LGBT Seniors Facing Going Back Into The Closet

Coming out all over again: Why the first gay-rights generation faces familiar challenges in old age

WENCY LEUNG
The Globe and Mail
Published Thursday, Oct. 09 2014, 12:29 PM EDT
Last updated Friday, Oct. 10 2014, 4:49 PM EDT




With the generation that led the gay-rights movement reaching retirement age, many LGBT seniors are forced to relive the struggle for acceptance, and even re-closet, as they enter care facilities populated with a generation raised to believe that homosexuality is a crime. Wency Leung reports


Ginny Lundgren, left, and Paulette Kupnicki, take a walk outside their Windsor condo with Zooki. The long-time couple had to come out all over again when they moved to a retirement condo a couple years ago, to often unenthusiastic neighbours. (Photos by Glenn Lowson for The Globe and Mail)
When Paulette Kupnicki and long-time partner Ginny Lundgren moved into a Windsor, Ont., condo for retirees two years ago, Kupnicki wanted to get to know her new neighbours. She put up flyers on the building’s bulletin board, advertising a seniors’ games group and an upcoming play about LGBT (lesbian, gay, bisexual, transgender) issues, in which she was involved.

The games group flyer was left in place, but her notice about the play was anonymously taken down. Its removal set Kupnicki’s heart pounding: The thought that some residents did not welcome same-sex couples filled her with dread.

“I just spent a lot of money to move out of my house into this place,” says Kupnicki, now 70. “Honestly, I’m walking around with a lump in my throat, thinking, ‘What the hell am I going to do?’”

Stories like Kupnicki’s are all too common. The generation that led the gay liberation movement now faces the prospect of moving into retirement communities, nursing homes, and long-term care facilities alongside more elderly occupants who were raised with the notion that homosexuality was a disease, and a criminal act.

Stories of seniors having to relive their struggle for acceptance are rife. Fearing discrimination from service providers and their peers, some even retreat to the closet when they seek health and social assistance, hiding their sexual orientations, gender identities and domestic relationships. That can be emotionally draining, and have serious consequences on their mental and physical health.

“The number-one fear we hear over and over [from LGBT seniors] is having to age out of their homes, move into care and potentially re-closet,” says Dana Parker, executive director of the Vancouver advocacy group Qmunity. She notes that middle-aged and younger LGBT individuals rarely give that future prospect a thought.

The issues around integration and acceptance have kickstarted campaigns to raise awareness and tolerance in senior-care facilities, and to educate staff members trying to welcome their first wave of uncloseted LGBT residents.

And as the number of openly LGBT individuals swells among the senior population, the need for sensitivity and inclusivity in elder care becomes more pressing. According to a discussion paper released last month by Qmunity, the number of open LGBT individuals aged 65 and older is believed to be about 6.7 per cent of the overall senior population. In the B.C. Lower Mainland alone, that translates to roughly 25,000 people.

It’s a figure that’s expected to grow to reflect a shift in demographics that will see seniors make up an estimated 19 per cent of the province’s population by 2020, up from 15 per cent today. If attitudes don’t change, Parker says, LGBT seniors will be vulnerable to loneliness, isolation and at risk of not receiving the care they need.

Deep-seated fears of discrimination are hard to shake among those who spent much of their adult lives in a world that treated homosexuality as a crime or a disease. The Qmunity paper points out that those who are 85 years old now were already 40 when homosexuality was decriminalized in 1969, and 66 at the time sexual orientation became protected under the Charter of Rights and Freedoms in 1995.

These older seniors, who may have had relationships and careers ruined because of their sexual orientation or gender identity, aren’t likely to live openly in elder care, particularly if they are housed with peers who still hold onto their prejudices. It has fallen on less reticent LGBT boomers, who spent their youth championing gay rights and are now greying themselves, to advocate on behalf of their elders and to push for change in senior care.


“I’m an activist, so I’ve never been in the closet,” says Marie Robertson, community developer of the Ottawa Senior Pride Network, which provides diversity training to long-term-care workers, volunteers and clients of senior services. Now in her 60s, she recalls marching in the streets for human rights protections when she was 19, and she continues to defend those rights. “When I do training,” she says, “I’ll say to the staff: ‘This is who we are. We’re not going back into the closet when we go into care. So here, you’d better get ready.’”

Much of the sensitivity training around LGBT seniors involves creating a safe environment in care homes by building empathy, ensuring staff and volunteers understand historic hardships LGBT individuals experienced, and making sure the language used on intake forms and in brochures is inclusive. Through her work, Robertson has heard heartbreaking accounts of the fear and humiliation LGBT seniors face in long-term care, such as the gay couple who had to visit the washroom just to hold hands, or the transgender woman whose care-worker made a scene upon discovering she had a penis.

Social exclusion is only one of the fears seniors have of being outed. “They’re afraid if the staff knows that they’re gay, that diapers aren’t going to be changed as fast, the call bell is not going to be answered,” Robertson explains. “And the reality is that those fears are justified. That’s what happens.”

Shoshana Pellman, 68, of Toronto, became comfortable enough to be openly transgender in 2005. Although she lives independently now, the idea of returning to the closet if she needs senior care in the future is unthinkable. “It’s like, which part of my body am I going to basically amputate? What part do I have to get rid of to meet your needs or your demands?” Pellman asks. “If someone is forced back in the closet, they’re denying who they are. They’re losing a part of who they are. That’s so cruel… Basically, they’re just surviving. You’re not living any more.”

Research points to positive mental health and wellness benefits linked to coming out in supportive settings, with subjects showing lower rates of depression, burnout and anxiety, and lower levels of the stress hormone cortisol. However, being openly LGBT may have the opposite effects in environments that are not supportive, says Robert-Paul Juster, a PhD candidate at McGill University’s Integrated Program in Neuroscience.

Concealment, on the other hand, has emotional and cognitive costs, says Richard Ryan, professor of psychology at the University of Rochester in New York state. “For example, to conceal, one must constantly monitor oneself, which is draining and requires a cognitive load. Concealing also has emotional costs associated with lower self-esteem, more depression and other negative states,” Ryan said in an e-mail.

Juster points out that much research in this area, including his own, has focused on LGBT youth, but he says there is growing interest in examining the mental health of LGBT seniors. “There is this feeling that they’re an under-represented portion of the population that people don’t know very much about,” he says.

Aware of the need to address a growing wave of openly LGBT seniors, some care facilities are proactively reaching out to advocacy groups for help, says Steven Little, education and training manager at The 519 Church Street Community Centre in Toronto. Although they’re willing to make changes, most seniors’ homes don’t know where to start, he says, noting that mental health resources for LGBT seniors are scarce. And for the first time, service providers may be grappling with how to care for aging clients who have HIV/AIDS.


When it comes to welcoming LGBT seniors, Toronto’s city-run long-term-care homes have taken a lead. At True Davidson Acres, for example, administrator Carlos Herrera says staff and volunteers hold a variety of LGBT-friendly programs, such as shows starring a local drag performer, and movie nights featuring films such as Brokeback Mountain. They participate with residents in the city’s annual pride parade, are careful to use the proper pronouns to address transgender residents, and they’ve made sure a rainbow flag and pink triangle, symbols of LGBT rights, are visible at the entrance to the home, signalling to visitors and residents that it is a supportive environment.

To be LGBT-positive, Herrera says, “we need to see it, we need to hear it, we need to feel it.”

The results of such efforts can be life-changing. At True Davidson Acres’s sister home, Fudger House, resident Alf Roberts, 85, finally felt comfortable enough to be openly gay for the first time in his life after moving into the home five years ago. At last, he says, he can be himself. “I hope that, eventually, more long-term-care homes will be more open so that people don’t have to worry about coming into a place like this,” he says

Back in Windsor, Kupnicki eventually summoned the nerve to address the issue of her missing flyer during a building meeting by pre-emptively thanking her neighbours for welcoming her and Lundgren, and inviting them to join her group activities. Although she made a few new friends that day, some people refused to even look at her.

Kupnicki, who is involved in a 50+ Proud group that provides diversity training on senior care, says it’s difficult to have to come out of the closet all over again. “At times, you think to yourself, I don’t think I can do this one more time,” she says, noting it’s more challenging for people to disclose their sexual orientation when in ill health.

Kupnicki, who had a Catholic upbringing, knew she was attracted to both males and females when she was in grade school, but she quickly hid her attraction to women when her parents discovered she had been kissing a girl. She did not open up about it until entering a relationship with Lundgren 32 years ago, after leaving her husband. Even so, for years Kupnicki was careful about disclosing the relationship, referring to Lundgren as her “friend” in public for fear of losing custody of her children. The process of coming out was also fraught with struggles with disapproving family members.

Kupnicki and Lundgren married eight years ago, and though they now live happily in their retirement condo, having warmed up to even those who initially gave Kupnicki the cold shoulder, the memories stay with them.

“As I talk about them, it comes back and reminds me how painful some of that stuff was,” she says, noting each senior brings his or her own struggles when accessing services or entering care. “Even if you’re out and you’ve been out a long time and all the rest of it, those experiences sit in the back of you.”

Follow Wency Leung on Twitter: @wencyleung

LGBT Eldercare

Caring for older lesbian, gay, bisexual, and transgender adults

Share on twitterShare on facebookShare on printShare on emailMore Sharing ServPublication Date: January 2013 Vol. 8 No. 1

Author: Kimberly Bailey, BSN, RN; and Henrietta Jones, BA

Current discussions on the unique health issues of lesbian, gay, bisexual, and transgender (LGBT) populations have prompted the healthcare professions to reexamine their mission and values. The American Nurses Association (ANA) Code of Ethics reminds us that nursing is committed to the fundamental uniqueness of the individual patient. The preamble to the International Council of Nurses’ (ICN) Code of Ethics states that nursing care should be “respectful of and unrestricted by considerations of age, color, creed, culture, disability or illness, gender, sexual orientation, nationality, politics, race or social status.”

Older adults are a vulnerable population. Besides health problems, many face ageism and sexual-orientation biases. In 2009, the National Gay and Lesbian Task Force Policy Institute estimated the LGBT community in the United States accounts for 5% to 10% of the total population. With the 65+ population projected to number 88.5 million in 2050, this means 1 of every 13 elders will be LGBT. According to the 2011 report “The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding” from the Institute of Medicine (IOM), stigma, discrimination, and violence are social determinants of health and well-being among LGBT elders. IOM’s consensus report on the state of science of LGBT health seeks to mobilize the healthcare community to address the unique health needs of LGBT persons.

Health disparities among LGBT elders

The IOM report detailed the following health needs and issues of LGBT elders:

• Transgender elders may experience negative health outcomes from long-term hormone use.
• HIV/AIDS affects older as well as younger LGBT individuals. However, few HIV prevention programs target older adults—a cohort that has been deeply affected by losses inflicted by AIDS.
• LGBT elders exhibit crisis competence (a sense of resilience and perceived hardiness).
• They experience stigma, discrimination, and violence across the life span.
• They are less likely to have children than heterosexual elders and thus less likely to receive care from adult children.

Lack of culturally competent healthcare providers contributes to ongoing health disparities, making LGBT elders an underserved minority in an aging society. This population has the highest rate of tobacco and alcohol use. With the risks of coronary heart disease, stroke, and diabetes increasing with age, added damage from nicotine and substance abuse puts LGBT elders at greater risk for morbidity and mortality. Also, although advances in AIDS treatment are helping people live longer and more productive lives, the combined effects of drug side effects and lingering infections place them at higher risk for stroke and other cardiovascular events.

Less support or care from adult children may lead to social isolation. In this era of patient-drive care that values diversity, healthcare providers need to understand the concept of “family of choice” among the LGBT population. Given the lack of Social Security benefits to unmarried partners, one partner’s disability or death may threaten the economic security of the surviving partner, causing added hardship and stress that may have negative health effects.

Mandate for LGBT healthcare equality

Through the Affordable Care Act, the Department of Health and Human Services (HHS) promotes cultural competency training for healthcare providers, allocates resources for improving the primary-care workforce, and increases funding for community health centers to address healthcare inequity among the LGBT population. In addition, HHS now requires equal visitation rights for same-sex partners. Starting in 2011, the Joint Commission (JC) began requiring hospitals to demonstrate how they are specifically responding to LGBT patients’ needs as part of the more comprehensive provider/patient communications standards for accreditation. This mandate provides further impetus to apply best practices in LGBT health care across the lifespan.

Inclusive nursing education and practice

With most nurses and other healthcare providers likely to care for LGBT elders with multiple comorbidities, cultural sensitivity and patient-centered care are among the core competencies a nurse must possess. To a large extent, nursing faculty and nursing curricula lack adequate knowledge of LBGT health. Teaching, practice, and research on LGBT health are deficient, too. Revising and aligning the nursing curricula and increasing faculty’s knowledge base in regard to LGBT health promotes adoption of best practices, as called for by the IOM report and the recommendations cited in Healthy People 2020, an HHS program that provides science-based, 10-year national goals for improving the health of all Americans.

Also, ongoing faculty and staff development initiatives should consider covering LGBT health topics involving policy, legal rights, and social justice issues—all of which affect the health of LGBT persons regardless of age.

Promoting culturally sensitive nursing care

To provide culturally sensitive care for all LGBT persons, the JC published a “field guide” to promote inclusiveness and bridge gaps caused by healthcare disparities. Called “Advancing effective communication, cultural competence, and patient- and family-centered care for the lesbian, gay, bisexual, and transgender (LGBT) community,” it offers guidance in the areas of leadership, care provision, workforce, data collection, and community engagement. The box below summarizes its recommendations related to leadership and provision of care domain. (Keep in mind, though, that the health needs of LGBT individuals aren’t uniform.)

Practice guidelines for inclusive and culturally sensitive health care Leadership Develop or adopt a nondiscrimination policy that guards patients from discrimination based on personal characteristics, including sexual orientation and gender identity or expression. Develop or adopt a policy ensuring equal visitation. Develop or adopt a policy identifying the patient’s right to identify a support person of their choice. Integrate and incorporate a broad definition of family into new and existing policies. Monitor organizational efforts to provide more culturally competent and patient- and family-centered care to LGBT patients, families, and communities. Develop clear mechanisms for reporting discrimination or disrespectful treatment. Develop disciplinary processes that address intimidating, disrespectful, or discriminatory behavior toward LGBT patients or staff. Identify an individual directly accountable to leadership for overseeing organizational efforts to provide more culturally competent and patient-centered care to LGBT patients and families. Appoint a high-level advisory group to assess the climate for LGBT patients and make recommendations for improvement. Identify and support staff or physician champions who have special expertise or experience with LGBT issues. Provision of care Create a welcoming environment that includes LGBT patients. Prominently post the hospital’s nondiscrimination policy or patient bill of rights. Ensure that waiting rooms and other common areas reflect and include LGBT patients and families (for instance, by showing a rainbow flag or LGBT-friendly periodicals). Create or designate unisex or single-stall restrooms. Ensure that visitation polices are implemented in a fair, nondiscriminatory manner. Foster an environment that supports and nurtures all patients and families. Don’t make assumptions about a person’s sexual orientation or gender identity based on appearance. Be aware of misconceptions, biases, stereotypes, and other communication barriers. Promote disclosure of sexual orientation and gender identity while remaining aware that disclosure or “coming out” is an individual process. Make sure all forms contain inclusive, gender-neutral language that allows for self-identification. Use neutral and inclusive language in interviews and when talking with all patients. Ask the patient what pronoun is preferred. Listen to and reflect patients’ choice of language when describing their own sexual orientation and how the patient refers to his or her relationship or partner. Provide information and guidance for the specific health concerns of LGBT patients. Become familiar with online and local resources available for LGBT people. Seek information and stay up-to-date on LGBT health topics. Be prepared with appropriate information and referrals. Source: The Joint Commission. Advancing effective communication, cultural competence, and patient- and family-centered care for the lesbian, gay, bisexual, and transgender (LGBT) community: A field guide. 2011.

Eliminating health disparities

Eliminating health disparities and enhancing efforts to improve LGBT health are crucial to helping LGBT persons lead long, healthy lives. Education for healthcare professionals should cultivate openness and inclusiveness. To achieve this, healthcare organizations and professionals should use inclusive language, welcome and normalize individuals’ disclosure of their sexual orientation and gender identity, and apply knowledge gained from professional development training in providing patient-centered care.

Nurses and ancillary staff comprise the largest group of healthcare providers in the United States. Because of our scope of practice and access to patients and families, we have both the privilege and the responsibility of providing compassionate, science-based care to LGBT elders. A basic premise in working with this population and other minority groups is to understand that historically marginalized communities don’t demand special rights butequal rights. To learn more about specific programs for LGBT elders, visit the web resources listed below:

• American Society on Aging: www.asaging.org
• LGBT Aging Issues Network (LAIN): www.asaging.org/lain
• LGBT Aging Project: www.lgbtagingproject.org
• Gay Men’s Health Crisis: www.gmhc.org
• Lambda Legal: www.lambdalegal.org
• National Gay & Lesbian Task Force: www.thetaskforce.org
• National Resource Center on LGBT Aging: www.lgbtagingcenter.org
• New England Association on HIV over 50: www.hivoverfifty.org
• SAGE (Services & Advocacy for GLBT Elders): www.sageusa.org/index.cfm
• Transgender Aging Network: www.forge-forward.org/tan

Selected references

Benjamin LA, Bryer A, Emsley HC, Khoo S, Solomon T, Connor MD. HIV infection and stroke: current perspectives and future directions. Lancet Neurol. 2012:11(10):878-90. doi: 10.1016/S1474-4422(12)70205-3.

Eliason MJ, Dibble S, Dejoseph J. Nursing’s silence on lesbian, gay, bisexual, and transgender issues: the need for emancipatory efforts. ANS Adv Nurs Sci. 2010:33(3):206-18. doi: 10.1097/ANS.0b013e3181e63e49

Fowler MD. Guide to the Code of Ethics for Nurses: Interpretation and Application. Silver Spring, MD: American Nurses Association; 2010 reissue.

Gay and Lesbian Medical Association. Guidelines for care of lesbian, gay, bisexual, and transgender patients. 2006. San Francisco, CA: Author. http://glma.org/_data/n_0001/resources/live/GLMA%20guidelines%202006%20FINAL.pdf. Accessed November 16, 2012.

Grant JM, Koskovich G, Somjen Frazer M, Bjerk S. Outing age 2010: Public policy issues affecting lesbian, gay, bisexual and transgender elders. 2010. Washington, DC: National Gay and Lesbian Task Force Policy Institute.www.thetaskforce.org/downloads/reports/reports/outingage_final.pdf. Accessed November 16, 2012.

Healthy People. US Department of Health and Human Services. Lesbian, gay, bisexual, and transgender health. 2012.www.healthypeople.gov/2020/topicsobjectives2020/overview.aspx?topicid=25

Institute of Medicine. The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Washington, DC: National Academies Press; 2011.

International Council of Nurses. ICN code of ethics for nurses. 2006.www.icn.ch/images/stories/documents/about/icncode_english.pdf.

Irwin L. Homophobia and heterosexism: Implications for nursing and nursing practice.Austral J Adv Nurs Online. 2007;25(1):70-6.

Joint Commission. Advancing effective communication, cultural competence, and patient- and family-centered care for the lesbian, gay, bisexual, and transgender (LGBT) community: A field guide. 2011. Oakbrook Terrace, IL: Joint Commission.www.jointcommission.org/assets/1/18/LGBTFieldGuide.pdf. Accessed November 16, 2012.

Lim FA, Bernstein I. Promoting awareness of LGBT issues in aging in a baccalaureate nursing program. Nurs Educ Perspects. 2012;33(3):170-5. http://dx.doi.org/10.5480/1536-5026-33.3.170

Lim FA, Levitt N. Lesbian, gay, bisexual and transgender health: Is nursing still in the closet?Am J Nurs. 2011:111(11):11. doi:10.1097/01.NAJ.0000407277.79136.91

Meyer H. LGBT aging: Lessons from life at the edges. Aging Today. 2011:32(4):7,10.

New York City Health and Hospitals Corp. HHC Will Adopt Mandatory Cultural Competence Training for Staff to Improve the Health of Lesbian, Gay, Bisexual, Transgender New Yorkers. May 25, 2011. www.nyc.gov/html/hhc/html/pressroom/press-release-20110525-lgbt-training.shtml. Accessed November 16, 2012.

U.S. Department of Health and Human Services. Statement by Secretary Kathleen Sebelius on LGBT Health Awareness Week 2012. March 26, 2012.www.hhs.gov/news/press/2012pres/03/20120326a.html. Accessed November 16, 2012.

U.S. Department of Health and Human Services. Medicare steps up enforcement of equal visitation and representation rights in hospitals. September 7, 2011.www.hhs.gov/news/press/2011pres/09/20110907a.html. Accessed November 16, 2012.

Fidelindo Lim is on the clinical faculty, James C. Pace is associate dean of the undergraduate program, and Henrietta Jones is an administrative assistant at New York University College of Nursing in New York, N.Y. Kimberly Bailey works in the intensive care unit at Robert Packer Hospital in Sayre, PA.

This post comes courtesy of American Nurse Today.