Estimated between 1 and 3 million elderly LGBT individuals in the U.S. currently • Estimate 2 to 6 million elderly LGBT individuals by 2030 • More than 1 in 10 same-sex couples includes individual > 65 yrs of age • VERY limited research/data available....what does this say about our attitude toward the LGBT community?
DISCUSS Framework • To ID barriers to service utilization • D - Discrimination, Insensitivity, Harassment (throughout levels) • I - Individual/Interpersonal level • S - System/Organizational level • C(u) - Community level • S/S - System/Social Policy level
Generation Differences generational differences in “coming out” identified as pre- and post-Stonewall generations Stonewall riots in 1969 marked beginning of LGBT civil rights movement pre-Stonewall generation tends to be much more apprehensive and anxious about acknowledging their orientation baby boomer generation tends to be slightly more open Younger generation also more aware of HIV epidemic
Emotional challenges • Anxiety regarding self-identification • Discomfort around friends/family • may vary by culture attitudes toward homosexuality • Distrust of physicians and health care workers • may fail to seek care or be honest about medical history • Stress about life planning/spouse • Suspicious of available resources
Health Risks of LGBT Population • Tobacco, alcohol, drug use more prevalent in LGBT population • Increased prevalence of risky behavior, depression, suicidality
Communication/Relationships • LGBT elderly patients may be apprehensive about reaching out • Poor doctor-patient relationship • May not rely on friends and family • May not take advantage of available resources for fear of discrimination/judgement
Interventions • Providers should provide a neutral and confidential environment for patients • Providers should avoid ever making assumptions about a patient • When aware of an LGBT patient, providers should be sensitive to cultural influences and personal situations • Recognize patients may be suspicious or untrusting of health care or service providers
Interventions • Awareness on part of health care providers • Gay & Lesbian Medical Association www.glma.org • Howard Brown Health Center www.howardbrown.org • Support groups • Nat’l Resource Center on LGBT Aging www.lgbtagingcenter.org • Resources for friends and family • Parents, Families, and Friends of Lesbians and Gays www.pflagillinois.org • Religious or other outlets for support • Gaychurch.org • Hebrew Union College http://huc.edu/ijso/SynOrg/LGBT/list
System/Organization Focus: Unequal Treatment Under Laws + Programs for LGBT Older Adults Advancing the Lives of LGBT Older Adults. SAGE publication. 2010
Civil Union Rights In Illinois According to the Illinois Dept. of Insurance; Civil Union and Insurance Benefits:RE: Statewide Relationship Recognition • Illinois does NOT provide marriage licenses for same-sex couples. • Illinois does NOT honor marriages of same-sex couples from other jurisdictions • The 2010 Civil union law enacted, effective June 1, 2011, allows same-sex and different-sex couples to enter into a civil union and receive "the same legal obligations, responsibilities, protections and benefits as are afforded or recognized by the law of Illinois to spouses.” http://insurance.illinois.gov/newsrls/2011/05/CivilUnionsFinal05-25-11.pdf
A Long Way To Go: Systemic Challenges Despite Civil Union According to SAGE publication, Improving the Lives of LGBT Older Adults, March, 2010: The Following Civil Union Challenges Persist. : • Social Security Benefits. No.Spousal impoverishment protections do not apply civil union partners. • Medicaid and Long-term Care. Spousal impoverishment protections do not apply civil union partners. • Tax-Qualified retirement Plans. Despite positive changes in the law in recent years, LGBT elders still lack the same benefits as their heterosexual peers when it comes to the treatment of IRAs and similar plans. • Employee Pensions/defined-Benefit Plans. No. Qualified Joint and Survivor Annuity (QJSA) or Qualified Pre-retirement Survivor Annuity (QPSA) do not offer civil union partners the same financial protections for a surviving partner or chosen family member. • Retiree health Insurance Benefits. A civil union partner’s insurance benefits are treated as taxable income. • Estate taxes. Civil union partners are required to pay inheritance taxes on some estates. • Federal Veterans’ Benefits. Civil union partners are not entitled to medical care, and home loan guarantees. • Inheritance Laws. Yes. Requires legal representation. Systemic Intervention LTC Facility
Social Security Disparities Advancing the Lives of LGBT Older Adults. SAGE publication. 2010
Lets Talk About Sex • When looking for peer reviewed, evidenced based articles on sex and older adults, few of the databases choosen (Cinahl, Ageline, LGBT life with Full Text, Primary Search, Ebsco, Social Work Abstracts and Psych Info) provided relevant information. In fact, the first “find” was: Sex-specific associations of depressive symptoms and cardiovascular risk factors in older adults. • The string sex and seniors proved more fruitful—but just one relevant article to our search was listed: Sex in Senior Living, 2008. 2008? That’s four years ago!
LGBT Sexuality • If the sexuality of olders adults or seniors is systematically ignored in peer reveiwed, evidenvced based articles, how can we even begin to accept LGBT sexuality? • If educated academicians don’t explore this topic, how are we going to educate LTC facilities about LGBT sexuality. • How will we even begin to challenge heterosexist sterotypes and homophobic attitudes?
Systemic Challenges Related to Rights and Sexuality Faced by LGBT Seniors in LTC Facilities • According to the LGBT Center on Aging Further Challenges Exist. • Persistent institutional heterosexism and homophobia often present major obstacles to the older LGBT adult seeking LTC care. • LGBT elders may feel uncomfortable asking for help and/or disclosing their sexual orientation due to hostility from LTC facilities and staff. • For many closeted LGBT elders, having paid attendants in their homes to provide personal care is simply not an option due to the fear of exposure. • Sensitivity to alternative gender identities and expressions--such as butch lesbians, feminine gay men, and transgender people who have not undergone a physical transition--is rare in long-term care facilities, and can pose a very real threat to the physical and emotional safety of LGBT people. • Whether they are out or not, LGBT elders may find themselves dependent on institutions that have long perpetuated heterosexist attitudes. • In addition, out LGBT elders must deal not only with risks of elder abuse in long tern care facilities, to which any older person may be exposed, but also to the harassment and violence for which any queer person may be at risk. Moreover, their awareness of--or first-hand experiences with--police brutality may make LGBT elders reluctant to report violence or abuse to the authorities. http://www.lgbtagingcenter.org/resources/resource.cfm?r=423
Interventions LTC Facility Lesbian Life Suggests the Following Recommendations/Interventions: • Establish relationships with organizations and businesses that serve LGBT populations. • Organize a volunteer day and help out a LGBT youth organization or HIV prevention program. • Do not assume that LGBT orientation is a problem. • Provide at least one bathroom that is gender neutral. • Don't assume your clients, customers or employees are heterosexual. • Invite an out gay or lesbian person to sit on your board of directors. • Advertise in the LGBT media. • Support political campaigns that support LGBT rights. Publicly oppose ones that take away rights. http://lesbianlife.about.com/od/lesbian activism/ht/GayFriendlyBiz.htm
Systemic Intervention LTC Facility • Develop an anti-slur and anti-harassment policy for clients and staff. • Include sexual orientation and gender identity in your non-discrimination policy. • Have positive images of gays and lesbians displayed in your workplace. If books or literature are displayed, be sure to include some gay and lesbian titles. • Support out staff members by encouraging them to talk about their partners and family. Make sure your family leave policies an benefits programs are equitable. • Start or sponsor a LGBT employee group. • Encourage LGBT employees to bring their partners and children to events where families are welcome. • Celebrate Gay Pride Month in June or Gay and Lesbian History Month in October. Consider sponsoring or marching in a gay pride parade. http://lesbianlife.about.com/od/lesbianactivism/ht/GayFriendlyBiz.htm
Systemic Foundations for Change Advancing the LIves of LGBT Older Adults. SAGE publication. 2010
References Systematic and Organizational Disparities • Improving the Lives of Older Adults, SAGE Publication, March 2010. • Illinois Dept. of Insurance; Civil Union and Insurance Benefits. http://insurance.illinois.gov/newsrls/2011/05/CivilUnionsFinal05-25-11.pdf • LGBT Center on Aginghttp://www.lgbtagingcenter.org/resources/resource.cfm?r=423 • Lesbian Lifehttp://lesbianlife.about.com/od/lesbian activism/ht/GayFriendlyBiz.html
Community Level • Disparities • Minimal protection • Active rejection • Racism / Ageism • Within LGBT communities • Deterrents to access • Limits availability of support
Community Level • Current or Potential Strategies to Overcome Barriers • Take advantage of National Family Caregiver Support Program (NFCSP) • Promote ties between LGBT and NFCSP agencies • Rally LGBT communities to develop services • Promote use of "safe place" symbol
Community Level • Potential Interventions • Adopt LGBT media and community/service campaigns • Persuade professional organizations to support media and community service campaigns • Encourage new LGBT retirement communities to incorporate education and training about caregiving
CHESS Framework • Aging and Health Report, "while family members related by blood or marriage play a primary role in the support of older adults in the general population, most LGBT older adults care for one another" • http://caringandaging.org/wordpress/wp-content/uploads/2011/05/Full-Report-FINAL-11-16-11.pdf • To help researchers, administrators, program developers, providers, etc. assess LGBT caregiving situations • Cultural context • Historical context • Employment, financial, and legal contexts • Social support context • Spiritual context
Cultural Context • Vary in openness about • Sexuality • Acceptable forms of sexuality • Ramifications of violating prohibitions • Attitudes may influence whether LGBT caregivers • Withhold or alter information • Avoid personal contact • Opt for anonymous services • Related to use of nontraditional health care • Service providers must be open and informed
Historical Context • Relevant events and processes • Changes in societal attitudes about • Sexuality • HIV/AIDS • Differentially affect older and younger cohorts of LGBT caregivers • Impact knowledge about and willingness to utilize services
Employment, financial, and legal contexts • Impacts compounded by discrimination vs LGBT employees • Lack of legal protection for LGBT partners • Prevents access to health benefits • Allows for interference by blood relatives or facility personnel in visiting rights and decision making
Social support context • Avoid stereotypical view that older LGBT persons are childless or alone • LGBT networks include family of origin and family of choice • Future cohorts of caregiving gay or bisexual men • may have smaller support networks due to losses from HIV/AIDS • may need more assistance
Spiritual context • Religious coping may be turned to less frequently or perceived as being less effective • Churches and temples may exist to serve LGBT community • Institutionalized religion may • be unsupportive • actively discriminate against them
SURE 2 Framework • To assist LGBT support group leaders • Empowerment perspective • Integrated with basic CBT methods • Developed in response to concerns of LGBT caregivers • Insensitivity and ignorance from family members who expect them to assume larger share of family caregiving
SURE 2 Framework • Expectations can • Exacerbate caregiver stress, • Negatively impact family-of-choice relationships, • Diminish positive aspects of caregiving • Force LGBT caregivers "out of the closet" or "in the closet" • Prior experience with HIV/AIDS caregiving • Creates both knowledge and skill re: caregiving • Can lead to burnout and tap into grief for members who have lost many from support network • Some LGBT caregivers may be asked to care for individual who disowned them
SURE 2 Framework • Conflicts at work r/t employers minimizing importance of caregiving responsibilities to LGBT partners or friends • LGBT caregivers face homophobia in home health and long-term care settings • Partners may endure conflicts with relatives over substitute decision making
SURE 2 Framework • Components • Sharing and Support • Unhelpful thinking and Understanding • Reframes and Referrals • Caregivers encouraged to reframe thinking and change behavior • Include ID of unique obstacles facing LGBT caregivers • Education and Exploration
Disparities in Marital rights • In the United states today, access to marriage, civil unions, and domestic partnerships for same sex-couples varies heavily from state to state • As of February 2012, 7 States and Washington DC have legalized same-sex marriage • In these regions, same sex married couples are granted all of the state recognized rights of marriage • 20% of states offer civil unions or domestic partnerships with most state recognized rights of marriage, while 12% of states offer domestic partnerships with some state recognized rights of marriage • About 35% of the population live in regions that have access to at least one of these partnerships for same sex couples • As of 2004, there are over 1,138 benefits, rights, and protections provided by the federal government on the basis of marital status. • Rights are only bestowed by federal government, not affected by state laws • Social security survivor benefits and spousal benefits, unpaid leave to care for an ill spouse; reduced taxes on income, estates, gifts, and property sales; immigration benefits, retirement benefits, access to employer sponsored health benefits, etc • DOMA (Defense of Marriage Act) • Federal law passed in 1996. • Defined marriage explicitly as the union between a man and a woman. • Same-sex couples are not granted any of the benefits awarded to married couples under federal law • As a consequence of these laws, elderly LGBT couples have lower household incomes, decreased financial stability, and decreased access to care in comparison to their heterosexual counterparts.
Affect on Healthcare Rights • Taxation of Health Benefits • Under federal law, expenses from spousal health benefits are not seen as taxable income, thus neither the employer or employee pay taxes on these funds. • However, because same-sex marriage is not recognized under federal law, funds paid for same sex partners is treated as part of the employee’s taxable income. Thus, both the employee and employer have to pay federal taxes on these funds. • This extra tax burden has made some businesses reluctant to offer health insurance for the spouses of same sex couples. This has in turn placed an even greater financial burden on the same LGBT couples • Lack of spousal impoverishment protections under Medicaid for LGBT partners • In order to qualify for Medicaid financial assistance for a long term facility, a person must have monthly incomes and assests that don’t exceed a predetermined threshold. • “Medicaid Spend Down” refers to the process of a person reducing their assests in order to qualify for medicare • For single individuals, that no longer have the liquid assets to pay their healthcare costs and need Medicaid, the state can take possession of their home to pay the beneficiaries expenses • However, federal law prohibits imposing this lein if beneficiaries are married to someone of the opposite-sex who’s still living in their home. Recent guidelines have allowed these rights to be extended to same sex couples, but leaves it up to the states to decide. Leading to various implementations from state to state. Illinois actually provides protection for same-sex couples • Opposite sex spouses are also entitled to between $21,192 and $109,560 of the couples assests, the shared home and part of the spouses income (depending on their cost of living) • In same sex couples, where the nursing LTCF bound partner is the main provider (owner of the home), the remaining partner is able to keep their own income and assets, but is not entitled to their spouses home or their spouses assets • As a result, providers in LGBT relationships are more likely to delay care/not seek services for fear of leaving their partner homeless
Potential strategies to overcome barriers • Increased Political Activisim • Many of the barriers to care faced by LGBT couples revolve around the inability to receive benefits equal to their heterosexual counterparts. Lobbying for fair protection under the law would go a long way to ensuring better financial security and in turn better access to care. • Repealing of the Defense of Marriage Act • Lobbying for equal rights under federal law for LGBT couples • Build partnerships with LGBT organizations in order to foster a support network for LGBT caregivers • Goal would be to provide LGBT couples with help in understanding their rights to healthcare services, accessing said health services, financial planning, etc.