Healthcare, Sexual Practices, and Cultural Competence with LGBT Elders

Abstract

Research on the health of LGBT elders is limited. However, we do know that LGBT older adults often have poorer health status as a result of a combination of factors including health challenges such as sexual orientation, gender identity issues, as well as a history of marginalization, prejudice, and the effects of non disclosure in health care encounters.  Additionally, commonly held misconceptions regarding the sexual practices of older adults contribute to the poorer health outcomes experienced by some LGBT individuals. LGBT older adults, like others, are entitled to quality health care.  This chapter introduces and discusses some of the major issues that affect the health of LGBT elders and explores opportunities to begin addressing these issues. Additionally, it reviews implications for improving service delivery from an interdisciplinary perspective and future research directions.

Appendices

Learning Exercises

Experiential Assignment #1

Visit your local Long-Term Care Ombudsman’s Office or an advocacy group for LGBT older adults in long-term care facilities. Ask for de-identified information or case review for one or two incidents involving staff/residents/family and a LGBT older adult relating to health.

Review the incident: What were the issues? What were the implications for the LGBT older adult? How was the matter resolved? What if anything could have been done to avoid the situation, or address the problem in the first case? If you were to create a cultural competence training workshop to prevent these sorts of problems in the future, what would that workshop look like? Explain your rationale.

Experiential Assignment #2

Interview two older adults of whom one must be a member of the LGBT population, about their health concerns as they age. Your questions should include health status, access to care, delivery of services, and quality of care. Compare the responses. How are they similar or different? Why? What implications if any emerge for their health? How do these interviews add to what you are learning about LGBT older adults and health?

Experiential Assignment #3

Challenging beliefs and feelings about LGBT aging through self-examination using role-play, through which students explore their beliefs, feelings, and attitudes about LGBT older adult sexuality, roles, identity, and orientation. Role-play occurs in the context of a healthcare encounter. One student plays the role of the healthcare provider, while another student plays the role of a lesbian, or gay, or bisexual, or transgender older adult. Roles can then be reversed if desired.

Suggested scenarios:

• (A) Older adult comes out as gay to the healthcare professional,

• (B) LGBT older adult encounters a homophobic healthcare provider, and

• (C) Healthcare encounter in which provider is trying to conduct a health assessment of an older adult believed to be LGBT.

Script should provide opportunities for the following:

• 1. Explore or showcase negative versus positive interventions with LGBT older adult patients and

• 2. Opportunities for introspection and self-examination of personal beliefs, feelings, attitudes, and expectations

Process:

• 1. Review and encourage open discussion about the issues raised and/or addressed.

• 2. Encourage students to discuss their observations, feelings, and discomforts if any.

• 3. Address any myths or stereotypes which come up.

• 4. Provide feedback and clarification as necessary.

Self-Check Questions

• 1. Explain how common misconceptions about patients sexuality impacts LGBT elders overall health.

• 2. Describe several of the age-related changes that could influence an older adult’s participation in sexual intimacy.

• 3. List and describe barriers to data collection among LGBT individuals in healthcare settings.

• 4. What obstacles impede the delivery of optimal health care to LGBT elders?

• 5. Discuss the effect of non-disclosure of sexual orientation or gender identity by LGBT elders on healthcare delivery. How can this issue be addressed from the perspective of the:

  • (a) LGBT older adult and

  • (b) healthcare provider.

• 6. What are the training needs of staff who work with LGBT older adults?

• 7. Identify the risk factors for HIV/AIDS among LGBT older adults.

• 8. Explain the importance of having LGBT cultural competency in healthcare personnel and settings.

• 9. Identify the three dimensions of cultural competency.

• 10. You are creating a LGBT cultural competence training program/workshop for healthcare providers in your county. Discuss the goals and components required to make it an effective program.

• 11. Explain why it is necessary not to treat the LGBT population as monolithic group, especially in relation to health and health care.

Multiple Choice Questions

• 1. Oftentimes, healthcare providers assume that older adults are as follows:

  • (a) Homosexual

  • (b) Transgender

  • (c) Heterosexual

  • (d) Asexual

• 2. Compared to previous generations, rates of illicit drug abuse among baby boomers are relatively/have relatively higher rates of illicit drug use as opposed to previous generations:

  • (a) Lower

  • (b) Higher

  • (c) Similar

  • (d) Nonexistent

• 3. Many older adults do not bring up the topic of sexuality with their healthcare providers because:

  • (a) They do not desire to be sexually active.

  • (b) They do not believe that their healthcare provider will have the answers to their questions.

  • (c) The healthcare provider often brings the topic up before the older adult has a chance to.

  • (d) They feel embarrassed or ashamed because they have internalized misconceptions regarding older adults and sexuality.

• 4. Structural barriers to obtaining health-related data from LGBT elder patients include the following:

  • (a) Poverty in the LGBT community

  • (b) Lack of provider training to address the specific health needs of the LGBT population

  • (c) Low rates of health insurance among LGBT individuals

  • (d) Lack of access to culturally appropriate health care

  • (e) All of the above

• 5. Which of the following statements is NOT true?

  • (a) HIV is not a concern among older adults

  • (b) Symptoms of HIV are often confused with symptoms of other chronic conditions that often affect elders.

  • (c) Making a diagnosis of HIV among older adults can be more challenging.

  • (d) Older adults get HIV the same way that young people do.

• 6. A person’s gender identity if different from sex at birth should:

  • (a) Always be honored

  • (b) Never be honored

  • (c) Be honored only if you are comfortable doing so

  • (d) Be honored only if the person has undergone particular medical interventions and a legal name change

• 7. The terms “sexual orientation and gender identity”….

  • (a) Mean the same thing

  • (b) Can be used interchangeably

  • (c) Have different meanings and are not interchangeable

  • (d) Can be used interchangeably when referring to lesbians only

• 8. Which of the following statements is correct? In order to assure better care experience and positive outcomes,

  • (a) LGBT elders should be treated like all other older adults.

  • (b) It is not enough to treat LGBT elders like the general older adult patient.

  • (c) Sexual orientation or gender identity is not a relevant consideration.

  • (d) Providers and practitioners should avoid embarrassing LGBT elders by bringing up sexual orientation or gender identity.

• 9. In order to be effective, cultural competence training should address:

  • (a) Knowledge

  • (b) Behavior

  • (c) Attitude

  • (d) A, B, & C

  • (e) Knowledge and behavior

• 10. You are the staff responsible for administering or arranging for certain sex-linked preventive care for the clinic’s patients. This week, you have a management intern shadowing your office. You are meeting with Janet Doe, a transgendered person who is in the clinic for her annual health check. You need to schedule some tests including mammogram and Pap smear. Which of the following constitutes best practices in order to ensure that Ms. Doe received appropriate care?

  • (a) The intern asks Ms. Doe what surgeries she has had as a transgender person.

  • (b) You ask Ms. Doe what surgeries she has had as a transgender person, while the intern takes notes.

  • (c) You provide privacy for Ms. Doe to answer the questions about what surgeries she has had as a transgender person.

  • (d) Ms. Doe is not asked any questions about any surgeries she has had as a transgender person.

Key

• 1. d

• 2. b

• 3. d

• 4. e

• 5. a

• 6. a

• 7. c

• 8. b

• 9. d

• 10. c

Resources

The National Resource Center on LGBT Aging

http://www.lgbtagingcenter.org/resources/index.cfm

Centers for Disease Control and Prevention-HIV among Older Adults

http://www.cdc.gov/hiv/risk/age/olderamericans/

Health Equity and LGBT Elders of Color

http://www.lgbtagingcenter.org/resources/pdfs/Sage_PolicyBrief_HealthEquity.pdf

LGBT Health

http://www.hrsa.gov/lgbt/

Stanford LGBT Medical Education Group

http://med.stanford.edu/lgbt/resources/

The Fenway Institute

http://www.fenwayhealth.org/site/PageServer

Services and Advocacy for Gay, Lesbian, Bisexual and Transgender Elders (SAGE)

http://www.sageusa.org/

Lambda Legal—National organization committed to achieving full recognition of the civil rights of lesbians, gay men, bisexuals, transgender people and those with HIV through impact litigation, education and public policy work.

www.lambdalegal.org/health-care-fairness.