Changing the Culture of Long-term Care: Combating Heterosexism

Susan V. Schwinn, BSN, RN; Shirley A. Dinkel, PhD, APRN, FNP-C, ANP-C Online J Issues Nurs. 2015;20(2)

Abstract and Introduction

The purpose of this article is to describe how heterosexism impedes the provision of culturally competent care for lesbian, gay, bisexual, transgender, and queer (LGBTQ) residents in long-term care (LTC) facilities. LTC facilities continue to employ staff members who lack an understanding of sexuality and sexual diversity in the elderly. In this article, we identify the heterosexual assumption, namely heterosexism, as the primary issue surrounding the holistic care of the LGBTQ elder in LTC. We first review the literature related to LGBTQ elders in LTC facilities, identifying the themes that emerged from the review, specifically the definitions of homophobia and heterosexism; perceptions of LGBTQ elders as they consider placement in LTC facilities; and staff knowledge of and biases toward sexuality and sexual diversity in LTC settings. Then, we suggest approaches for changing the culture of LTC to one in which LGBTQ elders feel safe and valued, and conclude by considering how facility leaders are in a unique position to enable LGBTQ elders to flourish in what may be their last home.

Introduction

It is estimated that by the year 2030, one in five Americans will be over the age of 65 (Vincent & Velkoff, 2010), and of that number, as many as three million will identify as lesbian, gay, bisexual, transgender, and queer (LGBTQ) (National Gay and Lesbian Task Force, n.d.). With advanced age comes the risk of functional loss. A loss of independence in three or more activities of daily living may precipitate the need for services in long-term care (LTC) facilities, known colloquially as nursing homes. Of specific concern are reports that LGBTQ elders relate a number of fears pertaining to the possibility of living in LTC facilities. These fears include potential rejection or neglect by healthcare providers, lack of acceptance and respect by fellow residents, and the feeling that it is necessary to hide their sexual orientation or ‘return to the closet’ once admitted to a LTC facility (Stein, Beckerman, & Sherman, 2010). These fears seem legitimate since there is evidence that LTC staff perceive same- gender sexual behaviors more negatively than heterosexual behaviors (Hinrichs & Vacha-Haase, 2010). In fact, according to Hollibaugh (2011) some LTC staff believed “…that LGBTQ elders were sexually volatile and promiscuous, and might create an atmosphere of sexual perusal…” (p. 9).

However, the 1987 Nursing Home Reform Act included provisions that all residents be treated with dignity and respect (Lambda Legal Defense and Education Fund [LLDEF], 2011). In an era when culturally competent care is mandated (Somers & Mahadevan, 2010), it is necessary for LTC staff to be aware of the unique challenges and care needs of this profoundly vulnerable population.

A review of the literature identified two primary areas of concern related to LTC environments for LGBTQ elders. These areas included a poor understanding by facility staff of sexuality and sexual diversity in the elderly and negative personal perceptions of safety and inclusion among LGBTQ elders and LGBTQ LTC residents (Bauer, McAuliffe, Nay, & Chenco, 2013; Hinrichs & Vacha-Haase, 2010; Hollibaugh, 2011; LLDEF, 2011). Each of these concerns is directly related to the concept of heterosexism.

We will begin by reviewing the literature related to LGBTQ elders in LTC facilities, and discussing the themes that emerged from the review, specifically the definitions of homophobia and heterosexism; perceptions of LGBTQ elders as they consider placement in LTC facilities; and staff knowledge of and biases toward sexuality and sexual diversity in LTC settings. Then, we will suggest approaches for changing the culture of LTC to one where LGBTQ elders feel safe and valued, and conclude by considering how facility leaders are in a unique position to enable LGBTQ elders to flourish in what may be their last home.

Review of Literature

To better understand the needs of LGBTQ elders in LTC settings, we conducted a review of literature. A search of CINAHL Complete database, Medline database, and Google Scholar was undertaken using the following keywords: heterosexism, homophobia, long-term care facilities, nursing homes, culturally competent care, gay, lesbian, LGBT, and sexual diversity. We chose articles due to their specificity about sexual diversity, LTC, and the current issues related to these areas. Twenty five articles and online professional resources were selected. The following three themes emerged from the review: the definitions of homophobia and heterosexism; fears and perceptions of LGBTQ elders as they consider placement in LTC facilities; and healthcare staff knowledge of and biases toward sexuality and sexual diversity in LTC settings. While the definition of staff varied between articles, for the purpose of this article, LTC staff is defined as registered and licensed practical nurses (RNs and LPNs), certified medication aides (CMAs), certified nurse aides (CNAs), certified restorative aides (CRAs), and activities personnel. Each theme is addressed below.

Homophobia versus Heterosexism

Although the word homophobia contains the word ‘phobia,’ the meaning of the term has evolved to mean homosexual prejudice rather than to describe a true fear (Ahmad & Bhugra, 2010). Homophobia is generally used to describe people with anti-gay attitudes or behaviors (Definitions, 2012) In contrast, heterosexism is defined as the assumption that everyone is or should be heterosexual, thereby marginalizing those who do not identify as heterosexual (UC Berkley Gender Equity Resource Center, 2014, Heterosexism). Many times, the terms homophobia and heterosexism are used interchangeably. However, although homophobia may lead to heterosexism, being heterosexist does not require one to be overtly homophobic. Traditionally, United States culture has held the belief that heterosexuality is the norm (and preferable), and non-heterosexual expression is contrary to the norm (and not preferable). Although homophobia is still prevalent in many parts of this country, heterosexism is a much more common phenomenon.

Heterosexism may manifest itself in several ways including over-sexualizing LGBTQ people, denying the personal and political significance of being LGBTQ, being naïve to heterosexual privilege, expecting LGBTQ persons to teach providers about their healthcare needs, and espousing LGBTQ stereotypes (James Madison University, n.d.). Simply, heterosexism may be manifested by failing to consider the possibility that the other is gay (Morrison & Dinkel, 2012). For instance, a nurse might ask a newly admitted female resident, “I see you’re wearing a ring, what’s your husband’s name?” Often well-intentioned people ask questions or make comments that are heterosexual gender specific, or not gender-neutral. This type of language illustrates heterosexism because it assumes a heterosexual norm and requires the listener to correct the speaker, if desired.

Heterosexism is an important factor to consider in the provision of care to people of all ages, including LGBTQ elders. The health of LGBTQ elders depends heavily on their ability to overcome social

inequities (Meneses & Monroe, 2007). Because health and well being is strongly linked to real or perceived injustice, LTC staff members have a responsibility to be aware of the negative implications of this often subtle phenomenon. While there is a growing, yet limited, body of knowledge about heterosexism in LTC, this assumption of heterosexism can have a negative impact on the provision of healthcare to LGBTQ elders. Unlike racial differences, which may be identified by skin color, LGBTQ elders are not typically visually identifiable, creating additional challenges to implementing awareness programs. Changing one’s awareness is made simpler when there are regular visual reminders in the environment. Becoming aware that LGBTQ residents exist in LTC facilities requires a change in how healthcare providers view sexuality in all people, understanding that diversity in sexual expression and sexual identity exists in people of all ages. When LTC staff remain consistently mindful of the existence of LGBTQ individuals, they will be better able to translate that awareness to their work setting.

LGBTQ Perceptions of Healthcare and LTC Environments

The second theme identified in the literature was LGBTQ elders’ perceptions of healthcare providers and LTC environments. The historical obstacles for LGBTQ people in obtaining healthcare cannot be overstated. LGBTQ elders who grew up prior to the gay liberation era lived with stigma and shame related both to overt discrimination by healthcare professionals, and in some cases, forced medical interventions (Brotman, Ryan, & Cormier, 2003). In fact, older LGBTQ individuals are less likely than younger LGBTQ individuals to seek healthcare services; when they do seek these services, they are less likely to reveal their sexual identity to healthcare professionals (Bluestein & Bach, n.d.; Jackson, Johnson, & Roberts, 2008; LLDEF, 2011; Solarz, 1999). Brotman et al. (2003) have noted that, in general, this population finds it unwise to trust in people and systems “…that have historically persecuted them, particularly as they confront the potential of becoming physically dependent on others as they grow older” (p. 196).

The prospect of LTC placement provokes a number of fears for the elderly. Admission to a LTC facility is most often precipitated either by a medical crisis that requires 24/7 nursing care or by an elder experiencing a loss in functioning that requires a reliance on caregivers for activities of daily living. This new vulnerability and loss of independence is difficult for anyone; but it may be complicated by other psychosocial factors for LGBTQ elders (Jackson et al., 2008). Although social stigmas related to homosexuality are rapidly changing in the US, LGBTQ elders have long personal histories of experiencing discrimination, histories that limit their willingness to disclose their sexual orientation (Bluestein & Bach, n.d.; Cohen, Curry, Jenkins, Walker & Hogstel, 2008).

The numbers of LGBTQ people residing in LTC facilities that fear for their safety and well being is of concern. In 2013, 29% of lesbian, gay, and bisexual LTC residents felt they would be treated differently from their heterosexual counterparts (Human Rights Campaign [HRC], 2013). In 2009–2010, LLDEF (2011) conducted a survey of LGBTQ elders living in long-term care settings across the US, of which 284 identified themselves as LGBTQ older adults. The survey also included 485 individuals who had direct and personal experiences with LGBTQ elders in LTC; these individuals included friends and family members of LGBTQ LTC residents, a number of social service providers, and healthcare workers. When asked what issues an LGBTQ individual might face in a LTC facility, 53% of respondents expressed fears related to staff mistreatment, and 77% feared discrimination and purposeful isolation by other residents.

Similarly, in a 2010 Metlife survey of 1,200 self-identified LGBTQ individuals aged 45 to 64 living across the US, transgender individuals were twice as likely as their heterosexual counterparts to feel vulnerable with a healthcare provider (36%), compared to lesbians (17%), gay men (19%), and male and female bisexuals (18%)(Metlife Mature Market Institute [MMI], 2010). Just four years prior, in a MetLife survey of 1,000 LGBT people aged 40 to 61, 27% stated they had serious concerns they would not be treated with dignity and respect by healthcare professionals (MMI, 2006, p. 5). In addition, a 2005 Washington State study of LGBT individuals of all ages indicated that 73% believed that discrimination occurred in LTC facilities and 35% stated they would return to the closet if they had to enter a LTC facility (Johnson, Jackson, Arnette, & Koffman, 2005). Returning to the closet is believed to be a self-protective mechanism designed to maintain physical and emotional safety in nursing homes (Cohen et al., 2008).

Other fears identified by LGBTQ elders were related to recognition of life partners and social supports. When a life partner is living, disclosure of the nature of the relationship is often avoided. As a protection against discrimination, occasionally the partner is identified as a sibling whom the elder has lived with for many years (Meneses & Monroe, 2007). Also, it is common for LGBTQ elders to be less connected to their biological families of origin; they often rely on partners and friends or their ‘chosen family’ as a means of physical and social support (Brotman et al., 2003; MMI, 2010). LGBTQ elders fear that their support persons will not be recognized or given rights to visitation, decision making, and caregiving (LLDEF, 2011). LGBTQ elders who have not formally identified partners or friends as their legal durable power of attorney for healthcare decisions (DPOA-HC) are often faced with an unfortunate dilemma. Because LTC facilities often require that a DPOA-HC be identified, LGBTQ elders can either rely on biological family, who historically may have been hostile, or else self-disclose their sexuality by identifying the partner as their decision maker. Additionally, despite the possibility that a number of these individuals may be legally married in states with gay marriage laws, LGBTQ elders may be barred from sharing a room with a spouse and the spouse may not be allowed to make funeral arrangements at the time of death (Jackson et al., 2008).

LTC Staff Knowledge and Barriers Related to Sexuality in the Elderly

The third major theme identified in the literature was LTC staff members’ limited awareness of and negative attitudes toward LGBTQ residents, along with a lack of knowledge of sexuality and sexual diversity in the elderly. While the majority of research on sexuality in LTC has been focused on heterosexual sexuality, Hinrichs and Vacha-Haase (2010) examined staff knowledge and attitudes toward both heterosexual and homosexual LTC residents. They conducted their investigation at seven LTC facilities in Colorado with a sample size of 218 LPNs and CNAs. Prior to an educational session, participants were given pre-tests assessing their knowledge and attitudes regarding sexuality in the elderly. Next, short vignettes were presented depicting resident sexual encounters. These vignettes were designed to gauge staff perception of same-gender sexual contact in LTC. Gender-neutral names were given to both residents in the vignettes but the genders of the residents were varied to include female-male, male-male and female-female gender pairings. Immediately after reading the vignettes, participants were asked a series of questions about each gender pairing. Participants reported they would react more negatively to same-gender pairing and also indicated that they would report all sexual contact among residents to a supervisor. Implications of this study suggested that LTC administrators should advocate for homosexual-affirmative education, practices, policies and procedures to protect residents from the effects of homosexual bias by LTC staff.

A study conducted in Australia evaluated the effect of a 3-hour education session that was presented to 112 residential, eldercare RNs and LPNs (Bauer et al., 2013). Participants were given a pre- and post-test designed to gauge attitudes and beliefs about elder sexuality, including same-gender sexual expression, using the Ageing Sexuality Knowledge and Attitudes Scale and the Staff Attitudes about

Intimacy and Dementia Survey. A three-hour workshop was presented between pre-and post-testing and included topics addressing human sexuality, sexual stereotypes, sexuality in aging, sexuality and illness, residents’ rights, staff responsibilities, and legal issues related to consent. Overall, chi-squared analysis demonstrated that staff attitudes were significantly more permissive toward heterosexual and homosexual residents following the educational session. However, when asked to consider their own relatives in LTC, results demonstrated less permissiveness. Researchers hypothesize that while knowledge may be increased through education, attitudes about sexuality among LTC staff may not change. The authors suggested an effort be made to help nurses avoid inadvertently playing ‘moral guardians’ to residents (p. 89).

Hollibaugh (2011), an LGBTQ advocate who helped create the first LGBTQ aging curriculum for Services and Advocacy for GLBT Elders (SAGE), interviewed more than 60 staff members, at nine nursing homes, who had indicated an interest in serving LGBTQ elders. While it was not clearly defined who were considered as staff, Hollibaugh found that overall those interviewed denied that there was any sexual activity occurring in their facilities because they believed sex was not an important component of the lives of elderly adults. Although staff at these facilities reported they had no known LGBTQ residents, some staff said that if they did they would be “…especially tolerant if gay residents weren’t flamboyant (men) or too masculine (women)” (p. 9). Despite the staff’s assumption that elders were asexual, staff reported that they believed that other residents would be uncomfortable with openly LGBTQ residents for fear that “…a gay elder might try to seduce a straight elder” (p. 12). These staff members also seemed surprised that there might be non-traditional gender identities in older adults, including transgendered individuals.

There remains scant literature related to the impact of heterosexism on LGBTQ residents in LTC, yet preliminary investigation reveals that LGBTQ elders may be at risk for substandard care. The literature provides evidence that education and awareness programs may have a significant impact on LTC staff permissiveness and attitudes toward the LGBTQ elder population (Bauer et al., 2013; Hinrichs & Vacha-Haase, 2010; Jackson et al., 2008; Stein et al., 2010). Further research is needed to more clearly describe the impact of heterosexism on elders residing in LTC.

Changing the Culture of LTC Related to LGBTQ Elder

While there is limited literature on the experience of LGBTQ elders in LTC facilities, research indicates that there are several themes to be considered. Adding to this body of knowledge requires further discussion on sexuality, strategies for changing LTC culture, and educating elders on their roles, responsibilities, and rights for their future healthcare. Each of these themes will be discussed below.

Discussion of Sexuality

While age is often used as the common denominator to explain behavior in the elderly, LTC facilities are mandated to provide culturally competent care based on a number of other parameters including spoken language, class, ability, gender, and race (Health and Human Services, n.d.; Meneses & Monroe, 2007; Somers & Mahadevan, 2010). Sexuality is a broad term that encompasses sex, gender, gender identity, gender roles, sexual orientation, pleasure and reproduction (World Health Organization [WHO], 2014).

When providing care for adults in LTC, staff must understand the distinctions among the complex aspects of sexuality. Sex refers to a person’s biological status and is typically categorized as male, female, or intersex. Gender is culturally defined as attitudes, feelings, and behaviors that a given

culture assigns to a person based on sex. Related to gender is gender identity, which refers to one’s sense of self as male, female, or transgender. Sexual orientation refers to one’s romantic and sexual attraction toward others and is fluid for some people. One’s sexual orientation does not always result in sexual behavior or sexual acts (American Psychological Association [APA], 2011). Sexual expression in LTC involves a complex interaction between individual preferences, laws, policies, family values, beliefs and staff attitudes and knowledge (Hinrichs & Vacha-Haase, 2010). Additionally, sex, sexuality, and sexual identity are often used interchangeably, and many researchers and healthcare providers fail to clearly identify differences between the three terms (Solarz, 1999). In the above review of literature on perceptions of LTC staff toward LGBTQ residents, researchers made little distinction between sexual orientation and sexual expression, contact, or behavior. Unclear definitions can result in ambiguity for LTC staff who may be accepting of residents that identify as LGBTQ but not of sexual behavior between same-sex couples. It is evident that education of LTC staff regarding the complex nature of sexuality is essential to providing culturally competent care for residents.

Approaches for Changing the Culture in LTC Facilities

Employees in LTC facilities are in a unique position to improve the lives of LGBTQ elders in their care by implementing a two-tiered approach to cultural change. The first tier consideration (assessment) begins by assessing both the fears of LGBTQ residents along with staff/resident attitudes toward, and knowledge about, LGBTQ residents under their care. This may include interviews, written questionnaires, and/or focus groups. It is important to assign these duties to professionals who are sensitive to the unique needs of the LGBTQ elder population. Assessment can potentially help to address two key issues: LGBTQ residents may voice their concerns and staff and residents with homosexual prejudice might have an opportunity to gain new perspectives. Just as the issue of heterosexism exists in the greater society and among LTC staff, so too, may it exist among heterosexual LTC residents. As such, it is the staff’s responsibility to identify residents who might be hostile toward their LGBTQ peers and to make every effort to prevent verbal/physical abuse and forced or self-imposed isolation of LGBTQ residents. Many LGBTQ elders believe that the most significant impact a LTC facility can make in fighting LGBTQ isolation and invisibility is to combat heterosexism (Stein et al., 2010).

A second assessment consideration is that of the environment. For example, art work in the facility could reflect diverse people, and reading material in public areas could include journals and books that illustrate LGBTQ points of view or characters. Conversely, one must caution to avoid art, reading material, and television programs reflecting homophobia and heterosexism. Facilities that place pink triangles or rainbow-colored safezone signs in public areas will indicate to LGBTQ patients and their families that the facility is safe and accepting of sexual minorities (Gay and Lesbian Medical Association [GLMA], n.d.). Environmental assessment also includes a review of facility forms. Adding inclusive language options to the questions related to spouse, relationship, family, and sexual history will help remove barriers to self-disclosure for LGBTQ elders. Inclusive forms also aid in normalizing LGBTQ experiences (GLMA, n.d.).

Assessment of policies and procedures is the third assessment consideration. Patient non- discrimination policies could include sexual orientation and gender identity as protected classifications. Visitation policies could explicitly grant equal visitation to LGBTQ patients and their visitors. The facility’s policy regarding couples sharing living quarters could be inclusive of same sex couples (Bluestein & Bach, n.d.; LLDEF, n.d.). To complement resident policies, employment non- discrimination policies could include the terms sexual orientation and gender identity. LGBTQ staff can

informally educate co-workers and residents and provide guidance to facility leadership (HRC, 2013). LTC facilities may also find it helpful to recruit board members who have a professional understanding of the lives of LGBTQ elders. When necessary, facility leaders should enforce a zero tolerance policy on discrimination against LGBTQ residents and staff.

The second tier consideration (cultural change) calls for expert training in LGBTQ patient-centered care. Formal healthcare education provides only a limited amount of core LGBTQ curricular content (Brennan, Barnsteiner, Siantz, Cotter, & Everett, 2012); the limits of this formal education increase the importance of workplace education for LTC staff. Since LTC residents are in daily contact with a wide variety of service providers, such as housekeepers, dietary workers, therapy staff and maintenance personnel, all persons working in a LTC facility should receive LGBTQ training.

An educational curriculum could focus on several content areas, including: human sexuality and aging; homophobia and heterosexism; sexual diversity among LTC residents; fears and experiences of LGBTQ in LTC facilities; inclusive policies and procedures; Health Insurance Portability and Accountability Act (HIPAA) requirements; and best practice in caring for LGBTQ residents (Bluestein & Bach, n.d.; HRC, 2013). Care should be taken to allow for question-and-answer sessions in order to dispel myths and discuss personal nursing/work experiences (Low, Lui, Lee, Thompson, & Chau, 2005). For example, during group and individual activities with LTC staff and residents, activities staff could be encouraged to include current events topics about LGBTQ newsworthy events, thereby normalizing the lives and experiences of LGBTQ residents.

However, increased training and education does not always result in a change in attitudes and behaviors. Because some employees may find this type of education in conflict with their religious beliefs, placing LGBTQ education in the context of professional practice and workplace requirements is critical (Hinrichs & Vacha-Haase, 2010). It is important to note that in order for training to be most effective, it must be ongoing and complemented with routine mentoring and performance evaluation. Several professional organizations have called for a standardized diversity education program, one that is developed in collaboration with LGBTQ advocacy programs and that may be utilized by LTC leadership (U.S. Administration for Community Living, 2014; Bluestein & Bach, n.d.; GLMA, n.d.; HRC, 2013).

Educating Elders Regarding Their Rights and Responsibilities

During a time of health crisis or significant change, it is challenging to consider the ramifications of long-term disability. Hence, prior to LTC placement, it is imperative that elders and their families understand their personal rights and responsibilities. This is of particular importance for LGBTQ elders who may not find anti-discrimination protection under state or federal laws and regulations.

Designating a DPOA-HC and identifying preferences in an advanced directive are two important documents that should be considered (Bluestein & Bach, n.d.). Information about LTC planning is available from multiple national organizations, including the following: the American Association of Retired Persons (AARP, n.d.); the Center for Positive Aging, (n.d.); the LongTermCare.gov (n.d.); the National Long-Term Care Ombudsman Resource Center (NORC, n.d.); the National Resource Center on LGBT Aging (n.d.); and the U.S. Administration for Community Living (2014). Additionally, elders may want to locate a LTC facility that specifically markets to LGBTQ residents. While multiple resources exist, healthcare providers at every encounter share in the responsibility of educating elders. In all healthcare settings, there should be the obligation to educate LGBTQ elders on preparing for their future healthcare needs.

Conclusion

This article illustrates the impact of heterosexism on LGBTQ elders in LTC and recommends strategies for change. However, to eliminate health inequities, it is necessary to look beyond the role of individual healthcare providers and individual agencies. For LGBTQ elders, this includes an exploration of historical and socio-political influences that have caused inequities to develop over time. In many instances, healthcare workers and LTC facilities perpetuate the heterosexist attitudes and behaviors found throughout society, further marginalizing LGBTQ elders. Because the health of LGBTQ elders depends on their ability to overcome long-established social inequities, continued intentional or unintentional victimization in LTC facilities may lead to substandard care and poor health outcomes.

Additionally, laws and regulations governing and regulating LTC facilities still support the heterosexual societal norm (Cohen et al., 2008; Meneses & Monroe, 2007).

Perhaps the most appropriate source of information for addressing the above issues in LTC facilities should come from LGBTQ elders themselves. Perhaps the most appropriate source of information for addressing the above issues in LTC facilities should come from LGBTQ elders themselves. Above all, LGBTQ elders state that they feel safe in gay-friendly environments (Jackson et al., 2008; Stein et al., 2010). Additionally, it’s important to remember the concept of residence. Residents of LTC facilities have the right to the same level of dignity and privacy as if they were in their own homes (Hinrichs & Vacha-Haase, 2010). In fact, in a LTC facility, residents are in their own homes where they should be able to expect that they will be safe and valued. However, when bias exists among LTC staff, LGBTQ residents risk maltreatment, either overtly through the expression of homophobia or subtly through the expression of heterosexism. LTC staff has the responsibility to create a milieu that feels like home for all residents. Facility leaders are in a unique position to create a culture of care that helps LGBTQ elders flourish in what, for many, may be their last home.

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