Cultural Competency in senior housing for LGBT older adults

The long-term care industry is founded on the desire to create a bright future in aging for everyone, regardless of identity. As a lawyer, I advocate for equal protection for all older adults. I have witnessed the diversity movement being driven by legal compliance in my employment law and health care areas of practice. I also have seen diversity competency emerge because providing safe, accepting workplace and housing environments to people from a variety of orientations, religions and ethnic backgrounds is the right thing to do.

Estimates say that 3 million lesbian, gay, bisexual and transgender (LGBT) elders live in the United States, and that number will double by 2030. These estimates signal a demand for LGBTQ-friendly senior housing. This article provides an overview of some long-term care considerations for LGBT adults, concrete strategies you can implement now to make your facility more welcoming, and ideas for further learning and resources.

Long-term care considerations for the LGBT adult
The U.S. Department of Health and Human Services offers excellent online resources for LGBT adults. Read on for additional sources of information. There are a multitude of special considerations to take into account for LGBT adults to an increase understanding of unique needs when planning for future care needs. There are also state and federal laws and regulations, along with programs and services, that may impact LGBT individuals and couples and their planning process. I also advise in these various areas.

Health disparities impacting long-term care
Many LGBT individuals experience health disparities throughout their lives. Health issues in anyone’s younger years may lead to the need for long-term care. But later in life, limited research shows that health disparities can have a major impact on some LGBT individuals, and this is important when planning for future long-term care needs. Below are categories of these disparities and our current understanding of how they impact LGBT individuals.

Barriers to health care access
LGBT adults are:

  • Less likely to have health insurance coverage
  • More likely to delay or not seek medical care
  • Facing barriers to access as older adults due to isolation and a lack of culturally competent providers
    • One study found 13 percent of older LGBT adults were denied or provided inferior health care.
  • More likely to delay or not get necessary prescription medications
  • More likely to receive health care services in emergency rooms
  • Fail to receive screenings, diagnoses and treatment for important medical problems
    • 22 percent of LGBT older adults do not reveal their sexual orientation to physicians. In some states, health care providers can decline to treat or provide certain necessary treatments to individuals based on their sexual orientation or gender identity.
  • Particularly distressed in nursing homes
    • One study indicates elderly LGBT adults face distress from potentially hostile staff and fellow residents, denial of visits from partners and family of choice and refusal to allow same-sex partners to room together.

Negative impact on physical and mental health and well-being
Societal biases are taking a toll on LGBT adults, who are:

  • Less likely to report having good health than their heterosexual counterparts
  • More likely to have cancer
  • More likely to suffer psychological distress
  • More likely to require medication for emotional health issues
  • Among women, less likely to receive mammograms and more likely to be overweight or obese
  • More likely to have a disability
    • 41 percent of LGBT adults older than 50 have a disability.
  • Among transgender adults, more likely to have suicide ideations

More likely to engage in risky behavior

  • LGBT adults are more likely to have problems with alcoholism.
  • Older lesbians are significantly more likely to engage in heavy drinking.
  • LGBT adults are more likely to smoke cigarettes.
  • Gay men are at higher risk of HIV and other STDs, especially among communities of color.

Among LGBT elders, many singles and couples are estranged from their families of birth, normally the largest source of support when long-term care is necessary. Many in the LGBT community are reliant on “families of choice” for their support. As defined by the National Resource Center on LGBT Aging, these are diverse family structures that:

  • Are usually created by LGBT people, immigrants, and racial or ethnic minorities
  • Include but are not limited to life partners, close friends and other loved ones not biologically related or legally recognized
  • Provide social and caregiving support
  • Provided a tremendous amount of support to gay men during the early years of the AIDS epidemic
  • Likely to be from the same age cohort
  • For the aging LGBT population, this may mean that many in their “families of choice” are also in need of support and services and therefore may not be available to provide the necessary level of support.

Building respect for LGBT older adults
The National Resource Center on LGBT Aging offers an online learning tool called Building Respect for LGBT Older Adults. This is a great introduction for communities offering safe, welcoming and inclusive services for all older adults, including LGBT elders. It includes an overview of the barriers that many LGBT older people face as they age, concrete strategies to make your facility or community more welcoming, and ideas for further learning and next steps.

Here is an overview of the tool’s six modules.

Module 1: Introduction
The first module introduces issues facing LGBT older adults, including lifelong discrimination and prejudice, a greater likelihood of social isolation and higher incidents of health problems. It also highlights several statistics that explain why many LGBT older people might hesitate to enter a nursing home or other long-term care facility. Fear of accessing services is not limited to long-term care facilities, however. Consider:

  • After years of fighting for LGBT rights, greater openness, and protections from harassment and violence, LGBT older adults often find they are fearful of discrimination in the continuum of care and social services and therefore hide their sexual orientation and gender identity.
  • LGBT people are only 20 percent as likely as their heterosexual counterparts to access services like senior centers and meal programs. Surveys show that older gay men or lesbians would not be welcome at 46 percent of local senior centers if their sexual orientation was known.
  • More than one in 10 (13 percent) of LGBT older adults report being denied health care or provided inferior care because they are LGBT. Overall, 15 percent of LGBT older adults fear accessing health care services outside the LGBT community.
  • In one study, 82 percent of LGBT older adult participants report having been victimized at least once, and 64 percent report experiencing victimization at least three times in their lives. One-quarter (23 percent) have been threatened with disclosure of their sexual orientation or gender identity. More than half of LGBT older adults have been discriminated against in employment and housing.

Module 2: Little things that make a big difference
This module presents some simple steps and ideas a community can implement immediately to create a more welcoming environment for LGBT older adults. Here are a few tips and ideas.

  • Do not assume LGBT older adults are open about sexuality and gender identities in every aspect of their lives. Do not refer to an individual as LGBT in a public setting without first getting permission. This is particularly important in group settings such as senior centers, day programs or support groups.
  • Prominently post the community’s non-discrimination policy on your website, all paper or print materials, in the lobby and on the website. The policy should specifically state your commitment to inclusion and protection of all people, as well as their caregivers, family members and friends, regardless of sexual orientation and gender identity. This should be done regardless of whether your state specifically prohibits discrimination based on sexual orientation and/or gender identity.

Develop LGBT-specific programming for clients. This is one of the best ways to demonstrate your commitment to inclusion and to attract LGBT older adults to your agency. You might modify current programming for LGBT clients. For example, when bringing in volunteer attorneys or financial advisors to help clients, be sure that they are using inclusive language and presenting information about particular issues that arise out of legal inequalities, such as different tax implications for same-sex couples or the latest information on the tax deductibility of transgender-related surgery. You can also create groups specifically for LGBT clients, such as an LGBT caregivers or transgender discussion group.

Module 3: Do’s and don’ts
The third module presents a variety of scenarios that staff in long-term care facilities might encounter when working with LGBT residents, some of which may also arise in non-residential settings.

Module 4: Rights and resources
This module reviews the Federal Nursing Home Reform Act (FNHRA), which details long-term care residents’ rights and protects them from discrimination. Your community can create and implement policies and resources that echo the rights laid out in FNHRA or in the role played by ombudsmen. For example:

  • Review your policies and definitions for “family” and make sure that they include both a client’s “family of choice,” such as friends, partners and other people close to the client, and their “family of origin,” such as biological family members or those related by marriage or kinship.
  • Consider appointing at least one person to ensure your community is continually improving services and care for LGBT and other diverse older adults. This individual could also serve as a direct liaison between residents and their loved ones, including taking input and suggestions on improving care for LGBT residents.
  • Create ongoing monitoring mechanisms for residents to report and address biased behavior from fellow residents or staff or for staff to report discriminatory behavior.
  • Have a designated staff person, preferably a human resources manager, handle complaints quickly and confidentially. Avoid creating a confrontational environment that places one person’s account against another’s.

Module 5: Training video
This module offers a glimpse at an in-person cultural competency training offered through SAGE’s National Resource Center on LGBT Aging. Visit the agency’s website for more training options.

Module 6: Making a difference
I’ve seen the positive impact of creating an inclusive and welcoming environment for all older adults, including LGBT elders. The ideas presented throughout the modules include many changes or actions that may seem simple, but that can mean a world of difference to LGBT older people

Additional resources
Listed below are a number of useful resources, as well as reports from which I obtained information in this article. 

Creating a safe, non-discriminatory environment for LGBT seniors is what the industry should be doing now and in the future. Developing cultural competency in your communities through training and inclusive policies and procedures will position them to provide necessary senior housing and aging services to this growing group of elders. For more information or assistance with these issues or comments, please reach out to me at

As a final note, I am thrilled to re-launch Adelman Law Firm, which I founded nearly 17 years ago. Having withdrawn as a founding shareholder of Hagwood Adelman Tipton, I’ll resume operations of my woman-owned firm serving the tri-states of Arkansas, Mississippi and Tennessee, along with our national counsel services. Joined by several lawyers and other legal professionals, I look forward to continuing to provide our gold-standard services and expanded practice areas. Adelman Law Firm’s address and phone number will remain the same at the beautiful, historic Central Station in Memphis, Tennessee. Contact me at

Rebecca Adelman is an entrepreneur, influencer, thought leader and founder of Adelman Law Firm, established in 2001. For nearly 30 years, Rebecca has concentrated her practice in insurance defense and business litigation. The firm’s practice extends through the tri-states of Arkansas, Mississippi and Tennessee.

Rebecca’s insurance defense practice includes representation of insurance companies and longterm care providers and their insurers, both regionally and nationally. She also provides consulting services and educational programming to health care professionals and business associates. She has active practices in the areas of general liability, professional liability, premises and employment law. She is a listed mediator serving all areas of business and health care litigation.

Rebecca Adelman