Professional Psychology: Research and Practice
2014, Vol. 45, No. 4, 269 –277
© 2014 American Psychological Association
0735-7028/14/$12.00 http://dx.doi.org/10.1037/a0037172
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
Promoting an Affirming, Competent Practice With
Older Lesbian and Gay Adults
Jennifer Hillman
Gregory A. Hinrichsen
The Pennsylvania State University, Berks College
Icahn School of Medicine at Mount Sinai
The American Psychological Association’s Practice Guidelines for older adults and for lesbian and gay
(LG) clients encourage psychologists to increase their awareness of the unique stressors faced by older
LG adults. Psychologists are increasingly likely to see an older LG client in their practice as the number
of LG elders is expected to swell to nearly 7 million within the next decade, in tandem with the aging
of the general population. This article promotes LG-affirming practice and competence by reviewing
issues related to stigma and discrimination, physical, sexual, and mental health disparities, legal issues,
and barriers in long-term care, as well the capacity for adaptation and resilience evident in many LG
older adults. The importance of racial and ethnic group membership and age cohort in the experience of
aging among LG adults is discussed. Case examples, resources, and recommendations for practice,
advocacy, and research related to LG aging also are provided.
Keywords: older adults, aging, lesbian, gay, psychotherapy
Supplemental materials: http://dx.doi.org/10.1037/a0037172.supp
Approximately 3 million older adults in the United States currently identify themselves as lesbian or gay (LG; National Gay and
Lesbian Task Force [NGLTF], 2006).1 Within the next decade the
number of older LG adults is expected to swell to more than 7
million because of the aging of the general population (NGLTF,
2006). Two national surveys of psychological service delivery to
older adults have been conducted. One found that nearly two-fifths
of psychologists provide at least some services to older adult
clients (American Psychological Association Center for Workforce Studies, 2008). The other study estimated that 79% of all
psychologists will provide services to an older adult at some point
in their career (Qualls, Segal, Normal, Niederehe, & GallagherThompson, 2002). Other research documented that more than half
of all therapists report seeing an LG client of any age within the
past week (Murphy, Rawlings, & Howe, 2002). LG adults also are
more likely to utilize psychotherapy than their heterosexual peers
for mood disorders, anxiety disorders, and chemical dependence
(Cochran & Mays, 2000). Therefore, psychologists are increasingly likely to see aging LG adults in their practice.
Findings from an American Psychological Association (APA)
Task Force on Bias in Psychotherapy with Lesbians and Gay Men
provide evidence of inadvertent mistreatment of LG clients, often
“I am gay.” A 65 year-old man, newly admitted to a nursing
home on the outskirts of a large Mid-Atlantic city scribbled this
statement on a piece of paper before sliding it across the table to
his new psychologist. The resident held his finger up to his lips,
looked cautiously out into the hallway, and whispered “shhh”
before taking the piece of paper back, and ripping it into tiny
pieces. Despite the significant strides taking place toward gay
rights in the United States, this event occurred in the psychotherapy practice of the first author in 2013. (Identifying information
for this and all subsequent clients has been changed.) Fear of
stigma and outright discrimination in a variety of health care,
institutional, and social service settings are well documented
among aging lesbian and gay adults (Fredericksen-Goldsen et al.,
2011; Metlife Mature Market Institute & The Lesbian and Gay
Aging Issues Network of the American Society of Aging, 2010),
including those who live in what one would expect as more
socially progressive, urban areas (Hinrichsen, 2010; Thurston,
2009).
JENNIFER HILLMAN received her PhD in clinical psychology from the
Derner Institute at Adelphi University. She is professor of psychology in
the Applied Psychology Program at the Pennsylvania State University,
Berks College. Her research interests include sexuality and aging, problem
behaviors in long-term care, and grandparenting.
GREGORY A. HINRICHSEN received his PhD in community psychology
from New York University. He currently is on the faculty of the Brookdale
Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai. His professional interests include evidence-based
psychotherapy for late life depression, geropsychology education, and
public policy and aging.
CORRESPONDENCE CONCERNING THIS ARTICLE should be addressed to
Jennifer Hillman, Applied Psychology Program, Penn State Berks, Franco
119, Tulpehocken Road, Reading, PA 19610. E-mail: [email protected]
1
Only limited empirical data are available regarding older bisexual
adults, with most information being drawn from small samples of convenience (Haber, 2009). Because many bisexual individuals describe their
sexual orientation as gay, lesbian, or heterosexual based upon the sex of
their most recent or current partner, they often become invisible (Kingston,
2002) even within the context of research. It also is essential to differentiate
between issues of sexual orientation and gender identity (American Psychological Association, 2009; American Psychological Association, 2012).
Accordingly, an appropriate discussion of the issues and challenges faced
by bisexual and transgender elders, and related concerns about competency
in psychotherapy are considered beyond the scope of the current article.
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HILLMAN AND HINRICHSEN
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270
stemming from a lack of knowledge (Garnets, Hancock, Cochran,
Goodchilds, & Peplau, 1991; Mabey, 2011). Consistent with these
findings, results from national surveys indicate that fewer than one
in four LG elders disclose their sexual orientation to a health
care provider (Fredrickson-Goldsen et al., 2012), and that one in
five LG baby boomers have little or no confidence that a health
care provider would treat them with dignity or respect (Metlife
Mature Market Institute & The Lesbian and Gay Aging Issues
Network of the American Society of Aging, 2010). To compound
these challenges to providing competent LG-affirming care, older
LG adults represent one of the least empirically studied populations in terms of their mental health needs and unique experiences
in therapy (David & Knight, 2008; Grant, 2010; Institute of Medicine, 2011; Pachankis & Goldfried, 2004). Graduate programs
also provide minimal training regarding the unique issues often
faced by both LG (Murphy et al., 2002) and older adults (Hinrichsen, Zeiss, Karel, & Molinari, 2010).
APA Practice Guidelines for both older (American Psychological Association, 2014) and LG clients (American Psychological
Association, 2012) encourage psychologists to build knowledge of
and skills in the treatment of the unique stressors and challenges
often experienced by LG elders in what is sometimes referred to as
the “double jeopardy” (Dowd & Bengtson, 1978) of ageism and
heterocentrism. Heterocentrism is negative, individual and collective attitudes, and behaviors associated with any deviation from
heterosexuality. Heterocentrism includes both implicit and often
unintentionally negative attitudes and behaviors that overlook the
presence of LG adults (e.g., an intake form asks only if a client has
ever been married rather use more inclusive language) as well as
explicit, intentionally negative attitudes, and behavior (i.e.,
homonegativity; Pachankis & Goldfried, 2004).
This article provides psychologists with information about aging
LG adults including historical and cohort influences, diversity,
specific challenges (e.g., health disparities, discrimination in longterm care, and legal issues), and evidence of significant adaptation
and resilience (e.g., David & Knight, 2008; Riggle, Whitman,
Olson, Rostosky, & Strong, 2008). Resources about LG aging and
recommendations for advocacy on behalf of older LG adults by
psychologists also will be offered. Because clinical examples can
enhance competence in work with diverse populations (Gallardo &
McNeill, 2009), they also will be provided.
Historical and Cohort Effects
All LG adults over the age of 50 lived through a time when their
sexual orientation was labeled immoral, illegal, and pathological;
homosexuality was only officially removed from the American
Psychiatric Association’s Diagnostic and Statistical Manual in
1973 (American Psychiatric Association, 1973). Individuals who
revealed their minority sexual orientation in younger years often
suffered significant psychological and physical abuse by the larger
community (e.g., verbal harassment, social isolation, sexual, and
physical assaults; Lehavot, Walters, & Simoni, 2010). The clinical
sequelae of these negative early life experiences for LG elders may
present themselves in later life as diffuse anxiety, depression,
somatic distress, and complaints, or even posttraumatic stress
disorder (Brown, 2011). LG elders also may have some degree of
internalized homophobia (e.g., holding a negative view of their
own sexual orientation; Kuyper & Fokkema, 2010) that can sig-
nificantly mitigate against seeking beneficial social support and
mental health care services (D’Augelli, Grossman, Hershberger, &
O’Connell, 2001).
American Psychological Association practice guidelines (American Psychological Association, 2014; American Psychological
Association, 2012) encourage psychologists to take into account
the impact of being part of a generational age cohort (e.g., baby
boomers) because experience and attitudes vary among age cohorts including attitudes toward mental health services. LG baby
boomers experienced significantly different historical events than
did earlier age cohorts. For example, the oldest LG elders came of
age in the 1950s when President Eisenhower’s, 1953 Executive
Order #10450 called for homosexuals to be fired from government
jobs, and McCarthy’s congressional hearings of 1954 sought to
expose homosexuals as well as other “subversive elements” including communists. Few LG individuals openly professed their
status out of fear of discrimination and violence, as individuals
found engaging in same-sex behavior could be and were sent to
prison or mental hospitals. During that era only married heterosexuals could adopt children, and no federal or state laws protected
LG individuals from victimization (see Kimmel, Rose, Orel, &
Greene, 2006, for a review). The mental health establishment
offered “treatments” to change homosexual orientation through the
provision of certain psychotherapies, electroconvulsive therapy,
and hormones (Jenkins & Johnston, 2004).
Previous generations of LG persons clearly experienced enormous social pressure to suppress sexual expression or hide sexual
orientation (Mabey, 2011). As a result, earlier generations of LG
elders (i.e., the now oldest-old LG elders) are more likely to have
married opposite sex partners, and in late life have ex-spouses,
adult children, and grandchildren when compared with LG baby
boomers. Compared with their heterosexual peers, however, these
oldest LG elders also have fewer biological relatives available to
assist them with instrumental and financial needs related to longterm health care (Grant, 2010).
In contrast, baby boomers came of age during the advent of the
gay rights movement which was catalyzed by the 1969 Stonewall
riot in New York City. These baby boomers grew up with the
American Psychiatric Association’s (1973) announcement that homosexuality was no longer regarded a mental disorder, the 1974
election of Kathy Kozachenko, the first openly gay or lesbian U.S.
public official, and the repeal of many states’ laws that criminalized homosexual behavior (see Kimmel et al., 2006). Due in part
to these events, LG baby boomers may represent the first LG age
cohort to be less hesitant to seek mental health care (Thurston,
2009). Future cohorts of LG elders (e.g., current millennials) will
likely share different characteristics, as they will have come of age
when a number of states began to recognize same-sex marriages,
and a U.S. President acknowledged gay rights for the first time in
his 2013 inauguration speech (Baker, 2013). In summary, although
every individual’s experience of stigma and discrimination in
relation to minority sexual orientation is unique, cohort effects
remain influential.
Diversity Among Lesbian and Gay Elders
As is evident, older LG adults are a heterogeneous population.
Aging LG adults who are members of ethnic and cultural minority
groups, conservative religious affiliations, or rural communities
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COMPETENT PRACTICE WITH OLDER LG ADULTS
often face additional social stressors (American Psychological
Association, 2014, American Psychological Association, 2012).
For example, a 74 year-old Black lesbian in Chicago may be living
with the experience of ageism, heterocentrism, sexism, and racism,
whereas a 62 year-old gay Latino man in rural Pennsylvania may
face significant social isolation as well as ageism, heterocentrism,
and racism. Cultural or ethnic minority LG elders may face additional forms of heterocentric discrimination within their own ethnic, cultural, and religious communities. In contrast, some LG
minority elders may be assigned positive qualities; Native American “two spirit” elders were traditionally revered and granted
special social status (Balsam, Huang, Fieland, Simoni, & Walters,
2004). Most research on LG adults has been obtained from samples of opportunity that over represent White, highly educated, gay
men living in urban areas (Mabey, 2011). Very little is known
about older LG minority elders, particularly those in rural areas,
who are Black or Hispanic, or the oldest-old. The practical import
for practitioners is that they should never make broad assumptions
about an older gay or lesbian adult, particularly if they have
additional minority group membership.
The influence of ageism, heterosexism, and racism (among
other stigmatizing factors) upon aging sexual minority group
members is likely cumulative and perhaps exponential beyond the
negative impact of each individual type of discrimination. A study
of older gay Black men reported significantly higher levels of
perceived ageism than older gay White men, significantly higher
levels of racism than younger gay Black men, and significantly
higher levels of homonegativity (i.e., overt negativity and hostility
in relation to their gay sexual orientation) than both younger Black
and White gay men (David & Knight, 2008). Unfortunately,
stigma, discrimination, and social isolation may substantially contribute to health disparities, barriers in long-term care, and legal
inequalities evident among LG persons.
Physical, Mental, and Sexual Health Disparities
According to the Centers for Disease Control (2011), LG adults
experience significant physical and mental health disparities when
compared with their heterosexual peers. Awareness of such discrepancies is vital when working with older LG clients as psychologists are encouraged “to understand diversity in the aging
process, particularly how . . . sexual orientation . . . may influence
the experience and expression of health and of psychological
problems in later life (American Psychological Association, 2014,
p. 40). Concealing one’s sexual identity from health care providers
can lead to ineffective or deleterious health care (Fassinger &
Arseneau, 2007.) Various reports indicate that more than 40% of
LG adults aged 50 and older suffer from at least one disability or
chronic illness, and are more likely to smoke and engage in binge
drinking than their heterosexual peers (Fredericksen-Goldsen et al.,
2011; Institute of Medicine, 2011). Compared with their heterosexual peers, LG elders are more likely to delay seeking treatment
for physical health problems, and to experience increased risk of
elder abuse and neglect. LG elders also are two times more likely
to live and age alone (without a life partner or significant other),
and are four times less likely to have adult children to call upon for
help and support (Brookdale Center on Aging, 1999; Espinoza,
2011). In fact, 1 in 5 older LG adults reported having no one to call
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on in a time of crisis, compared with only 1 in 50 older heterosexual adults (Brookdale Center on Aging, 1999).
Within the context of such limited social support, older United
States LG adults appear to experience more mental distress than
their same age, heterosexual peers (Fredriksen-Goldsen et al.,
2011). Nearly 1 in 3 older LG adults from a large scale study of
more than 2,300 LGBT United States older adults reported that
they lacked companionship and felt lonely, and met criteria for
clinical depression on a standardized measure. In addition, nearly
1 in 3 older LG study participants indicated that they seriously
considered committing suicide at some point in their lives, often in
response to concerns about their sexual orientation (FredriksenGoldsen et al., 2011). A study of older LG Europeans revealed
similar findings, in which internalized homonegativity and social
stigma contributed to mental health issues (Kuyper & Fokkema,
2010).
In terms of sexual health, older adults in general often encounter
vaginal dryness, erectile dysfunction, and prostate changes. Gay
male elders face increased risk of infection for HIV and other
STDs, and both older gay men and older lesbian women face
challenges in terms of poor or limited preventative screenings and
clinical care (Hillman, 2012). Although gay men represent about
two percent of the general population, they account for nearly half
of all AIDS related deaths and new HIV infections (Centers for
Disease Control and Prevention, 2008). Specifically, more than
17% of new HIV/AIDS cases occur among adults over the age of
50, with older men having sex with men, and older Black and
Latino men, at greatest risk (Centers for Disease Control and
Prevention, 2008; although transmission of the HIV virus via
female to female sexual contact has been documented, it is rare;
Wapenyi, 2010). Rates of HIV/AIDS infection are increasing
nearly four times faster among older than young adults (Chiao,
Ries, & Sande, 1999), and within the last decade, new HIV
diagnoses among adults over the age of 50 increased by more than
30% (Centers for Disease Control and Prevention, 2008). By the
year 2015, more than half of all individuals infected with HIV in
the United States will be over the age of 50 (Emlet, 2010).
Regrettably, no national HIV/AIDS education programs exist for
older adults, much less an aging gay male population.
For now aging gay members of the baby boom generation, the
impact of HIV/AIDS must not be underestimated. Death and
disability were widespread among gay men at the height of the
AIDS epidemic especially in major metropolitan areas with large
LG populations. Lesbians witnessed the pain and passing of their
gay male counterparts and often provided care and engaged in
advocacy on their behalf. For older LG adults, these experiences
were not only highly salient, but for gay men now aging with HIV,
there are long term adverse professional, economic, social, community, and health consequences of the epidemic. Gay male baby
boomers now living with HIV typically face depleted caregiving
and friendship networks, chronic health issues including depression and heart disease, and economic challenges often compounded by early career upheaval and the high cost of treatment
(Rosenfeld, Bartlam, & Smith, 2012). Despite these many stressors, work has documented the resilience of older adults living
with HIV. Specific areas of strength identified in this population
include self-acceptance, optimism, service to others, social support
and connections, personal responsibility, will to live, and self-care
(Emlet, Tozay, & Raveis, 2011).
HILLMAN AND HINRICHSEN
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272
Older gay men in committed relationships also are more likely
to face the diagnosis and treatment of prostate cancer than older
heterosexual men. Specifically, older gay men may face prostate
cancer in relation to their own health, their partner’s heath, or both
(Blank, 2005). Like their heterosexual peers, older gay men often
possess limited and incorrect knowledge about the diagnosis and
treatment of prostate disease (Asencio, Blank, Descartes, & Crawford, 2009). Persons with lower socioeconomic status have limited
knowledge of prostate cancer, and older Black gay men possess the
least accurate knowledge. All older gay participants in the aforementioned study, however, expressed concern about how the treatment for prostate cancer would affect their sexual functioning,
their relationship with their current partners, and their ability to
develop or sustain relationships in the future. Although the ability
to orgasm may remain intact with nerve sparing procedures in the
treatment of prostate cancer, an inability to ejaculate may challenge a man’s sexual identity, particularly a gay man’s (e.g.,
Martinez, 2005).
A primary concern for older lesbians is not an increased risk of
sexually transmitted diseases (STDs) per se, but a failure to disclose information about their sexual orientation and history to their
health care providers (Politi, Clark, Armstrong, McGarry, & Sciamanna, 2009). Despite prevalent myths held by both older lesbians
and health care providers that lesbians are immune to the transmission of STDs, nearly half of older lesbians report having
heterosexual intercourse at some point in their lives, and 20% of all
women who never had heterosexual intercourse are infected with
the HPV virus, the primary cause of cervical cancer (Addis,
Mavies, Greene, MacBride-Stewart, & Shepherd, 2009). Older
lesbians should receive educational messages about their individual risk factors for STDs and screenings (e.g., pap smears) when
appropriate. Therapists can encourage older LG individuals to
discuss any concerns about their sexual health, and help them
communicate more effectively with their health care providers
who are unlikely to discuss STDs with their older patients, regardless of their sexual orientation (Hillman, 2008, 2012).
Caregiving and Long-Term Care
As revealed in the Metlife Mature Market Institute & The
Lesbian and Gay Aging Issues Network of the American Society
of Aging (2010) survey of more than 1,200 LG adults, LG elders
are twice as likely to serve as a caregiver for a parent, family
member, partner, friend, or neighbor, and to spend significantly
more hours per week providing that care, when compared with
their heterosexual counterparts. This finding suggests supports the
notion that older LG adults maintain a “family of choice” well
beyond biological and legal boundaries. Nearly 20% of all LG
caregivers spend more than 40 hr a week providing nonpaid care,
and more than 40% of all LG caregivers provide care for someone
who is a nonrelative (e.g., a partner, friend, or neighbor; Thurston,
2009). The significant economic contribution, as well as the psychological, physical, and financial demands placed upon this population should not be overlooked. Without the assistance of these
nonpaid LG caregivers, individuals are less likely to remain in
their own homes. Although 75% of LG baby boomers surveyed in
a 2010 MetLife study expected that they would provide care for a
partner, spouse, friend, neighbor, or other family member at some
point in the future, nearly 20% of these individuals had no idea
who would care for them.
Significant challenges also exist for LG adults who enter institutional settings to receive long-term care. Discrimination, including outright hostility and substandard care, is well documented
among LG residents in nursing home and other institutional settings (Institute of Medicine, 2011; Mabey, 2011). Professional
caregivers hold significantly more negative attitudes toward sexual
activity among same-sex than heterosexual residents (Hinrichs &
Vacha-Haase, 2010). Such negativity and hostility can even take
the form of physical abuse.
Case Example
The second author, a psychologist, was asked to consult with
long-term care staff on an incident in 2000 in which a male nursing
aide struck an older resident. The staff seemed uncomfortable
discussing the incident and some laughed nervously as they described the circumstances that prompted the assault. They reported
that a nursing aide found two older male residents having sex with
each other which upset him so much that he punched one of the
residents. The psychologist facilitated a discussion with staff about
their attitudes toward and feelings about sex among older adults
and between same-sex persons.
Challenges to Living Authentically
Both fear of discrimination and fear of living an asexual lifestyle
within a long-term care setting lead the majority of older LG adults
to report that they want to live independently, within their own
homes, for as long as possible (Metlife Mature Market Institute &
The Lesbian and Gay Aging Issues Network of the American
Society of Aging, 2010). To complicate matters, only 22 states
have passed laws that prohibit discrimination against sexual
orientation in public or private housing (United States Department of Housing & Urban Development, 2013). In other states,
a nursing home or public housing administrator can simply
refuse to admit an LG individual with no legal recourse available to that individual.
Many LG residents in long-term care, including those who have
lived authentically, go to great lengths to avoid discrimination and
feel compelled to “go back into the closet” (Maddux, 2011; National Senior Citizens Law Center, 2011). Some LG partners
legally change their last name to match that of their partner’s, so
that they can live together in the same room unobtrusively as
“brothers or sisters.” Other LG residents are so fearful of mistreatment from staff and other residents that they decide to act as if they
were straight. Still others hide personal photos of partners and
other mementos to avoid revealing their LG status (Maddux,
2011). For any psychotherapy client facing difficult decisions
about long-term care, a therapist’s knowledge of these unique
challenges and information about available resources becomes
essential.
Case Example
In 2013, Lorraine, a newly admitted 62 year-old nursing home
resident, disclosed to her psychologist, the first author, that she
was a lesbian. Lorraine explained that her partner of nearly 20
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COMPETENT PRACTICE WITH OLDER LG ADULTS
years died of breast cancer a few years earlier, when she herself
was diagnosed with Parkinson’s disease. Lorraine felt grief for her
loss, and also felt extremely fearful about revealing her sexual
orientation to the staff and residents at the nursing home. “Having
someone . . . treat me badly or strangely because [I’m a lesbian],
well, I just don’t want to deal with it. This is a really small
[socially conservative] town, and I know that people aren’t thrilled
about anyone being gay around here . . .” Lorraine became tearful
and added, “I was ‘out’ for so long in my own little neighborhood
. . . and now it’s so hard being ‘back in the closet,’ but I just don’t
feel like I can risk it here. When you can’t even change your own
[adult diaper], you really are at someone else’s mercy.”
In therapy, Lorraine and her psychologist discussed issues related to grief, loss of control, and identity. Lorraine’s therapist also
told her about some LG and aging Web sites. Because Lorraine did
not have her own computer or smart phone, she was worried about
using the residents’ shared computer located in the activities room;
“What if someone sees me looking at this? Then I’m ‘out’ whether
I want to be or not.” In response, her therapist helped her to engage
in problem solving and self-advocacy. Subsequently, Lorraine
approached the activities director and asked if the computer could
be moved to a more private location. Within 2 days, the computer
was moved to a private alcove. Lorraine reported later that although she often felt lonely, it made her feel better and less
socially isolated to have “a link to the outside world [LG community].” Lorraine’s therapist also decided to host an in-service
training for the nursing home staff regarding LG issues and care.
Lorraine told her therapist she still was not comfortable being
“out” with the nursing home staff, but that she might think about
living more authentically in the future if she began to sense a
overall, more accepting attitude in the facility.
Legal Issues and a Call for Advocacy
As individuals age, they are increasingly likely to use services or
access benefits in institutions like hospitals or long-term care, and
government entities such as Social Security and Medicare. For LG
elders, who may not enjoy equal protection under state and federal
law (e.g., a same-sex married couple who retired or moved to one
of the more than 30 states that fails to recognize same-sex marriage; Reuters, 2013), adequate preparation for a variety of potential legal and related financial challenges becomes increasingly
relevant. It is essential that both psychologists and their LG clients
become familiar with rapidly changing federal and individual
states’ laws regarding same-sex marriage, civil unions, and discrimination on the basis of sexual orientation.
The 2013 U.S. Supreme Court ruling that struck down Section
3 of the Defense of Marriage Act (DOMA; United States v.
Windsor, 2013) has granted same-sex married couples access to an
estimated more than 1,000 federal rights including 401(k) survivor
and hardship withdrawal benefits, coverage under the Family and
Medical Leave Act (FMLA), access to COBRA benefits, savings
on federal inheritance taxes, veteran’s benefits, and green cards for
binational couples; Lambda Legal, 2013a). The DOMA ruling also
granted same-sex married partners access to federal Supplemental
Security Income (SSI), disability, death, and spousal benefits,
which have been estimated to account for nearly 125 million
dollars annually in lost income for LG adults (Cahill & South,
2002; Thurston, 2009). The federal provisions for Medicaid spend-
273
downs, designed to keep a healthy, community-living spouse from
losing his or her home and becoming bankrupt when paying for the
nursing home care of an ill or disabled partner, also now apply to
same-sex married couples.
Despite the apparent benefits of the 2013 DOMA ruling, however, same-sex married couples must still contend with individual
states’ laws that may fail to recognize same-sex marriages. If a
legally married gay or lesbian couple retires to a state that has a
constitutional ban against same-sex marriage, for example, they
may become ineligible for spousal Social Security benefits, the
FMLA, retiree health plan benefits, and inheritance tax breaks
(Services and Advocacy for Gay, Lesbian, Bisexual, & Transgender Elders, 2013). The DOMA ruling also fails to confer federal
benefits to same-sex couples in a legally recognized civil union.
Similarly, when same-sex partners separate, only states that legally
recognize their committed relationship through marriage or a civil
union provide guidelines for the distribution of property and assets,
alimony, and visitation with children or grandchildren (Cahill &
South, 2002; some same-sex couples elect to create a Revocable
Living Trust to avoid the public disclosure of a will during probate,
and better limit the risk of potential contests from surviving heirs;
Lambda Legal, 2013b). In response, therapists can recommend that
their LG clients, regardless of their marital status, carefully prepare
powers of attorney as well as wills and trusts, preferably with
lawyers familiar with both elder and LG issues (Mabey, 2011).
Therapists also can advise their clients to keep notarized copies of
this paperwork readily accessible. Valuable time and rights can be
lost if a partner needs to wait one or two business days to gain
access from a safety deposit box.
Institutional discrimination can be just as negative as individual
discrimination. Recent prospective studies (Hatzenbuehler, Keyes,
& Hasin, 2009; Hatzenbuehler, McLaughlin, Keyes, & Hasin,
2010) revealed that lesbian and gay adults living in states that ban
same-sex marriage and fail to provide protection against hate
crimes and employment discrimination based on sexual orientation
were significantly more likely to be diagnosed with depression,
dysthymia, and generalized anxiety, posttraumatic stress, and alcohol abuse disorders than those living in states that did not ban
same-sex marriage and or provided such legal protection. In contrast, heterosexual adults showed no such differences in the prevalence of these mental health disorders by state membership.
Allowing LG clients to express their anger and frustration in
therapy about such legalized forms of discrimination, without
pathologizing their feelings, remains essential (Pachankis & Goldfried, 2004). LG clients also can be encouraged to seek out
Ombudsman services in hospital and long-term care settings if
problems with visitation and other rights arise. The need for
psychologists to advocate for public policies, and state and federal
laws that prohibit discrimination based upon sexual orientation,
also appears urgent and clear.
Adaptation and Resilience
Although LG elders represent a unique, at-risk population, they
also display evidence of significant adaptation and resilience. More
than 80% of LG adults report that they engage in some type of
wellness activity. Approximately 40% of both older lesbian and gay
men attend some kind of spiritual or religious service monthly, and
more than 70% of those LG adults report that they are out to their faith
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274
HILLMAN AND HINRICHSEN
community (Fredrickson-Goldsen et al., 2011). In contrast, more than
50% of older heterosexual women and men attend some kind of
spiritual or church service weekly (Pew Forum, 2008). Nearly half of
recently surveyed LG baby boomers reported that their experience of
living in a predominantly heterosexual culture helped them prepare
for aging in some way (Metlife Mature Market Institute & The
Lesbian and Gay Aging Issues Network of the American Society of
Aging, 2010). A qualitative study of older LG adults suggests that
many learn to cope with a stigmatized identity by developing a strong
sense of independence, autonomy, and inherent self worth, establishing a variety of interests outside of their family and career, whereas
fostering and maintaining both platonic and romantic relationships
(Wolf, 1982). Some researchers posit that successful coping in response to the stress of coming out may better prepare LG adults for
life in an ageist society (Kimmel et al., 2006). An older LG client in
the midst of crisis also can be reminded of previous, successful
adaptive responses and personal resilience to help them cope better
with current stressors.
Case Example
In 2012 a 73 year-old gay male client was suffering from severe
anxiety in relation to his partner’s recent diagnosis of prostate
cancer. When asked by his psychologist, the first author, how he
coped with traumatic events in the past, her client recounted, “I
had it bad when I was younger. I had to hide [in the closet] when
I was in the military, and my personal life really suffered when I
came out to my family in my thirties . . . I even got beat up once.”
After some additional reflection he added, “I guess now that I think
about things that way, dealing with [my partner’s] prostate cancer
almost seems like a piece of cake compared to what I lived through
[by coming out.]”
Additional Factors
Social support is a critically important part of life that allows
someone to adapt and adjust more easily to life changes and crises.
One difference observed between LG and heterosexual elders is
that LG elders typically garner more social support from friends
and “family members by choice” than legal or biological family
members (Metlife Mature Market Institute & The Lesbian and Gay
Aging Issues Network of the American Society of Aging, 2010;
Thurston, 2009). Although long-standing social norms suggest that
family members are expected to provide instrumental support (e.g.,
financial help, caregiving), LG individuals have historically developed meaningful, supportive friendship networks, in part, because
their own family may be unsupportive of their sexual orientation.
With a broader social network, LG elders are often better equipped
to gather different types of support from multiple sources when
compared with their heterosexual peers (Mabey, 2011). Friends,
compared with family members, are more likely to engage LG
elders in life review conversations including difficult or sensitive
topics such as personal disappointments, fears of aging, and past
and present romantic and sexual relationships (Lewittes, 1989).
Ironically, some theorists suggest that various stereotypes associated with aging may actually work to the advantage of LG
individuals (McDougall, 1993). Because widely held ageist beliefs
hold that older adults are both ineffectual and asexual, it often
becomes more socially acceptable for older men and women to
live together as same-sex partners. It also is important to note that
although such ageist beliefs may provide some benefits such as
freedom from harassment for older LG individuals, particularly in
rural or conservative communities, these elders are still denied the
ability to be appreciated and affirmed for their own identity (e.g.,
Kuyper & Fokkema, 2010).
Implications for Practice, Advocacy, and Research
A variety of recommendations can be made to help LG elders,
including ethnic, racial, and cultural minority LG elders, feel more
comfortable and accepted in a clinical setting (California Department of Health Services, 2013; Lyons, Bieschke, Dendy, Worthington, & Georgemiller, 2010). For example, therapists can
change the language on intake and other forms to ask about one’s
relationship versus marital status, and family members by choice.
Additional recommendations include altering the physical environment in offices, waiting areas, and Web sites to display or link
to magazines reflecting both LG and aging readership (e.g., Out;
More, AARP), newsletters from organizations such as SAGE (Service and Advocacy for Lesbian, Gay, Bisexual, and Transgender
Elders), a rainbow flag or pink triangle, pictures featuring LG
couples and families from a variety of ages, racial, ethnic, and
cultural backgrounds, and pamphlets about caregiving, substance
abuse, domestic and elder abuse, and HIV and aging. (Please see
the Appendix, provided as online supplemental material, for a
variety of resources.) Therapists also can celebrate National Coming Out Day, World LGBT Pride Day, AIDS Day, and other
LG-affirming events. Recent efforts are notable by the U.S. Department of Veterans Affairs (VA) health care facilities to make
the VA a more welcoming place for LGBT veterans. Psychologists
have played a key role in these efforts that include more inclusive
hospital visitation policies and the establishment of policy on
respectful care for transgender veterans. About half of veterans
receiving care in the VA health care system are older adults
(Department of Veterans Affairs, 2013).
To provide competent practice, psychologists themselves must
examine their own attitudes toward both older and LG adults, particularly if coming from a culture or religious affiliation that does not
affirm an LG orientation (Pachankis & Goldfried, 2004). Therapists
also are advised to provide training for staff and post a nondiscriminatory statement that equal care will be provided to all clients regardless of their age, sexual orientation, ethnicity, race, religion, physical
ability and attributes, and gender identity (California Department of
Health Services, 2013). Fortunately, various educational opportunities
are available in relation to work with both older adults and LG adult
clients. Seeking supervision and peer consultation with both age and
LG affirming therapists and other experts also can be helpful (Hinrichsen, 2006; Lyons et al., 2010). In addition, simple exposure and
familiarity with LG elders (Mabey, 2011) can help reduce stigma and
alert potential minority clients that options are available for competent, affirming care. Fostering the resilience of LG elders, including
the nonfamilial exchange of care, participation in formal and informal
LG and aging support groups, and increased health advocacy for
HIV/AIDS, remains essential.
Consistent with the APA Practice Guidelines for older (American
Psychological Association, 2014) and LG adults (American Psychological Association, 2012), psychologists are encouraged to engage in
advocacy for their individual clients (Shannon & Woods, 1991) as
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This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.
COMPETENT PRACTICE WITH OLDER LG ADULTS
well as LG elders at large to promote social justice and civil rights
(Moradi, Mohr, Worthington, & Fassinger, 2009). Specifically, psychologists can advocate for changes in individual states’ laws to
recognize same-sex marriage and for the passage of antidiscrimination laws that would benefit older LG adults. Such antidiscrimination
laws would include protections against hate crimes and discrimination
in both private and public housing, including both nursing homes and
assisted living facilities. Passage of such state laws would help provide same-sex couples, including medically frail elders, access to
spousal medical benefits (e.g., Medicaid) and placement in appropriate long-term care facilities if needed (Lambda Legal, 2013b). It also
is essential to note that simply passing an antidiscrimination law in
long-term care housing based upon sexual orientation does not prevent such discrimination; it only provides legal recourse for those
affected. (It is already a challenge for many residents in nursing
homes to assert their rights to participation in consensual heterosexual
relationships; Hillman, 2012.) To provide a safe and welcoming
environment for LG elders in long-term care, same-sex couples
should be able to share a room. For this to take place, however, staff
training and even resident education are likely to be necessary (cf.,
Hinrichs & Vacha-Haase, 2010). The VA training model and a staff
training curriculum on LGBT elders developed by the National Resource Center on LGBT Aging are good resources. Such LG affirming trainings, designed to reduce both heterosexism and ageism, will
ultimately benefit both LG and heterosexual elders.
Research also is needed to assess the extent to which LG elders
are aware of the judicial decisions regarding the repeal of DOMA
and their individual states’ laws on same-sex marriage. For example, to what extent do members of the oldest-old LG population
maintain knowledge of changes in state and federal statutes, and do
their attitudes vary by age cohort? It also will be important to
examine the extent to which care providers, including psychologists, are aware of these judicial changes and as well as contemporary practice with LG older adults.
Conclusion
Significant physical, sexual, and mental health disparities exist
among older LG adults when compared with their heterosexual peers.
Despite the more egalitarian same-sex laws being adopted by a variety
of individual states in the United States (e.g., the recognition of
same-sex marriage), psychologists can play a critical role in advocacy
for state and local legislation that prohibits discrimination based upon
sexual orientation that will benefit the growing population of aging
LG adults. Therapists also are encouraged to seek education and
training regarding the unique challenges often faced by older LG
adults, and to provide an LG-affirming practice to better serve this
burgeoning, diverse population.
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Received October 31, 2012
Revision received May 7, 2014
Accepted May 7, 2014 䡲
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