Summer 2008

Invisible Individuals — LGBT Elders
By Florence Gelo, DMin, NCPsyA
Aging Well
Vol. 1 No. 3. P. 36

Through years of denial, uncertainty, and fear, lesbian, gay, bisexual, and transgendered individuals kept a low profile. Now, as older adults, many fail to seek necessary healthcare or are underserved by unenlightened professionals.

Positive images of lesbian, gay, bisexual, or transgendered (LGBT) people in popular culture, such as successful TV host Ellen DeGeneres and entertainer RuPaul, along with increasing media attention on the LGBT community, show a growing change in social consciousness. However, phobias relating to sexual identity still prevail. Homophobia and transphobia (related to transgendered people) are aversions to LGBT people and their lifestyle and remain one of the “the last permissible prejudices.” LGBT people experience a range of societal reactions, including acceptance, tolerance, hostility, outright rejection, or violence.

The National Gay and Lesbian Task Force’s Aging Initiative estimates that about 3 million Americans over the age of 65 are LGBT, a figure likely to double by 2030. This is only an estimates since social prejudice and institutional discrimination have resulted in LGBT people’s fears of being identified. LGBT elders represent a generation that lived through years of fear, self-hatred, identity confusion, loneliness, isolation, and shame. Protecting oneself from a hostile culture was not just an option—it was a way of life. Invisibility became a common strategy employed to ensure safety. To the extent that invisibility continues today, it remains a barrier to assessing LGBT older adult needs and providing appropriate support and services.

Historic LGBT Struggles
To understand lesbian and gay older adults’ desire for anonymity requires reviewing a bit of modern history. LGBT individuals have been described as an invisible population, a term coined by feminist scholar Margaret Cruikshank. Prior to the 1970s, little knowledge about homosexuality existed, except for the widely held opinion that it was deviant and immoral. Gay sexuality was criminalized and known homosexuals were routinely fired or experienced discrimination in employment. Gay liberation movements and support groups, such as the Mattachine Society and the Daughters of Bilitis, existed in the 1950s but remained largely hidden.

Nearly 50 years ago, Alfred Kinsey’s studies, though statistically flawed, challenged traditional notions of “normal” sexuality. Kinsey suggested that one third of American males and 13% of American females claimed to have had at least one same-sex orgasmic experience by the age of 45. Other research suggested that only 4% of white men and 2% of white women in the United States were exclusively homosexual. These reports were vehemently attacked as promoting unhealthy and immoral behavior. Later studies have estimated that 10% of the total population is gay, lesbian, or bisexual as part of a spectrum of sexual behaviors for all men and women along a continuum from exclusive heterosexuality to exclusive homosexuality.

Within this culture, lesbian and gay people concealed their sexual orientation. They feared physical and emotional abuse; rejection from family, friends, and religious communities; and job loss. Additionally, they faced harsh persecution, institutionalization, and incarceration. Many viewed themselves as abnormal and suffered shame and anguish over their same-sex attractions. Hiding the truth of their sexual orientation from themselves or others, many entered into heterosexual marriages despite the uncomfortable knowledge about themselves, and some had children. Others cautiously or recklessly sought same-sex relationships. Many entered or were forced into reparative psychotherapy to be cured of a “severe and pervasive emotional disorder” and to alter their sexual orientation. Yet some still managed to find and sustain loving partnerships.

In 1969, a rebellion occurred. Emboldened by the liberation movements of the era and angry at the persistent harassment, physical brutality, and incarceration that followed raids in bars and social spaces frequented by lesbian and gay people, customers at the Stonewall Inn in Greenwich Village, NY, fought back after a police raid. Later that night and for days afterwards, lesbian and gay people along with supporters held marches in the streets of New York City demanding an end to violence and the establishment of civil rights. This one episode launched a mass movement for equality for lesbians and gay men.

Only a year later, in June 1970, the first Christopher Street Liberation Day celebration took place in New York’s Central Park. Other cities celebrated gay pride as lesbians and gay men demanded equal rights. Continued activism led to the 1973 decision by the American Psychological Association to acknowledge that homosexuality was not, in fact, a mental illness. Though changes in policies and attitudes have resulted in increasing acceptance of LGBT people over the last four decades, prejudice, institutional discrimination, and hate crimes continue.

Today’s lesbian and gay elders are women and men who grew up in the 1930s, 1940s, and 1950s, and their personal histories of oppression create particular challenges. LGBT elders struggle with internalized homophobia and isolation, often causing them to remain hidden, wrestling with whether, when, and how to disclose their sexual orientation. And since discrimination and prejudice continue against LGBT people, these elders face a variety of social, political, and personal challenges.

Healthcare Barriers
Understanding the existence of homophobia and transphobia toward LGBT people within the medical profession and the barriers to care they present are important issues.

Many lesbian and gay elders may delay or be reluctant to seek medical care due to historic and contemporary encounters with bias, discrimination, stigmatization, or experiences of having been refused medical treatment. Fear of abuse or disclosure, as well as provider attempts to convert the person through religious indoctrination or reparative psychological therapies, are other contributing factors, along with limited income or insufficient insurance coverage. For example, many lesbian elders do not receive preventive breast or gynecological care and may face an increased cancer risk as a result. 

Services and Advocacy for GLBT Elders (SAGE), the nation’s largest social service and advocacy group for this population, reports one study suggesting that LGBT seniors may be as much as five times less likely to access needed healthcare and social services. A 2001 study by Funders for Lesbian and Gay Issues found that 75% of LGBT seniors interviewed reported not being completely open about their sexual orientation to healthcare workers. 

More than one quarter (27%) of LGBT boomers reported great concern about discrimination as they age, and less than one half expressed strong confidence that healthcare professionals will treat them with dignity and respect, according to the 2006 study “Out and Aging: The MetLife Study of Lesbian and Gay Baby Boomers.” Fears of insensitive and discriminatory treatment by healthcare professionals are particularly strong among lesbians, 12% of whom said they have absolutely no confidence that they would be treated respectfully.

Physicians and other healthcare providers may neglect to obtain a sexual history or discuss an LGBT patient’s sexuality and often assume that their patients are heterosexual. As a result, they are unaware of the particular medical needs of LGBT elders, which compromises their ability to diagnose and provide optimal medical care. This is also apparent in the often overlooked instances where homophobic assault is the cause of a patient’s medical condition.

Compounding the problem is that academic and clinical training regarding treatment needs for LGBT elders is not commonly available to healthcare professionals, who may also be unaware of population-based research that identifies differential health risks of LGBT elders in contrast to heterosexual elders.

Only a decade ago, the American Academy of Family Physicians adopted a policy promoting equal treatment of LGBT physicians, patients, and their families, encouraging diversity in their physician workforces, physician groups, and healthcare systems to help ensure their ability to deliver culturally competent care to all segments of their patient populations.

Finally, health professionals have long recognized the negative effects of chronic stress on people’s physical and emotional well-being. LGBT elders can experience chronic stress due to the challenges inherent in a hostile society, thereby placing them at higher risk of illnesses, including physical (e.g., cardiovascular disease and cancer), spiritual (hostility and rejection from a faith community), and psychological (low self-esteem, depression, anxiety, suicide, and addictions).

These health risks are increased for LGBT individuals who experience multiple forms of oppression such as racism and homophobia as LGBT persons of color or sexism, racism, and homophobia as lesbians of color.

An Underserved Population
LGBT elders may be economically and physically in need of help as a result of multiple health problems, reduced or severely limited income and savings, and the emotional impact of multiple losses which may include self-esteem, loved ones, mental and physical health, safe and affordable housing, employment, and meaningful social engagement.

To address the needs of LGBT elders, it is insufficient to simply know that homophobia and transphobia exist. To provide appropriate and life-affirming social services, it is vital that providers understand the lives of LGBT elders and the devastating outcomes that result from living in a homophobic and heterosexist society. Sensitivity to these issues is critical to working collaboratively with LGBT elders to address their needs.

SAGE cites a recent study revealing that 96% of America’s social service and caregiving agencies for older adults offer no services specifically designed for LGBT seniors. Additionally, the survey noted that 46% of the same agencies indicated that LGBT elders would be unwelcome at senior centers in their areas if their sexual orientation were known.

In an article about a 2003 study of Washington, DC, nursing homes featured in the Washington Blade, reporter Laurel Faust wrote that “retirement facilities don’t have sexual orientation non-discrimination policies in their staff manuals, and if they do, their employees are often unaware of the policies.” A 2000 study of New York City long-term care facilities revealed that only 13% made sensitivity to sexual orientation part of staff training while 65% dealt with racial and ethnic diversity.

Reports suggest abuse and neglect of LGBT elders by other residents and professional care providers in the nursing home system and long-term and assisted care facilities. LGBT elders are at a greater risk of abuse primarily because they are often hidden, choosing to not ask questions or question authority and fearing the exposure that would ensue if they inform others of their emotional, physical, or psychological abuse since the abuser may be another resident, a healthcare worker, or any other caregiver.

Family members may also abuse LGBT older adults, who may not report the abuse due to distrust of social service institutions, being threatened with placement in a nursing home or other residential facility, or fear of further abuse and neglect. 

Domestic violence also exists within LGBT relationships. Contributing factors include alcohol and drug abuse, mental health issues such as dementia, social isolation, economic hardship, and a lack of social and familial support. Barriers to recognition and intervention in all of these situations are exacerbated by the fear of encountering homophobia.

Legal Discrimination Plaguing LGBT Elders
Discrimination also extends to LGBT elders with partners. Same-sex partners are frequently denied hospital visitation rights, decision-making power for medical treatment, or the right to shared residence in nursing homes. These are crucial issues in providing medical care and social services to LGBT elders since those shunned by their families of origin have created alternative family structures for support and socialization, commonly referred to as families of choice. Families of choice and domestic partners lack the legal protections given to heterosexual couples and families. For this reason, LGBT individuals should create a durable power of attorney for healthcare and an advance directive (living will) to document their wishes and ensure that those designated have authority to make decisions.

Banned from legal unions and marriage, LGBT couples do not benefit from the legal rights automatically conferred on married couples. For example, surviving partners are not eligible to obtain Social Security survivor benefits or Social Security spousal benefits that allow the surviving partner the right to one half of the spouse’s Social Security benefit if it is larger than his or her own benefit. Medicaid stipulations that protect the assets and homes of married spouses when the other spouse enters a nursing home or long-term care facility do not apply to LGBT partners.

Inheritance of a shared home or assets and benefits such as annuities are not protected for same-sex couples. However, there are ways around some of these restrictions. For example, signing a jointly held mortgage or designating a same-sex partner as the beneficiary of an annuity or retirement plan via a will can direct assets to a same-sex partner.

Economically deprived non-spouse beneficiaries can take advantage of the Pension Protection Act, signed into law in 2006, which allows receipt of a rollover from a 401(k) retirement benefit or withdrawal of money from a partner’s retirement fund in case of emergency. Surviving same-sex partners can also transfer the deceased partners’ retirement funds into an IRA account for use over their own life times.

Recent data reported by the Human Rights Campaign state that “Internal Revenue Code § 2056 exempts amounts transferred to a surviving spouse from the decedent’s taxable estate. For same-sex couples who are legally barred from marriage, this exemption is not available, creating an inequity in taxation.”

The Family and Medical Leave Act that guarantees family and medical leave to employees to care for parents, children, or spouses does not provide leave to care for domestic partners or domestic partners’ family members. Domestic partners of federal employees are excluded from the Federal Employees Health Benefits Program and from reimbursement for expenses incurred by a domestic partner.

The federal Consolidated Omnibus Budget Reconciliation Act does not require employers to provide domestic partners with the continued coverage guaranteed to married couples but rather only to “qualified beneficiaries” (spouses or dependent children).

Older adults in general are legally protected from ageism in the workplace, yet LGBT elders can be terminated from employment on the basis of sexual orientation without additional cause and without recourse. This threat increases the likelihood of invisibility, isolation, and financial insecurity.

Embracing LGBT Elders
In a 2003 report by the Family Caregiver Alliance, David Coon asserts that “until LGBT individuals no longer experience the discrimination and social isolation that create barriers to receiving competent care, service providers and other professionals need to increase not only their understanding of the issues LGBT caregivers face but also their competence in service provision to these family caregivers.”

Individually and collectively, providers should consider advocating for policy and legal changes. To do so requires that healthcare and service providers must identify and challenge personal biases, respect and collaborate with families of choice, recognize the existence and diversity of LGBT seniors, learn more about LGBT issues such as the destructive effects of homophobia or transphobia and ageism, and identify LGBT referral resources, especially those within the LGBT community. Outreach to this community is vital since most LGBT elders are unlikely to seek out the services they need.

— Florence Gelo, DMin, NCPsyA, is an associate professor in the department of family, community, and preventive medicine at Drexel University College of Medicine in Philadelphia.

Ten More Good Years
Inspired by some remarkable elders, director Michael Jacoby embarked on a filmmaking project that is truly a labor of love. Ten More Good Years tells the compelling stories of four brave individuals who are advocates for the nearly forgotten community of lesbian, gay, bisexual, or transgendered (LGBT) elders. With stories of courage in the face of discrimination from their government, social services networks, and even their own communities, Jacoby documents many of the harsh realities of what it means to be old and gay in America.

Through the narratives of elders who have emerged as survivors rather than victims of unjust, antiquated policies, the film poignantly depicts issues such as outdated tax laws; unfair Medicaid, Medicare, and Social Security regulations; a lack of cultural competence in social services; and the need for nondiscriminatory housing.

Jacoby feels indebted to these individuals from whom he's learned so much about the LGBT community. About his filmmaking experience, Jacoby writes, “As a gay man in 2008, I feel lucky to have had the opportunity to pay homage to the men and women who took the first bold moves in the LGBT civil rights movement and who made it possible for me to even make this film. From them, I learned that the fight for LGBT equality is far from over, and that many of the elders we owe so much to are the ones suffering the most.”

Ten More Good Years was screened at this year’s Aging in America conference in Washington, D.C., and at the 2008 Vancouver, San Francisco, and London LGBT film festivals. It can currently be seen on the Sundance and the LOGO channels. For more information, visit

— Marianne Mallon is executive editor of Aging Well.