specifically to help us do this, and one example is the Pain Assessment in Advanced Dementia, or PAINAD. What makes the PAINAD different is that it identifies behaviors typical of many people with dementia that are often not associated with pain, such as:
- Presume you have LGBT residents.
- Do not assume you can identify an LGBT person.
- Do remember a client’s sexual orientation and gender are only two aspects of a person’s overall identify and life experience. In addition to sexual orientation and gender identity, each resident brings with them their racial, ethnic, and cultural heritage, as well as their unique individual history.
- Do ask your residents about their sexual orientations and gender identities in a safe and confidential manner. Remember that while it is important to ask about sexual orientation and gender identity along with all of the other key components of care, LGBT people have significant histories of discrimination and stigma, which make them far less willing to disclose these parts of their identifies. Ask the questions as you would any other factual question, but do not force anyone to answer. If a resident looks uncomfortable, anxious, or refuses to answer, move on to the next question.
- Do not assume that treating everyone the same, regardless of sexual orientation or gender identify, is effective or will make LGBT elders feel safe or welcomed. More often than not, treating everyone the same translates to treating everyone as heterosexual, and glosses over challenges LGBT elders may have faced, including discrimination, physical and emotional stress, and violence.
First Impressions: What does welcome look like?
Including same-sex couples in marketing materials sends a positive message. In addition, prominently post your facility’s non-discrimination policy on your website, on paper or print materials, and in the lobby. The policy should specifically state your facility’s commitment to inclusion and protection of all people, as well as their caregivers, family members, and friends, regardless of sexual orientation and gender identity. Place LGBT-inclusive images or other signs of inclusion such as rainbow flags in the lobby, in public hallways, or on office doors. Make copies of LGBT-relevant magazines, publications, and information about local LGBT resources available for residents, along with books with LGBT content, characters, and authors.
Making it Happen: Facility Policies and Procedures
All facility policies and procedures should be reviewed to ensure that they promote, rather than detract from, LGBT inclusion. Forms should be updated to include relationship options such as “partner” or “significant other.” Review your policies and definitions for “family” and make sure that they include a resident’s “family of choice”—friends, partners, and other people close to the individual—as well as “family of origin.” Create an opening for LGBT residents by asking them open-ended questions such as, “Who do you consider family?” or “Who in your life is especially important?” Policies for accepting visitors should be the same for both same-sex and opposite-sex partners. Further, encourage clients to write in their own gender designations by inserting a blank line besides “male and female.” Having this additional fill-in-the-blank welcomes people to define their own gender.
Sometimes problems can emerge with roommates who may be uncomfortable with sharing a room with someone who is LGBT, or with other another resident who says hurtful things about people who are LGBT (including sometimes people with dementia, who may say things they would never say if they were not demented). Staff should be encouraged and helped to handle these issues the same way they handle other roommate or resident conflict issues, with the awareness this may be an opportunity to open up a conversation. As with other residents, someone who is LGBT should not have to share a room with a person who is hostile to them.
It is important to create ongoing monitoring mechanisms for residents to report and address biased behavior from fellow residents or staff and for staff to report discriminatory or biased behavior. This process should be presented to residents and staff and also posted in high-traffic areas. Complaints should be handled quickly.
Making it Real: Training and Cultural Competency when Caring for
Training all staff on how to identify and address the needs of LGBT elders is key to making a nursing home inclusive. Staff should begin by examining how assumptions they may have about LGBT residents, based on labels or stereotypes, can be harmful and prevent them from offering safe and affirmative services. Staff must be willing to explore their own internal assumptions about labels and learn to set them aside to see each person as an individual with unique needs and concerns. The training should also provide strategies for helping staff address situations with other residents or family members who may say or do things which are hurtful to LGBT elders.
Adapted with permission from “Inclusive Services for LGBT Older Adults: A Practical Guide to Creating Welcoming Agencies,” National Resource Center on LGBT Aging.