LGBTIQ+ Awareness in Aged Care

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

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

• Homosexuality was only decriminalised in Tasmania in 1997
• Same-sex marriage was legalised in 2017
• It wasn’t until 2018 that same-sex couples could adopt children in all Australian states and territories.

(Wang 2020)

It is, therefore, safe to assume that LGBTIQ+ older adults who are ‘out’ will have experienced first-hand stigma, discrimination, criminalisation, rejection, and isolation.

The stigma around being LGBTIQ+ is still prevalent, including in the healthcare sector. For example, the Private Lives 3 survey in 2020 found that only 57.5% of LGBTIQ+ people who accessed a mainstream medical clinic felt their sexual orientation was very or extremely respected, while only 33.6% felt their gender identity was very or extremely respected (Hill et al. 2021).

Furthermore, the same survey conducted in 2012 found that roughly 34% of people who identify as LGBTIQ+ reported hiding their sexual and/or gender identity when accessing services (Leonard et al. 2012).

Unfortunately, due to discrimination, many older LGBTIQ+ Australians remain invisible in the healthcare sector and the broader community (Duncan et al. 2019).

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

So, how can we support older LGBTIQ+ Australians in the aged care system?

Note: While LGBTIQ+ awareness is crucial in all healthcare sectors, this article focuses specifically on LGBTIQ+ care in an aged care context.

The LGBTIQ+ Community’s Right to Fair Treatment

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

The most recent survey on sexual orientation in Australia found that 11 in 100 Australians may have a diverse sexual orientation, sex or gender identity (AHRC 2015).

The same survey found that gay, lesbian, bisexual and transgender people are three times more likely to experience depression than their non-LGBTIQ+ peers (AHRC 2015).

The rise of LGBTIQ+ 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 to 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 (AHRC 2015).

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

This article provides practical steps that care workers and their facilities can take to provide LGBTIQ+ residents with the care and respect they deserve.

LGBTIQ+ Awareness Under the Strengthened Aged Care Quality Standards

The Aged Care Quality Standards state that older people’s sexual preferences and gender expressions should be recognised and respected. This is specified in Standard 1: The Person - Outcome 1.1: Person-centred care (Action 1.1.3).

Glossary of LGBTIQ+-Related Terms to Familiarise Yourself With

The following are terms associated with the LGBTIQ+ community.

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

(Dastagir 2022; NYU 2022; Stonewall 2024; Amnesty International 2023; Rosenstreich 2013; Vic.gov.au 2023; The Center 2023)

Six Actions to Ensure Inclusive Care for LGBTIQ+ Residents

In February 2019, the Australian Government’s Department of Health released Actions to Support LGBTI Elders: a Guide for Aged Care Providers - a guide for aged care providers on how to care for LGBTIQ+ older people.

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 LGBTIQ+ older people (DoH 2019).

The following six outcomes originate from the Aged Care Diversity Framework 2017 and are applied in the guide to the needs of LGBTIQ+ people. 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 LGBTIQ+ community.

The outcomes include:

1. Making Informed Choices

Within your facility, LGBTIQ+ people 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 providing LGBTIQ+ care information in an appropriate format (such as online, hardcopy, newsletter or verbal) and in a way the resident can easily understand.

First Steps to Meeting Outcome 1:

At an individual level:

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

As a facility:

• An LGBTIQ+ person can clearly see that your facility will cater for their LGBTIQ+-inclusive individual, personal, clinical, spiritual, social, end-of-life, and palliative care needs.
• LGBTIQ+ advocacy services are readily available to older people.
• Complaints procedures are in place for LGBTIQ+ people.
• The facility provides older people with information regarding how and why their personal details will be recorded in regard to sexuality, gender, and intersex status, and the facility complies with privacy laws.
• Information is disseminated regarding LGBTIQ+-focused lifestyle activities, events, services, health, and wellbeing needs.

Aim Towards

• Evaluating physical and virtual environments in order to guarantee that your facility is culturally safe for LGBTIQ+ people.
• Establishing an LGBTIQ+ Advisory Group.

(DoH 2019)

2. Adopting Systematic Approaches to Planning and Implementation

LGBTIQ+ people are active partners in the planning and implementation of the aged care system.

For example: older people 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 an older person’s care.

As a facility:

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

Aim Towards

• Establishing partnerships with LGBTIQ+ and HIV organisations and engaging them in developing and evaluating older people’s care plans.

(DoH 2019)

3. Accessible Care and Support

All LGBTIQ+ older people 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.

First Steps to Meeting Outcome 3:

At an individual level:

• Support older people to engage with community events and groups.

As a facility:

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

Aim Towards

• Partnering with LGBTIQ+ organisations in the development and provision of flexible models of care for LGBTIQ+ older people.

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

Aim Towards

• Ensuring that the recruitment process, employment policies, and employment contracts stipulate that your organisation is inclusive of LGBTIQ+ people and requires all staff to meet these organisational needs.

(DoH 2019)

5. Respectful and Inclusive Services

Services and facilities effectively meet the specific needs of LGBTIQ+ older people 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 support the provision of care that takes into account diverse characteristics and life experiences.

First Steps to Meeting Outcome 5:

At an individual level:

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

As a facility:

• Review employment practices and rosters so that LGBTIQ+ 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 LGBTIQ+ people.
• Ensure all care workers and other staff are aware of the right of LGBTIQ+ residents to personalise their own homes and rooms to reflect who they are. Invite older LGBTIQ+ people in the community to share their stories and experiences with other residents at social events.
• Educate staff on the range of LGBTIQ+ family structures, and develop policies and procedures that highlight the importance of families of choice in the LGBTIQ+ community.
• Ensure that all care workers and other staff respect the right of LGBTIQ+ 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 sentiments when they occur in the facility.

Aim Towards

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

(DoH 2019)

6. Meeting the Needs of the Most Vulnerable

LGBTIQ+ older people 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.

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 LGBTIQ+ people.
• Develop and implement policies and practices that meet the unique needs of Aboriginal and Torres Strait Islander LGBTIQ+ people, including Brotherboys and Sistergirls. 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 against by non-LGBTIQ+ people but also often endure hostility/abuse from gay and lesbian people.
• Trans and gender-diverse people should be empowered to express their gender identity and expression openly; 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 people 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.

Aim Towards

• Engaging organisations that represent LGBTIQ+ people to conduct an audit of your facility to ensure that it is safe for LGBTIQ+ older people.

(DoH 2019)

If you are interacting with a person within the LGBTIQ+ community and you want to know how they identify, ask them. Start by asking for their pronouns 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 LGBTIQ+ 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).

See The Feed’s video on the abuse faced by LGBTIQ+ older adults in residential aged care: