LTC Staff Sensitized to Needs of Gay Elders

by Barry Jay Kaplan

Part One of this series (see "Gay Elders Face Uncomfortable Realities in LTC" in the November 2002 issue of Caring, p. 1) showed how lack of information about lesbian, gay, bisexual, and transgender (LGBT) seniors is fed by heterosexist assumptions, staff difficulties in dealing with any kind of sexuality among seniors in long-term care, and unspoken homophobia. This creates an environment in which LGBT seniors often feel unwelcome--even in danger. Part Two looks at a new LTC staff training program that is dealing with these problems and helping to change the LTC facility culture.

A recently launched collaborative effort between Senior Action in a Gay Environment (SAGE; (www.sageusa.org) and the Brookdale Center on Aging (www.brookdale.org) in New York City is providing much-needed training for LTC staff in the needs and care of LGBT residents.

Identifying Needs

The needs of LGBT seniors in long-term care has reached crisis proportions, according to SAGE's Director of Outreach and Media Relations, Amber Hollibaugh. The organization receives numerous calls from members in different parts of the country who expressed terror at having to enter--or having to put a lover into--a long-term care facility. Are there any residential, retirement, or assisted living sites that are LGBT specific? Is there anyone anywhere they could talk to about it? "We've been hearing this anxiety for years," says Ms. Hollibaugh. "People want to know if we know of a place that is safe."

The long-term care facilities that were perceived as gay friendly had limitations, Ms. Hollibaugh continues. "They would invite us to do a gay pride event, and that was the extent of inclusion. They really didn't know how to do anything more. They didn't have a way to take the issue on with their staff. Staff members who were gay, by default ended up dealing with any gay issues."

Even if a facility's personnel manuals contained non-discrimination policies, they meant little in practice. "What does it mean to be 'welcoming' to LGBT people? How does that play out in practical terms?"

It was clear to Hollibaugh and the staff at SAGE that staff training was needed. They began by putting together a long-term care task force that gathered research materials on the subject. With a huge binder of material, they joined with the Brookdale Institute in New York City, applied for and were awarded a SHARE award from the GlaxoSmithKline-University of Pennsylvania Institute on Aging.

"We were the first LGBT organization they ever funded," Ms. Hollibaugh noted. "This will enable us to begin to do the groundbreaking work of increasing recognition of the problem, creating a curriculum, and then the training of staff." The program will also show that diversity in the aging population "isn't just a theoretical idea," she added.

Creating the Curriculum

The curriculum does not attempt to change people's attitudes about homosexuality, Ms. Hollibaugh emphasizes. "What we're trying to say to staff is that in a workplace where people are vulnerable, they need to be treated with respect and care, and need to be valued. In order for you to do that well, you need to understand something about their lives without their necessarily telling you that they're gay."

The curriculum is also designed to help facility staff examine their policies, look at their intake forms, discuss the way they do their outreach, and advocate for including the use of visual images of LGBT people in the way they present their institution.

The curriculum first creates a context for homosexuality, Ms. Hollibaugh explains. "Staff needs to know the basics: that homosexuality is not a medical condition, and that LGBT communities may have constructed families rather than biological families. People don't necessarily have legal rights. They're not necessarily married to their partners. Staff needs to be aware of the impact of stigma and discrimination on older gay people, and how this might affect their care or needs" (a civil rights history of the Gay Rights Movement was added to the curriculum after the pilot program so that staff have a sense of the context of discrimination against LGBT people and the reason people might be in the closet).

Staff should also understand the role that sexuality plays in a patient's life so that they can be sensitive to his or her needs, noted Carol Chambers, the Training Consultant at Brookdale who wrote the curriculum. In addition to differences in lifestyle, partners, and family issues that patients bring with them, she says, there are also health issues.

"Lesbians historically have a poor record of seeking gynecological care, and when they come into nursing homes they have gynecological problems. With gay men, there are health problems related to certain sexual practices."

The curriculum for the pilot program was structured as two two-hour sessions that included guidelines, videos, historical context, exercises, and scripted role play that would allow for reflection, discussion and sharing.

In the scripted role play, Ms. Chambers created four friends--a gay man, a lesbian, a bisexual man, and a transgendered woman--put them in a coffee shop, and had them talk about the concerns of getting older. Participants in the training would read the script aloud.

Pilot Program

When a facility agreed to receive training, it also agreed to submit to a Facility Diversity Tolerance index, assessed by a researcher would go through the facility's personnel policies, workplace manual, intake forms, outreach materials, and patient forms to see whether there was any recognition or explicit definition of LGBT concerns, issues, or identity. Was there anything in the forms, for example, that allows a person be recognized as a partner, not a husband or wife?

Even the most liberal LTC facilities have traditionally treated LGBT people as if they were invisible, says Ms. Hollibaugh. "Often, it's not because of resistance or homophobia but lack of knowledge and any place to get that knowledge. The nursing home library would have no explicit gay material, no books or videos that would indicate that if you were a gay person going into the library, you could be open here, because this is a place that's thought about this. There were no film nights that had LGBT films. No documentaries. No photographs on the walls or in the outreach materials of same sex couples. No description that didn't assume heterosexuality and biological family."

The first facility to receive training was Village Nursing Home, in New York City's Greenwich Village. Located in a neighborhood that has a large LGBT population, Village Care identified itself as "gay friendly." When SAGE offered to conduct sensitivity training, Director of Social Work Michael Bobrowski initially thought there was no need for it. "We've always been sensitive to the gay population. There didn't seem to be an issue," he says.

What surprised Mr. Bobrowski was that so many people wanted to sign up for the training. "In some cases, the willingness to talk about gay issues was really in terms of their own lives, or their children or some family member," he says. His staff was aware that there were gay residents, and had always been willing to create privacy for romantic or sexual possibility for all patients.

But was the staff actually trained to know how to do that? Did they know whether policies were in place to cover that? Could the staff proactively think about issues of romance and sexuality in relation to LGBT people? Could they--did they--go to supervisors and say "there's a gay man whose partner is visiting, but they're afraid to kiss because he shares a room, so I'd like to have that conversation with him? What can I offer him?"

It was important for the training to begin with definitions, and not assume that people knew what was meant by the words bisexual, transsexual, lesbian, or gay. It was made clear what those words represented so that people had clear tools from the very beginning. Staff resistance was clearly present. "Some of the staff are very religious, fundamental Christians and have very strict prohibitions against homosexuality," Mr. Bobrowski noted.

"We said that we're not here to change your views or beliefs or force you to think the gay lifestyle is acceptable. We just want to give you information about people that you're supposed to be taking care of. We're taught that we're supposed to care for all people, regardless of their beliefs, religion, or color. Our expectation was that they would become better professionals, better able to do their jobs, and would recognize that there may be issues that they need to be more sensitive to in order to be more effective caregivers."

As the session continued, the staff admitted to being unclear about handling privacy issues for LGBT people. "They didn't know how to talk about it," says Ms. Hollibaugh. "They started out saying: everybody's the same, we treat everybody the same. But if your sexuality is same sex, is that really true? If you're a gay man and they find you and another man making out in your room, will you be treated the same way a man and a woman would be?"

The staff agreed that the answer was: probably not. "Sexuality is always hard to deal with it, especially if people are public about it. But where we might think it's kind of cute or understandable when it's heterosexual, we're much more ambivalent about how to deal with it if it's same sex."

Staff were interested in discussing partnering. "Since LGBT people aren't married, if a resident is in trouble, who should they be calling in to be the person's ally?" says Mr. Bobrowski. "When the resident has a relationship that they're unwilling to define to the institution, how should staff respect that relationship when nobody said it's gay but everyone believes that's what it is? The person is deciding not to tell you, yet they need space for their friend or partner to be part of their life. How do you deal with the lack of definition when you don't want to insult anyone by insisting that someone come and tell you they're gay in order for you to be sensitive? The range of discussion was remarkable."

The training included an exercise with cards labeled Health, Family, Partner, Friends, Community, representing the things that people bring to support them in an institution. A hypothetical situation is set up: You are an LGBT person who ends up in an institution and you're estranged from your children, therefore you can eliminate the card labeled Family. Your lover is afraid to touch you in public because he's afraid it will compromise your health care, therefore you can eliminate the card labeled Partner. Staff are made to see how LGBT people often are forced to eliminate all the things that are the difference between someone surviving or not in LTC.

The most surprising thing that happened to the staff at Village Care, according to Ms. Chambers, was the discovery that their perception of themselves as gay friendly was not quite accurate; the training revealed that there was still a ways to go. "They thought they were already there--and in many ways they are--but they also saw more ways to improve their sensitivity."

Successful Outcome

The training was meant to engage staff in thinking about what their facility could do to be more inclusive, and to challenge the heterosexual norms. "We want to help make it clear that whether or not a [LGBT] person is willing to self identify, this is a safe place for them to be," says Ms. Hollibaugh. "Our goal is not to 'out' people and not to assume that it's better or worse to be out, but rather that these sexual orientation issues are fundamental and that if your facility doesn't think about it, it could be a problem."

When the training was over, Mr. Bobrowski gave out the rainbow pin, a symbol of gay pride, for staff to wear. Subsequently, he noticed that residents he would not have expected to say anything about being gay, looked at it and lit up.

"One of the residents started talking about being gay," Mr. Bobrowski recalls. "He'd been here for a good six months and had never said anything like this. Gay family members immediately recognized [the pin] and seemed to feel more comfortable. The niece of a patient saw the pin and started talking to me about a certain movie theatre that showed gay oriented films. She never talked like this before the training. She recognized that it was OK. It really has made a change. We're still chipping at the iceberg, but it's a nice big chip."

Future articles in this series will feature interviews with LGBT elders in long-term care.

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