Lesbian, Gay, Bisexual, Transgender and Intersex (LGBTI)
Australia’s ageing LGBTI population
Current estimates from the Department of Health (2019) state that approximately 11% of the Australian population identify as lesbian, gay, bisexual, transgender or intersex (LGBTI). Many have experienced gender and sexuality-based discrimination over their lifetime. Discrimination can be experienced as unfair treatment, social stigma, criminalisation or persecution based on identity, family rejection, barriers to accessing health and aged care services and inappropriate medical treatment, which can result in greater social isolation for LGBTI people.
Mainstream care approaches often assume that people are heterosexual and gender conforming. Many older LGBTI people may hide their sexual orientation or gender identity for their own safety or due to their previous life experiences. Decriminalisation of homosexuality in Australia did not occur until the 1970s, and institutional discrimination around the exclusion of same-sex couples from civil marriage was only recently resolved. Older LGBTI people are particularly vulnerable due to age and sexuality-based discrimination.
For many LGBTI people, sexuality represents an important part of who they are but defining someone solely by their sexual orientation, sex or gender identity is not appropriate. Some LGBTI people are, or have been, involved and visible in LGBTI communities and happily identify and socialise with these communities, while others may have minimal contact with the wider LGBTI community. Some LGBTI people have experienced rejection from their families and may be socially isolated or have formed their own non-biological family. These alternative families or ‘families of choice’ need to be incorporated into care planning, reflecting person-centred care approaches.
The impact of discrimination on health
Ongoing sexuality and gender-based discrimination can affect the health and well-being of LGBTI people. Discrimination experienced by LGBTI people has been proven to lead to poorer health outcomes, reduced participation in social activities and avoiding or delaying accessing health care due to fear of prejudice. A range of mental health outcomes are associated with experiences of marginalisation, discrimination, stigma, violence and abuse. LGBTI people may experience mental health conditions and may be at an increased risk of suicide. People have better health outcomes when they feel they belong and are accepted by their communities for who they are. LGBTI adults have a higher incidence of life-limiting illness than the general population, and often present to palliative care services with more advanced disease.
Following a person-centred and consumer directed care approach will best ensure the needs of older LGBTI Australians are identified and met.
Diversity within diversity among LGBTI individuals
There is ‘diversity within diversity’ among older LGBTI Australians. People who identify as LGBTI are from all backgrounds, ages, ethnicities and socio-economic status, and have unique lived experiences. They may belong to other minority groups (e.g. culturally and linguistically diverse, Aboriginal and Torres Strait Islander, veterans, care leavers, receiving palliative care, suffering financial disadvantage, living with HIV, dementia, or disability, and living in rural and regional areas). Belonging to multiple minority groups can compound disadvantage. Public representations of Australia’s LGBTI community tend not to include Aboriginal and Torres Strait Islander and/or culturally and linguistically diverse individuals. These individuals often face added difficulty in discussing or disclosing their sexual orientation or gender identity with their families, and may be ostracised within their own ethnic, religious and cultural communities.
Each person who identifies as LGBTI will have specific social, cultural, psychological, medical and care needs and requirements in aged care. For example, transgender and intersex individuals have different needs than gay men, and often have additional requirements to be considered by health services and providers. All older LGBTI Australians share the common experience of being part of a minority, who have likely experienced a life-course of exclusion, discrimination and stigma. Homophobia can be experienced within families and/or the wider community. Those who experience intersectional risk and increased discrimination are more likely to have poorer overall health and well-being. The people who often need the most support may be those who are most invisible and isolated in wider society.
LGBTI individuals in regional and rural areas
Older LGBTI people in regional or rural areas often lack support and choice in health providers, and have increased concerns about privacy, confidentiality and anonymity. Such challenges are often not as pronounced in metropolitan areas. Many people in smaller communities fear disclosing their sexuality or gender identity and are wary of ‘being outed’ by health and care staff in these communities. Rural areas are believed to be less tolerant and more discriminatory against LGBTI Australians. Organisations must provide culturally safe care to LGBTI adults. One important consideration is ensuring client confidentiality and privacy. This is especially important for those who are living longer with HIV/AIDS which will see an increase of people with these health concerns requiring aged care services in future. ASHM (Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine) have developed a resource for aged care workers regarding HIV and ageing.
Aged care considerations for LGBTI individuals
Ageing impacts social support and isolation. It is important to note that your clients and residents’ pre-existing social networks may be diminished due to the loss of partners, friends and families. Older adults often have greater physical impairment and may live with illnesses which can impact the social support they receive. Reduced income can further change living circumstances and increase isolation.
Australian research and policy has mostly focused on older gay and lesbian people. Bisexual, transgender and especially intersex individuals are still fairly invisible within mainstream health care and aged care settings. Many organisations are actively considering how their service can respond to the needs of older LGBTI people. Organisations may feel ill-equipped or unaware of the issues involved or actions which should be taken. For more information and relevant case studies, see the Department of Healthand Aged Care’s Actions to support Lesbian, Gay, Bisexual, Trans and Gender Diverse, and Intersex Elders, and the National Lesbian, Gay, Bisexual, Transgender and Intersex (LGBTI) Ageing and Aged Care Strategy. The best practice guidelines: Accommodating older gay, lesbian, bisexual, trans and intersex (GLBTI) people includes helpful infographics. Matrix Guild Victoria have several publications containing relevant information for older LGBTI adults in aged care
Legal requirements and guidelines govern the care of older LGBTI adults, to protect against sexuality and gender-based discrimination. This also applies to faith-based aged care providers. Religious beliefs have often contributed to actual and perceived discrimination, and faith-based providers may have limited awareness of the needs of LGBTI people. Education and training is necessary to prevent LGBTI discrimination. There are many projects and programs to support aged care providers in fostering LGBTI inclusive services. Organisations may be Rainbow Tick Standards accredited, reflecting they are LGBTI safe and inclusive. Rainbow Health Victoria have a range of LGBTI inclusive practice resources.
The 10 questions to ask about lesbian, gay, bisexual, transgender, intersex needs in residential aged care factsheet may also be useful. The Department of Health and Aged Care have developed a video on LGBTI inclusion and awareness in aged care, information about delving into My Aged Care: Aged Care for LGBTI elders: Getting started with My Aged Care, and a factsheet to help in finding a LGBTI inclusive home care package on the service finder.
The Mosaic app can help LGBTI individuals to better plan and manage their aged care services and improve overall health outcomes. It contains resources for LGBTI people, their partners, families of choice, aged care workers, and aged care service providers.
The prospect of aged care or palliative care can be challenging for many older LGBTI people who may not feel recognised or supported by wider society. They may have a strong desire to age at home, due to previous experiences of prejudice and a fear of residential aged care. Same-sex couples often fear being separated in aged care facilities. It is important to know that some LGBTI people will avoid disclosing their sexual orientation, sex or gender identity in aged care settings, while others will strongly wish to disclose and have their identity recognised. Some transgender and intersex individuals may not have any choice about disclosing.
Organisations can encourage LGBTI friendly environments and foster positive inclusion by implementing various strategies, including:
- educating and training staff and volunteers on LGBTI awareness and issues
- employing staff who can relate to the organisation’s client base
- treating all clients and residents with dignity and respect
- maintaining client privacy and confidentiality where possible
- avoiding assumptions about an individual’s sexual orientation
- ensuring organisational intake assessment forms are inclusive of all sexual orientations (e.g. including non-binary options)
- using appropriate, respectful and inclusive language with each person (reflecting the language the individual prefers and identifies with)
- asking people how they would like information about their sexual orientation to be shared with staff and other residents, and in care notes
- using gender-neutral and non-discriminatory language (e.g. ‘partner’ rather than ‘husband’ or ‘wife’) when conversing with clients and residents
- including same-sex partners in activities and care
- recognising LGBTI activities, events and days
- reflecting LGBTI imagery throughout documentation and physical environment, to ensure representation
- recognising the lasting impact of historical discrimination faced by older LGBTI people
- appreciating the health issues which may uniquely affect LGBTI individuals
- acknowledging the specific experiences of transgender and intersex individuals, including possible historic trauma
- working towards and obtaining Rainbow Tick Accreditation.
Palliative care and advance care planning considerations for LGBTI individuals
The specific needs of LGBTI people at end of life are not well understood. The Department of Health and Aged Care has released an exploratory analysis of barriers to palliative care and advance care planning report on people who identify as LGBTI, which contains approaches for improving access and quality of care for this group. LGBTI Australians often experience barriers with respect to advance care planning including lack of knowledge, lack of perceived need, social isolation, potentially strained relationships with biological family, difficulties identifying alternative decision-makers and difficulties communicating end of life care wishes to their partners and ‘family of choice’. Advance care directives or plans can be especially useful in outlining and recognising living arrangements, domestic partnerships and friendship groups of older LGBTI people, as these factors impact end of life (including medical guardianship, enduring powers of attorney / substitute decision makers, funerals, inheritance for same-sex couples, and financial legislation arrangements). Not recognising a chosen partner as an individual’s approved decision maker is discriminatory.
There have been recent challenges of some historical and current state legislation resulting in different laws around next of kin and decision making for LGBTI Australians (e.g. the Relationships Register Bill 2016, which recognises same-sex couples married in jurisdictions which allow same-sex marriage). Recent Australian legislations have also made it possible for same-sex couples to benefit from life insurance, by amending the definition of ‘spouse’ to include same-sex partners.
It is important to remember that some LGBTI Australians do not have children or may have children who do not accept their sexuality or gender. ‘Family of choice’ should be included in care planning, similar to biological family. Assisting LGBTI individuals to feel safe and welcome can greatly impact later life and experiences with health services, aged care and palliative care. Discussions should be had as early as possible in the trajectory of the illness. For more information, visit LGBTI Advance Care Planning by State and Territory by the Department of Health and Aged Care. For further information on LGBTI issues, visit the National LGBTI Health Alliance, The Equality Project, Alice’s Garage, palliAGED and CareSearch.