What Would Good Practice Look Like for Each of These People?

Westwood, S, King, Andy, Almack, K, Suen, Y-T, Bailey, L (in press) ‘Good Practice in Health and Social Care Provision for Older LGBT people’, J. Fish and Kate Karban (eds) Social Work and Lesbian, Gay, Bisexual and Trans Health Inequalities: International Perspectives The Policy Press. FINAL DRAFT

Vignette

Laura, Gary, Bridget, Chris and Theresa have been referred to social services. Laura is an 83-year-old White British lesbian. Her civil partner died last year and she now lives alone in their large multi-storey house in a rural area. She has several private pensions. Her eyesight is deteriorating and she can no longer drive. She is lonely and depressed. Gary is a single 70-year-old gay man of African Caribbean decent, living in an inner city local authority flat and reliant on state pensions and other forms of welfare support. He is showing signs of memory loss and confusion. Bridget is a 65-year-old bi-identifying woman of White Irish Catholic origin. She lives in the suburbs with her partner, Chris, aged 69, a White British bisexual man who has multiple sclerosis, needing increasing care and support. Their daughter is supportive, but lives a long distance away. Theresa is a 61-year-old heterosexual trans woman with an Asian/White British heritage, who transitioned[1] three years ago. She has a son, but they are estranged. She lives in a sheltered housing scheme for people with mental health issues. Theresa has complained that staff are discriminating against her.

What would good practice look like for each of these people?

Introduction

Lesbian, gay, bisexual and trans (LGBT) ageing occurs in wide ranging socio-legal contexts. In countries where there is a lack of legal recognition and social protections, the health of LGBT people is impacted not only by the accumulated effects of discrimination but also by the fact that their older age care needs are served by health and social care systems that offer little or no recognition of their minority identities (AGE Platform Europe and ILGA-Europe, 2012). Even in more liberal countries offering some forms of legal rights, older LGBT people experience a range of health inequalities. These disadvantages (Fredriksen-Goldsen et al, 2013a, 2013b) can be clustered into four main areas:

·  the cumulative physical and psychological effects of discrimination, stigma and marginalisation across the lifecourse;

·  a relative lack of social capital, particularly informal social support, compared with heterosexual and cisgender older people;

·  health and social care provision that is ill-equipped to recognise and meet the needs of older LGBT people (Fish 2007 & 2009);

·  the intersection between increased need for formal support and a reluctance on the part of older LGBT people to access health and social care provision because of concerns about how they will be treated (Ward et al, 2011).

This chapter will first locate older LGBT health inequalities in a theoretical context before outlining core areas of good practice for older LGBT people across health and social care contexts. It will then explore specific areas of good practice linked to vignettes, which are composites, drawn from our respective pieces of empirical research.

Context

Older LGBT health inequalities can be understood through the lens of both health determinants and resilience. From a health determinants perspective (Williams et al, 2013), the impact of ‘minority stress’ (that is, the cumulative effects of having a marginalised identity) is now recognised as having a major effect on older LGBT people’s health and wellbeing (Fredriksen-Goldsen et al, 2013a, 2013b) and can result in depression, self-harm and lifestyle issues such as drug and alcohol use and obesity (Witten and Eyler, 2012). Moreover, many older LGBT people are ageing with reduced social capital (Cronin and King, 2013), which in turn has an impact on health. Older LGBT people are more likely than their heterosexual peers to be single and living alone, to be childless and to have less contact with biological family (Stonewall, 2011; Fredriksen-Goldsen et al, 2013a). While older LGBT people have ‘families of choice’ (Weeks et al, 2001) networks, they are often of the same generation, so that as friends die there is no younger cohort available for ongoing informal care and support. It is now generally recognised that older LGBT people are in need of formal health and social care provision sooner than their heterosexual peers, because of relatively diminished social support networks, and because of health needs linked to minority stress.

Yet at the same time, the quality of health and social care provision for older LGBT people is extremely variable. Some European countries lack policies that are responsive to and reflective of older LGBT people’s needs, while in other countries those policies are in place but are not appropriately implemented (AGE Platform Europe and ILGA-Europe, 2012). Even where policies are effectively in place, heteronormativity, homophobia, biphobia and transphobia[2] can mean that older LGBT people go unrecognised at best and experience discrimination at worst (Ward et al, 2011). Social work has a major role to play in addressing and redressing these health inequalities (Coren et al, 2010), through both tackling LGBT stigma and marginalisation, and thereby reducing/mitigating their effects on health. Additionally, taking a resilience approach (understanding the complex interplay of risk and protective factors) to the lives of older LGBT adults can involve both risk reduction and also protection enhancement (Fredriksen-Goldsen et al, 2013a, 2013b). In particular, improved social support has a key role to play in both reducing risk associated with social isolation and enhancing resilience in terms of social support (Knocker et al, 2012). Health and social care providers should not only become more inclusive in the services they offer, but should also work on preventative issues, particularly the need for more, better-resourced, older LGBT people support networks. While older LGBT people continue to be marginalised in both services for older people and generic services for LGBT people, there is a growing number of publications that identify good health and social care practice guidelines in working with older LGBT people (Knocker, 2006; Concannon, 2009; GRAI and CHIRI, 2010; Opening Doors London, 2010; Age UK, 2011; LGBT MAP and SAGE, 2012; National Resource Center on LGBT Aging, 2012; Stonewall, 2012). These highlight seven main areas of good practice:

·  inclusive consultation in service design and delivery;

·  appropriate equality and diversity and LGBT-specific policies;

·  creating a safe working and living environment for staff and service

users;

·  a robust staff training strategy;

·  appropriate language and cultural representation;

·  person-centred assessment and care planning;

·  setting and auditing standards.

Each of these will now be addressed.

Inclusive consultation

Older LGBT people should be included in the design, implementation and monitoring of service provision, through:

·  community group liaison;

·  confidential monitoring of sexual orientation and gender identity among staff and service users;

·  service user feedback, including via safe and supportive LGBT staff and service user networks (for example, Anchor Housing; see Stonewall, 2012).

Appropriate policies

Services should employ staff and service user equality policies that explicitly address sexual orientation, gender identity and gender expression. Anti-discrimination policies should be clearly displayed in publications and on public display. Managers should make clear to staff and service users that discrimination is not tolerated, staff should be confident that they will be supported in challenging discrimination and there should be a safe, confidential and robust complaints procedure.

A safe working and living environment

LGBT staff need to be made to feel confident and comfortable in the workplace, by creating a culture of inclusion. If LGBT staff are comfortable at work it is much more likely that LGBT service users will be as well.

A robust staff training strategy

There should be comprehensive training about older LGBT people on all social work training courses, as well as for managers, practitioners, educators and healthcare staff. Practitioners and policy makers need to appreciate how LGBT histories inform their fears about engaging with health and social care provision (River and Ward, 2012). ‘Homosexuality’ was classified as a psychiatric disorder under the Diagnostic and statistical manual of mental disorders (DSM-II) until it was removed from its seventh printing in 1973 (McCommon 2009) and many older LGB people will have experienced enforced psychiatric ‘cures’. Many trans people continue to be pathologised under the DSM-V diagnosis of ‘gender dysphoria’[3] (APA, 2013), making them particularly wary of engaging with mental health services (McNeil et al, 2012).

Appropriate language and cultural representation

All staff should be careful not to use language that makes assumptions about someone’s sexual orientation or gender identity. Promotional materials (brochures, leaflets, websites and so on) for older people should include visual representations of older LGBT people and should make explicit a service’s commitment to working with older LGBT people. Healthcare, day care and residential establishments should have pictures and photographs representing older LGBT people, display LGBT publications and advice sheets, and hold LGBT social events and celebrations.

Person-centred assessment and care planning

LGBT people do not want to have the added hassle of explaining or defending their sexualities and/or gender identities when they may already be stressed and/or in crisis. They want personalised care plans that take all intersecting aspects of their identity into account, tying in with the United Kingdom (UK) government’s personalisation agenda, which emphasises individualised care packages rather than ‘one size fits all’ (DH, 2007). Examples of good care planning include:

George would like to have his subscription to Gay Times continued. He enjoys having some of the articles read out to him. He likes going through the ‘personal ads’ column thinking about who he might like to contact.

Rosaria would like to go out to a local gay pub with three of her closest female friends on a monthly basis. (Knocker, 2006, p 28)

Age UK highlights areas of good practice with older trans people.

Sometimes small choices can make a big difference. For example, if a trans man in a nursing home has feet that are too small for men’s slippers, rather than buying women’s slippers, service providers should purchase boy’s slippers instead (Age UK, 2011, p 24).

Setting and auditing standards

A number of ways have been suggested to raise the bar for LGBT health and social care provision, including:

·  kite-marking;

·  commissioners requiring service providers tendering for contracts to evidence how their service meets the needs of older LGBT people;

·  mobilisation of equality and human rights legislation to challenge inadequate provision.

The next section considers these good practice guidelines in the contexts of the vignettes.

Implications for social work practice

Laura

Laura is an 83-year-old White British lesbian …

Some older lesbians have identified and lived as lesbians all their lives. The oldest are most likely to have led hidden lives and not to have children. They may belong to a rich informal network of other women/lesbians, but are all of a similar age, meaning that they may develop extra care needs at around the same time. Some women have lived a significant part of their lives as heterosexuals, but in later life form same-sex relationships, some identifying as bisexual, some as lesbian and others mobilising a sexual fluidity discourse. These women are more likely to enjoy informal support from children and grandchildren but have greater difficulty meeting and socialising with other lesbians (Cronin and King, 2013).

LGBT people living in rural areas, who may have geographically dispersed communities, may find it more difficult to access those communities in later life, leading to loneliness and isolation, which in turn can lead to depression (Jones et al, 2013). LGBT bereavement is less likely to be recognised, supported and socially validated, which in turn leads to ‘disenfranchised grief ’ and an increased risk of depression (see Chapter Ten, this volume).

An assessment of Laura’s needs should take into account her recent bereavement, and her low mood. In terms of her loneliness, referring Laura to a local day centre, where there may be no other ‘out’ lesbians, may only add to her sense of isolation (Langley, 2001). Local and national support networks for older lesbians should be considered, as well as how she can be supported to maintain/restore pre-existing social networks.

If Laura decides that she wishes to live in sheltered housing, she should be supported in identifying suitable provision. There should be a menu of housing choices available to older lesbians and all older LGBT people. For example, a significant number of older lesbians want LGBT-specific housing, and many want it to be women-only or lesbian-only (Stonewall, 2011; Averett and Jenkins, 2012). Others want ‘LGBT-friendly’ mainstream provision, fearing ghettoisation in specialist services. Emergent projects in Australia, Spain and the United States suggest that some specialist housing projects and/or collective co-commissioning of services might be a possibility (Carr and Ross, 2013). Addressing Laura’s housing and social support needs will both reduce the risk of loneliness and depression (and consequent effects on her physical health), and promote her resilience to physical and mental health issues.

Gary

Gary is a single 70-year-old gay man of African Caribbean descent …

Older gay and bisexual men experience elevated health risks compared with both the general population and older lesbian/bisexual women, including in relation to drug and alcohol use, increased internalised stigma and associated mental health problems and less social support, again impacting on physical and mental health (Fredriksen-Goldsen et al, 2013b). Older gay men ageing with HIV are especially vulnerable to deficiencies in informal social support (Rosenfeld et al, 2012) and this in turn impacts their resilience in coping with their health needs. Black older gay men also report significantly higher levels of perceived ageism and social exclusion than white older gay men (David and Knight, 2008).

Gary has very limited material and social resources, which impact his ability to maintain social networks in later life, in turn affecting overall wellbeing (Heaphy, 2009). He is also showing the early signs of dementia. While dementia among black and minority ethnic (BME) populations is receiving increasing attention (APPG, 2013), there is very little awareness so far about dementia among LGBT individuals. Much of dementia care is geared towards people with heterosexual and gender-congruent identities (Price, 2008). So while Gary, if assessed and given a diagnosis, may be recognised as a black man with dementia, he is less likely to be recognised as a gay man with dementia, and even less likely to be recognised as a black, gay man with dementia. Dementia care spaces are dominated by women, as both care providers (because of the gendering of care work) and service users (because women live longer than men). This means that Gary, going into any form of dementia provision, be it day care or residential care, may experience a triple inequality because he is black, gay and a man.