Devan Nambiar 19 June, 2013

1. Healthy Aging Forum: Addressing the emerging needs of our aging HIV, LGBTQ, and Hepatitis-C communitiesInvisible Lives: Providing Culturally Competent Care for LGBT Seniors • Devan Nambiar • 19 June, 2013

3. RHO Conference: February 5 -7, 2014

4. Agenda • Introduction to LGBT Seniors: history • Definitions and language and/or lack of • Impact of Oppression on LGBT Seniors • Understanding and working with LGBT seniors • Summary of issues for care providers

5. Defining LGBT Health • Sexual orientation is a determinant of health • Gender identity is a determinant of health • We include individuals and communities whose health and wellbeing are impacted by • heterosexism, homophobia, prejudice and discrimination due to Sexual Attraction, Sexual Identity, Sexual Behaviour, Gender Identity or Gender Expression.

6. Diversity within LGBT Communities

7. The holocaust: gays and lesbians • > 50, 000 gay Germans convicted in prison under Paragraph 175 (1933-1945) • Conditional release if agree to voluntary castration • Subjected to electro-shock therapy, invasive surgery of castration, lobotomy, live targets for firing range, phosphorus research, living targets nausea inducing drugs to remove erotic feeling at the con. camp, insert artificial gland –T therapy Pink Triangle Rudolf Brazda, 95 years old 1913-2011 (German memorial) black (asocials) triangles

8. Penal code on same sex behavior Drafted in 1834, implemented in 1864 • 80 countries with state-sponsored homophobic laws • 77 punish LGBT with punishment • 5 punish LGBT with death penalty • Colonialism and the legacy of systemic, institutional and state sanctioned homo/bi/transphobia across the world. • The Alien Legacy: The Origins of "Sodomy" Laws in British Colonialism (2008). Retrieved from http://www.hrw.org/sites/default/files/reports/lgbt1208_web.pdf

9. Human Rights for LGBT • 1969Consensual sex between same sex adults removed from Criminal Code of Canada • 1973 Homosexuality no longer classified as a mental Illness • 1974Gays and lesbians permitted as immigrants to Canada • 1977-98 Territories/provinces prohibited discriminationon basis of sexual orientation • 2003 Ontario legalized same sex marriage • 2005 Canada opens doors to LGBT marriage and immigration Trans?

10. What do we know about LGBT Seniors? • “Demographic studies on elderly people do not distinguish between gay men, lesbians and bisexuals.” • “Elderly gay men and lesbians seem to be invisible not only in society and the media but also in the gay community.” • “Elderly gay men and lesbians appear to be struggling against ageism and rejection on the part of younger gay men and lesbians.” http://www.hc-sc.gc.ca/hcs-sss/pubs/acces/2001-certain-equit-acces/part3-doc1-eng.php

11. Terms and Definitions

12. Sex and gender Biological Sex hormones, chromosomes, anatomy, genitals, genetics, intersex Gender Identity female, male, boi, transgender, transsexual, 2-spirit, androgynous, genderqueer Sexual Orientationheterosexual, queer, bisexual, lesbian, gay, etc. Sexual Behavior MSM, WSW, serial monogamy, polyamory, celibacy, kink, etc. XX-female , XY- male

13. Sex and gender • Sex is the anatomical and physical differences between males and females determined by genetic factors. • Sex refers to physical aspects of our body: e.g., chromosomes (XX, XY), genitals, hormones, facial hair • Gender is the attributes and behaviors associated with the person’s sex. • Gender describes how we think of ourselves (gender identity) and how we want to convey that to others (gender expression) • Gender stereotypes are cognitive frameworks used to process information regarding a gender. In other words, we have a set of attributes and norms associated with the term “male” or “female”. • Sexual orientation: To who we’re attracted • Emotionally, spiritually, sexually, romantically, financially… http://psychbits.com/do-you-know-the-difference-between-sex-and-gender

14. Quiz: Find the preferred / correct definition for the term on each page Time: 10 mins

15. 1 A 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Score……./20 Exercise: Find the preferred / correct definition for the term Refer to Handout exercise. 10 mins

16. People use many words to describe sexual orientation and gender identity … Lesbian Gay Bisexual Transgender Transsexual (e.g. MTF, FTM) Intersex Queer Questioning 2 spirit Third gender Not everyone uses these terms. Some cultures have their own concepts of sexual orientation and gender. Others do not label behaviours as identities DL, MSM, WSW http://www.rainbowhealthontario.ca/glossary.cfm

17. What’s the Difference Between… • TRANS gender • Someone whose gender identity and/or gender presentation does not match their assigned sex and gender. Often used as an umbrella term to include many other gender variant identities. • CIS gender • Someone whose gender identity and gender presentation is consistent with their assigned sex and gender assigned at birth *The terms cis and trans are from Latin, in which cis means "on the same side" and trans means "on the other side" or “across. http://en.wikipedia.org/wiki/Cisgender

18. More Definitions… • FTM = Female to Male = Trans Man • MTF = Male to Female= Trans Woman • (Use references that describe someone’s present gender identity, not their assigned identity at birth) • Pre-op (before surgery) • Post-op (after surgery) • SRS: Sex Reassignment Surgery (Not all trans persons receive surgery)

19. Passing Transition GID More Definitions… • PASSING: Being identified as your chosen gender/as cis. • TRANSPHOBIA • Hatred of, or expression of aversive and oppressive behaviour towards trans people. • TRANSITION • the time period during which trans people begin changing in various ways in order to become aligned with their internal identity (LOTS of variance!) • GID: Gender identity dysphoria

20. Definitions GENDER IDENTITY • Transsexual • Transgender • Transwoman • Transman • Genderqueer • Intersex • Biological sex • Two spirit • FTM/MTF • Transition • Cisgender OTHER TERMS Homophobia, biphobia, transphobia • Heterosexism • Coming out • Questioning • WSW/MSM • Outing • SEXUAL ORIENTATION • Lesbian • Gay • Bisexual • Heterosexual • Homosexual • Queer • Two spirit http://www.rainbowhealthontario.ca/glossary.cfm

21. Historical Experiences of Discrimination • Senior LGBT may have experienced: • criminal prosecution • mental health diagnosis • religious/moral disapproval • rejection by biological family and/or community • Intense Hostility - it was impossible to be openly LGBT and be safe from violent attacks, loss of jobs, rejection by family, police arrest and in many cases forced medical treatment • Older LGBT persons may face discrimination based on their age as well as sexual orientation/gender identity

22. Timeline of Oppression on LGBT Adapted : Bill Ryan, McGill University

23. “And [the nurse] said, ‘Yes. Was that you?’ [the lesbian identified in a newspaper article] I said, ‘Yes, it was me.’ From then on, I couldn’t get anyone to help me out of bed. It was time I learned to get back into bed myself, but it was hard. Because of the pain, you know. But that was the end of that.” Senior, Vancouver http://www.mcgill.ca/files/interaction/Executive_Summary.pdf

24. “I went to the same doctor for over 20 years and it was a male doctor and my partner also went to that doctor and that doctor was so utterly clueless. He never asked a question and I never volunteered. And that was one of the reasons that about 18 months ago, both my partner and I switched to a woman doctor and were able to talk openly about who we were and what we were and it’s a much more comfortable relationship.” Senior, Vancouver http://www.mcgill.ca/files/interaction/Executive_Summary.pdf

25. “I had some patients... one of the women was in a motorcycle accident, and so her lover found out, ran to emergency and said, you know, 'I'm here to see so-and-so', and so the nurse said 'are you related?' and she said 'well we live together'... And the nurse said, 'well I'm sorry you can't see her'. So she was really upset, but she went, it was almost shift change and she sat in the waiting room and waited until the nurses changed and then went up, and a new nurse came, and she said 'I'm here to see so-and-so' 'are you related?' and she said 'oh yes, I'm her aunt'. 'Oh right this way please'. I mean, how humiliating.” http://www.hc-sc.gc.ca/hcs-sss/pubs/acces/2001-certain-equit-acces/part3-doc1-eng.php

26. Less Social Support • LGBT seniors have significantly diminished support networks when compared to the general senior population • LGBT seniors are: • 2 x as likely to age as a single person • 4 x as likely to have no children to call upon in times of need • 2 x as likely to live alone • Many older LGBT people have experienced rejection by their families of origin • For gay/bi men, loss of partner, friends and social networks as a result of the AIDS pandemic

27. Barriers for LGBT in the Health/Social Service System • Profound invisibility - presumed to be heterosexual • Face real dangers of neglect, discrimination and discomfort from staff, other residents and families of other residents • Long term relationships are devalued - couples in long term relationships may be separated • Definitions of “family” based almost exclusively on biological kin • Self-advocacy may be delicate & difficult if they are not out

28. Crisis competence skills • Due to stigma, discrimination, alienation, (family disruption, intensive feelings, sometimes alienation from family, etc.) some LGBT people develop “a perspective on major life crisis.” • Crisis competence is “development or enhancement of life skills as a result of having to deal with being a sexual minority and all that entails living in a heterosexual society.” • Very sensitive to cues about safety or danger Institute of Medicine. pp. 272- 273

29. LGBT Aging Issues

30. Complex Identity Issues • Majority of LGBT people 65+ have lived most of their lives in environments where homosexuality was a sin, a crime or a mental illness • Less likely to identify as gay or lesbian or to participate in LGBT community organizations • Differences in the extent to which they have disclosed their sexual orientation/gender identity • Forced to accommodate to the closet and did so successfully - hiding was and continues to be a strategy of survival

31. Racialised LGBT: Sexual orientation and gender identity • LGBT as a recent western construct • Do not always label sexual behavior as an orientation or identity • May choose a heterosexual sexual identity due to many personal reasons • Gender identity/same-sex expression in homo-social activities: religious celebration, God/Goddess, priest/priestess, poetry, literature, etc. • Racialised LGBT does not always fit the “western construct” of masculinity, femininity, sexual behavior/ orientation, gender role, expression and identity • Concept of beauty and desire based from a western ideology • Family/traditional/cultural values vs. individuality (western)

32. “I think that, you know, my friends who are white always have easier times in the medical system than my First Nation friends, who I go to the hospital with. One of them asked me to come with her, because I'm white. It's awful... And I think that each time you're more marginalized... that makes it harder and harder to navigate the system. And there are fewer and fewer doctors that are going to support you in your right to navigate that system.” http://www.hc-sc.gc.ca/hcs-sss/pubs/acces/2001-certain-equit-acces/part3-doc1-eng.php

33. LGBT Seniors • Lack of LGBT senior services in many areas of Ontario • Alienation from “younger body conscious” LGBT/ mixed identification with LGBT Pride movement • Mixed reception from health care providers/ might have avoided primary care and may have chronic health needs • Loss of friends, partners/ lovers due to HIV/AIDS • Many feel they must choose between accepting services and disclosing identity (feel unsafe)

34. Issues for Care Providers

35. Heterosexual patient Spouse/ partner/ husband/wife Children Relatives Friends LGBT patient Chosen family*/friends Partner/spouse* Relatives Children Typical order of next of kin *A group of people to whom you are emotionally close and consider ‘family’ even though you not biological or legally related *partnered LGBT may have varying living arrangements Institute of Medicine, pp. 275-277

36. Invisibility • Health care providers rarely ask about sexual behavior or sexual orientation or gender identity • Sexual behavior is as important as sexual orientation, but sexual behavior may differ from orientation • Everyone is assumed to be “straight” and this perpetuates the invisibility of LGBT people • Very few health care messages are targeted towards LGBT communities and LGBT are usually excluded from health promotion campaigns

37. What are the Life Experiences that Care Providers Need to Look For? • Effect of being closeted for many years • Effect of harassment & violence • Effect of homo/bi/transphobia & heterosexism

38. What are the Special Needs of LGBT Seniors? • To be physically and psychologically safe from violence and harassment • To have their relationships and experiences understood and fully accepted • In long-term care - a welcoming and culturally appropriate environment

39. General Issues in caring for LGBT seniors Using appropriate language, pronouns, etc Making it safe to receive services Providing a welcoming and interesting environment (whether people come out or not). Acquiring some historical and cultural knowledge Being aware that health care may have been avoided, and stress may have led to mental health issues Understanding the significance of relationships with partners, friends, etc.

40. Special issues regarding trans residents Use name and pronoun of chosen gender (regardless of hormone or operative status) Residents should be accommodated with others according to their chosen gender Care providers need to continue to prescribe and administer hormones (oral or injection) Screening and preventative care is essential Impact of dementia on chosen gender identity

41. Trans patients • Dress and grooming should support the person’s chosen gender • Barriers can include apparent mismatch between genital anatomy and gender of presentation and or expression can result in disclosure • Creates difficulty in obtaining appropriate sensitive health services Institute of Medicine, p. 275

42. HIV positive LGBT seniors • Stigma, discrimination and disclosure • Long term impact of side effects of antiretrovirals and living with compromised immune system • HIV associated neurocognitive disorders (HAND) • Cardiovascular diseases • Bone density /osteopenia/osteoporosis • Organ dysfunction and toxicity • Unknown drug interactions with ARV • STIs-ED+ recreational drug use + V (men) HCV co-infection

43. Communication: Using Inclusive Language

44. First impressions • Intake forms – do you normally ask about family, couple relationships? • Sexual orientation? Gender identity? Next of kin? • Ethnic or racial group • Food preference • Religious or spiritual practice • If you need to know about the above – ask don’t guess! • Do forms allow same-sex couples/partners to register • Do signs or instructions assume heterosexuality?

45. First impressions : communications and decor • Check language used in agency communications: brochures, website, annual report, program descriptions • Language can be excluding, neutral or inclusive • Look at graphics in brochures, on website, and at choice of art, posters and community information • Recognition of relevant public events (Pride, International Day against Homophobia, Trans Day of Remembrance)

46. Examples of Inclusive Language Use: Do you have a spouse or domestic partner? Partner, spouse Are you the parent or guardian? Who is the biological father/mother? Comment: Does not assume sexual orientation or gender of sexual partners As above More inclusive of different types of families Describes the genetic parent and is useful if genetic information is needed • Instead of: • Are you married? • Girlfriend/ Boyfriend • Are you the mother/father? • Who is real father/mother? SOURCE: Primary Care for Lesbians and Bisexual Women, American Family Physician (2006), Vol: 74 Issue: 2 , 279-286.

47. Communicating with LGBT Patients • Use the pronoun that matches the person’s gender identity (Ask preferred name or pronoun, do not assume) • If the patient seems offended by something you've said, you may simply apologize and ask what terminology the patient prefers • Friends and partners of LGBT patients should be given the respect and privileges usually given to a spouse or biological family

48. Communicating with LGBT Patients Ensure that questions you ask are open-ended and apply to all patients Mirror the patients’ language and terminology: how do they identify their sexual orientation and partner? Their gender? Use gender neutral terms and pronouns when referring to partners, unless you are absolutely sure

49. Communication: Avoiding Assumptions • Don’t assume that: • all LGBT patients use traditional labels • all patients are heterosexual • sexual orientation based on appearance • sexual behaviour based on sexual identity • bisexual identity is only a phase • All transgender patients are gay, bisexual or lesbian

50. Outreach • Affirm the value of staff who are LGBT members or allies with community knowledge and networks • Develop relationships with community leaders in your area - remember that many activities in LGBT communities are grass-roots, informal • Use LGBT community resources like newspapers, websites, email listserves, Pride Day activities