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An Intersectional Approach to Services and Care for LGBT Elders
posted 06.29.2016

By Michael Adams

In recent years, LGBT aging issues have started emerging from near uniform invisibility in the LGBT and aging sectors to achieve growing, if modest, levels of attention. Some notable indicators of progress include increased attention to LGBT cultural competence in aging service programs; the emergence of local initiatives—including elder services and housing—designed with LGBT older adults in mind; the first official LGBT delegate at the White House Conference on Aging in 2005; the first federal grants to LGBT elder service programs in the early years of the Obama Administration; the launch of the National Resource Center on LGBT Aging as a partnership between the federal Administration on Aging and Services & Advocacy for GLBT Elders (SAGE) in 2010; and public efforts by the U.S. Department of Housing & Urban Development in 2015 to eradicate anti-LGBT discrimination in federally supported senior housing.

Dedication to the Treasured Lives Lost in the Orlando Massacre

"In this Pride month, it is my honor to dedicate the newly released Summer 2016 issue of Generations on LGBT Aging to all those who lost their lives in Orlando, to those who were wounded, to their loved ones, to all who have in the past endured hate and violence, and to my community that rallies together, moving ever forward with our allies to build a safe and loving world."

-Karen Fredriksen Goldsen

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The predominant narrative in today’s limited literature on LGBT elders fueling this progressfocuses on the unique challenges faced by LGBT older adults as a group relative to older Americans in general, and how those challenges link to the sociocultural context of anti-LGBT bias  and practices. Generally this narrative has not dwelled on the heterogeneity and rich nuances manifest across the breadth of aging and LGBT experiences. This is due partly to a severe scarcity of data to illuminate different experiences across social positions (race, gender, gender identity, socioeconomic status, etc.) among LGBT older adults. This narrative also reflects an effort to crack the wall of invisibility that has surrounded LGBT aging by delivering a consistent, understandable message that could penetrate persistent indifference.

This article calls for a new, intersectional approach that recognizes and embraces the multiple social identities and experiences that shape the lives of the more than 3 million LGBT older Americans. This approach would take into account the reality that women, people of color, transgender people, and other social groups under the LGBT umbrella have differing life experiences and different interactions with social and economic power structures that influence their needs for aging services, the resiliencies and perspectives they bring to bear as they age, and their stakes in policies that address aging. An intersectional approach has important implications for practitioners in the field of aging, for social change agents, and for policy makers.

The One-Dimensional Analysis

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from this issue

Some strides have been made in beginning an intersectional analysis of LGBT aging. Notable contributions include the first needs assessment of Latino LGBT older adults, published by the National Hispanic Council on Aging (NHCOA) in 2014 (NHCOA, 2014); the pioneering work of Karen Fredriksen-Goldsen and her colleagues on health disparities and health equity (Fredriksen-Goldsen et al., 2014); SAGE’s groundbreaking 2013 report on Health Equity & LGBT Elders of Color (SAGE, 2013); and the collaborative analysis of transgender aging undertaken by the National Center on Transgender Equality (NCTE) and SAGE (2012).

While these early efforts focus attention on how social positions based on race and gender identity help shape the experiences of members of LGBT communities as they age, the predominant narrative has nonetheless largely focused on a uni-dimensional analysis of LGBT elder lives. This analysis calls out unique challenges as definitional for the LGBT aging experience. The analysis, while limited, still provides an initial knowledge base for practitioners and policy makers who historically have disregarded the experiences and needs of LGBT older adults.

Research and on-the-ground experience show that LGBT older adults as a group are at high risk for severe social isolation. They are as much as four times less likely to be parents, twice as likely to be single and live alone, and significantly more likely to be disconnected from their families of origin. The relative absence of partners, adult children, and traditionally defined family members often results in thin social and care networks (SAGE and MAP, 2010).

This vulnerability in the later years is exacerbated by health disparities as explored by Fredriksen-Goldsen and colleagues in their report on disparities and resilience (Fredriksen- Goldsen et al., 2011). LGBT older adults are at higher risk for poor mental health, have higher rates of disability and HIV infection (gay and bisexual men and transgender women), and more physical limitations (Fredriksen-Goldsen et al., 2014). Moreover, LGBT elders face heightened risk of financial insecurity in their later years due to historical inequities in benefits like Social Security, and lower retirement savings reflective of a lifetime of wage and benefits discrimination (SAGE and MAP, 2010; Diverse Elders Coalition [DEC], 2012).

Social isolation, thin support networks, health disparities, and financial insecurity result in a greater need for aging and long-termsupport services on the part of LGBT elders. However, these services are less available to LGBT elders because of discrimination and a lack of cultural competency on the part of service providers. As a result, many LGBT older adults report that they avoid accessing services for fear of mistreatment. LGBT elders who access services sometimes decide to re-enter the closet in an attempt to avoid discrimination. Weak support networks and community-based supports can result in prematurely resorting to institutional care (SAGE and MAP, 2010).

At SAGE, we repeatedly encounter LGBT elders for whom this situation leads to nursing home placement far earlier than it would have taken place if they had back-up supports in the home. Without advocates, LGBT elders often are at the mercy of a healthcare system that rewards expediency over person-centered care. This is a deeply troubling pattern, not only because it denies LGBT elders the opportunity to age in place, but also because evidence indicates that the long-term-care sector may be the least prepared to effectively address the needs of LGBT people with culturally competent care (Justice in Aging, 2015).

The predominant narrative assumes a homogeneous aging experience by LGBT older adults, but that experience varies markedly depending upon race, gender, and other factors. A growing number of LGBT older adults, including but not limited to LGBT elders of color, elder lesbians, and transgender elders, live at the intersection of two or more of these identities. If we build an approach that focuses on these intersections, the analysis will be more textured and adhere more closely to the lived experiences of the emerging majority of LGBT older adults. But apart from the general value of shining a light on lives that have been rendered invisible, why is bringing attention to the intersections so important?

The Case for an Intersectional Approach

The case for a more intersectional analysis that takes into account LGBT elders’ heterogeneity starts with demographics.

Immigrant status, race, and ethnicity

Approximately two in ten LGBT elders are persons of color; that number will grow to more than four in ten by 2050. Blacks make up approximately 9 percent of older Americans; that percentage will increase to 12 percent by 2050. The comparable statistics are 7 percent and 20 percent for Latino elders, 3 percent and 9 percent for Asian American and Pacific Islander (AAPI) elders, and .5 percent and 1 percent for American Indian and Alaska Native (AIAN) older adults (SAGE, 2013). Similarly, the number of immigrant elders is increasing rapidly. U.S. foreign-born older adults (ages 65 and older) increased from 3.3 million in 2000 to 4.6 million in 2010, a growth trend that is expected to continue (Population Reference Bureau [PRB], 2013).

These statistics clearly demonstrate that in the decades ahead the demographics of older Americans—both LGBT and non-LGBT—will shift substantially along race and ethnicity lines. This demographic shift would not be so consequential for practitioners and policy makers if the life experiences, service and care needs, and policy interests of the emerging majority of LGBT elders of color were identical to those of white LGBT elders, who have received most of the attention to date. But there is ample evidence indicating that the differing social positions of LGBT elder sub-groups—which include but are not limited to people of color, women, and transgender people—link to quite different life experiences and interactions with social and economic power structures. These marked differences result in significantly different needs and assets.

Disparities in financial security

Poverty rates among elders of color are notably higher than among white elders. While poverty among white elder Americans stands at 6.8 percent, the poverty level is 63 percent for AIAN elders, 18.7 percent for Latino elders, 17.3 percent for black elders, and 11.7 percent for AAPI elders (SAGE, 2013).

Such disparities in financial security have been exacerbated by the effects of the Great Recession, with the median net worth of Latino households falling 66 percent from 2005 to 2009, and the median net worth for black households falling 53 percent during the same time period. (By contrast, the median net worth for white households fell 16 percent during that time) (NHCOA, 2014). Poverty also tracks to gender in the United States. Data from the Williams Institute at UCLA indicate that older lesbian couples are much more likely to live in poverty than older heterosexual couples and older gay male couples (Albelda et al., 2009).

Disparities in Health

Differential life experiences among LGBT elder sub-groups extend to health disparities. Black older adults are twice as likely as white older Americans to have Alzheimer’s and other dementias; the rate for Latino older adults is 1.5 (SAGE, 2013). Latino older adults have much higher rates of diabetes (NHCOA, 2014). Black and Hispanic men are significantly more likely to have HIV than white and AAPI men (NHCOA, 2014) (DEC, 2014). Lesbians and bisexual women have higher levels of obesity (Fredriksen-Goldsen et al., 2014). Transgender older adults face an array of health risks and vulnerabilities (SAGE and NCTE, 2012). LGBT aging service practitioners recognize that translating these disparities into effective program interventions requires relevant approaches be developed for each sub-group, and that culturally competent community spaces are a critical component to positive health outcomes.

Sub-groups’ range of assets, resiliencies

It is not only the existence of deeper deficits that makes the case for deploying an intersectional approach: recent research and experience on the ground indicate that sub-populations also bring different assets and resiliencies that can be leveraged in service and policy interventions. A 2014 national SAGE study of LGBT older adults found that African American LGBT elders are three times as likely as white and Latino elders to report churches or faith organizations as part of their support system (SAGE, 2014). TheNational  Hispanic Council on Aging has documented heightened levels of emphasis on traditional family support by Latino older adults (NHCOA, 2014). Fredriksen-Goldsen and colleagues have noted larger social networks among transgender people than among cisgender (non-transgender) people (Fredriksen-Goldsen et al., 2014), while other researchers have found differing dynamics and friendship networks among older women versus older men (Adams, Blieszner, and de Vries, 2000). The practice implications of this data require multiple approaches to program design. As an example, recognizing that older lesbian- and bisexual-identified women create rich social networks outside congregate settings, SAGE engaged a women’s program coordinator to act as liaison between those external networks and the organization’s group service programs.

Assuming efforts to provide services, care, and other opportunities to LGBT older adults seek to prioritize those elders with the greatest economic and social need (a reasonable assumption, given the prioritization of elders with greatest economic and social need by the Older Americans Act), these efforts must be informed and guided by an intersectional analysis that recognizes the distinct life experiences and needs of LGBT elder sub-groups. Similarly, an asset-based approach to care and services that leverages the considerable resiliencies of LGBT older adults will fall significantly short without an intersectional approach that recognizes the distinct resiliencies of LGBT elder subpopulations. The relevance of an intersectional approach to LGBT aging is founded in the importance of both addressing vulnerability and leveraging  resiliency.

Implications for Practitioners

Practitioners in the field of aging who are interested in addressing the needs of the most vulnerable LGBT elders, and in leveraging elder resiliencies and assets, should take an intersectional approach to their work. But what exactly does this mean?

A holistic approach

One important component is imbuing all aging services with a holistic approach to cultural competence. With regard to LGBT aging, the early approach to cultural competence has focused on educating service and care providers to develop a deeper understanding of the life experiences of LGBT older adults and how to effectively and respectfully address LGBT elders’ needs. An intersectional approach extends cultural competence beyond this uni-dimensional approach to weave in race, gender, ability and-or disability, and other social positions that have important impacts on elders’ life experiences.

In 2015, SAGE embarked on a racial equity initiative designed to increase cultural competence by training its staff and board of directors in a shared framework around race and white privilege, and how these social conditions play out for SAGE’s elder constituents and LGBT aging programs. This more holistic approach to cultural competence is a beginning, not an end, with much learning required along the way. It is expected to result in new program and organizational practices that will be relevant to a fuller diversity of LGBT elder communities.

Tailored programs and services

A second practice receiving increased attention in the LGBT aging field is the development of programs and services tailored to the specific needs of elder sub-groups and that leverage these groups’ unique assets. GRIOT Circle, the country’s only service provider founded specifically to address the needs of LGBT elders of color, has pioneered African-influenced woodcarving classes and the Ujamaa Men’s Group for the predominantly black LGBT elder population the agency serves. SAGE Harlem has designed community-led workshops on theological reflection to capitalize on strong faith connections among many African American LGBT elders.

To be effective, designs for tailored programs must be heavily informed by feedback from diverse LGBT elders. Healing Detroit and the LGBT Older Adult Coalition of Metro Detroit simultaneously held town hall meetings for LGBT elders to share dialogue about their perspectives and needs (Lipscomb and LaTosch, 2012). Healing Detroit attendees primarily were African American Detroit residents, while the LGBT Older Adult Coalition attendees predominantly were white elders from surrounding suburbs. Certain concerns were common to both—social isolation, the need for LGBT-welcoming senior services, and financial worries. At the same time, the African American elders who attended the Healing Detroit convening put their strongest emphasis on the need to address employment challenges for older adults.

Access

A third consideration for practitioners involves geography and equitable access. LGBT elder services, like LGBT community-based services in general, have for the most part been located in predominantly white “gayborhoods” in urban areas or in similar locations frequented predominantly by LGBT white people. An intersectional approach to LGBT elder services recognizes that we live in a society marked by high levels of residential segregation by race, and that traveling long distances to access senior services simply is not an option for many LGBT elders. Given these realities, LGBT-friendly elder services must be readily available in neighborhoods in which many people of color reside, and these services must be available through community providers who offer linguistic and other forms of cultural competence specific to their audiences.

Credibility and cultural competency, partnerships

A fourth consideration for practitioners is credibility. Many LGBT elders from historically marginalized sub-groups have endured decades of negative experiences as LGBT people, as people of color, and as members of other oppressed communities. These experiences can contribute to skepticism and fear of mistreatment that frequently translate into avoidance of services and care. Practitioners who fail to demonstrate cultural competence by taking a hetero- and Anglo-normative one-size-fits-all approach to elder services reinforce the skepticism and fear held by marginalized LGBT elders of color. Demonstrable cultural competence in all aspects of service provision is critically important to counteract this dynamic and encourage elders to access services (National Resource Center on LGBT Aging [NRC] and SAGE, 2012). Thus, the NRC recommends that service and care providers undertake a comprehensive cultural competence audit of all aspects of operations—from wall decor to marketing and application language, to staff knowledge base and practices (NRC and SAGE, 2012).

This last point highlights a fifth implication for service providers—the importance of community-based partnerships. In many instances, the most effective way to provide services and care to LGBT elders of color and other marginalized elder sub-populations is in partnership with community-based organizations that have earned credibility and trust through years of authentic, culturally competent work. This can present challenges to large providers, as community-based organizations that have credibility with marginalized LGBT elders often are marginalized and resource-starved, and initially they may lack the business acumen and capacities to facilitate partnerships with large providers. As a result, larger providers may need to find ways to support capacity-building within community-based partner organizations.

Implications for Social Change Agents and Policy Makers

One of the exciting implications that an intersectional approach brings for social change agents is the opportunity to find new allies and leaders to support our efforts to achieve greater equity for LGBT elders. Using an intersectional approach does not just mean identifying the distinct needs and resiliencies that emerge from different social profiles and life experiences. It also means recognizing the ways in which the disadvantages of different marginalized groups are interconnected, even while the details are distinct. While specific negative effects of culturally incompetent service provision vary by sub-population, denying access to services is a shared theme. Shared themes, in turn, create the opportunity for shared action and shared agendas for systems change.

Five years ago, SAGE joined with leading organizations in aging that serve people of color, like the National Hispanic Council on Aging and the National Asian Pacific Center on Aging, to form the Diverse Elders Coalition (DEC), a national collaborative that engages in policy advocacy and community education on behalf of low-income LGBT elders and elders of color. For participating people-of-color organizations, DEC’s formation represented a decision to formally embrace LGBT older adults and their needs as an important part of a diverse elder agenda. For SAGE, joining the DEC meant that issues like immigration reform, language competency in aging services, and disenfranchisement of Native American elders needed to become part of its advocacy agenda.

When the National Indian Council on Aging and other organizations in aging that serve people of color confronted serious threats to elder workforce programs for their communities, SAGE made protection of those programs one of its policy priorities. Similarly, these same organizations in the DEC have strongly supported SAGE’s efforts to make the federal Older Americans Act LGBT-inclusive.

This kind of intersectional approach by social change agents has important implications for policy makers because it calls upon them to recognize the interconnections between policy issues affecting different social groupings and to look for opportunities for national solutions. One of the Surgeon General’s first steps to help implement the Affordable Care Act was to adopt a National Prevention Strategy to guide the nation toward effective strategies to improve health and well-being. Because the DEC collectively flagged the importance of interconnected health disparities across marginalized subpopulations of elders, the intersection of those elder health needs was highlighted in the Surgeon General’s strategy.

Conclusion

A uni-dimensional analysis of the unique challenges facing LGBT older adults as a whole has contributed to a gradual increase in attention to the needs of this population in both the aging and LGBT sectors. But this narrative’s efficacy is limited because it does not take into account the texture and nuanced experiences of elders whose lives have been shaped not just by being LGBT, but also by other important identities based on race, gender, and other social conditions. Especially given the rapidly changing demographics of the country’s older population, the time has come to replace this one-dimensional analysis with an intersectional approach that takes into full account the differing life experiences across social identities. Such an intersectional approach will prove invaluable to practitioners committed to addressing the needs of the most vulnerable older adults. Not only will it leverage this population’s considerable strengths and resiliencies, but this approach also will fuel new opportunities for social and policy progress by creating shared agendas and collaborative action founded on the intersecting needs and interests of diverse elder communities.


Michael Adams, J.D., M.A., is the chief executive officer of Services & Advocacy for GLBT Elders (SAGE), headquartered in New York City. He can be contacted at madams@sageusa.org.

Editor’s Note: This article is taken from the Summer 2016 issue of ASA’s quarterly journal, Generations, an issue devoted to the topic “LGBT Aging” ASA members receive Generations as a membership benefit; non-members may purchase subscriptions or single copies of issues at our online storeFull digital access to current and back issues of Generations is also available to ASA members and Generations subscribers at Ingenta Connect. For details, click here.


References

Adams, R. G., Blieszner, R., and de Vries, B. 2000. “Definitions of Friendship in the Third Age: Age, Gender, and Study Location Effects.” Journal of Aging Studies 14(1): 117–33.

Albelda, A., et al. 2009. Poverty in the Lesbian, Gay and Bisexual Community. Los Angeles, CA: Williams Institute, UCLA School of Law.

Diverse Elders Coalition (DEC). 2012. Securing Our Future: Advancing Economic Security for Diverse Elders. New York: DEC.

DEC. 2014. Eight Policy Recommendations for Improving the Health and Wellness of Older Adults with HIV. New York: DEC.

Fredriksen-Goldsen, K., et al. 2011. The Aging and Health Report: Disparities and Resilience among Lesbian, Gay, Bisexual, and Transgender Older Adults. Seattle, WA: Institute for Multigenerational Health.

Fredriksen-Goldsen, K., et al. 2014. “The Health Equity Promotion Model: Re-conceptualization of LGBT Health Disparities.” American Journal of Orthopsychiatry 84(6): 653–3.

Justice in Aging. 2015. LGBT Older Adults in Long-Term-Care Facilities: Stories from the Field. Oakland, CA: Justice in Aging.

Lipscomb, C., and LaTosch, K. 2012. “Exploring the Needs of Lesbian, Gay, Bisexual and Transgender Elders in Metro Detroit.” Detroit, MI: LGBT Detroit.

National Hispanic Council on Aging (NHCOA). 2014. In Their Own Words: A Needs Assessment of Hispanic LGBT Older Adults. Washington, DC: NHCOA.

National Resource Center on LGBT Aging (NRC) and Services & Advocacy for GLBT Elders (SAGE). 2012. Inclusive Services for LGBT Older Adults: A Practical Guide to Creating Welcoming Agencies. New York: NRC and SAGE.

NRC and SAGE. 2015. LGBT Programming for Older Adults: A Practical Step-by-Step Guide. New York: NRC and SAGE.

Population Reference Bureau (PRB). 2013. Elderly Immigrants in the United States. Washington, DC: PRB.

SAGE and Movement Advancement Project (MAP). 2010. Improving the Lives of LGBT Older Adults. New York: SAGE and MAP.

SAGE and National Center for Transgender Equality (NCTE). 2012. Improving the Lives of Transgender Older Adults. New York: SAGE and NCTE.

SAGE. 2013. Health Equity and LGBT Elders of Color. New York: SAGE.

SAGE. 2014. Out & Visible: The Experiences and Attitudes of LGBT Older Adults, Ages 45–75. New York: SAGE.


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