LGBTQI Awareness in Aged Care

LGBTQI awareness is crucial in all healthcare sectors, this article focuses specifically on LGBTQI care in an aged care context.

Older Australians who identify within the LGBTQI community have witnessed significant social and cultural transformation over the span of their lives.

Australia’s progress on LGBTQI rights has been slow and painful for the community:

• Homosexuality was only decriminalised in Tasmania in 1997;
• Same-sex marriage was legalised in 2017;
• The Northern Territory only passed adoption equality laws in 2018.

(Winsor 2016; Wikipedia 2019)

It is therefore safe to assume that LGBTQI elders who are ‘out’ will have experienced first-hand stigma, discrimination, criminalisation, rejection and isolation (AIHW 2018).

The stigma around being LGBTQI is still prevalent; roughly 34% of people who identify as LGBTQI report hiding their sexual and/or gender identity when accessing health services (AIHW 2018). Due to lack of statistics, older LGBTQI Australians remain invisible in the sector and broader community (AIHW 2018; Duncan et al. 2019).

While we may not know the numbers of older LGBTQI people living in Australia, we know that older LGBTQI Australians are more likely to need aged care services because many do not have children or support structures (Duncan et al. 2019).

The LGBTQI Community’s Right to Fair Treatment

Statistics from the National LGBTI Health Alliance are an annual reminder that LGBTQI people report poorer mental health conditions and have a higher rate of suicides than non-LGBTQI Australians, with trans people continuously fairing the worst in these reports.

The most recent ABS survey on sexual orientation (2014) found that 11 in 100 Australians may have a diverse sexual orientation, sex or gender identity (Australian Human Rights Commission 2014).

The same survey found that gay, lesbian, bisexual and transgender people are three times more likely to experience depression than their non-LGBTQI peers (Australian Human Rights Commission 2014).

The rise of LGBTQI+ health services, including queer-specific counselling, psychology and sexual health clinics, could signal either a knowledge gap in traditional health services; general distrust or bad experiences with traditional health services; or simply that the community demands greater attention for this facet of their identity.

The Sex Discrimination Act 1984 states that it is unlawful to discriminate on the basis of a person’s sexual orientation, gender identity or because they are intersex (Australian Human Rights Commission 2015).

Despite this legislation and a perceived growing acceptance of the community in the light of marriage equality, a very recent news report released by The Feed has shone light on the discrimination faced by LGBTQI+ population in aged care (Duncan 2019).

This article provides practical steps that care workers and their facilities can take to provide LGBTQI residents with the care and respect they deserve, as outlined in the Aged Care Quality Standards.

LGBTQI awareness directly relates to Aged Care Quality Standard 1: Consumer Dignity and Choice.

Glossary of LGBTQI-Related Terms to Familiarise Yourself With

The following are terms associated with the LGBTQI community.

(Note: This glossary is to be considered foundational, it provides the minimum knowledge needed to interact meaningfully with the community. This should be the starting point for your own further research.)

Term	Definition
Ally	A (usually) heterosexual and/or cisgendered person who actively supports the LGBTQI community.
Androgyny	A person deliberately presents or displays characteristics typically associated with both maleness and femaleness, their gender may appear ambiguous.
Asexual	Someone who experiences little or no sexual attraction to other people.
Cisgender	A term used to describe someone whose gender identity lines up with the gender they were assigned at birth.
Drag	The performance of one or more genders in a theatrical manner.
Heteronormativity	The pervasive, society-wide assumption that heterosexuality is the default state of being and that heterosexuality is superior to homosexuality and bisexuality.
Gender dysphoria	The experience of distress or discomfort due to a disconnect between a person’s sex assigned at birth and their gender identity.
Gender pronouns	The words we use to refer to someone's gender in conversation, for example, he/she, him/her. Some people prefer gender neutral language such as they/them or ze/zir.
FTM	A term used to describe a person who was assigned a female gender at birth and who now identifies as male, lives as male, or identifies as masculine.
LGBTQI	A term used to identify the entire community, it stands for Lesbian, Gay, Bisexual, Trans, Queer/Questioning and Intersex. It also appears as LGBTQI+, LGBT, gay community, or queer commuity.
MTF	A term used to describe a person who was assigned a male gender at birth and who now identifies as female, lives as female, or identifies as feminine.
Non-binary	A term used by people whose gender identity does not fit comfortably within the bounds of male/female.
Passing	The situation in which a person is accepted as their preferred gender and often will be perceived as heterosexual.
Queer	A term to describe an identity which, in essence, breaks binaries and defies heteronormativity. Queer was long considered derogatory, it is now reclaimed and celebrated by the LGBTQI community.
Sexual orientation / Sex / Gender identity	Different, distinct aspects of identity that are not necessarily connected, for example, a trans person could be heterosexual, homosexual or bisexual or anywhere else on the spectrum.
Trans	An umbrella term to describe people whose gender is not the same as, or does not sit comfortably with, the sex they were assigned at birth.

(Dastagir 2017; NYU n.d.; Stonewall n.d.; Amnesty USA 2015; Rosenstreich 2013)

Six Actions to Ensure Inclusive Care for LGBTQI Residents

In February 2019 the Australian Government’s Department of Health released a guide for aged care providers on how to care for LGBTQI residents.

The guide is an action plan intended to be used by aged care service providers to better understand how they can advocate for and support LGBTQI elders (Department of Health 2019).

The following six outcomes originate from the Aged Care Diversity Framework 2017 and are applied in the guide to the needs of LGBTQI residents. They are intended to provide you with a foundational understanding of the Framework and it is strongly recommended that you commence further reading upon finishing this article.

While this article provides examples of how to meet these outcomes, as an ally you are encouraged to go beyond these suggestions and think creatively of ways to support the LGBTQI community.

These outcomes include:

1. Making Informed Choices

Within your facility, LGBTQI elders have easily accessible information about the aged care system and services and this information assists them in practising choice and control over the care they receive.

An example of meeting this outcome is by providing LGBTQI-care information in an appropriate format, (such as online, hardcopy, newsletter or verbal) and in a way the resident can easily understand.

(Department of Health 2019)

First Steps to Meeting Outcome 1:

At an individual level

• Respect and understand why LGBTQI people might be sensitive and/or reluctant to disclose personal information.

As a facility

• An LGBTQI resident can clearly see that your facility will cater for their LGBTQI-inclusive individual, personal, clinical, spiritual, social, end-of-life and palliative care needs.
• LGBTQI advocacy services are readily available to residents.
• Complaints procedures are in place for LGBTQI residents.
• Your facility provides resident information regarding how and why information will be recorded in regard to sexuality, gender and intersex status, complying with privacy laws.
• Information is disseminated regarding LGBTQI-focussed lifestyle activities, events, services, health and wellbeing needs.

(Department of Health 2019)

Aim Towards

• Evaluating physical and virtual environments in order to guarantee that your facility is culturally safe for LGBTQI residents and establishing an LGBTQI Advisory Group.

(Department of Health 2019)

2. Adopting Systematic Approaches to Planning and Implementation

LGBTQI elders are active partners in the planning and implementation of the aged care system.

For example: residents are engaged in a way that is culturally safe and supportive, they are enabled to participate as active partners and can express their individual needs.

First Steps to Meeting Outcome 2:

At an individual level

• Recognise, respect and involve families of choice (not necessarily biological) in the planning of a resident’s care.

As a facility

• All care workers and other staff are across anti-discrimination laws, policy, and are familiar with the Aged Care Quality Standards.
• All care workers and other staff have completed a LGBTQI assessment to measure performance, for example, against the Rainbow Tick Standards and Aged Care Quality Standards.
• The entire governing body commits to embedding LGBTQI-safe practices into the residential aged care facility.

(Department of Health 2019)

Aim Towards

• Establishing partnerships with LGBTQI and HIV organisations and engaging them in developing and evaluating residents’ care plans.

(Department of Health 2019)

3. Accessible Care and Support

All LGBTQI elders living in rural, remote and metropolitan areas in Australia can access aged care services and supports appropriate to their diverse characteristics and life experiences.

For example: your facility collaborates with stakeholders to identify and overcome geographical barriers in accessing the healthcare system.

(Department of Health 2019)

First Steps to Meeting Outcome 3:

At an individual level

• Support residents to engage with community events and groups.

As a facility

• Trial the use of technologies to connect LGBTQI residents living in your remote facility with wider LGBTQI communities.
• Ensure organisational policy supports culturally safe, responsive and trauma informed practice, particularly with the aim of supporting Aboriginal and Torres Strait Islander LGBTQI people, Brotherboys and Sistergirls.
• Families of choice are introduced to staff and other residents (if this is desired by the individual).
• Plans are put in place to combat isolation and safety risks for LGBTQI elders.
• Conduct regular staff activities in which staff are asked to reflect on their own culture, attitudes, values and beliefs and how these factors influence their interaction with the LGBTQI community.

(Department of Health 2019)

Aim Towards

• Partnering with LGBTQI organisations in the development and provision of flexible models of care for LGBTQI elders.

(Department of Health 2019)

4. A Proactive and Flexible Aged Care System

A proactive and flexible aged care system that meets the needs of existing and emerging diverse groups, requiring a diverse aged care workforce.

For example: engaging with the community and stakeholders to identify emerging needs and how service provision models can be shaped to embrace those needs.

First Steps to Meeting Outcome 4:

At an individual level

• Promote informal education about the lived experiences of LGBTQI, such as sharing case studies, stories and news articles with other staff in your facility.

As a facility

• Provide education and training to all care workers and other staff on the different lived experiences of LGBTQI peoples, instructed by a reputable, qualified LGBTQI organisation.
• Educate all care workers and other staff on safe and inclusive services for intersex peoples, in recognition of the specific trauma faced by intersex communities.
• Educate all care workers and other staff on the needs and experience of people with HIV or other blood borne illnesses to enable appropriate support measures.
• Adopt workforce recruitment, retention and development approaches that guarantee a skilled and culturally safe workplace, responsive to LGBTQI/HIV people.
• Partner with HIV and LGBTQI organisations and invite them to visit your facility to provide advice, education, information and support, including developing care plans for LGBTQI residents.

(Department of Health 2019)

Aim Towards

• Ensuring that the recruitment process, employment policies and employment contracts stipulate that your organisation is inclusive of LGBTQI peoples and require all staff to meet these organisational needs.

(Department of Health 2019)

5. Respectful and Inclusive Services

Services and facilities effectively meet the specific needs of LGBTQI elders with diverse characteristics and life experiences, as well as their families, carers and representatives in a way that is respectful and inclusive.

For example: develop tools, training and information that supports the provision of care that takes into account diverse characteristics and life experiences.

(Department of Health 2019)

First Steps to Meeting Outcome 5:

At an individual level

• Create an environment that celebrates LGBTQI culture in residential aged care by including LGBTQI literature, art and posters–celebrate key LGBTQI events such as local Pride festivals and the Transgender Day of Remembrance.
• Communicate and share the work you and your facility is doing to be LGBTQI inclusive, ideally by engaging with LGBTQI media.

As a facility

• Review employment practices and rosters so that LGBTQI people can choose whether they would prefer a female or male (or non-binary if available) care worker.
• Collaborate with residents and their families to develop, review, implement, monitor and evaluate policies and practices on the inclusion of LGBTQI peoples.
• Ensure all care workers and other staff are aware of the right of LGBTQI residents to personalise their own homes and rooms to reflect who they are. Invite older LGBTQI people in the community to share their stories and experiences with other residents at social events.
• Educate staff on the range of LGBTQI family structures, develop policies and procedures that highlight the importance of families of choice in the LGBTQI community.
• Ensure that all care workers and other staff respect the right of LGBTQI people to connect, relax and share intimacy with significant others regardless of their gender–and that this is reflected in policies and practices.
• Ensure all care workers and other staff are skilled in and sensitive to providing personal care for older people who are trans, gender diverse or intersex.
• Develop and implement clear policies that address and quash homophobic or transphobic sentiment when it occurs in the facility.

(Department of Health 2019)

Aim Towards

• Appointing a group of LGBTQI ‘champions’ within the organisation who communicate information, provide advice, act as a safe contact for residents and develop a community of practice.
• Obtaining LGBTQI accreditation (currently the Rainbow Tick).

(Department of Health 2019)

6. Meeting the Needs of the Most Vulnerable

LGBTQI elders are able to access high quality and safe aged care services and supports that meet their needs, irrespective of their personal, social or economic circumstances.

For example: provide inclusive service models to meet the needs and requirements of the most vulnerable and work with stakeholders to ensure that all of these needs are met.

(Department of Health 2019)

First Steps to Meeting Outcome 6:

At an individual level

• Recognise and respect that women who identify as lesbians may want to be cared for by female and/or queer staff.

As a facility

• All care workers and other staff should have information available on the specific characteristics of common intersex variations.
• Encourage a culture in your facility in which open questions are encouraged and staff do not make assumptions about the life experiences of older LGBTQI people.
• Develop and implement policies and practices that meet the unique needs of Aboriginal and Torres Strait Islander LGBTQI people, including Brotherboys and Sistergirls and review these policies often.
• Recognise and educate all other care workers and other staff on the trauma experienced by gay men as a result of losing friends, family and partners to the AIDS epidemic.
• Educate care workers and other staff on the experiences of bisexual people, explain that bisexual people are not only discriminated by non-LGBTQI people but also often endure hostility/abuse from gay and lesbian peoples.
• Trans and gender diverse people should be empowered to openly express their gender identity and expression, this right must be respected by all staff.
• Significant relationships and gender expression should be respected and acknowledged in policy and procedures.
• All staff should advocate on behalf of trans and gender diverse residents where coercive or abusive relationships have occurred, and expert guidance should be provided.
• Residents with HIV should be able to access ongoing appropriate health, medical care and social support services.
• All staff should have knowledge of, and compliance with, universal precautions for bodily fluids, particularly in regard to caring for residents with HIV.
• All staff are to read and affirm commitment to the Darlington Statement–developed by intersex organisations and advocates, it articulates the human rights stipulations of intersex individuals of Australia and Aotearoa/New Zealand.

(Department of Health 2019)

Aim Towards

• Engaging organisations that represent LGBTQI people to conduct an audit of your facility to ensure that it is safe for LGBTQI elders.

(Department of Health 2019)

If you are interacting with a resident within the LGBTQI community and you want to know how they identify, ask them. Start by asking their preferred pronoun and proceed to listen to them openly.

Avoid making assumptions, asking invasive questions, or interrupting to draw connections to your own experience.

We are only now getting a picture of aged care facilities from an LGBTQI perspective–the Royal Commission into Aged Care Quality and Safety was established in October 2018 as a response to thousands of submissions from older Australians, their families, health professionals and aged care providers (Duncan et al 2019).

It is due to provide an interim report by October 31st this year.

See The Feed’s video on the abuse faced by LGBTQI elders in residential aged care:

Additional Resources

• Ausmed article, Carlson, K 2018, '4 Key Actions to Advocate for LGBTQIA Patients': https://www.ausmed.com/cpd/articles/advocating-for-lgbtq-patients
• Ausmed article, Tredenick, S 2017, ‘LGBTI-Inclusive Practice – Bringing Diversity into Your Workplace’: https://www.ausmed.com/cpd/articles/lgbti-inclusive-practice
• Aged Care Quality Standards: https://agedcare.health.gov.au/quality/aged-care-quality-standards
• Alice’s Garage (a social enterprise empowering LGBTI Elders): https://alicesgarage.net/
• Department of Health, Actions to Support LGBTI Elders A Guide for Aged Care Providers: https://agedcare.health.gov.au/sites/default/files/documents/02_2019/actions-to-support-lgbti-elders-a-guide-for-aged-care-providers.pdf
• Silver Rainbow LGBTI Ageing and Aged Care: https://lgbtihealth.org.au/ageing/
• The Statistics at a Glance: The Mental Health Of Lesbian, Gay, Bisexual, Transgender And Intersex People in Australia: https://lgbtihealth.org.au/statistics/

References

• Amnesty USA 2015, LGBTQI Glossary, Amnesty USA, viewed 5 September 2019, https://www.amnestyusa.org/pdfs/AIUSA_Pride2015Glossary.pdf
• Australian Human Rights Commission 2014, Face the Facts: Lesbian, Gay, Bisexual, Trans and Intersex People, AHRC, viewed 5 September 2019, https://www.humanrights.gov.au/our-work/education/face-facts-lesbian-gay-bisexual-trans-and-intersex-people
• Australian Human Rights Commission 2015, Face the Facts: Lesbian, Gay, Bisexual, Trans and Intersex People, AHRC, viewed 5 September 2019, https://www.humanrights.gov.au/our-work/education/face-facts-lesbian-gay-bisexual-trans-and-intersex-people
• Australian Institute of Health and Welfare 2018, Older Australia at a Glance, AIHW, viewed 5 September 2019, https://www.aihw.gov.au/reports/older-people/older-australia-at-a-glance/contents/diversity/identify-as-lgbti
• Dastagir, A 2017, LGBTQ Definitions Every Good Ally Should Know, USA Today, viewed 5 September 2019, https://www.usatoday.com/story/news/2017/06/15/lgbtq-glossary-slang-ally-learn-language/101200092/
• Department of Health 2019, Actions to Support Lesbian, Gay, Bisexual, Trans and Gender Diverse and Intersex Elders, Commonwealth of Australia, viewed 4 September 2019, https://agedcare.health.gov.au/sites/default/files/documents/02_2019/actions-to-support-lgbti-elders-a-guide-for-aged-care-providers.pdf
• Duncan, E & Aboud, P 2019, ‘Elderly LGBTQI+ Aged Care Residents Say They’re Being Forced Back Into The Closet', The Feed SBS, viewed 4 September 2019, https://www.sbs.com.au/news/the-feed/elderly-lgbtqi-aged-care-residents-say-they-re-being-forced-back-into-the-closet
• Gold M 2018, ‘The ABCs of L.G.B.T.Q.I.A+’, The New York Times, viewed 4 September 2019, https://www.nytimes.com/2018/06/21/style/lgbtq-gender-language.html
• National LGBTI Health Alliance 2016, The Statistics at a Glance: The Mental Health of Lesbian, Gay, Bisexual, Transgender and Intersex People in Australia, LGBTI Health, viewed 5 September 2019, https://lgbtihealth.org.au/statistics/
• NYU n.d., Glossary of Important LGBT Terms, NYU, viewed 5 September 2019, https://www.nyu.edu/students/communities-and-groups/student-diversity/lesbian-gay-bisexual-transgender-and-queer-student-center/glossary-of-important-lgbt-terms.html
• Rosenstreich, G 2013, ‘LGBTI People Mental Health and Suicide’, Revised 2nd Edition, National LGBTI Health Alliance, Sydney.
• Stonewall n.d., Glossary Terms, Stonewall, viewed 5 September 2019, https://www.stonewall.org.uk/help-advice/glossary-terms
• Wikipedia 2019, LGBT Rights in Australia, Wikipedia, viewed 5 September 2019, https://en.wikipedia.org/wiki/LGBT_rights_in_Australia#Decriminalisation
• Winsor, B 2016, ‘A Definitive Timeline of LGBT+ Rights in Australia’, SBS, viewed 5 September 2019, https://www.sbs.com.au/topics/sexuality/agenda/article/2016/08/12/definitive-timeline-lgbt-rights-australia