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Geriatric Care Management

FALL 2002

NUMBER 3

VOLUME 12

Published by the

NationalAssociation ofProfessionalGeriatric CareManagers1604 North CountryClub Road

Tucson, Arizona85716-3102

520.881.8008 / phone

520.325.7925 / fax

www.caremanager.org

Guest Editor’s Message: Geriatric Care Managementwith Sexual Minoritiesby Sandra S. Butler, Ph.D.page ....................................................................................................................... 2

Long Term Care Issues Affecting Gay, Lesbian,Bisexual, and Transgender EldersBy Sean Cahill, Ph.D.page ....................................................................................................................... 4

Culturally Competent Practice with Elderly LesbiansBy Tara Healy, MSW, Ph.D.page ....................................................................................................................... 9

Notes From the Field: Care Management with GLBTElderlyBy J Donna Sullivan, Ms.Ed, CSW,C-ASWCMpage .....................................................................................................................14

Rethinking Community, Place and Ritual in Aging GLBTPopulationsBy Nancy Webster, MPA, MSW, LCSW And Travis Ericksonpage .....................................................................................................................16

Geriatric Care and Management Issues for theTransgender and Intersex PopulationsBy Tarryn M. Witten, M.S., Ph.D., FGSApage .....................................................................................................................20

GCMFall 2002

Guest Editor’s Message: Geriatric CareManagement with Sexual Minorities

by Sandra S. Butler, Ph.D.

(continued on page 3)

The elder population of thiscountry is very diverse. Of all groups,older adults are perhaps the mostheterogeneous. Providing quality careto an elder client requires sensitivityto that individual’s unique needs,culture, and life experiences. As careproviders, we have an obligation tobecome knowledgeable about thediversity among the elders with whomwe work; diversity based on class,race, gender, ability, religion,ethnicity, and sexual orientation. Thisissue of the GCM Journal is devotedto the topic of gay, lesbian, bisexual,and transgender (GLBT) elders. Theprimary goal is to sensitize readers tothe experiences and needs of GLBTseniors and to challenge heterosexistassumptions—assumptions that denyand stigmatize GLBT elders’ identity,relationships and community.

There is considerable diversitywithin the GLBT community itself.Lesbian, gay, bisexual, andtransgender elders vary in socio-demographic characteristics such ascultural, ethnic or racial identity,physical ability, income, education,and place of residence. “They are alsodiverse in the degree to which theirLGBT identities are central to theirself-definition, their level of affiliationwith other LGBT people, and theirrejection or acceptance of societalstereotypes and prejudice” (Meyer,2001, p. 856). Despite these differ-ences, GLBT individuals of all agesshare experiences related to stigma,rejection, discrimination, and, at times,violence. In most parts of the UnitedStates (though selected cities, states,and businesses have nondiscrimina-tion ordinances, laws and clauses) it islegal to discriminate against GLBTpeople in housing, employment andbasic civil rights. In 16 states, archaicsodomy laws continue to brand GLBTindividuals as criminal despiteongoing efforts to repeal thesestatutes (Meyer, 2001).

Since the Stonewall riots in 1969(a famous demonstration againstpolice harassment of patrons at a NewYork City gay bar) and the birth of athe Gay Liberation Movement in the1970s, the experience of being gay orlesbian has dramatically changed.Prior to 1973, homosexuality waslabeled a disease by the American

Psychological Association and GLBTindividuals were considered sick andimmoral. Many elder GLBT individu-als spent their earlier lives in constantfear of being discovered, and conse-quently they constructed elaboratesystems for maintaining their privacyand remaining in the closet. Thisrequired considerable emotional andpsychological energy (Barranti &Cohen, 2000). Now in their senioryears, many of these individuals areunlikely to “come out” to their healthcare providers due to their early lifeexperiences and their ongoing,realistic perceptions of societalhomophobia (defined as the irrationalfear of homosexuality) andheterosexism in society.

Similar to all older adults, GLBTelders face pervasive ageism in oursociety. Unfortunately, they also faceageism within the GLBT communityitself. Gay culture has been guilty ofbeing particularly youth focused;what is old has been seen as lessattractive and less worthy than what isyoung. Thus GLBT elders become“twice hidden.” First, they areinvisible due to both heterosexism inthe larger, often unwelcoming, societyand secondly to ageism within theirpreviously safe havens in the GLBTcommunity (Blando, 2001). Conse-quently, GLBT elders may not feelcomfortable in either traditionalagencies serving older adults or GLBTcommunity organizations. Yet, asGLBT seniors grow older and increas-ingly frail, they may be forced to havemore contact with heterosexistinstitutions. For some, the fear ofexperiencing homophobic orheterosexist attitudes may preventthem from seeking needed assistance,placing them at risk for decreasedquality of life, self-neglect andincreased mortality risk (Senior HealthResources, undated). Moreover,GLBT elders are more likely to livealone than others in their age cohortand thus may be in need of specialattention as “older adults who livealone are more likely to live in poverty,have poor nutrition, feel depressed,and eventually move into an institu-tion” (AoA, 2001, p. 2).

Despite the greater likelihood ofliving alone in old age, it is importantto point out that the myth depicting

GLBT elders as leading lonely,isolated lives is largely untrue. In fact,there are several reasons why GLBTindividuals may experience fewerdifficulties with aging than theirheterosexual counterparts. Barrantiand Cohen (2000) suggest severalfactors that could account for thiscomparative ease with the agingprocess:

Coping skills developedthrough the process of accept-ing their sexual identity mayhelp GLBT seniors in theacceptance of aging.Skills developed through thecoming out process and themanagement of the socialperception of “difference”throughout life prepares GLBTseniors for society’s percep-tions of old people in a youth-oriented society.The stigma of being old is oftenexperienced as less severe thanthe stigma, of being “queer”that GBLT seniors faced in theiryouth.In part due to rejections eitherby families of origin or procre-ation, GLBT individuals oftencreate “families of choice” thatare able to provide extensivesocial support in times of need.Greater flexibility in genderroles exhibited by GLBTindividuals can be helpful in theaging process.

Thus GLBT elders, while facingsome unique challenges in ourhomophobic and heterosexist society,are also very resilient and may evenhave some advantages over their non-GLBT counterparts in coping withpervasive ageism. Making geriatriccare more accessible and sensitive toGLBT elders is not unlike makingservices more welcoming for anynumber of oppressed groups in that itcan be challenging, but getting it rightis rewarding (Smith & Calvert, 2001).In this special issue of the GCMJournal, a group of experts in the fieldof GLBT aging broaden our under-standing of geriatric care for GLBTelders. Each of the following articlesprovides us with greater insight onhow to “get it right.”

GCMFall 2002

Published by the:National Association of

Professional Geriatric Care Managers1604 North Country Club RoadTucson, Arizona 85716-3102

www.caremanager.orgPublished quarterly for members of GCM

Non-member subscriptions: $75.00 per year

© Copyright 2002The GCM Journal is published as a membership benefit to membersof the National Association of Professional Geratric Care Managers.Non-members may subscribe to GCM Journal for $75.00 per year.Send a check for your one-year subscription to: Subscription Depart-ment, GCM, 1604 N. Country Club Road, Tucson, AZ 85716-3102.

EDITORIAL BOARDRona Bartelstone, MSWFort Lauderdale, FL

Lenard W. Kaye, Ph.D.Bryn Mawr, PA

Karen Knutson, MSN,MBA, RNCharlotte, NC

Marcie Parker, Ph.D.Golden Valley, MN

EDITOR--IN CHIEFMonika White, Ph.D.Santa Monica, CA.

COMMUNICATIONSDIRECTORJihane K. RohrbackerTucson, AZ

COMMUNICATIONSCOORDINATORStefan M. PalysTucson, AZ

GRAPHICDESIGNERKristin L. HagerRedmond, WA

Geriatric Care Management

Sean Cahill, Director of thePolicy Institute of the National Gayand Lesbian Task Force and co-authorof the seminal publication Outing Age,sets the stage for the subsequent fourarticles by outlining the significantlong-term care issues facing GLBTseniors. He provides an informativediscussion on some of the key policyconcerns for this population includingunequal treatment under retirementincome support programs, seniorhousing issues, and particular barriersrelated to caregiving and health care.He advocates for increased training inthe particular issues facing GLBTelders for all the professionalsentrusted with their care and for moreresearch on this population’s uniquecaregiving needs.

Tara Healy draws on both herpractice experience as a clinical socialworker and her own research witholder lesbians in her exploration ofculturally competent practice withelderly lesbians. She vividly portraysthe struggles of elderly lesbians in aheterosexist world and how thismanifests itself in the health careenvironment. She concludes with acomprehensive and extremely helpfulset of guidelines for culturallysensitive and competent care manage-ment.

Geriatric care manager J DonnaSullivan illustrates culturally sensitiveand competent practice through twoprovocative case studies from her ownpractice. She demonstrates how GLBTclients are indeed “hidden clients,”and the importance of examining ourassumptions for all our clients. Shereminds us that each case must beindividualized to meet the needs ofthat specific client and that we shouldnot categorize clients with a perfunc-tory checklist of needs.

Nancy Webster and TravisErickson provide us with an explora-tion of “place identity,” ritual, andoppression for GLBT elders. Theydemonstrate how the lack of bothsocially sanctioned rituals and a“sense of place” profoundly impact aGLBT elder’s identity. We arechallenged to confront our ownprejudices and to work toward asociety which gives all its memberscomplete access to all the rights ofbelonging, association, expression,respect, and the ability to age insafety and fullness.

Tarynn Witten closes this specialissue with a discussion of the specific

geriatric care issues for thetransgender and inter-sex populations.She opens her article with a compre-hensive review of quality of life issuesfor older transsexual and transgenderindividuals, including access toappropriate medical care and socialadjustment to gender variance.Suggestions for sensitive, respectful,and informed practice by geriatric caremanagers and other helping profes-sionals working with this populationare outlined with particular attentiongiven to the issues of body image,sexuality and intimacy, and assistedliving and social support.

In summary, this set of fivearticles complement one another byemphasizing different aspects of themultifaceted challenge of providingquality care to GLBT elders. Theyprovide readers with importantinformation of the unique life situa-tions and needs of this population andoffer guidelines for respectful andappropriate care management. I inviteyou to read and learn from theseauthors, just as I have, and to includethis in your library of resourcesrelated to culturally competentpractice.

Sandra S. Butler, Ph.D., is anAssociate Professor in the School ofSocial Work at the University of

(continued from page 2) Maine and is the Faculty Scholar atthe University of Maine Center onAging. She is currently a HartfordGeriatric Social Work FacultyScholar.

ReferencesAdministration on Aging (AoA). (2001).The Many Faces of Aging: Lesbian, Gay,Bisexual, and Transgender OlderPersons. Retrieved April 28, 2001 fromwww.aoa.gov/May 2001/factsheets/LGBT.html.

Barranti, C.C. R., & Cohen, H.L. (2000).“Lesbian and Gay Elders: An InvisibleMinority.” In R.L. Schneider, N.P. Kropf,& A.K. Kisor (Eds.) GerontologcialSocial Work: Knowledge, Service Settings,and Special Populations (2nd ed, 343-367).Pacific Grove, CA: Brooks/Cole.

Blando, J.A. (2001). “Twice Hidden:Older Gay and Lesbian Couples, Friendsand Intimacy.” Generations, 25 (2), 87-89.

Meyer, I. H. (2001). “Why Lesbian, Gay,Bisexual, Transgender Public Health?”American Journal of Public Health, 91 (6),856-859.

Senior Health Resources. (undated). SHRFact Sheet: Gay, Lesbian, Bisexual andTransgender Seniors. Washington, DC:Author.

Smith, H. & Calvert, J. (2001). OpeningDoors: Working with Older Lesbians andGay Men. London: Aging ConcernEngland.

GCMFall 2002


LongTerm Care Issues Affecting Gay,Lesbian, Bisexual and Transgender Elders

By Sean Cahill, Ph.D.

Although gay elders share many of the same human needs and concerns

as their heterosexual peers, gay and lesbian seniors often experience

particular barriers as well, including: discrimination; unequal treatment

under Social Security, pensions and 401(k)s; and concerns related to housing,

health care, and long-term care. Federal programs designed to assist elderly

Americans can be ineffective or even irrelevant.

During the past decade the U.S.gay, lesbian, bisexual and transgender(GLBT) rights movement has achievedsignificant advances. We have seennotable improvements in publicopinion toward gay issues, withmajority or plurality support forequality in most areas (sexual orienta-tion nondiscrimination, militaryservice, adoption, inheritance rights)except for the right to marry.1 In 2000,for the first time the National ElectionStudy found that a majority ofRepublicans support sexual orienta-tion nondiscrimination laws, as dooverwhelming majorities of Indepen-dents and Democrats (Yang, 2001).There has been a dramatic growth inlocal and state nondiscrimination laws,such that today more than 100 millionAmericans–more than a third of thepopulation–live in a municipality orstate with a sexual orientationnondiscrimination law. Twenty-threemillion Americans, or 8 percent of thepopulation, live in a city or state witha transgender nondiscrimination law.Increasingly corporate America isadopting sexual orientation nondis-crimination policies and offeringdomestic partner benefits to same-sexpartners of employees.

The 1990s also witnessed theemergence of a sizable gay voting blocof four to five percent in nationalelections. These numbers are allevidence of a growing trend towardequality and political power. Yet GLBTcommunity is just beginning toarticulate perspectives in a wide range

of policy debates that affect gaypeople. While it is obvious thatnondiscrimination laws and hatecrimes are of particular concern to gaypeople, other policy frameworks notusually thought of as “gay issues”(including welfare, immigration, andaging policies) can have dramatic andspecific impacts on GLBT people.

The Particular BarriersGay Seniors Face

The GLBT elderly population,currently estimated at one to threemillion people, will increase to four tosix million by 2030 (Cahill, South andSpade, 2000)2. We can only estimatethe population’s size because mostresearch does not ask about sexualorientation or gender identity.Gerontologists and governmentresearchers could capture much-needed information on gay seniors byadding a standard sexual orientationself-identifier to all surveys, such asthe federal Elder Abuse and NeglectSurvey.

GLBT elders face a number ofparticular concerns as they age. Oftengay seniors do not access adequatehealth care, affordable housing, andother social services that they need,due to institutionalized heterosexism.3

Existing regulations and proposedpolicy changes in programs like SocialSecurity or Medicare, which impactmillions of GLBT elders, are discussedwithout a gay perspective engagingthe debate. The GLBT community, ledby elderly GLBT activists and elder

advocates, are attempting to changethis dynamic, and intervene in thesecritical policy discussions on behalf ofGLBT elders.

Although gay elders share manyof the same human needs andconcerns as their heterosexual peers,gay and lesbian seniors often experi-ence particular barriers as well. Theseinclude discrimination; unequaltreatment under Social Security,pensions and 401(k)s; and concernsrelated to housing, health care, andlong term care. Federal programsdesigned to assist elderly Americanscan be ineffective or even irrelevantfor GLBT elders. Several studies ofboth nursing home administrators anddirectors of Area Agencies on Agingdocument widespread homophobiaamong those entrusted with the careof America’s seniors (Fairchild,Carrino, & Ramirez, 1996). Even seniorcenters can be hostile places for gayelders.4 Many GLBT elders do notavail themselves of services otherseniors thrive on. Some retreat backinto the closet, reinforcing isolation.But GLBT baby boomers who havebeen out for most of their lives areincreasingly unwilling to retreat to thecloset when they encounter homopho-bia in aging services.

Long Term Care IssuesHeterosexism and homophobia

are widespread in nursing homes andare symptomatic of a larger sex-phobiaoften associated with those providingservices to seniors. In a mid-90s

GCMFall 2002

survey of nursing home socialworkers, more than half said theircoworkers were intolerant or con-demning of homosexuality amongresidents, while most other respon-dents avoided answering the ques-tion. The staff in one nursing homerefused to bathe a resident becausethey did not want to touch “thelesbian,” and a home care assistantthreatened to “out” a gay client if hereported her negligent care (Cook-Daniels, 1997).

Many gay elders experienceactual abuse from care providers. Fewservice providers have institutedpolicies to address this homophobicbehavior, leaving some GLBT elders inhostile and dangerous environments.In one instance, a nursing assistantentered a room in a nursing facilitywithout knocking and saw two elderlymale residents engaging in oral sex.The two were separated immediatelyafter the assistant notified hersupervisor. Within a day, one manwas transferred to a psychiatric wardand placed in four-point restraints. Acommunity health board held that thetransfer was a warranted response to“deviant behavior.” This episode,reported in a 1995 article in Contempo-rary Long Term Care, would notsurprise anyone familiar with theexperiences of GLBT elders. In asociety that desexualizes older peoplein general, the compounding influenceof homophobia can foster a hostileenvironment for these seniors(Parsons, 1995).

Gay elders entering assistedliving facilities and other institutionsare often presumed to be heterosexualand may feel compelled to hide theirsexual identity. Long term relation-ships may be devalued and unrecog-nized. Assisted living centers,congregate housing, and home healthcare services need to take proactivesteps to minimize discrimination,abuse, and neglect directed at GLBTelders. Caregivers should be trained tobe competent in issues of sexualityand gender variance. Diversitytraining is critical given documentedexamples of bias among senior careproviders. Nursing homes shouldinclude detailed sexuality policieswithin residents’ rights policies, andaccommodate the appropriate, private

expression of the sexual needs ofresidents, be they homosexual,bisexual, or heterosexual. Nursinghome staff should also be trained tounderstand and better serve the needsof GLBT clients.

Particular CaregivingNeeds

Gay elders may also haveparticular caregiving needs. Sincemost caregiving in the US is providedby biological children, and since gaysand lesbians are less likely to havechildren and appear more likely to livealone in old age than heterosexualelders, an urgent question presentsitself: who will care for GLBT elders?A number of the problems faced byGLBT elders also stem from the factthat they often do not have the samefamily support systems as hetero-sexual people, compounded by thefailure of the state to recognize theirsame-sex families. Since a dispropor-tionate share of GLBT elders livealone, innovative support networksare critical (Brookdale Center onAging, 1999)5. Not only are gay andlesbian elders less likely to havechildren than the general elderpopulation; they also may be es-tranged from their families of origindue to homophobia and/or fear ofrejection. Consequently, they may notbe able to rely upon traditionalcaregiving support networks.

There are also indications thoseGLBT elders, who are perceived to be“single” and without attachments(even though they may have lifepartners and even children andgrandchildren), are disproportionallyrelied upon by heterosexual siblings totake care of parents, aunts, uncles,and other aging family members.Despite the attempts of the right wingto construct “family” and “gay” asmutually exclusive categories, one inthree gay men and lesbians providesome kind of caregiving assistance—either to children or to adults with anillness or disability (Fredriksen, 1999).The National Gay and Lesbian TaskForce is currently partnering withPride Senior Network and severalFordham University gerontologists toexamine the particular caregivingpractices and needs of GLBT elders.

Unequal TreatmentUnder Retirement

Income SupportPrograms

In a free-market system, income isa critical determinant in the quality oflife one enjoys in retirement, includingquality of care for those elders in needof caregiving. Those serving GLBTelders need to take into account theimpact of the unequal treatment same-sex couples experience under policiesregulating retirement income. Forexample:

Social Security pays survivorbenefits to widows andwidowers, but not to thesurviving same-sex life partnerof someone who dies. This maycost GLBT elders $124 million ayear in unaccessed benefits(Cahill et al., 2000).Married spouses are eligible forSocial Security spousalbenefits, which can allow themto earn half their spouse’sSocial Security benefit if it islarger than their own SocialSecurity benefit. Unmarriedpartners in life-long relation-ships are not eligible forspousal benefits. We do notknow how many millions ofdollars a year this costs GLBTelders.Medicaid regulations protectthe assets and homes ofmarried spouses when the otherspouse enters a nursing homeor long-term care facility whileno such protections are offeredto same-sex partners.Tax laws and other regulationsof 401(k)s and pensionsdiscriminate against same-sexpartners, costing the survivingpartner in a same-sex relation-ship tens of thousands ofdollars a year, and possiblymore than one million dollarsduring the course of a lifetime.

Each of these issues is exploredfurther below.Social SecuritySocial SecuritySocial SecuritySocial SecuritySocial Security Nearly two-thirds of U.S. retireesrely on Social Security for more thanhalf of their annual income; for 15percent of seniors, Social Security istheir only source of income (Liu,1999). But lesbians and gay men in


(continued from page 4)

GCMFall 2002

same-sex partnerships are not eligiblefor the spousal benefit or the survivorbenefit. This lack of eligibility costslesbian and gay elders hundreds ofmillions of dollars in unaccessedincome per year. The September 11th

terrorist attacks illustrated theunfairness of this policy, as same-sexsurvivors of victims were deniedSocial Security survivor benefits aswell as funds from the victimscompensation fund administered bythe U.S. Justice Department.

Social Security survivor benefitsallow widows, widowers and depen-dent children to put food on the table,and provide a sense of fairness whenan employee pays into the system hisor her whole life, but dies before beingable to enjoy these retirement savings.But gay and lesbian survivors are noteligible for these benefits. In 1998,781,000 widows and widowersreceived an average of $442 a month insurvivor benefits, a total of $4.1 billiondollars that year. If only three percentof the total population of seniors whosurvived their life partner are gay orlesbian, the failure to pay survivorbenefits costs gay and lesbian seniorsabout $124 million a year.

The spousal benefit allowshusbands and wives to receive anamount equal to 50 percent of theirspouse’s monthly Social Securitycheck, if that amount is higher thanwhat their own earnings would makethem eligible for each month. Inmarriages where one spouse earnssignificantly more than the other and/or has a longer work history, takingthe spousal benefit instead of theindividual’s own payment makessense. However, lesbian and gaypeople in same-sex relationships arenot eligible for the spousal benefit.Unequal treatment underUnequal treatment underUnequal treatment underUnequal treatment underUnequal treatment underpension regulationspension regulationspension regulationspension regulationspension regulations Because GLBT people can still bediscriminated against in employmentin most of the country, and becausegay couples are not treated equallyunder Social Security, pension incomeis an important policy issue affectingGLBTelders. Social science researchindicates that, contrary to a widelyheld stereotype of gay affluence, gaymen and lesbians earn no more thanheterosexual men and women. In fact,gay men earn about 15 to 20 percent

less than heterosexual men. Lesbiansearn the same as heterosexual women,but because women on average earnless than men, lesbian couple house-holds earn significantly less thanheterosexual couple households(Klawitter & Flatt, 1998). Manytransgender people suffer fromsignificant economic hardship.

Same-sex spouses do not receivethe legal protections provided marriedspouses under the Retirement EqualityAct (REA) of 1984. The retirementincome gay seniors lose due tounequal treatment can amount to tensof thousands of dollars a year perindividual, and can exceed a milliondollars over the course of a lifetime.The design and administration ofpension plans vary greatly fromemployer to employer. Unfortunately,for same-sex couples in retirement, theone aspect most plans have incommon is that very few pay benefitsto anyone but a legal spouse follow-ing the death of a participant. Inaddition, if a person dies afterbecoming vested in a pension plan butbefore reaching the age of retirement,a legal spouse is entitled to a cashbenefit beginning in the year that thedeceased would have started receiv-ing the pension. The surviving spousereceives this benefit until death.Surviving same-sex partners are noteligible for this benefit.

A hypothetical scenario illus-trates the cost of this unequaltreatment. Picture two couples, first alegally married heterosexual coupleand then a same-sex couple. Every-thing is the same about these twocouples except that the heterosexualcouple has the legal protections ofmarriage. In each couple one partnerworks for an employer that offers apension plan. This employee is fullyvested in the pension plan, and isentitled at retirement to a sum equal to$35,000 a year. At his retirement partythe employee dies of a heart attack.What does the surviving spousereceive in pension benefits? Thesurviving spouse in the heterosexualcouple would receive $35,000 (or aportion of this amount depending onthe nature of the plan) each year forlife. The surviving partner in the same-sex couple would receive nothing. Ifthe surviving heterosexual spouse andthe surviving homosexual partner wereto die at 75, ten years after retirement,

this means that the surviving spousein the heterosexual married couplewould receive $350,000 more inretirement income than the survivingpartner of the same-sex couple.Unequal Treatment Un-Unequal Treatment Un-Unequal Treatment Un-Unequal Treatment Un-Unequal Treatment Un-der 401(k) Regulationsder 401(k) Regulationsder 401(k) Regulationsder 401(k) Regulationsder 401(k) Regulations

If a person with a 401(k) plan diesthe tax implications for the beneficiarydepend on whether or not thebeneficiary is a legal spouse. If thebeneficiary is a legally married spousethen he or she may roll over the totalamount of the distribution into anindividual retirement account (IRA)with no tax implications exceptapplicable estate taxes. The spousecan maintain the funds in an IRA untilhe or she turns 70 and a half, the ageat which withdrawals from retirementaccounts become mandatory. How-ever, if the beneficiary is a same-sexpartner who is unable to legally marry,then he or she is subject to a 20percent federal withholding tax.Depending on the beneficiary’s taxbracket, he or she may also beresponsible for paying additionalincome tax on the amount received, aswell as applicable estate taxes.

The effect of this unequaltreatment is striking. Assume Deborahdies at age 50 with $100,000 in her401(k) account, which she leaves toher life partner, Pat, also age 50. Patwill receive the sum less taxes (at least$20,000), for a total of $80,000 or less.Pat is not able to roll the sum over intoa tax-free IRA. If Pat were a man andDeborah’s widower, Pat would receivethe full $100,000 and be able to shieldit from taxes until age 70 and a half.The survivor of the legally marriedcouple would have a nest egg toinvest which is at least 20 percentlarger than that of the survivingpartner in the same-sex couple. Thenest egg could grow in a tax-deferredaccount until the maximum age ofdisbursement for the surviving spousein a legally married couple. Thesurviving partner of the same-sexcouple, however, would not be able toroll the initial disbursement into anIRA. Over 20 years time, this unequaltreatment could add up to cost thesurviving lesbian partner tens ofthousands of dollars in potentialretirement income.



GCMFall 2002


The Medicaid Spend-The Medicaid Spend-The Medicaid Spend-The Medicaid Spend-The Medicaid Spend-Down Provision andDown Provision andDown Provision andDown Provision andDown Provision andSame-Sex CouplesSame-Sex CouplesSame-Sex CouplesSame-Sex CouplesSame-Sex Couples Similar to many heterosexualelders, the lack of coverage for long-term care for most GLBT eldersconstitutes a crisis in their care as wellas personal finances. Often seniorswho enter nursing homes spend all oftheir assets on their care and thensimply apply for Medicaid when theyhave next to nothing left, a phenom-enon known as the “Medicaid spend-down.” Medicaid regulations allowone member of a married heterosexualcouple to remain in the couple’s homefor the rest of his or her life withoutjeopardizing his or her spouse’s rightto Medicaid coverage. Upon thesurvivor’s death, the state may thentake the home to recoup the costs ofterminal care. However, since same-sexcouples cannot marry, Medicaidregulations do not offer the sameprotection for same-sex partners, evenif they have spent their entire adultlives together. This unequal treatmentcan force same-sex couples into aHobson’s choice between getting themedical coverage to meet a partner’shealth care needs or foregoing medicalcare in order to avoid giving up thecouple’s home and life savings.Medicaid regulations should bechanged to treat same-sex couplesequally to married heterosexualcouples. Same-sex partners should beable to remain in their home withoutjeopardizing their partners’ right toMedicaid coverage (Dean, Meyer,Robinson, Sell, Sember, Silenzio, et al.,2000).

Clearly, unequal treatment ofsame-sex couples under SocialSecurity and retirement plan regula-tions denies gay elders access tofunds we are entitled to, from systemswe all pay into all our lives, but whichwe cannot access due to the

heterosexism of current policies.These unaccessed income sourcescould help ensure our economicsecurity in old age. Unequal treatmentunder the Medicaid spend-downprovision also limits our economic andemotional security in old age.

Senior Housing IssuesUnder the Clinton Administration

the Department of Housing and UrbanDevelopment (HUD) practice was tomake decisions about renting thecountry’s three million subsidizedsenior apartments without regard tothe sexual orientation of applicants.This administrative practice lacked thelegal force of a written regulation orfederal nondiscrimination law.Inclusion of sexual orientation andgender identity in the Fair HousingAct of 1968 would ban anti-GLBTdiscrimination in senior housing.Inclusion of sexual orientation in thetargeting provisions of the Act, alongwith outreach training for the staff ofsubsidized senior housing develop-ments and other congregate housingfacilities, would help ensure morecomprehensive fairness in housing.

There are now several gay seniorhousing projects in various stages ofdevelopment in Seattle, Washington;Boston, Massachusetts; and Palmettoand Fort Meyers, Florida. While gayhousing developments are welcome,most units will only be accessible toupper-income people. The housingneeds of rural, poor and middle-income GLBT elders can best beaddressed by making senior housinggay-friendly and passing a federalnondiscrimination law which covershousing as well as employment.

Health CareIn addition to the need for

accessible health care and prescriptiondrug coverage that gay elders share

with other seniors, GLBT seniors mayexperience physician bias and oftenlack access to health coverage from apartner’s work benefits. Anti-gay biasin health care is widespread. A 1994study by the Gay & Lesbian MedicalAssociation found that two-thirds ofdoctors and medical students reportedknowing of biased caregiving bymedical professionals, half reportedwitnessing it, and nearly 90 percentreported hearing disparaging remarksabout gay, lesbian, or bisexualpatients (Schatz and O’Hanlan, 1994).

Assuming GLBT seniors can findappropriate care, they must then facethe problem of paying for it. For many,Medicare plays a vital role in coveringmedical expenses and is especiallyvital for GLBT old people, as life-longincomes may be lower than similarheterosexual-headed households. Oneshortcoming of Medicare is that itdoes not pay for prescription medica-tions. This is especially harmful forthe larger proportion of older gay andbisexual men who are living with HIV/AIDS and who need expensiveantiretroviral medications. Whilemarried spouses often take employer-provided health coverage for granted,most private and public sectoremployers do not provide suchcoverage to same-sex partners. Thesetwo factors—health care provider biasand lack of access to a partner’sbenefits—mean many gay people mayenter retirement without havingaccessed health care on a regularbasis during their lives.

ConclusionThe documented persistence of

homophobia in long-term careenvironments and senior centerspresents barriers to care for GLBTelders and challenges for elder serviceproviders. Elder service and healthcare professionals can address these

(continued from page 6)Assume Deborah dies at age 50 with $100,000 in her 401(k) account, which she

leaves to her life partner, Pat, also age 50. Pat will receive the sum less taxes

(at least $20,000), for a total of $80,000 or less. Pat is not able to roll the sum

over into a tax-free IRA. If Pat were a man and Deborah’s widower, Pat would

receive the full $100,000 and be able to shield it from taxes until age 70 ½.


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barriers by mandating training in theparticular issues affecting GLBT eldersfor all those entrusted with their care.Longer term, professional develop-ment institutions such as schools ofsocial work, health professionaltraining programs, and gerontologyprograms can incorporate competencyin serving GLBT populations into theireducational programs. More researchis needed to understand the particularcaregiving needs and practices ofGLBT elders, who are less likely tohave children than heterosexualelders, but who may be relied upondisproportionately to provide care foran ailing parent or uncle. Unequaltreatment of same-sex couples underincome support programs should beaddressed in the political arena. TheDemocratic National Committee tookan important step in this direction byissuing a resolution supporting equaltreatment of lesbian and gay couplesunder Social Security in January 2002.Such a move also enjoys widespreadsupport among the U.S. public.6

Finally housing and health policyframeworks also have impacts oncaregiving issues affecting gayseniors.

The principle of equal treatmentregardless of sexual orientationalready enjoys widespread supportamong the US public. As Americaages and a sizable cohort of gay babyboomers enters retirement, GLBTactivists look forward to working withelder service professionals and elderactivists to ensure that this principleof equality is realized for elderAmericans as well.

Endnotes1. A March 31, 2002 ABC News pollfound for the first time that moreAmericans support gay adoption thanoppose it, 47 percent to 42 percent.Only about one third to two fifths ofAmericans express support for same-sex marriage in opinion polls. Mostpolls about nondiscrimination laws askabout sexual orientation but notgender identity.

2. This figure is based on an estimatethat the gay, lesbian and bisexual

ReferencesBrookdale Center on Aging. April,1999.Assistive Housing for Elderly Gays andLesbians in New York City. A report fromthe Brookdale Center on Aging of HunterCollege, commissioned by Senior Actionin a Gay Environment (SAGE), a NewYork-based GLBT senior advocacy group.

Cahill, S., South, K., & Spade, J. 2000.Outing Age: Public Policy Issues AffectingGay, Lesbian, Bisexual, and TransgenderElders. Washington, D.C.: PolicyInstitute, National Gay and Lesbian TaskForce.

Cook-Daniels, L. (1997). “Lesbian, GayMale, Bisexual and Transgendered Elders:Elder Abuse and Neglect Issues,” Journalof Elder Abuse and Neglect, 9(2), 35-49.

Dean, L., Meyer, I, Robinson, K., Sell, R.,

population represents 3 to 8 percent ofthe U.S. population, based on a rangeof estimates from several studies(Cahill, South and Spade, 2000).

3 . Heterosexism is the system thatdenies, denigrates and stigmatizes anynon-heterosexual form of behavior,identity, relationship or communitywhile homophobia is the fear or hatredof GLBT people based solely on theirsexual orientation.

4. Forty-six percent of New Yorkstate’s Area Agencies on Aging(AAAs) the regional entities thatdistribute federal funds for seniorservices reported that openly gay andlesbian seniors would not be welcomeat senior centers in their areas,according to a 1994 study. And only19 percent of the lesbian and gayseniors interviewed had anyinvolvement with their local seniorcenter (LGAIN, 1994).

5. The Brookdale Center study foundthat 65% of 253 lesbian and gayseniors surveyed in New York Cityreported living alone, nearly twice therate of seniors as a whole in New YorkCity (36% of whom report living alone).Other studies have found thatanywhere from 41% to 75% of oldergays and lesbians live alone.

6. In a 1997 Princeton Survey ResearchAssociates poll, 57 percent ofAmericans surveyed supported “equalrights for gays in terms of socialsecurity benefits for gay spouses”(Yang, 1999).

Sean Cahill, Ph.D., is the Director ofthe Policy Institute of the NationalGay and Lesbian Task Force.

Sember, R., Silenzio, V. et al. January(2000). Lesbian, Gay, Bisexual, andTransgender Health: Findings andConcerns. New York: Gay and LesbianMedical Association and the Center forLGBT Health, Columbia UniversitySchool of Public Health.

Fairchild, S.K., Carrino, G.E., & Ramirez,M. (1996). “Social Workers’ Perceptionsof Staff Attitudes Toward ResidentSexuality in a Random Sample of NewYork State Nursing Homes: A PilotStudy.” Journal of Gerontological SocialWork, 26(1/2), 153-170.

Fredriksen, K.I. (1999) “FamilyCaregiving Responsibilities AmongLesbians and Gay Men,” Social Work, 44,(2),142-155.

Klawitter, M., & Flatt, V. (1998). “TheEffects of State and Local Antidiscrimina-tion Policies on Earnings for Gays andLesbians.” Journal of Policy Analysis andManagement. 17(4), 658-687.

Lesbian and Gay Aging Issues Network(LGAIN), American Society on Aging,(1994, Winter). “Recommendations to theWhite House Conference on Aging,presented by the Lesbian and Gay AgingIssues Network of the American Societyon Aging”. Outword, 1(2), 4-5.

Liu, G., (1999). “Social Security and theTreatment of Marriage; EspousalBenefits, Earnings Sharing and theChallenge of Reform.” Wisconsin LawReview,1,1-64.

Parsons, Y. (1995). “Private Acts, PublicPlaces.” Contemporary Long Term Care,18(3), 48-52.

Schatz, B., & O’Hanlan, K. (1994). Anti-Gay Discrimination in Medicine: Resultsof a National Survey of Lesbian, Gay andBisexual Physicians, San Francisco, CA:American Association of Physicians forHuman Rights.

Yang, A. (2001). The 2000 NationalElection Study and Gay and LesbianRights: Support for Equality Grows. NewYork: Policy Institute of the National Gayand Lesbian Task Force.

Yang, A. (1999). From Wrongs to Rights,1973-1999: Public Opinion on Gay andLesbian Americans Moves TowardEquality. New York: Policy Institute ofthe National Gay and Lesbian Task Force.


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Culturally CompetentPractice with Elderly

LesbiansBy Tara C. Healy, MSW, Ph.D.

Selected Guidelines forCulturally Sensitiveand Competent Care

ManagementAwareness• Begin with self-reflection

concerning your viewsabout sexualorientation.

Combat heterosexistassumptions• Assume that you do not

know the sexualorientation of yourclients and their familymembers. Assume thatyou do not know thegender of significantothers.

• Assume that lesbianfamilies have manystrengths.

• Assume diversity withinthe lesbian populations.

Knowledge necessary forculturally competentpractice• Become knowledgeable

about how lesbians maybe unfairly treated bypublic policies.

• Be aware of legalprotections, such ashealth proxy or durablepower of attorney.

Inclusive language andaction necessary forculturally sensitiveaffirmative practice• Avoid gendered

pronouns when askingabout significant others.Ask instead is thereanyone who has been aconfidant or who hasbeen very important toyou.

Although approximately eight toten percent of the population is gay orlesbian (Cahill, South, & Spade, 2000)there is scarcely any attention given tothis population in the gerontologicalliterature. For example, it is commonfor gerontological and case manage-ment text books to devote no morethan two pages to elderly gays andlesbians (e.g., Rothman & Simon,1998). In contrast, there is a largebody of literature focusing on longterm care in nursing homes eventhough a far smaller proportion, onlyapproximately four percent, of thepopulation of persons over the age of65, reside in nursing homes at anygiven time (Older Americans 2000,2000). Although approximately thesame percentage of the adult popula-tion are caregivers as are gay andlesbian, approximately 10 percent, theliterature addressing the needs ofcaregivers is extensive (Feinberg,1997). This disparity in the literaturereflects the heterosexism in societythat influences providers of health,social, legal and financial services tolesbians. This article is intended toaddress this gap in the literature byproviding care managers with guide-lines that foster respectful practicewith the lesbian families they serve. Ihave drawn the ideas for this articlefrom the literature available, my ownpractice and a focus group conductedin 2001 with lesbians over the age of55 years.

Invisibility andHeterosexual Assumption

It may be helpful to begin bydefining some terms that are typicallyused in the lesbian subculture and inthe literature concerning lesbianfamilies. Heterosexual assumptionmeans that “parties to any interactionare presumed to be heterosexualunless demonstrated to be otherwise”(Ponse, 1976). “Coming out” or being

“out” refers to self-disclosure that oneis self-identified as a lesbian. “Pass-ing” is a term used when the sexualorientation of a lesbian is presumed tobe heterosexual.

Care managers must consider theextensive invisibility of lesbianfamilies (Barranti & Cohen, 2000).Heterosexual assumption bothfacilitates passing and creates barriersto self-disclosure. Therefore, invisibil-ity of lesbian families is, in part,caused by the pervasive heterosexualassumption in society. The process ofcoming out is an unending processbecause lesbians typically faceheterosexism in every new encounter.Every day lesbians must makedecisions about physical, emotionaland economic safety related todisclosure of their sexual orientation.The invisibility of lesbian families isfurther compounded by the existenceof “women who have chosen to livetheir entire lives with otherwomen…and have received themajority of their affection and supportfrom women, yet do not definethemselves as lesbian” (Quam &Whitford, 1992). Clearly the preva-lence of invisibility of lesbian familiescalls for a high degree of culturalsensitivity on the part of care manag-ers.

Because invisibility is the normfor elderly lesbians and their families,care managers most likely will notknow if an elder is lesbian or hasimportant relationships with lesbians.Moreover, many elders have lesbian,gay or bisexual relatives or friends.Therefore if care managers are to besensitive to the needs of lesbians,they must practice in a manner that isculturally sensitive and competentregarding lesbian concerns with allfamilies. Conceptually, applyingmethods that are sensitive to theneeds of lesbians with all clients

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parallels the use of “universal precau-tions” instituted to protect careproviders from exposure to HIVinfected blood in the mid-1980s.Initially, many health care providersbelieved that universal precautionswere unnecessary because theythought they could identify gay menand use precautions only with thosepersons. Soon, however, it becameclear that the stereotypes of gay menobscured the reality that gay personsare very diverse in their appearanceand thus invisible to careproviders. It is proposedthat practices that arerespectful of lesbianfamilies are respectful toall families and shouldbecome part of every daycare managementpractice. It would beunfortunate if caremanagers replicated pastmistakes by assumingthey are able to recognizea lesbian or know whento apply specializedtechniques.

I will use the phrase“culturally sensitive” torefer to practices that areaffirming to lesbianfamilies. Affirminglanguage and behaviorvalidates, acknowledgesand accepts lesbianfamilies. “Culturallyinsensitive” practiceconsists of negatinglanguage and behaviorinvolving denial orrejection of lesbianidentity (Healy, 1999).Culturally competentpractice with lesbianfamilies requires that caremanagers acquire knowledge about thediversity within the lesbian population,learn the resources available to lesbianfamilies, gain an understanding of theunique challenges faced by lesbianfamilies due to the laws and policies inforce that discriminate against them,and be sensitive to the general impactof heterosexual assumption in thehealth and social service system.

Struggles with HeterosexismCahill, South, and Spade note that

lesbian “struggles with heterosexism

can pose serious threats to health,well-being and happiness in old age”(2000, p.17). Heterosexism is institu-tionalized through laws as well as bythe language, behavior, and attitudesof those who serve the public.Lesbians generally assume that theywill confront heterosexist assump-tions in their contacts with caremanagers and other health and socialservice providers. Shevy Healey hasdescribed the dilemma posed by theheterosexist assumptions held by

care providers: “When I come out Iplace myself in jeopardy. When I donot come out I feel diminished andfraudulent” (1994, p.114).

Surviving the adversity posedby heterosexism has strengthenedsome lesbians. One member of thefocus group noted that she hasbecome strong because of herexperiences in the 1950s and 60s(before the gay liberation movementbegan). She believes that she isbetter prepared to face the assaults ofageism in society because of this.

This phenomenon is called “crisiscompetence” in the literature (e.g.,Friend, 1987). However, it is importantto realize that there is a great deal ofdiversity within the lesbian populationregarding their views about crisiscompetence. For example, anotherfocus group member disagreed withthe idea that confronting heterosexismstrengthens lesbians. She said thatthe absence of validation for being alesbian “could have a totally oppositeeffect” leaving one less prepared for

facing the pressure ofsocietal ageism.

Health and SocialServices

Lesbians in thefocus group noted thatthey share the sameconcerns as other oldwomen: “We want toget good care and betreated well.” Forlesbians being treatedwell means that careproviders will not basetheir communicationson heterosexualassumptions. Unfortu-nately, discriminationagainst GLBTpeople ispervasive in the healthcare system (Schatz &O’Hanlan, 1994). Evenwell-meaning behaviorby providers of healthand social services maybe received as negating.One lesbian in the focusgroup described feelingemotionally assaultedevery time she has gonefor her mammogrambecause she has beenaddressed as either

Mrs. or Miss. Both expressions negateher identity because she has sharedher life with a lesbian partner fortwenty years and is thus not singleand is not allowed by law to marry herpartner rendering “Mrs.” inappropriateas well. In this situation, a lesbian isforced to “out” herself repeatedly inorder not to be devalued. The neutralterm “Ms.” does not convey theheterosexual assumption. Moreover,the simple gesture of asking someonehow she prefers to be addressedconveys respect and honors an

Lesbian and Gay Aging Issues Network (LGAIN):http://www.asaging.org/lgain/

Gay and Lesbian Advocates & Defenders (legal matters):http://www.glad.org/

Gay and Lesbian Association of Retired Persons:http://www.gaylesbianretiring.org/

National Center for Lesbian Rights (NCLR):http://www.nclrights.org/

National Gay and Lesbian Task Force Policy Institute, Aging:http://www.ngltf.org/

Download Outing Agehttp://www.ngltf.org/downloads/outingage.pdf

Old Lesbians Organizing for Change (OLOC):http://www.oloc.org/

Online Information for Old Lesbians:www.seniorpages.com/gay

Parents, Families and Friends of Lesbians and Gays:http://www.pflag.org/

Pride Senior Network:http://www.pridesenior.org/

Senior Action in a Gay Environment (SAGE):http://www.sageofbroward.org/

Online Resources



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individual’s wishes. The ongoingprocess of coming out can be exhaust-ing and anxiety provoking. Lesbiansshould not have to confront suchchallenges when in need of health andsocial services.

Lesbians often experiencenegating behavior during hospitaliza-tion. For example, one lesbian withwhom I worked reported that she wasunexpectedly hospitalized without ahealth proxy or durable power ofattorney. When she was in a coma, thehospital personnel refused to allowher partner to participate in decision-making. They would talk only to herson. Similarly, one focus groupmember reported that even when sheasked that her partner be listed as heremergency contact at the hospital,someone wrote the name of her sister,who resides in another state, withouther permission. Thus even whenlesbians face the anxiety that oftenaccompanies disclosing their lesbianidentity to health care providers, theymay have their wishes ignored. Caremanagers can play an importantadvocacy role in such situations byaugmenting a lesbian’s voice andinsisting that her wishes be honored.

Jean Quam provides a vividexample of the negation of a life longlesbian relationship during a medicalcrisis:

“When a woman in a forty-twoyear old lesbian relationship becomesdisabled, her partner becomes herprimary caretaker. However, when thecaretaker becomes ill, distant familymembers take over decision-makingresponsibilities and without regard totheir wishes, separate the women intwo different nursing homes. Alesbian social worker realizes thenature of the relationship and advo-cates with the respective families tohave the two women placed togethershortly before one partner dies”(Quam, 1997, p. 97).

In this particular situation, alesbian social worker recognized theimportance of this relationship andwas able to advocate for their reunionin one of the nursing homes. Lesbiansshould be able to count on the samerespect and advocacy from hetero-sexual care providers. Recognizing theimportance of a life-long relationship

does not mean that care managersshould label the relationship aslesbian. Instead, care managers shouldrespect relational significance byconsidering options for care planningthat maintain the continuity ofimportant relationships. If caremanagers do not expect to see intimaterelationships between women, theywill not “see” them and therefore notrespond in an affirming manner.

Lack of support for lesbiancaregivers is another factor that cannegatively affect the health and wellbeing of lesbians. Lesbians who arethe primary caregiver for their domes-tic partners do not have access to thesame benefits as heterosexual marriedpartners. For example, lesbianpartners are typically denied unpaidleave for caregiving under the Familyand Medical Leave Act of 1993 (Cahillet al., 2000). Given the double jeop-ardy of discrimination based on ageand sexual orientation in employment,a lesbian takes a great risk to leave herjob in order to care for her partner.Care managers must be sensitive tothe increased burden that olderlesbian couples may face because ofpossible discrimination and seekalternative means of meeting their careneeds.

Financial and LegalConcerns

Care managers must becomeknowledgeable concerning thefinancial and legal constraints thatface lesbian families if they are todeliver culturally competent services.Economic well-being is intricatelyrelated to legal matters involvinghealth care and financial planning.Lesbians in the focus group notedthat navigating the health and legalsystems can be much more difficult forlesbians who are not out and for thosewho do not have knowledge concern-ing their legal vulnerability or thefinancial means to pay for an attorney.To not have legal documents such asa health proxy or a durable power ofattorney leaves lesbians at risk ofhaving their wishes ignored by thehealth care system. Although laws ineach state vary, generally with legalassistance lesbians can obtain legaldocuments naming their partner, orwhomever they wish, as the desig-nated person to make medical deci-

sions should they become incapaci-tated. Care managers must learn abouttheir state’s laws and the resourcesavailable to lesbians for obtaining theneeded legal protection.

The lesbians in the focus groupsaid that without a will any survivinglesbian or gay partner would be atrisk of losing his or her home and hisor her economic well-being. Nonethe-less, many focus group membersnoted the limits of legal protectionprovided by a will. Several noted thateven with a will they fear that theirpartner’s family members may contesttheir partner’s last will and testamentcreating a crisis at a time of acutegrief. Given the extreme hardship thatmay face a surviving lesbian partner,care managers must address theseissues as a routine part of caremanagement. Waiting until there is animpending death may be too late.

Financial planning for survivingthe death of a partner is very challeng-ing for lesbians. Lesbians tend to beeconomically disadvantaged due tothe lower wages women receive fortheir work over a life time. Thisdisadvantage has a cumulative effectand is compounded by laws andpolicies governing health and socialbenefits in our society (Cahill et al.,2000). Retirement income may bereduced because many lesbians havetaken time out of the work force toraise children but will not be able toaccess their partner’s social securitybenefits, as do married women.Moreover, pensions and 401(k) plansare subject to heterosexist policiesthat disadvantage lesbians. Forexample, married partners have accessto life long pensions if their partnerspredecease them. In contrast, lesbianpartners receive nothing (Cahill et al.,2000). Further loss may be experiencedbecause lesbian partners are notallowed to roll over 401(k) plans as aremarried partners and are thus subjectto a 20 percent tax on this inheritance.It is important that care managers beaware of these legal constraints onfinancial planning in order to providelesbian families with competentservices in long term planning.

Lesbians in the focus group wereacutely aware of the financial disad-vantage they faced because theycould not be included on their


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partner’s health insurance. Onelesbian was paying $300.00 per monthfor health care that a heterosexualmarried woman would receive at nocost through her partner’s insurance.Another member of the group hadprivately paid for health insurance forover 10 years because she could notbe included on her partner’s insur-ance. These costs add up over timeand make financial planning forretirement much more challenging forlesbians than for their heterosexualcounterparts.

Furthermore, heterosexistassumptions may be made by financialplanners and lawyers. One lesbiancouple reported that they were oncegiven false information by a hetero-sexual lawyer with regard to their will.Another focus group member reportedthat she was once told by an insur-ance representative that she could notname her partner as beneficiary. Shestated:

“I knew better and told him that Iknew that I could name any one Iwished, not only a blood relative.What about other lesbians and gaymen who might not know to stand upfor their right to name their partner?”

Protection from spousal impover-ishment is only afforded to legallymarried spouses under Medicaid law(Cahill et al., 2000). If a lesbian coupleowns their home, they may have tochoose between obtaining the medicalcare needed and keeping their home.Clearly this is an untenable choice.One colleague was shocked when shediscovered this constraint in Medicaidlaw when working with an old lesbiancouple. This shock stimulatedadvocacy and education of herprofessional peers. Care managersshould realize that many of theirprofessional colleagues might lackbasic information concerning thebarriers lesbians face in current healthcare policy. It is important that caremanagers participate in educating theircolleagues as well as actively seekingalternative resources for their clients.

There are only nine states thatprotect against discrimination due tosexual orientation in public accommo-dation. Low-income housing throughHousing and Urban Development(HUD) does not allow for non-relatedhouseholds. Even though this policy

may be ignored in some areas,allowing lesbian partners to livetogether, lesbians remain at risk ofhaving the policy enforced and thusmay be unlikely to seek such housing(Cahill et al., 2000). Therefore, caremanagers must be informed about thelack of protection lesbians faceregarding their housing choices. Thepotential influence of these policieson lesbians’ quality of life must beevaluated with clients.

Culturally sensitive practicetechniques should assist caremanagers in discerning whether or nottheir clients lack information aboutpertinent laws and policies that coulddramatically affect their lives. Simplyexploring clients’ wishes withoutassuming the gender or legal relation-ship of the person they may choose asa heath proxy or beneficiary can openthe door to a discussion that ad-dresses a lesbian’s true wishes. Giventhe diversity within the lesbiancommunity, care managers must notassume that lesbians are knowledge-able about these legal matters andgovernment policies. If women livingtogether for a lifetime have not self-identified as lesbian, or if lesbianshave not disclosed their sexualidentity, they have not had access toinformation disseminated in thelesbian community. Moreover,lesbians may lack the financialresources for legal counsel. Therefore,care managers should be aware ofresources such as the Gay andLesbian Advocates and Defenders(GLAD, http://www.glad.org/ ) in orderto locate legal assistance for low-income lesbian families.

Social and EmotionalConcerns

For many lesbians, theirsocial network of friends and family isextremely important and is one of thegreatest strengths of their lesbiancommunity. One focus group memberremarked, “Powerful women friendsare important wherever we live.”Sensitivity to the importance ofkeeping contact with friends and thefear about being separated from theirpartners and their community offriends is extremely important. In fact,remaining in touch with their lesbiancommunity may be one of the reasonslesbians resist leaving their own

homes to receive health care. The keyfactor for care managers to rememberis that recognition of the powerfulemotional support provided by lesbianfriendship networks is central toemotional well being in late life formany lesbians. Thus, care planningmust include ways in which lesbianfamilies can maintain communitycontact without suffering fromdiscrimination.

The self-restraint lesbianstypically exercise in predominantlyheterosexual environments may beexperienced as self-negation (Healy,1999). Lesbians also often exerciseself-restraint while engaged in leisureactivities. A fairly universal self-restraint is to refrain from touchingaffectionately even when heterosexualcouples are doing so freely. Forexample, even though all the hetero-sexual couples were freely expressingaffection while watching a sunset, onelesbian in the focus group noted thatshe consciously kept herself fromtouching her partner. Lesbians notedthat in some cultures, their physicalwell-being could be endangered ifthey did not exercise such restraints.These lesbians stated that limitationson self-expression were central to theiraversion to relocating into a primarilyheterosexual environment such asassisted living or nursing home.

Although friends are verymeaningful to lesbians, it is importantfor care managers to remember thatmany older lesbians are single; caremanagers should not assume thatfriends will necessarily provide thehands-on care that an unpartneredlesbian may need in old age. In onestudy, 68% of lesbians over the age of50 reported that they could notidentify someone they would rely onfor caregiving should the need arise(Cahill et al., 2000). This issue raisesthe importance of care managerspromoting education and culturalsensitivity training for the formal careproviders who will be needed bylesbians in the community as well as inresidential settings.

Another major problem that isconfronted by lesbians and theirfamilies is the experience of invali-dated grief. Imagine facing a will beingcontested or one’s house being taken


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away during a period of acute grief.Imagine the dismissal of a life partneras “only a friend.” Imagine not beingallowed to make funeral arrangementsfor a life partner. All these experiencescontinue to happen to lesbians facingloss. Furthermore, heterosexual familymembers may have their grief invali-dated as well. For example, a formerheterosexual client once recountedhow she had never shared withanyone her grief about the death ofher daughter’s lifelong companionbecause “no one would understand.”It is not only lesbians who must makedecisions about coming out to healthcare providers. Coming out is anongoing process for family membersas well. Thus culturally sensitivepractice concerning lesbian issuesmust be universally applied in ordernot to negate the importance ofrelationships in the lives of caremanagers’ clients who are lesbian aswell as those who have importantrelationships with lesbians.

Guidelines for CulturallySensitive and CompetentCare Management

By applying the followingguidelines, care managers can combatthe heterosexual assumptions thatcreate barriers for lesbian families andprovide culturally competent andsensitive services that are affirming tothe lesbian families they serve.

AwarenessBegin with self-reflectionconcerning your views aboutsexual orientation.Combat heterosexistassumptionsAssume that you do not knowthe sexual orientation of yourclients and their family mem-bers. Assume that you do notknow the gender of significantothers.Assume that lesbian familieshave many strengths.Assume diversity within thelesbian populations.Do not assume lesbians arecomfortable coming out to you.Do not assume that failure todisclose lesbian identity isassociated with mental distress.

Knowledge necessary forculturally competent practiceBecome knowledgeable abouthow lesbians may be unfairlytreated by public policies.Be aware of legal protections,such as health proxy or durablepower of attorney.Be aware that lacking a will,lesbian survivors are in dangerof losing their homes.Be aware that lesbians may beunderestimating their financialneeds in retirement becausethey may not know about thetax burdens they will face in thefuture.Inclusive language and actionnecessary for culturallysensitive affirmative practiceAvoid gendered pronounswhen asking about significantothers. Ask instead is thereanyone who has been aconfidant or who has been veryimportant to you.Ask how your clients want tobe called.

· Create culturally sensitiveforms: spouse/partner ratherthan marital status.Explore all important relation-ships. Do not limit inquiry to“relatives.”Use the phrase “sexual orienta-tion” rather than “sexualpreference.”Explore intergenerationalresources with the inclusive,gender neutral language.Advocate for pro bono legalservices for lesbian couplesthat cannot afford a lawyer.Expand your resource base andrefer to gay affirmative socialservices.Advocate for staff developmentregarding gay affirmativepractices where needed.

The most important point for caremanagers to remember is that theseguidelines must be applied in theirwork with all families. The invisibilityof lesbian families and the lesbianrelatives and friends of elders requiresthe universal application of sensitivepractices that affirm lesbians.

Barranti, C. C. R., & Cohen, H. L. (2000).“Lesbian and Gay Elders: An InvisibleMinority.” In R.L. Schneider, N.P. Kropf,& A. J. Kisor (Eds.), GerontologicalSocial Work (2nd Ed.) (343-367).Belmont, CA: Brooks/Cole.

Cahill, S., South, K. & Spade, J. (2000).Outing Age: Public Policy Issues AffectingGay, Lesbian, Bisexual, and TransgenderElders. Washington, DC: The PolicyInstitute, National Gay & Lesbian TaskForce.

Feinberg, L. F. (1997). Options forsupporting informal and familycaregiving: A Policy paper. San Francisco,CA: Pew / American Society on Aging.

Friend, R. A. (1987). “The Individual andSocial Psychology of Aging: ClinicalImplications for Lesbians and Gay Men.”Journal of Homosexuality, 14 (1-2), 307-331.

Healey, S. (1994). “Diversity with aDifference: On Being Old and Lesbian.”Journal of Gay & Lesbian Social Services,1(1), 109-117.

Healy, T. (1999). “A Struggle forLanguage: Patterns of Self-Disclosure inLesbian Couples.” In J. Laird (Ed.),Lesbians & Lesbian Families, Reflectionson Theory and Practice (123-141). NewYork: Columbia University Press.

Older Americans 2000: Key Indicators ofWell-Being. (2000). Hyattsville, MD:Federal Interagency Forum on Aging-Related Statistics.

Ponse, B. (1976). “Secrecy in the LesbianWorld.” Urban Life, 5 (3), 313-336.

Quam, J. K. (1997). “The Story of Carrieand Anne: Long-Term Care Crisis.”Journal of Gay and Lesbian SocialServices, 6 (1), 97-99.

Quam, J. K., & Whitford, G. S. (1992).“Adaptation and Age-Related Expecta-tions of Old Gay and Lesbian Adults.”The Gerontologist, 32 (3), 367-374.

Rothman, J. & Simon, J. S. (1998). CaseManagement(2nd Ed.). Boston: Allyn andBacon.

Schatz, B., & O’Hanlan, K. (1994). Anti-gay discrimination in medicine: Results ofa national survey of lesbian, gay, andbisexual physicians. San Francisco, CA:American Association of Physicians forHuman Rights.

Tara C. Healy, MSW, Ph.D., is anassociate professor of social work atthe University of Southern Maine inPortland, ME. She can be contactedat [email protected].

References


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As a geriatric care manager, Ihave found that I have needed to drawon my own intuition and creativity inworking with gay, lesbian, bisexualand transgender (GLBT) elders. I havehad to learn from my mistakes. Therewas nothing in my education thatspecifically addressed the needs ofthis population, so I’ve needed todevelop practice wisdom over theyears. Perhaps above all I havelearned the importance of not assum-ing heterosexuality.

As care providers we need to beinformed and sensitive to the unique-ness of the older GLBTclient. Weneed to approach these individualswith an openness that lets them feelthat disclosure will be safe andconfidential. We must also meet themon their terms. All indications andinformation may cause one to believea particular client is homosexual,however years of being closeted mayhave conditioned this individualincapable of disclosure to physicians,therapists or social workers no matterhow non-judgmental these profession-als may be. If clients are not willing to“out” themselves to you, then thatmust be respected. Sensitive question-ing can evolve into a relationship thatwill be beneficial to the client and alsoto the care manager. For example,asking about special people in one’slife, rather then asking the name of ahusband or wife can ease a client’sanxiety and identify you as a caringand nonjudgmental individual.

Recent studies throughout theUnited States and Canada have shownthat a significant number ofGLBTelderly are living alone. Livingalone is one risk factor to needingcare, so as geriatric care managers wemay find these individuals in ourcaseloads. How do we provide forthem and especially how do wesensitize staff to GLBTelders? Asgeriatric care managers, we must bethe role models; we must not allowdiscriminatory activities on the part ofworkers to overtly or covertlyundermine the care of that individual.

Differences in culture, religion andeconomic status often are the cause ofclashes between caregiver and client.Add to that the possible hostility of ahomophobic caregiver and troublemay occur. Identifying open andaccepting health care staff is essentialto the health and well being of anyclient, but perhaps in particular anelder GLBT client.

Over the years, I have perhapshad GLBT elder clients who eitherchose to remain closeted to me, or I,unwittingly, assumed heterosexuality.My growing awareness of thispopulation became key to betterassessing the clients that cameseeking services. The following twocases were not only memorable, butwere also true learning experiences forme. The client names have beenchanged to protect their privacy.

Clarence B.Clarence was a 79-year-old

gentleman whose family was out ofstate, and who wanted to make sure hewas taking care of himself after a longhospital stay. I was assigned as hiscare manager and although he neverspecifically stated he was gay, he didspeak openly to me about his longtime companion who had passed awaysome years before. He understoodthat he needed someone to help himwhen he got home and I went aboutsetting things up. One of Clarence’seccentricities was that when he wentout he would wear make-up and ratherdramatically at that. I, however, didn’ttake that into account since he did notwear makeup when he was in theapartment. I set him up with a homehealth aide that I had worked withbefore and he seemed pleased with thearrangement. Then, one day, I got anhysterical call from the aide babblingabout going out for a walk withClarence and the make-up. I set a timeto meet with the aide and listened toher story of shock and disbelief whenshe and Clarence were venturing outfor their first walk together. I had tomake a quick assessment of the

situation since I knew that the aidewas excellent but just uneducated inGLBT issues. I explained aboutClarence and hoped for the best.Although she had strong religiousfeelings she agreed to continueworking for Clarence and as time wenton they became quite close. The aidealso started buying makeup forClarence, reporting he was not usingthe correct color!

Rose K.In another case that I handled

many years ago, I came face to facewith my own inability to recognize aGLBT elder. I was also at a loss toknow exactly how to handle thesituation and had no real resourcesupon which to draw. The following ismy story of Rose.

Rose was an 83-year-old Polishborn single woman who had beenreferred to our office through aguardianship proceeding. Rose hadbeen living alone in a rather fashion-able apartment for many years and hadbeen functioning well on her own.She had fallen on the street one dayand was brought unconscious to thelocal hospital. Tests revealed that shehad a large tumor behind her right eyebut she refused surgery. Hospitalauthorities felt she was also sufferingfrom dementia and contacted legalservices. After a guardian wasappointed, our offices were contactedto get her apartment in order and toset up home care. On my initial visit, Ifound a very cluttered, dirty apartmentbut with beautiful paintings andsculptures throughout. I arranged forcleaning and garbage removal. I alsohad a hospital bed brought into herbedroom. In the bedroom was afreestanding metal closet with a chainand lock on it. It was rather small and Imerely moved it to the other side ofthe room in order for the bed to bemoved in. Several days before Rosewas to come home I had to move thecloset again and I thought, “if it wasempty maybe it could be discarded.” Iquickly broke the flimsy lock and

Notes From the Field: CareManagement with GLBT Elderly

By J Donna Sullivan, Ms.Ed, CSW,C-ASWCM


GCMFall 2002

found contained inside more clothing -men’s clothing- but not thinkingfurther of this, I just closed the doors

and moved it to the hallway. Back inmy office, I inquired if Rose had beenmarried and was told no. I keptthinking about the clothes I had seen.The next day I waited in the apartmentfor Rose to come back from thehospital. The closet still intrigued meand I took another look. I now

surveyed the contents more closely –several men’s shirts, a man’s suit, ties,two fedora hats, and a pair of wing-tipshoes. What struck me about themwas that they all were extremely small,especially the shoes. I took out oneof the jackets and held it up. It wasmuch too small for even a small man –then I realized, perhaps these were herclothes? I closed the closet and re-locked it.

Over the next several weeks I sawRose. She did not like me; I wasconsidered a nuisance. But I foundher weak spot – Hagen Daas VanillaIce Cream! She slowly softened andbegan to tell me about her work andher travels through Europe and theworld. One day she asked me wherethe metal closet was and I showed herwhere I had moved it. She then askedme if I had opened it. I thought aminute and although I could haveeasily said “no” I told her I had.Initially her response was of angerand then she began crying. In thatinstant, I thought, “now what am Isupposed to do?” Suddenly it came tome and I leaned over to her and said,“Don’t worry Rose, I have a closet likethat at home myself.” With thisstatement her anger and tears stoppedand a moment later she looked at meand smiled.

After that day we spoke openlyabout her life as a gay woman in the1930s and 1940s—it was intriguingand wonderful. As her tumor wors-ened, there were some days shecouldn’t talk but she knew I wouldkeep her secret. Some weeks later shereturned to the hospital and lapsedinto a coma, we never spoke again. Ihad known her 3 months.

Both these cases, though quitedifferent, point out the complexity ofthe issues we face as we try to bestserve our clients. There are severalthings we can do to enhance thequality of life for our aging GLBTclients. For example, we can usegender-neutral forms, categories thatask for “significant other” rather thanspouse. When possible, we shouldlook around the homes of our clientsfor clues—perhaps there are photos,books or magazines that provideinsights about our clients’ sexualorientation. I have found that themore information I can garner beforesetting up home care, the better, so asto avoid the potential problem of

assigning home care staff who areunprepared or unwilling to work withGLBT clients. Soliciting this informa-tion from the client or the client’sfamily members should be done withsensitivity to the client’s privacy, andmay require indirect questioning whenclients or family members are particu-larly protective or ashamed about theclient’s sexual orientation.

Ultimately, we should not assumea probable lifestyle nor should wecategorize clients with a perfunctorychecklist of needs. We should doeverything we can to ensure aneducated and accepting staff. Eachcase must be individualized to meetthe needs of that specific client. Andin the GLBT community that must bedone with understanding and aconscious belief that one is doing themost one can to make one’s client feelas comfortable as possible.

Training and education will be themainstay of any initiative to improvegeriatric care. In a recent paperdelivered before the Senate Committeeon Aging, Perry (2002) emphasizes theneed for geriatric training at all levelsand warns of the problems that may lieahead: “Despite decades of warningsfrom policy makers, physicians, socialscientists, and advocates, an acuteshortage of health care professionalswith geriatric training persists in theUnited States” (Perry, p. 2). Further-more, he advises, “students invirtually every health care field—social workers, nurses, pharmacists,and physicians, must receive geriatrictraining as part of their coursework.”(Perry, p. 4). Clearly, anygeriatric training initiative will beimproved if it includes the needs ofour GLBTelders. It is my hope that wewill all learn and develop new andinnovative approaches for thisvulnerable and hidden population.

J Donna Sullivan, Ms.Ed, CSW,C-ASWCM is Director of Older AdultServices at Scarsdale/EdgemontFamily Counseling Services inScarsdale, NY.

ReferencesPerry, D. (2002). “Patients in Peril:Critical Shortage in Geriatric Care”Alliance for Aging Network. RetrievedApril 14, 2002 at www.aging research.org.

One of Clarence’s

eccentricities was that

when he went out he

would wear make-up

and rather

dramatically at that. I,

however, didn’t take

that into account since

he did not wear

makeup when he was

in the apartment. I set

him up with a home

health aide that I had

worked with before

and he seemed

pleased with the

arrangement. Then,

one day, I got an

hysterical call from

the aide babbling

about going out for a

walk with Clarence

and the make-up.


GCMFall 2002

Rethinking Community, Place and Ritualin Aging GLBT Populations

by Nancy Webster, MPA, MSW, LCSW And Travis Erickson

We sit, curved over computers, ina small office in a corner of theUniversity. We are a young, gay,graduate student and an aging lesbianprofessor struggling to put order toour thoughts on the aging process.We tease out words and concepts,reality and optimism from the flatnessof words. There are muffled soundsoutside the office door. We areworking late into the evening as agroup meets in the classroom acrossthe hall. The campus Gay/Lesbian/Bisexual/Transgendered (GLBT)Group has been guaranteed privacy,secrecy for its furtive monthlymeeting. The shades have beendrawn. The doors have been closed.Absolute privacy has been extendedbecause of fear of exposure. Feardrives the need for secrecy andprivacy on this university campus -fear and the extension of oppression.There are both internalized fears fromprevious experiences with beinghomosexual and fear of the physicalenvironment. With the hushedbackground noise, we continue ourtask of reaching for words of meaningfor this article on GLBT aging. Wetwist language and hope for eloquentstatements to those who help, healand guide aging gay and lesbianelders. As we finish our night’s workand leave the building we reflect onthe shadowy shapes moving behindthe drawn blinds in the building andonce again the issues of safety andidentity flash in front of us.

One of us no longer needs to hideher lesbian identity; she is privilegedwithin oppression. She is white,educated, appears more traditionalthan the internalized image of “alesbian,” but as she ages the issuesthat have shaped her as a lesbian inthe dominant culture increasinglychallenge her. As we write, theyounger gay co-author speaks of hiscommitted relationship and the fear he

has that if he and his partner were tohave children and something shouldhappen to him, his parents, rather thanhis partner, might gain custody of thechildren. His are not random musings;his partner is a police officer, a gaymale in a bastion of heterosexuality.We murmur softly of oppression andcontinue on with our writing. He, too,is privileged within oppression; he iswhite, middle class, educated, andappears more traditional; relativelymore “straight” than many gay men.But together, a generation apart, wewill move into aging with a sharedhistory. This history includes a lackof “place” in the dominant culture, anabsence of ritual and the omnipresentand cumulative stressors of ageismand presumptive heterosexuality.

While both the mainstreamculture and GLBT individuals mustconfront the issue of ageism, gay menand lesbians must also confrontheterosexism and institutionalizedhomophobia as a component of theaging journey. This article examinesthe integral components of “placeidentity,” ritual, and oppression aspart of the identity formation andaging journey of GLBT elders. Thispaper further examines the triad ofageism, heterosexism and institutionalhomophobia as markers of the agingjourney. Finally, consideration isgiven to the matter of “presumptiveheterosexuality” and homophobia as aharsh force in the aging experience ofgay and lesbian individuals.

The issues embedded in the gayand lesbian aging population are bothcongruent and incongruent with theheterosexual population. Congruentissues include reduced incomefollowing retirement, cumulative lossof friends and family members andconfrontations with ageism in ourculture. The issues that appearincongruent include the linking ofageism and homophobia, the lack of

legal and public recognition of same-sex relationships, the “coming of age”as an elder in a youth-oriented GLBT,and coming out under significantpublic scrutiny and judgment. Thelack of congruence is also illustratedin the lack of a “sense of place.” Place,both in the sense of a physical placeand in the safety of place. Further lackof congruence includes the lack ofsocially sanctioned rituals, such asmarriage, and the construction of asense of self and an identity with a lifelived in secrecy. It is the life lived asshadowy shapes behind drawn blinds.

Let us first consider the identityand composition of the aging GLBTpopulation. This culture has devel-oped and matured in a social climatewith few civil rights, often hiddenidentities, few socially sanctionedrituals, and little development of placeattachment nor identity with a senseof place. Gay and lesbian individualshave often experienced a deepinstitutionalized and personalizedoppression. There have been fewpublic monuments and permanentpublic spaces dedicated to or inacknowledgment of gay and lesbianidentities. The temporary claiming ofpublic space through Gay Prideparades and demonstrations is astrategy that speaks to this lack.Rituals, in the form of coming of age,coming out or of marriage ceremonies,have not been part of the developmen-tal and social construct of the GLBTcommunity. It is ritual that lays thefoundation for social and culturalrecognition (Laird, 1984). Without afoundation for social and culturalrecognition there is a concurrent griefand loss process; a legacy of histori-cal trauma. There is also a searchingfor and seeking of an identity vali-dated by the culture.

Gay and lesbian individualsexperience coming out as a lifelong


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While both themainstream culture

and gay andlesbian individualsmust confront theissue of ageism,

gay men andlesbians must also

confrontheterosexism andinstitutionalized

homophobia as acomponent of the

aging journey.



process. Coming out is defined asbeing open and visible about one’ssexual orientation to oneself andothers. The issue of proclaiming a gayor lesbian identity is always compli-cated. It is complicated for youth andit is particularly complicated for theaging individual who must come out inmidlife or in institutionalized settings,such as during hospitalizations, or inthe application for social services.However, coming out to health careprofessionals and social workers isoften a necessity for GLBT elders sothat they can maintain access to theirpartners or their community. AgingGLBT individuals have grown old inan environment of persecution,isolation, marginalization andunacceptability. The lack of both“place identity” and the choice of safeand welcoming venues has compli-cated the coming out ritual. Comingout and claiming to oneself and othersone’s sexual identity, while always acourageous act, defines the individualand places the individual at themargins of the culture—it identifiesthe individual by his or her sexualorientation. One’s identity quicklybecomes linked to sexual orientationrather than to the continuum of traitsthat makes one whole. One becomesthe gay male, the lesbian professor,the gay police officer, and the lesbianfarmer. One loses one’s wholeness,one’s roundedness, and one’scentrality to the trait of sexualorientation.

Oppression, as described byYoung (1990), consists of five “faces”:exploitation, marginalization, power-lessness, cultural imperialism, andviolence. Each of the faces representsa family of concepts and conditionsthat present a “disadvantage andinjustice” to a particular group orindividual. A group is described asbeing oppressed if at least one of thefive faces impacts the respectivegroup or individual. In most casesoppression is a product of a “well-intentioned society,” though manifes-tation of dominant value and politicalsystems often go unquestioned(Young, 1990). While older GLBTpeople report high life satisfaction andlow self-hatred, a significant number

of those who are “out” still experiencehigh levels of shame, poor health, andloneliness (D’Augelli, Grossman,Hershberger, & O’Connell, 2001). Thenegative systems of thought broughtabout by the systematic oppression ofgay and lesbian adults may becovertly internalized within theindividual resulting in diffused formsof self-hatred and shame. Theencasement within the identity statusof gay and lesbian and within thephysical body, social body ofcommunity and the body of cultureand locality, all contribute to beingmoved, placed, and pushed to the

margins of the cultureHow do the issues of ritual,

place and oppression interact with theaging individual and the dominantculture to shape the aging process?How do we establish a healthy agingidentity when there is no distinctculture or sense of shared history toconnect gay and lesbian individuals totheir environment and culture? Let usfirst look at the issue of place identityor place attachment. Place attachment

is a positive emotional bond thatdevelops between individuals orgroups and their environment (Altman& Low, 1992). In that sense, the studyof place attachment is the study ofemotional investment in place. Placeattachment, that is the connection tosafe and welcoming places, link anindividual to his or her environment.Place attachment is likely to helpindividuals to develop a set of normsand effective formal and informalcontrols over their environment.Neighborhoods, communities, publicmonuments, and the social andphysical nature of the area often markattachment to place. But what of thosewho cannot claim a sense of place,what of those who remember place asdangerous, secretive, furtive, andhostile? What of those who rememberplace less as a positive physicalenvironment and more as of a series ofbars, clandestine weekends or weeklong vacations at GLBT friendlyresorts? How is aging impacted whensocial relationships are non-local andpeople have no attachment to thephysical community?

Along with the deprivation ofplace identity, individuals in the agingGLBT community have not experi-enced symbolic rituals. Rituals revealthe deepest levels of shared meaningsand values, and rituals link individualsto the self and to the community.Rituals are symbolic and they commu-nicate metaphorically groups’ sharedconstructions of reality. Rituals alsolegitimize particular worldviews, moralstances or social constructs. Ritualsmay perpetuate cultural myths andhave tradition-making power andshape cultural unity. Rituals, such asbaptism, marriage, and anniversariesspeak to the non-verbal part of theself, and shape the unspoken in thedominant culture. Such ritualsminimize disconnections, differences,paradoxes, and conflicts (Laird, 1984).

In the gay and lesbianpopulation, ritual is often discon-nected from tradition making powerand from cultural unity. There are nosymbolic rituals that indicate atransition, a separation, or an alter-ation to or from couple status. There

GCMFall 2002



are no rituals of incorporation, nomarking the establishment of newfamilies, no moments of signaling achange in the family’s or individual’sequilibrium. There are no rituals foraging, retirement, or rituals to amelio-rate the sadness precipitated by therelocation to a new home, assistedliving center or nursing facility. Theserituals for aging and the marking ofaging in symbols are also absent fromthe mainstream culture. However,there is a particular poignancy that ispresent in the GLBT elder community.This poignancy is particularly painfulbecause identity for GLBT elders is sodiffused, so rife with “presumptiveheterosexuality”, that in order tocreate rituals for aging one must again“come out” as gay and lesbian and“come out” as old. This processmoves the individual to the margins ofthe culture.

A consideration of the issues ofplace identity and ritual leads one toquestion why we, as gay and lesbianpeople, don’t have connection toplace or form? Why have we notdeveloped our own mythology,traditions, forms or functions? Suchquestions spiral back on to theoverwhelming effects of living life onthe margins - shadowy shapes behindwindow shades - and the lack ofpublic acknowledgment of GLBTindividuals. As we circle ourselves, weare again confronted with the effectsof oppression of gay and lesbianpeople and the potential impingementon the aging process.

And where do we stray as aginggay and lesbian individuals? Does thepressure of prejudice force us tobecome placeless, displaced, notbelonging to a nation, to a class, to aregion? Does oppression force andshape our lack of ritual within commu-nity, and ultimately how does thisencroach on the aging process? If weare to assume that the forces ofhomophobia shape cultural responsesto gay and lesbian individuals, howare we to understand the experience ofaging in a youth-oriented gay andlesbian culture? How are we tounderstand the pressure of comingout in mid-life, and how are we to

understand the aging process withfew models for healthy aging?

Can we imagine for a moment theexperience of the late life gay maledisclosing to his children and grand-children his “gayness?” Can weimagine the experience of lesbianpartners struggling to come out tohealth care professionals, to nursinghome officials, in order to feel safe aslesbian individuals in the multiplesystems that comprise old age? Canwe reflect on the experience of dis-connection from the gay and lesbiancommunity because of age, anddisconnection from the heterosexualcommunity because of same sexpreference? Can we move in ourcompassion and understanding ofGLBT elders to that place of isolation,fear and loneliness and still under-stand that these individuals experi-ence high life satisfaction, and highself esteem? Can we, as helpingindividuals, immerse ourselves in theparadox and can we be a part ofreducing the pressures of oppression?

Let us use, for a moment, atheoretical lens in considering identitydevelopment and the relationshipbetween identity development andritual and place. In what way do dis-placement, and the lack of ritual andthe forces of “presumptive hetero-sexuality” work to shape identity.Anthony D’Augelli (1994) proposed amodel of lesbian, gay and bisexualidentity development. D’Augelli’sfocus is on the identity process as asocial construction. He offers severalassumptions as a foundation for histheory. First, sexual identity is a lifelong process and may be fluid likewith its developmental plasticity.Second, the individual must give upthe heterosexual identity that theyhave possessed since birth. Third, anindividual has a significant role intheir own development throughmaking choices and taking action.D’Augelli identified three sets ofinterrelated variables, which interactto mediate the identity developmentprocess. The variables are labeled aspersonal subjectivities and actions,interactive intimacies, andsociohistorical connections.Sociohistorical connections may be

understood as place identity, interac-tive intimacies as form, symbol andritual and personal subjectivities asdevelopment of identity within theculture.

If we draw on D’Augelli’s modelfor lesbian, gay, and bisexual identitydevelopment as a framework forunderstanding the individual’sdevelopment within a social context,we can begin to paint a picture of howthe individual lesbian or gay elder isimpacted. Personal subjectivitiesconnect one’s psychological pro-cesses, self-concept and the expres-sion of feelings to the external world.Exposure to the scripts forstraightness become internalized andlearned from the relationships withothers and from stimuli throughout theculture in the United States. Interac-tive intimacies refer to those relation-ships we have with other people, forinstance, sons, daughters, siblings,parents, peers, etc. These relation-ships are transactional for most as wegain from these relationships, andpresumably give in return. However,there are barriers to these transac-tional relationships for gay andlesbian individuals and often thesebarriers are formed because of theirgay or lesbian identity. Relationshipsare invaluable to maintaining a senseof self-worth, and significantlycontribute to the formation of placeattachment. Sociohistorical connec-tions may refer to the laws, policies,local history, and greater culturalsystems in which the lesbian or gayindividual exists. These systemsimpact the individual, often withunearned consequences related to thefear, hatred, and invisibility of lesbian,gay and bisexual individuals in theU.S. Consequently, the impact on theindividual lesbian or gay elder bringsto bear challenges within our relation-ships. Lesbian or gay elders do notsolely feel the impact of thesesystems. Women and men whoidentify as straight and becomeconfined by these scripts also feel theimpact.

Keeping this model in mind let usreturn to the shadowy shapessilhouetted behind the drawn blinds.

GCMFall 2002

Metaphorically, these shadowyshapes are also our gay and lesbianelders and the question may well be,how do we lift the shades to revealpositive methods to support theseindividuals in the process of “healthyaging?” How do we clear the trail ofhomophobia and “presumptiveheterosexuality” that are so ofteninsidious? Do we take the time tounderstand how a “presumption” ofheterosexual identity may shape anddefine our perspective on individuals?How do we give a rooted quality tothe lives of aging GLBT individualsand how do we assist with form andritual to allow fullness in the agingprocess?

We must begin at the beginning.The beginning is the process ofbreaking down the assumptions thatlead to “presumptive heterosexuality”and heterosexism. This will requireeducation, confrontation, systemicintervention, and dialogue with healthcare providers and individuals whowork with and give care to agingGLBT elders. It will require challengesand participation by leaders andeducators, and it will require thedevelopment of a common language tospeak of the issues that affect thehealth and well being of these gay andlesbian elders. It will also requireconfrontations with the self about the“presumptive” qualities of our ownthinking, about the small prejudiceswe maintain, and the little innuendosand cruelties we inflict on othersbecause of those prejudices. It willalso require a rethinking and reorient-ing of the wisdom, and value we placeon aging and elders and demand thatwe, as providers of service to theseindividuals, confront our own ageism,our own internalized homophobia andour own levels of “presumptiveheterosexuality.”

Second, “place attachment,” andritual must be acknowledged andincluded in our conversations with theaged, and development of safephysical place to accommodate aginggay and lesbian individuals and theirpartners must be created. Further,health care professionals must beginto raise their own consciousness

about the issues of displacement andthe need for ritual in the aging process.

During the writing of this article acolleague tearfully related to us astory from her recent life. Her closefriend of 30 years had recently died ofa brain tumor. Her friend was a lesbianand, together with her partner, hadraised a son. The son, now in themilitary, was denied compassionateleave to attend his “other mother’s”funeral because they were not of ablood relationship. The remainingfamily members grieved separatelyfrom him, not unified by a ritual ofdeath, dis-placed by homophobia.This young man will retain thisexperience forever. His mother’s deathmay well become secondary to thedeprivation and harshness of oppres-sion. As individuals serving olderadults we have a responsibility tochallenge these moments, but thechallenge is far better served if weknow our own feelings about homo-sexuality and ageism.

None of us are free of homopho-bia. Certainly in a culture thatoppresses one group, all groups areequally oppressed. Homophobia is noexception, nor is ageism. For thosewho hide behind the blinds asshadowy shapes, the rest of us remainclosed out, deprived, and limited bytheir experience. For those whodeprive life partners of moments ofintimacy in nursing home or institu-tional settings, or choose not tounderstand the dynamics of oppres-sion, or choose not to join with GLBTelders, they too are deprived of therichness of knowing individuals fully.

It is the challenge and theresponsibility of society and cultureto enable all its members to grow intotheir full humanity, with completeaccess to all rights of belonging,association, expression, respect andthe ability to age in safety andfullness. People who are drawn tointimate relationships with people oftheir own gender are no less qualified,needy, or deserving of those rights.Individuals who have grown old underthe heavy burdens of sociallyaccepted contempt, bigotry and fearare among our most powerless

oppressed citizens. We must notcease to correct those attitudes whichallow for such inequitable conditions,beginning with our own prejudicesand fears. Only when any group ofindividuals feels free to meet insidelighted rooms, with open shades, canwe all be more free.

Nancy Webster, MPA, MSW, LCSW, isan assistant professor of Social Workat the University of Maine in Orono.She teaches courses in clinicalpractice and social welfare policyand is the Training Specialist at theUniversity of Maine Center on Aging.

Travis Erickson is currently agraduate student at the University ofMaine in Orono seeking a Master’s ofEducation with a concentration insexual diversity.

ReferencesAltman, I., & Low, F.M. (Eds.). (1992).Place Attachment, NY: Plenum.

Cahill, S., South, K., & Spade, J. (2000).Outing Age: Public Policy Issues AffectingGay, Lesbian, Bisexual and TransgenderElders. Washington, DC: The PolicyInstitute, National Gay and Lesbian TaskForce.

D’Augelli, A.R. (1994). “IdentityDevelopment and Sexual Orientation:Toward aModel of Lesbian, Gay andBisexual Development.” In E.J. Trickett,R.J. Watts, & D. Birman. (Eds.), HumanDiversity: Perspectives on People inContext, San Francisco; Jossey-BassPublishers.

D’Augelli, A.R., Grossman, A.H.,Hershberger, S.L., & O’Connell, T.S.(2001).

“Aspects of Mental Health Among OlderLesbian, Gay and Bisexual Adults.” Agingand Mental Health, 5(2), 149-158.

Laird, J. (1984). “Sorcerers, Shamans, andSocial Workers: The Use of Ritual inSocial Work Practice.” Social Work, 29(2), 123-129.

Young, I.M. (1990). Justice and thePolitics of Difference. Princeton, NJ:Princeton University Press.


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BackgroundThe historical development of

modern day biomedicine, psychology,and psychoanalysis is bound up inthe complex interactions of aEurocentric, heterosexual, Judeo-Christian viewpoint. Obviously,restriction of the underlying theoreti-cal construct of sex and gender to thedualistic genital sex model haseliminated all biomedical and psycho-social health care research on behalfof both the intersex population(Witten, 2002) and gender-variantindividuals (South, 2000).

Clearly, limiting the discussion todualistic heterosexuality forces healthcare workers to buy into the Judeo-Christian paradigm of the family. Thisconsequently eliminates all theoreticalconstructs that would deal with non-normative sexualities, genders, and thepotential variety of combinations thatemerge from partnering and creation offamilies (both immediate and ex-tended). For example, such a restric-tion could not realistically attempt toaddress issues of elder care fortransgendered elders within the familyor in any type of retirement, assistedliving, or nursing home facility.Assumption of heterosexuality alsoeliminates any theoretical constructsdealing with the dynamics of aging fornon-normative sex and gender roles ina heterosexual society (See forexample: Currah & Minter, 2000; Grant,2001; Grossman, D’Augelli &Hershberger, 2000). Given the exten-sive body of literature detailing theimportance of social support net-works, religiosity and spirituality, andquality of life issues in the “norma-tive” elderly heterosexual population,it would not be a surprise to healthcare workers that these areas need tobe addressed in the elderly gender-variant and intersex communities aswell.

Defining Gender-Variance,Transgender, Transsexualand Intersex

It is impossible, within the briefspace available here to address all ofthe different variants for definitions of

Geriatric Care and Management Issuesfor the Transgender and Intersex

Populationsby Tarynn M. Witten, M.S., Ph.D., FGSA

transsexual, transgender and intersex.For definitions related to gender-variance, the interested reader shouldreview Witten and Eyler (1999) and thereferences contained therein. Genderminority persons (also referred tocollectively as the “gender commu-nity,” T* community, or transpersons)include transsexuals, transgenders,cross-dressers, and others withgender self-perceptions other than thetraditional Western dichotomousgender world-view (i.e., including onlymale and female). The descriptorsused by transpersons are varied anddynamic. I will use these generallabels as a first approximation fordiscussion. For a detailed discussionof the intersex condition and intersexdefinitions, the reader is invited toread the literature at the website of theIntersex Society of North America(www.isna.org) for further details.

Cohort EffectsBased upon preliminary data

regarding incidence and prevalence inthe United States and worldwidepopulations, I have made estimates(Witten, 2002) of the projectednumbers of elder transgender andintersex persons in the United Statesand worldwide. Using these projec-tions, I have been able to demonstratethat there will be an increasing numberof elder members of both the intersexand the transgender communities overthe next decades. It is also vital tounderstand that both the intersex andthe transgender elder populationscontain a number of sub-populationswith unique lifecourse experiences.

Looking at these two generalpopulations, we can see that theelders of the intersex population willbe likely comprised of a number ofsmaller cohort populations. Most ofthe elder individuals will likely havehad genital surgery forced upon themat early ages and may have beensubjected to hormonal treatments aswell. Consequently, they may well bedealing with numerous psychologicalissues related to the undesiredviolation of their bodies and theeffects that the undesired surgery hashad on their lifecourse. Additionally, if

they have had hormonal treatments forany length of time, they may well bedealing with the medical conse-quences of long-term hormonal usagedating back to a period of time whenhormone doses were much strongerthan those currently used.

For the transgender or transsexualpopulation, as well as the younger old(i.e., 60 to 74 years of age) intersexpopulation, individuals will fall intovarious sub-cohorts; themselvesfurther sub-divided based uponnumerous factors. For example, for agiven younger old transperson, timeof transition (hormonal and surgicalmodification) can be important tounderstanding the aging process.There are many ways to arrive at theendpoint of being an oldertransperson. A person may be elderlywhen they choose to transition orthey may already have transitionedearlier in life and now are older in theircontra-gender identity and body,having dealt with a longer duration oflifespan in the already transitionedstate. Thus, one individual is old, buthas lived only a short period of timewithin the contragender roles, whileanother is old; having lived a longtime within the contragender roles.Each of these individuals may or maynot be hormonally or surgicallymodified. And, as such, theirlifecourse experience as elders will bedifferent and require understandingfrom the geriatric case manager andcaregiver. Currently, Female-to-Male(FTM) transsexuals usually self-identify during their teens, twenties,or thirties, often following a period ofyears of lesbian identification.However, male-to-female (MTF)transsexuals and transgenders moreoften attempt to suppress their self-perception of gender variance foryears or decades, and thereforefrequently present for medical sexreassignment services during mid-lifeor older age.

Transsexualism and OtherGender Identities

Transsexuals experience variance(not deviance) between natal sex and“psychological” gender and often


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seek medical sex reassignmentservices, including hormonal therapyand genital surgery. Transgendersfrequently identify with, or areambivalent about, the “natal” genitalsex and often adopt a lifestyle andappearance that is consistent withtheir psychological gender self-perception. This is often supported bythe use of hormonal medications, butgenital sex reassignment surgery isusually not desired (although it maybe eventually considered and pur-sued). Some transgendered personspresent as members of their natal sexin certain situations and for practicalreasons, such as to avoid prematuretermination of employment. Cross-dressers cultivate the appearance ofthe other sex, particularly with regardto clothing. Cross-dressing may beundertaken on a part-time or recre-ational basis, such as at clubs andsocial events, and may or may nothave erotic significance. Women whoprefer men’s clothing because of itscomfortable or practical nature, butwho self-identify as female, are notconsidered to be cross-dressers.

Many indigenous peoples alsorecognize genders other than male andfemale. For example, Tewa adultsidentify as women, men, and ‘kwido’,although their New Mexico birthrecords recognize only females andmales. Persons with such non-Western gender identities are alsogender minority individuals, althoughdiscussion of the cultural andanthropological aspects of gendervariance is beyond the scope of thispaper. It is also difficult to providedata-based information about some ofthe health issues faced by elderlytranssexuals, as this group is particu-larly “epidemiologically invisible”(Witten, 2002), with many of itsmembers preferring not to reveal theirnatal sex due to perceived and realrisks and stigma associated with being“out.” In contrast, most “out” (i.e.,publicly identified) transsexual,transgendered or cross-dressingpersons are young adults; many havechosen to be involved in politicalactivism on behalf of the gendercommunity. Nonetheless, in an era inwhich forecasting the health of elderlypopulations is increasingly moreimportant, discussion of quality of lifeissues faced by older transsexuals andother gender minority persons shouldnot be further deferred. For an excellentgeneral overview of aging issues in theLGBT community, see South (2000).Issues of health for the LGBT areextensively discussed in the HealthyPeople 2010 (2000) and the companiondocument to the Healthy People 2010(GLMA, 2000).

Finding a Place: Quality ofLife Issues for OlderTranssexuals

Contragender medical care.Individuals who pursue gendertransition later in life face differentchallenges than do their youngerpeers, and also possess certainadvantages. Quality of life issues maybe affected by a constellation ofmedical and social considerations.These issues are both similar anddissimilar to those encountered bynon-transsexual elderly persons. Inthis section, I will briefly explore therealities influencing quality of life forolder transsexual, transgendered, andcross-dressing individuals.

Two types of individual will beconsidered. The first is the oldertrans-individual who transitionedearlier in life and has experienced asignificant portion of the adultlifespan as a contra-gendered indi-vidual. Here, questions relating tolong term stress (Kraaij, Arensman, &Spinhoven , 2002), negative lifeexperience, long-term exposure tohormones, and transition in midlife canprofoundly affect socio-economicstatus for the transperson. While thiscan have numerous immediate effects,it also has long-term effects. Forinstance, alterations of the oralenvironment—saliva production forexample—due to use of estrogencould have potential implications forlong-term risk of cardiovasculardisease.

Persons who undertake gendertransition during mid-life or the elderyears are more likely than theiryounger peers to experience difficul-ties related to physical health status.Ill health, especially cardiac orpulmonary dysfunction (Aronow,Ahn, & Gutstein, 2002), may precludeeligibility for surgical proceduresincluding breast or genital reconstruc-tion. In addition, persons withmoderate or severe hypertension orother conditions of old-age may bepoor candidates for estrogen therapy.Similarly, androgen supplementationin female-to-male (FTM) transsexualsand transgenders may exacerbatedepressed HDL cholesterol andincrease coronary artery disease risk.Androgen supplementation is also arisk factor for the development ofpolycythemia, a potentially life-threatening condition, but may benefitFTM individuals with pre-existinganemia or loss of bone mineralization.While much is known about pharma-cology of aging and about hormonesand aging, little is known about theinteraction of “normal’” agingprocesses and cross-hormonaltreatment, from a physiological,

psychological, and biomedicalperspective. One exception is the workdone by Asscherman, Gooren, &Eklund (1989) on the mortality andmorbidity rates for transsexual andtransgender patients on cross-hormonal treatment.

Health care and personal assis-tance services are more complex forpersons who are transgendered thanfor those who are transsexual andpost-operative. Apparent mismatchbetween genital anatomy and genderof presentation can result in difficultyin obtaining medical services, practicalnursing care, or even appropriatefunereal arrangements (as in the caseof Billy Tipton, whose female genitaliawere “discovered” by the morticianand sensationalized in the tabloidpress). More recently, Tyra Hunter, apre-operative male-to-female trans-sexual was refused appropriate andtimely medical care by Washington,D.C. paramedics who, when arrivingon the scene of a hit-and-run caraccident involving Ms. Hunter,discovered her transgenderism.Believing that her gender incongruityimplied that she must also be homo-sexual, the paramedics refused torender treatment because theythought that Ms. Hunter might haveAIDS. The case of Leslie Feinberg,who was forced to leave an emergencyroom when his female anatomy wasdiscovered, is also well-known in thegender community. Many health carepersonnel consider transgenderism (ortranssexualism or cross-dressing) tobe evidence of psychiatric pathology,and inappropriate psychiatric referralsmay result.

The financial aspects of trans-sexual and transgender healthcare arealso affected by gender discrimination.Many FTM transsexual andtransgender adults begin gendertransition after years of lesbianidentification. Survey data (Eyler andWitten, unpublished) indicate thatincomes well below the nationalaverage are commonplace. Con-versely, MTF transsexual andtransgendered persons tend to beolder at the time of transition, and tohave enjoyed decades of maleprivilege and income. Nonetheless,attempts to transition in the workplaceare at times met with dismissal; onlyone state and a handful or municipali-ties provide legal protection fromemployment discrimination based ongender presentation.

Despite the increased medicalrisks that may accompany gendertransition for older persons, thephysical (morphological) realities ofaging may facilitate social gendertransition. For example, women and



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men share more physical similarityduring the elder years than at any timesince childhood. Loss of facial skintone produces a softer appearance formany genetic males, and the naturaldiminishment of circulating estrogens,accompanied by a shift towardsandronization of the hair follicles,facilitates the production of new beardgrowth in FTM transsexuals. Further-more, the loss of muscle mass andincreased body fat content which isexperienced by both male and femaleelders often results in phenotypicgender convergence of the bodyhabitus (i.e., women and men appearmore alike than previously with regardto body fat distribution, girth andposture). These physiologic alter-ations are clearly advantageous totranssexual persons who begin thetransition process later in life, as theymay obviate the need for excessiveweight reduction (for genetic males),body building muscle development(for genetic females) and minorcosmetic procedures (for both).

Physical functioning, such as thatrequired for the performance of theusual activities of daily living, isgenerally unaffected by gendertransition or sex reassignment surgery,as far as we currently know. Progres-sion to ADL dependence in thetransgender population is unstudiedand important. Exceptions includecases in which post-surgical recoveryis complicated or prolonged, or inwhich empathic, non-judgmentalpersonal care assistants are unavail-able during the post-operative period.

Although cross-dressers do notusually seek contragender hormonalservices, middle-aged and elderlycross-dressing persons often experi-ence difficulty in obtaining appropri-ate healthcare services due to privacyconcerns. For example, most MTFcross-dressers remove leg and bodyhair in order to appear as normalwomen while dressed en femme. Theneed to seek medical care often forcesthe dilemma of whether to discloseone’s personal behavior to thephysician or other practitioner, orwhether instead to attempt to post-pone services until the body hair hasre-grown. In those cases in which achronic illness is present, avoidanceof medical care for any length of timecan have serious consequences.Situations in which the cross-dressingindividual requires emergency(cardiac, for example) or long-term care(nursing home, rehabilitative care, forexample) can be problematic for similarreasons.

Gender variance and socialadjustment. Quality of life issues forolder members of the gender commu-

nity often center upon the degree ofsocial integration which the individualhas been able to achieve earlier in life,or on the personal flexibility andresilience available for the develop-ment of new relationships during thelater years. Community resources andacceptance of persons with non-traditional life paths can also becrucial. These needs are similar tothose of elderly non-transgenderedpersons who find that social networksupport and community resources areimportant for the ongoing mainte-nance of well-being. Data for theelderly transsexuals and transgendersare unavailable at present.

Elderly persons frequentlydevelop a high degree of spirituality,though not necessarily a great desireto attend traditional church or otherreligious services. Although thepatterns of participation in religiousactivities among gender minoritypersons are not currently known,recent survey research has revealedthat a majority do self-identify asbeing a part of a traditional religion oras being highly spiritual (Witten &Eyler, unpublished data).

Gender transition at any agerequires physical, legal, and socialadaptation. Although advice availablewithin the gender community topersons beginning this process oftenemphasizes the physical aspects (e.g.,how and where to obtain appropriatehormonal and surgical therapies), theother components of the processpredominate in many cases. Importantsteps include legal name change andrevision of pertinent documents(including driver’s license, passport,insurances and governmental records,employment and educational records,and financial documents). In manystates, the birth certificate sex can alsobe legally changed following genitalreconstruction surgery (including sexreassignment surgery). Furthermore,the prevailing belief that changing onepartner’s sex will invalidate a legalmarriage is not accurate; existingmarriages can not be forcibly dis-solved by the government of theUnited States.

Family relationships may bealtered following the older person’s“coming out” with regard to his or hergender identity. Fatherhood andmotherhood, siblingships,grandparenthood and other aspects ofthe family constellation may bereevaluated during the gendertransition process. Children andyoung adults are usually (though notalways) accepting of gender change.Young children may respond well tobeing offered an actual or fictitiousreference to provide even a tangential

“model” for transgenderism (such asDustin Hoffman in the film, “Tootsie,”or Robin Williams as “Mrs.Doubtfire.”) Children ages four toseven often still practice magicalthinking to a higher degree than theirolder peers, and frequently have theleast difficulty in accepting cross-dressing, transgendered and gendertransitioning adult relatives (personalcommunication, Randi Ettner, August20, 1999). Therefore, concernsregarding the appropriateness ofdisclosing gender minority behaviorsto grandchildren and other youngrelatives are unwarranted. However,young children are also vulnerable tothe prejudicial attitudes of theirparents, and may react negatively iftheir parents are rejecting of agrandparent or older relative.

Although gender transitionamong the elderly, and within thecontext of a very long term marriage orpartnership, is still relatively rare,experience with middle-aged couplesin which one partner is transgenderedor transsexual suggest severalpossible patterns. Many spouses orlong term partners of transgenders ortranssexuals will choose to maintainthe relationship as their husband, wifeor lover changes gender presentation,genital sex, or both. Many others willnot. Couples who do maintain amarriage or partnership may need to“redefine” their relationship. (Moreversatile persons can maintain a sexualrelationship; other couples become“friends”, “sisters,” etc.)

Body image. Gender transitionlater in life may enable the individualgreater freedom of expression as her/his true self. Furthermore, the normalbodily changes of aging will bepartially offset by hormonal andsurgical therapies. Specifically,breasts that develop in mid-life or theelder years, due to cross-genderhormonal administration, will notbegin the ptotic process until very latein life. Genital (labial or scrotal) ptosiswill also be greatly postponed forindividuals who have experiencedgenital reconstruction during the elderyears. Conversely, the other normalchanges of aging (e.g., body habitus,dermal integrity) will be experiencedequally by transsexuals and theirgender congruent peers, and thebodily changes associated with sexreassignment surgery, even if stronglydesired, may represent a positivestressor for the elderly client. Geriatriccare managers who are providingmental health services to oldertranssexual persons, are well-advisedto prospectively address this potentialwith their clients, and to remain alertfor more specific questions and



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complaints during (and especiallyafter) the gender transition process.

Sexuality and intimacy. Thegreatest obstacle to sexual expressionamong older adults (particularlyheterosexual women) is the lack ofavailability of suitable partners.Consequently, a MTF transsexualperson who undertakes gendertransition later in life is more likely toexperience sexual isolation or depriva-tion than would have been the caseprior to this transformation (i.e., whenthe individual had been perceived asmale). In addition, the current cohortof elderly women has been primarilysocialized to believe that female sexualbehavior is acceptable only within thecontext of marriage, and possibly forthe exclusive purpose of procreationas well. However, persons whochange gender presentation later inlife may share in these perceptions toa lesser degree than do their non-transsexual peers. Furthermore, sexualexpression may be positively en-hanced by the newfound congruencebetween the body and the psychologi-cal (true) self.

Information specific to sexualconcerns of single, elderly cross-dressers is currently unavailable.Middle-aged and older MTF cross-dressers who are currently in hetero-sexual marriages have usually reachedequilibrium during the course of therelationship, though this may havetaken years to achieve. Women whoare unaware of their husbands’ cross-dressing behavior at the time of themarriage and who discover it at a laterpoint may respond by leaving themarriage, by attempting to place limitson the context of the presentation enfemme (e.g., only at home, or only atcross-dressing parties) or by embrac-ing the cross-dressing as a sign ofempathy with the feminine aspects ofthe psyche.

With regard to the mechanics ofsexual functioning following sexreassignment surgery, few generaliza-tions can be made. Orgasmic capabil-ity is preserved in the majority of FTMgenital reconstructive procedures andin many MTF surgeries as well.However, the sexual response cycleusually requires a greater length oftime among elderly persons thanamong their young and middle-agedpeers. The effect of sex reassignment(and in effect, post-operative genitalretraining) is not yet known. Forelderly female-to-male transsexuals,genital reconstruction (including theplacement of an implantable penileprosthesis) may result in a morereliable erectile capability than thatwhich is commonly experienced byelderly genetic males. However, the

strength and integrity of the genitaldermis may be reduced, relative toearlier in life, and may thereforecompromise post-surgical recovery.Male-to-female transsexuals may alsoexperience a lack of resilience of theneo-vaginal lining and labial skin. Inaddition, the vaginal vault is usuallyless distensible among transsexualwomen than their non-transsexualpeers. The effects of aging on thisphenomenon (as well as the initiationand duration of estrogen therapy andthe timing of surgery) are not cur-rently known.

Despite the aforementionedobstacles to sexual expression, mosttranssexual persons experience apositive development of personalsensuality when they are able to livein congruence with their deepest self-perception. Patterns of sensualexpression are usually present acrossthe life-span, with sexual behaviorserving also as a vehicle for the basichuman need of the sense of touch.When touch is absent, severepsychobiological stress and symp-tomatology can result. The increasedsensuality experienced by transsexualand transgendered persons who areable to achieve a sense of bodilywholeness may serve to enhancephysical and mental health byproviding additional capability forhealthy touch. Cross-dressingpersons who are able to integratetemporary role change into healthypartnered or social relationships maysimilarly benefit.

Health care professionals canassist clients in this regard byvalidating the sensual expressions andpotentials of their elderly clients,offering sexual counseling andeducation when needed, and assistingother family members in accepting thegender presentation and sexualexpression of their older relatives.Increased education for health careprofessionals serving these communi-ties, regarding gender diversity andsexual expression among the elderly,may also be needed in order forprofessionals in inpatient, chronic,and acute care settings to provideappropriate and compassionate carefor their older clients and patients.Dispelling myths regarding eldersexuality, providing informationregarding the usual physical changesof aging and the human sexualresponse cycle across the lifespan,and offering interventions whichaddress sexual expression in cases ofphysical disability, may also beparticularly useful for social workersand other professionals who providecare to older persons.

Assisted living and social

support. The needs of older membersof the gender community are similar tothose of their non-transgenderedpeers with respect to the significantlife transitions of the elder years.Loss of the spouse or significant other(and longstanding friendship group)due to death, decreased ability tomaintain a private residence, loss ofdriving capability, transition from anindependent residence to an assistedliving environment (and ultimately todependent nursing care) serve toerode personal control and aresignificant issues in the lives of allpersons who survive to become the“oldest old.”

In the case of transsexual,transgendered and cross-dressingelders, these challenges are com-pounded by issues regarding disclo-sure, privacy, isolation fromtransgendered peers (due to a morespecialized [minority] communitysocial system which is furtherdecimated by aging and death of itsmembers), specialized health careneeds, and the potential forostracization and judgment by thehealth care professions and other careproviders. Within the gender commu-nity, transsexuals who have under-taken sex reassignment surgery atearlier life stages may not experiencethese difficulties, due to congruencebetween gender presentation com-bined with elimination of historical tiesto the pre-transition life which occurwith the passage of time. However,transgenders, cross-dressers, andtranssexuals who undertake transitionduring the elder years must makenumerous decisions with regard tosharing confidential (and potentiallysensational or ostracizing) personalinformation with their caregivers. Inaddition, post-operative transsexualsmust confide with their physicians andother health care professionals withregard to past medical history, or risklater exposure. For example, an MTFwoman who has completed sexreassignment surgery in her youth willstill retain her prostate. Ideally, sheshould receive routine prostateexaminations by a health care providerwho is familiar with her past medicalhistory. If this option is not availableto the patient, her prostate may beperceived as a “rectal mass” duringroutine physical examination per-formed upon hospital admission.

Geriatric care managers can bestassist older transsexual,transgendered and cross-dressingclients by providing them withinformation regarding the importanceof routine healthcare (includingpreventive services), arrangingreferrals to providers who are em-



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pathic and supportive to members ofthe gender community, and educatingothers involved in the clients’ carewith respect to the realities of humangender diversity. This latter endeavormust include medical, nursing, andsocial work colleagues, as well asunskilled and semi-skilled assistants.In addition, facilitation of supportgroup formation for older members ofthe gender community (Slusher,Mayer, & Dunkle, 1996); education ofleaders of existing groups, such asthose operated by religious organiza-tions and gay/lesbian/bisexualnetworks; and specific inclusion oftransgendered persons in visible roleswithin retirement communities, healthcenter sponsored programs and otherservice networks, may positivelyimpact quality of life within the gendercommunity. Moreover,intergenerational dialogue should beestablished; the young transgenderedmust be made aware of the lifecourseissues of aging.

Conclusion and ClosingThoughts

Transsexuals, transgenders,cross-dressers, and other personswhose gender expression or identifica-tion is other than the “traditional”male or female represent a substantialbut epidemiologically invisibleminority group within the worldwideelderly population. Quality of lifeissues for this community have, asyet, been but marginally addressedwithin the medical and sociologicalliterature (Docter, 1985). The intersexelder community remains invisible andthere is no literature available on elderissues and intersex. The absence ofdetailed discussion within this articlefurther magnifies the need for greaterresearch in this area. Attention to theneeds of the gender and the intersexcommunities with respect to biologi-

cal, medical, psychological, and socio-cultural facets can be best servedthrough a comprehensive and holisticapproach, including family, provider,and community education and thedevelopment of appropriate profes-sional and community networks.Health and social policy developmenton behalf of both the transgenderedand the intersex elderly (including theassurance of nondiscrimination withregard to quality healthcare services,privacy, confidentiality, respectfultreatment and caregiving, andpersonal safety) is also stronglyneeded (Witten, 2002).

Tarynn M. Witten, M.S., Ph.D., FGSA,is the executive director ofTranScience Research Institute inRichmond, VA. She is a Fellow of theGerontological Society of Americaand holder of the Inaugural NathanW. Shock New Investigator Awardfrom the Gerontological Society ofAmerica.

ReferencesAronow, W.S., Ahn, C., & Gutstein, H.(2002). “Prevalence and Incidence ofCardiovascular Disease in 1160 OlderMen and 2464 Older Women in a Long-term Healthcare Facility.” The Journals ofGerontology: Medical Sciences, 57A(1):M45-M46.

Asscherman, H., Gooren, L.J.G., &Eklund, P.L.E. (1989). “Mortality andMorbidity in Transsexual Patients withCross-gender Hormone Treatment.”Metabolis, 38(9): 869-873.

Currah, P. & Minter, S. (2000).Transgender Equality: A Handbook forActivists and Policy Makers. Washington,DC: Policy Institute, National Gay andLesbian Task Force.

Docter, R.F. (1985). “Transsexual Surgeryat 74: A Case Report.” Archives SexualBehavior, 14(3): 271-277.

GLMA. (2000). Healthy People 2010:Companion Document for Lesbian, Gay,Bisexual, and Transgender (LGBT)Health. U.S. San Francisco, CA. Gay andLesbian Medical Association. RetrievedJuly 11, 2002. Available at http://www.glma.org.

Grant, A.M. (2001). “Health of SociallyExcluded Groups: Lessons Must beApplied.” British Medical Journal, 323,1071.

Grossman, A.H., D’Augelli, A.R., & S.L.Hershberger. (2000). “Social SupportNetworks of Lesbian, Gay, and BisexualAdults 60 years of Age and Alder.” TheJournals of Grontology: PsychologicalSciences, 55B(3): P171-P179.

Healthy People 2010. (2000). U.S.Government Printing Office, Superinten-dent of Documents. Retrieved July 11,2002. Available at http://www.glma.org.

Kraaij, V., Arensman, E., & Spinhoven, P.(2002). “Negative Life Events andDepression in Elderly Persons: A Meta-analysis.” Journal of Gerontology:Psychological Sciences, 57B(1): P87-P94.

Slusher, M.P., Mayer, C.J., Dunkle, R.E.(1996). “ Gays and Lesbians Older andWiser (GLOW): A Support Group forOlder Gay People.” The Gerontologist, 36(1), 118-123.

South, K. (2000). Outing Aging: Report ofthe NGLTF Task Force on Aging.Washington, D.C.: NGLTF. Retrieved onJuly 11, 2002. Available at http://www.ngltf.org.

Witten, T.M. (2002). On the Epidemiol-ogy and Demography of Transgender andIntersex: A White Paper. TranScienceResearch Institute Preprint Series, 2.Richmond, VA: TransScience ResearchInstitute.

Witten, T.M. & Eyler, A.E. (1999).“Hate Crimes Against the Transgendered:An Invisible Problem,” Peace Review, 11(3): 461-68.


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