By Charles P. Hoy-Ellis, Michael Ator, Christopher Kerr, and Jessica Milford
Recent population-based research indicates that compared to older heterosexual adults, lesbian, gay, and bisexual (LGB) older adults have significantly higher levels of psychological distress (Fredriksen-Goldsen et al., 2013c; Wallace et al., 2011). Caring and Aging with Pride (CAP), a national community-based study, suggests that transgender older adults may have even higher levels of psychological distress than non-transgender LGB older adults (Fredriksen-Goldsen et al., 2013a). Given these disparities, it is time that we focus our collective attention on ways to effectively address psychological distress among lesbian, gay, bisexual, transgender, and queer (LGBTQ) older adults. A disparity is merely a metric by which we measure a particular population’s health outcomes relative to health equity—the opportunity to attain the best health possible regardless of social position or any other dimensions of diversity (Braveman, 2014), including the physical and mental health of LGBT people (Fredriksen-Goldsen et al., 2014).
"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
Achieving mental health equity among LGBTQ older adults requires recognizing and addressing multi-dimensional, multi-level barriers and strengths and resiliency factors that inhibit and-or promote mental health. This article highlights innovative ways that LGBTQ peer and community supports are employed to address mental health and aging equity among LGBTQ older adults. As a 63-year-old gay male participant in the CAP study said, “The LGBT[Q] community has stepped up in the past to address coming out, AIDS, and civil rights. The next wave has to be aging” (Fredriksen-Goldsen et al., 2011).
Discrimination and Its Effects on Service Access
Medical institutions have shaped and continue to shape discourse that frames LGBTQ mental health. From its 1952 description as a psychiatric disorder in the first edition of the Diagnostic and Statistical Manual of Psychiatric Disorders, until the removal of that designation in 1973, homosexuality—not then differentiated from gender identity and expression—was officially classified as a sociopathic personality disturbance by the American Psychiatric Association (APA) (Silverstein, 2009).
Gender dysphoria—experiencing significant discomfort with one’s assigned birth gender—remains a diagnosable psychiatric disorder (APA, 2013). Although the trend in recent years has been one of increasing recognition and inclusion of LGBTQ people, LGBTQ older adults continue to fear, expect, and experience discrimination and abuse in the larger community and in mainstream healthcare settings (Fredriksen-Goldsen et al., 2011).
Despite the 2015 U.S. Supreme Court ruling in favor of full marriage equality, discrimination based on sexual orientation and gender identity remains legal in a majority of states (Human Rights Campaign, 2015).
In November 2015, voters in Houston, the fourth most populous city in the United States, rejected an equal rights ordinance that would have protected citizens against discrimination based on sexual orientation or gender identity, among other classes.
Even in the absence of overt discrimination, LGBTQ older adults still may experience barriers to equitable mental health services through more subtle forms of marginalization. Lack of knowledge regarding historic and current realities of LGBTQ older adult lives contributes to the perception among many service providers that they treat everyone equally and do not discriminate against LGBTQ elders. While often well-meaning, this stance can become a barrier, as it assumes that everyone stands on equal ground, having equal representation and access. If LGBTQ older adults do not see themselves or LGBTQ symbols in agency materials and outreach efforts, they may construe such environments to be neither affirming nor inclusive, and conceivably dangerous. It is understandable that many LGBTQ older adults remain distrustful, and are reluctant to interact with mainstream mental health care supports and other aging services and programs.
Social Isolation, Depression Complicate Service Access
Though social isolation and depression are not unique to LGBTQ older adults, associated social and psychological aspects of these conditions increase this cohort’s lack of access to services. Compared to older heterosexual men, older gay and bisexual men are less likely to have children and are more likely to live alone (Fredriksen-Goldsen et al., 2013c; Wallace et al., 2011). Living alone increases the risk of social isolation and loneliness, which are significant predictors of depression among midlife and older adults in the general population (Cacioppo et al., 2006).
Ironically, the modern LGBTQ rights movement’s success may contribute to social isolation among LGBTQ older adults. As the LGBTQ population has become more assimilated into the general population, neighborhoods in large metropolitan areas that were historic enclaves with high concentrations of LGBTQ people (e.g., the Castro in San Francisco, Montrose in Houston) have diminished markedly. The geographic dispersion that has accompanied LGBTQ assimilation may make it more difficult to sustain social networks, contributing to loneliness and social isolation. LGBTQ community agencies and programs typically are located in these districts, making them more difficult for LGBTQ older adults to access, especially for those of lower socioeconomic status, who are disproportionately displaced into more affordable, outlying neighborhoods with less accessible transportation.
Community belonging is an important protective factor against social isolation among older adults (Nicholson, 2012). Today’s LGBTQ older adults typically were rejected in their youth and young adulthood by friends, family, and community because of their sexual orientation, gender identity and-or expression, yet many found a sense of belonging in nascent LGBTQ communities (Canaday, 2009). These communities have become increasingly youthcentered (Knauer, 2011); as a consequence of this ageism, the communities that once provided refuge and support may now exclude LGBTQ older adults because of their age (Emlet, 2006), further contributing to their social isolation.
Ageism within LGBTQ communities also negatively impacts LGBTQ youth. They suffer disproportionate poor mental health outcomes, including substance abuse, suicidality, and depression from ongoing discrimination, victimization, and rejection. Because of the intergenerational divide, ageism, and heterosexism, LGBTQ youth often have no accessible positive role models (Redman, 2012), which may in turn increase their risk for current psychological distress (Bird, Kuhns, and Garofalo, 2012) and depression as they enter their middle and later years (Fiske, Wetherell, and Gatz, 2009).
Depression and related factors are both cause and effect in poor mental health outcomes among LGBTQ older adults. Lifetime experiences of discrimination and victimization based on sexual orientation and-or gender identity have been linked to increased risk for depression among LGB (Fredriksen-Goldsen et al., 2013b) and transgender (Fredriksen-Goldsen et al., 2013a) older adults. And during their coming-of-age years, LGBTQ older adults internalized the pervasive stigma and prejudice that cast homosexuality and gender variance as a sickness and a perversion. The shame and cognitive distortions accompanying internalized stigma increases the risk of psychopathology. Internalized stigma also has been found to be an independent predictorof depression among LGB (Fredriksen-Goldsenet al., 2013b) and transgender (Fredriksen-Goldsen et al., 2013a) older adults. Primary care providers often are the first to recognize symptoms of depression among older adults in the general population, referring them on to mental health care providers. But these providers may lack cultural competence in LGBTQ issues and miss crucial cues. Also, support and therapeutic groups for older adults with depression generally are located within mainstream aging agencies. And many LGBTQ older adults are fearful of accessing healthcare services, especially when they have all too often been denied care or been given inferior care (Fredriksen-Goldsen et al., 2011). These factors’ net effects combine to further increase lack of access to supportive mental health and aging services.
Resources Are Lacking, Ageism Is Pervasive
Another issue driving lack of access is insufficient community resources to support and sustain programming specific to LGBTQ older adults’ needs. Mainstream providers who lack knowledge of the unique histories and circumstances of LGBTQ communities may not be aware of the particular needs of LGBTQ older adults, such as LGBTQ-specific social supports to reduce isolation, and the necessity of LGBTQ cultural competency training for mental health providers who treat these older adults. Providers may believe that by “treating everyone equally,” they are offering sufficient access and services, and see no need to allocate resources specific to LGBTQ older adults.
Similarly, ageism (as noted above) remains a significant issue in LGBTQ communities, with funding going primarily to programming for younger LGBTQ people. Most aging and mental health services that target LGBTQ older adults are located in major metropolitan areas; they may not provide resources for transportation for those who are geographically distant or have other mobility limitations. Unfortunately, in all too many locales, LGBTQ older adults remain completely invisible. Consequently, resources will not be allotted to an issue “that does not exist.” Fortunately, some mainstream providers are becoming increasingly aware of and beginning to address unique issues around lack of access to mental health and aging services for LGBTQ older adults. LGBTQ communities are leading efforts to provide peer and community supports to address mental health and social isolation among today’s LGBTQ older adults. One innovative example is outlined below.
The Montrose Center: A Proactive Partnership
The Montrose Center in Houston, Texas, offers a range of services tailored specifically to LGBTQ adults ages 60 and older through its Seniors Preparing for Rainbow Years (SPRY) program. By making the case that social isolation, depression, and resistance to traditional mental health and other services were significant issues affecting the basic health and well-being of LGBTQ older adults, the Center successfully partnered with Legacy Community Health, a federally qualified health center with strong ties to Houston’s LGBTQ community, to secure grant funding to provide mental health services to the city’s aging LGBTQ population. With additional guidance from an elder needs assessment and input from LGBTQ older adults, SPRY built trust through personal, consistent, empathic, one-on-one engagement, and now provides culturally competent mental health services to older LGBTQ Houstonians.
Understanding the lived history of LGBTQ elders, many of whom out of necessity spent much of their younger years in the closet and continued to maintain separate public and private identities throughout adulthood was a key element of the Program’s early development. From its outset, SPRY was clear that this particular generation of LGBTQ older adults would be distrustful of things “mental health,” and with good reason. Decades of either inadequate or abusive, reparative treatment by mental health professionals; discrimination in general in the elder services industry; fear of being labeled as “crazy”; and continued discrimination, even in today’s world of marriage equality, is often enough to keep LGBTQ elders from seeking services.
LGBTQ older adults often are hidden and invisible. While ageism and “youth-centeredness” within LGBTQ culture contribute to older adults becoming isolated, other factors exist that make this group especially difficult to reach. With broader boundaries and less population density than comparably sized cities, Houston’s LGBTQ community is becoming geographically more diffuse. Excepting a dozen or so stalwart bars and the Montrose Center, Houston’s once vibrant LGBTQ enclave in the Montrose district has more or less disbanded due to greater mainstream acceptance of sexual minorities and steeply rising inner-city housing costs. While in the broader sense a positive and equalizing trend, these issues combine to weaken or even eliminate social networks among LGBTQ older adults.
SPRY’s initiative for engaging isolated LGBTQ elders centers on peer support, using an evidence-based Indigenous Leadership model (Wiebel, 1993). LGBTQ peers engage and then connect older adults to a welcoming social environment. Initial support took the form of weekly men’s and women’s peer support groups led by lay peer counselors, and an occasional gender-inclusive social gathering. Individual therapy and case management were “wrapped around” the social component, but were not required for participation. Participants who regularly attended SPRY groups saw their isolation and sense of separation from the community decrease significantly, even among those not receiving therapy.
Consequently, the Center began to expand its social support offerings. Today, SPRY hosts a dedicated drop-in program three days a week (called “Montrose Diner”) that centers on congregate meals funded by Harris County Area Agency on Aging, through a partnership with Neighborhood Centers Inc., one of Houston’s largest nonprofits. The SPRY social calendar also includes monthly potlucks, movie screenings, games, wellness activities, educational programs, and several annual chartered day trips.
An unanticipated outcome of SPRY is that many regular participants come to rely less upon clinical interventions, such as individual and group therapy, and more on the congregate meal and peer support programs. Natural bonds and mutual support that occur between participants, even during stressful or challenging times, can be enough to alleviate depression and other stressors for some LGBTQ older adults; for others, the peer social programs are a first step into the Center’s continuum of mental health and case management services and other community supports.
SPRY deploys LGBTQ older adults—most of them retired from life-long occupations as teachers, engineers, and in finance—as peer outreach workers to actively engage isolated LGBTQ older adults by connecting them with existing LGBTQ social and civic groups, churches, and businesses. The outreach workers also are trained to provide screening for depression, suicide, and substance-use risks, as well as brief supportive interventions in the field. These outreach efforts can provide significant services and supports to LGBTQ older adults who may otherwise be unable to access SPRY.
Any attempt by providers to gain cultural competency and create more inclusive and affirming environments helps LGBTQ older adults feel more welcome and less likely to avoid or resist care. Visits by SPRY outreach workers to assisted living communities, nursing care agencies, and primary care clinics often result in the provider requesting more information about LGBTQ aging issues. Occasionally, there are requests for in-service training sessions with front-line staff, which the Center eagerly accommodates. Without this ongoing outreach component, it is unlikely that SPRY would be as vital as it is today.
Isolation among LGBTQ older adults often is accompanied by depression and reinforced by extremely rigid routines, and it may take more than a casual referral to get someone who is isolated to break free from that comfort zone. SPRY outreach is about building rapport and trust first; having other LGBTQ older adults doing this work makes a huge difference. There’s a reason LGBTQ people, even strangers, refer to each other as “family.”
Not every community has the resources to sustain such dedicated LGBTQ older adult programming, or even a dedicated LGBTQ space. Yet SPRY is evidence that peer-led outreach, coupled with a vital supportive network, can go a long way toward decreasing isolation and restoring a sense of community belonging among LGBTQ older adults. One could argue that the SPRY peer support model is simply a cultivated version of naturally forming affinity groups that sprout among networks of friends and acquaintances. In the case of LGBTQ older adults, all that may be needed is an older adult member representing that community to plant the seeds of engagement, trust, and hope—and the right “greenhouse” to allow this network to grow. This may be a mainstream community center, a church, even a restaurant or cafe—any place where LGBTQ people feel welcome and accepted.
LGBTQ communities have a long history of creativity. SPRY has demonstrated that programming targeting the social needs of LGBTQ older adults can have the “unanticipated outcome” of reducing the need for clinical mental health interventions. Good mental health is essential to healthy aging; opportunities to be more fully integrated into LGBTQ communities can be an important contributor to the mental health of LGBTQ older adults (Knauer, 2011). Innovative approaches that foster social and psychological well-being among LGBTQ older adults should consider direct, targeted approaches, such as those at SPRY.
Charles P. Hoy-Ellis, M.S.W., Ph.D., L.I.C.S.W., is assistant professor at the College of Social Work, University of Utah, in Salt Lake City. He can be contacted at Charles.Hoy-Ellis@socwk.utah.edu. Michael Ator, M.S.W., L.M.S.W., is community projects specialist at the Montrose Center, in Houston, Texas. He can be contacted at firstname.lastname@example.org. Christopher Kerr, M.Ed., M.A., M.Div., L.P.C-S., is clinical director of the Montrose Center. He can be contacted at email@example.com. Jessica Milford is an M.S.W. candidate at the University of Utah’s College of Social Work.
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 store. Full 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.
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