Health care for LGBTI+ elders living in Nursing Homes.

OBJECTIVE
to describe and analyze the scientific production on health care for Lesbians, Gays, Bisexuals, Transvestites, Transsexuals, Transgenders, Intersex (LGBTI+) and other variations of gender or sexual orientation living in Nursing Homes (NHs).


METHODS
a scoping review, in which PubMed, Web of Science, Scopus and Virtual Health Library databases were analyzed and studies from other sources were added. After assessment by two independent reviewers, 19 publications were selected to compose the sample.


RESULTS
the studies were grouped into two categories.


FINAL CONSIDERATIONS
NHs are configured as spaces that are not very inclusive, where LGBTI+ elders' demands are not considered due to the cis-heteronormativity in force in these places. Training and awareness of health professionals on the LGBTI+ theme is a tool that can make such spaces more inclusive for this population.


INTRODUCTION
Contemporaneity highlights a situation in which internalized ideologies about old age and elders are resistant to changes (1) . Old age is usually characterized by the perspective of asexuality and androgyny, the aged body is almost always seen as devoid of sexuality and desire (2) . One of the dilemmas is in the fusion between the sex-gender system in force in society and the oppressions that permeate it, i.e., the social stereotypes that this population faces due to sexuality, sexual orientation and gender identity (3) .
Today it is observed that the proportion of people over 60 years old grows faster than that of other age groups (4) . World Population Prospects pointed out that by 2050, one in six people in the world will be over 65 (5) . With this, a series of new challenges for the country arises when the subject is aging, which makes this theme more and more recurrent in debates on public health and social security policies (6) .
It is important to highlight that, despite the absence of accurate census data for LGBTI+ (Lesbians, Gays, Bisexuals, Transvestites, Transsexuals, Intersexual) individuals and other gender identities, the demographic transition also occurs in the generation of elders who recognize themselves as such. However, this population requires more attention from the State to reduce inequities and health disparities, as they suffer double discrimination -by age and sexuality -and present poor health results, less chance of resorting to medical services, higher rates of depression, disability physical and financial barriers to healthcare (7)(8)(9) .
In this scenario of indispensability of embracement in formal support networks necessary for old age, with housing linked to health care being a protective factor for elders (10) , Nursing Homes (NH) appear. Although they are not recent establishments, their approach has been reframed and improved considering the current demands of population aging. They are characterized as collective households of people aged 60 or over, with or without family support, under conditions of freedom, dignity and citizenship (11) .
Considering this process of institutionalizing elders, the provision of services in these spaces must address the needs of LGBTI+ elders, including respect for their sexual orientation and gender identity (12) . Studies show that approximately one fifth of LGBTI+ elders do not disclose their sexual orientation or gender identity to health professionals for fear of not receiving appropriate care (13) . The literature points to a deficit in the production of studies on LGBTI+ elders, including in health sciences (14) . Thus, knowing the scientific production on health care for LGBTI+ elders living in NH can contribute to the restructuring of this type of service, supporting the creation of public policies and training strategies for health professionals, expanding the sense of dignity and social inclusion of this population. In addition to its social relevance, this study can support further research and favor the development of this topic in academia.

OBJECTIVE
To describe and analyze the scientific production on health care for Lesbians, Gays, Bisexuals, Transvestites, Transsexuals, Transgenders, Intersex (LGBTI+) and other variations of gender or sexual orientation living in Nursing Homes (NHs).

Research question identification and inclusion criteria
This is a literature scoping review (15) that used the PCC strategy to elaborate the research question: how does the health care of LGBTI+ elders living in NH take place? "P" corresponded to the population (LGBTI+ elders), "C", to the concept that was intended to be investigated (health care) and "C", to NH.
Studies whose population was composed of elders living in NH were included, and those carried out in places where health care was not offered were excluded. This review included primary studies, review studies, theses and dissertations and technical documents that fit the selection criteria. Editorial texts and book chapters were not included. There was no time limit for the search, and studies in Portuguese, English, and Spanish were included.

Identification of relevant studies
Database search was conducted between September 2019 and March 2020 by two independent reviewers, authors of this study, including publications from the Virtual Health Library, PubMed, Scopus and Web of Science databases. These bases were chosen in order to cover national and international publications dealing with the theme at different levels of health care. National descriptors were selected on the Health Sciences Descriptors (DeCS) platform, and international descriptors using the PubMed platform Medical Subject Headings (MeSH) research method. Keywords used by the authors were also used. "LGBT" and "ILPI" were the descriptors in Portuguese used, as well as their English counterparts "Sexual and Gender Minorities", "Homes for the Aged", "Nursing Homes" and "Long Term Care". In both languages, these terms have been combined with the Boolean operator AND. The search strategy adopted in each database, the descriptors and the number of publications found are described in Chart 1. PubMed "Sexual and Gender Minorities" AND "Homes for the Aged" 7 4 lgbt AND "nursing homes" 10 5 lgbt AND "long term care" 18 8 Scopus "Sexual and Gender Minorities" AND "Homes for the Aged" 5 3 lgbt AND "nursing homes" 15 7 lgbt AND "long term care" 32 10 Web of science "Sexual and Gender Minorities" AND "Homes for the Aged" 0 0 lgbt AND "nursing homes" 7 2 lgbt AND "long term care" 24 9 of Health care for LGBTI+ elders living in Nursing Homes Silva Jr JR, França LD, Rosa A, Neves VR, Siqueira LD.

Characteristics of studies
Most studies included in this review (n=16) were published in the last five years, indicating that the concern with inclusive themes for the LGBTI+ population is a recent phenomenon. Most publications originated in the United States of America (USA) (n=9), followed by the United Kingdom (n=5), Canada (n=4), and Spain (n=1). As for the method adopted in the investigations, mostly qualitative approaches were adopted (n=11) with LGBTI+ elders, NH workers (managers, health professionals) and members of civil society LGBTI+ and human rights activists as participants (Chart 2).

Insecurity and prejudice in health care for Lesbian, Gay, Bisexual, Transvestite, Transsexual, Transgender, Intersexual elders in Nursing Homes
In this category, studies were included that analyze the characteristics of NH and the perception of LGBTI+ elders on aspects related to inclusive care, fundamental points for the identification of weaknesses, planning and execution of actions that transform the reality in these institutions. These individuals are more concerned with long-term health care options. LGBTI+ elders can lose social capital through actions associated with housing in aging, but they can also develop and expand it, although important inequalities must be considered (29) . Operating facilities have little or no information available regarding inclusion and compromised care for elders of sexual and gender minorities (30) .
NHs are considered unsafe environments by residents, with the ability to raise the potential for social isolation, decrease their independence and decision-making capacity and increase their vulnerability to negative beliefs and perceptions related to their LGBTI+ identity (24) . Several stressful events have been found for LGBTI+ elders in NH, such as fear of encountering prejudice and receiving precarious care based on sexual orientation, gender identity and expression, anticipatory stress related to the concealment of their identities and associated suicidal ideation (16,20,24) .  (16) .
To describe and analyze the expectations, desires and specificities of care for lesbian and gay couples regarding the possibility of living in a NH and needing home care.
A qualitative study carried out with lesbian and gay couples, carried out through a semistructured questionnaire, telephone interviews and face-toface interviews.
12 couples: 24 participants, four gay couples and eight lesbian couples.
The main problems faced in NH and home care were discrimination, concealment of identity, emotional and physical exhaustion and the need for specificity in the care offered.
To assess LGBTI+ inclusion in NH based on research produced in partnership between researchers from academia and the LGBTI+ community.
A qualitative study with members of the LGBTI+ community who served as auditors to assess the degree of inclusion of older LGBTI+ people in six NH. During assessment, they promoted training, lasting four months, for employees.  (18) .
To analyze the strategies adopted and used by NH to become reference environments in LGBTI+ inclusion.
A qualitative study carried out through semi-structured telephone interview with NH administrators and, later, a one-to-one conversation, held in two days.

NH and 25
participants.
The most used strategies to make NH inclusive places were the training of caregivers and the holding of educational events with programming on LGBTI+ themes, such as showing films or round tables.

Study selection for this review
Through this search strategy, 125 publications were identified. In addition to these, three studies were obtained from other sources by searching the references of the researched studies and were included in the review. After excluding 76 duplicate articles and 10 publications that did not meet the inclusion criteria by reading title, 42 studies were selected for reading abstract, of which five were excluded for not meeting the inclusion criteria. Finally, the remaining 37 studies were read in full. Of these, 18 were discarded and 19 were included in the review, as shown in the PRISMA flow chart (Figure 1)
To describe an action research initiative called Care Home Challenge, in which NH collaborated to assess and develop their services.
A formal assessment was carried out involving qualitative interviews before and after intervention. The combination of community participation with the experiences of workers and managers helped in the collective exploration of solutions to problems related to inclusion.
Six managers of NH and eight volunteers from the LGBTI+ community as community counselors.
Before the intervention, managers acknowledged the low levels of awareness among employees and service users about the experience and the needs to support LGBTI+ individuals. Most reported having no experience with residents identified as LGBTI+.
To investigate the current and anticipated needs and concerns of LGBTI+ elders in NH.
A qualitative study carried out through seven focus groups, in which participants shared important characteristics and a series of experiences, desires, concerns and fears regarding the focus of the discussion.
50 participants self-identified as LGBTI+ and aged between 55 to 87 years.
The main themes identified were: the availability or not of resources, values and previous experiences, which shaped expectations and fears. As for these fears, they expressed two main areas of need: inclusive environments for LGBTI+ individuals and a staff of trained professionals who are sensitive to the issues of this population.
To enable Health Education for institutionalized LGBTI+ elders and in health settings, for nurses and health professionals.
A qualitative and quantitative study, during which training sessions were held in 23 health facilities (academia, hospitals and NH), through the HEALE curriculum (Health Education About LGBTI+ Elders) and application of a pre-and posttraining.
The study demonstrated the course's effectiveness in informing, raising awareness, training and promoting changes in health care for LGBTI+ elders.
To describe guidelines to promote the inclusion of LGBTI+ elders in healthcare environments and NH.
A theoretical study that proposes guidelines on the topic.
-Topics and steps needed to reduce health disparities, highlight the need for training for caregivers, the importance of academic research and the promotion of dignified and adequate inclusion of LGBTI+ residents in NH.
To analyze professionals' perspectives working in NH and LGBTI+ individuals on issues and needs of this population.
A systematic review, which presented an analysis of 19 studies. - The main themes that emerged were: lack of knowledge and training on LGBTI+ health issues and attitudes of professionals towards LGBTI+ elders; concern with NH planning, fear of discrimination by professionals and inclusive NH solutions.
To explore the fears and hopes of older LGBTI+ people when considering entering Long-Term Care Facilities.
A qualitative study, carried out through focus groups.
23 participants identified as part of the LGBTI+ community.
The results were organized into four main themes: strong fears, social isolation, concerns about dependency and safe and inclusive spaces.
To question health professionals who provided mental health care at NH about their skills, training and barriers to working with LGBTI+ elders.
A qualitative study carried out through a virtual platform on mental health care.
57 professionals, among them psychologists, social workers, psychiatrists and nurses, with an average age of 52 years.
Professionals reported that LGBTI+ issues were relevant to their practice (87%), that they felt a little or well prepared to work with this population (76%) and were also a little or very willing to learn more (90%).
To assess the LGBTI+ cultural competence of NH employees, identify the needs regarding the training of these professionals and develop a structure so that the LGBTI+ cultural competence is understood.
A qualitative study during which four focus groups were formed, with employees from different areas of three NH, for discussions.

employees.
The qualitative analysis of the focus group discussions revealed a central category identified as "Sensitivity of the NH staff to residents' sexual orientations and gender identities", and eight main categories that described and explained the components of LGBTI+ cultural competence among study participants.
To discuss the criticality of the visibility of LGBTI+ elders and the inclusion of this population in the main healthcare environments.
A theoretical study. - The need to add large-scale education sessions to the visibility strategies in order to promote the staff improvement and the consequent preparation to challenge homophobic comments and support the people affected by them.
To investigate NH professionals' knowledge, attitudes and skills to respond to the needs of LGBTI+ elders.
A qualitative study of focus groups and interviews with LGBTI+ elders.  (30) .
To analyze the perception of LGBTI+ elders regarding their experiences in health services.
A phenomenological study that focused on the emotional domain and based on participants' experiences. Interviews were conducted in focus groups at an LGBTI+ organization.
Eight gay men.
Three main themes were exposed based on the interviews: the quality of daily health care, the concern for financial stability and the future and access to culturally competent Long-Term Care Facilities.
To analyze the experience of LGBTI+ elders living in NH.
A qualitative study developed through semi-structured interviews.
Six individuals: two LGBTI+ people living in NH, two LGBTI+ activists and two NH workers.
The interviews pointed to three main themes: insecurity taking over sexuality due to fear of discrimination due to sexual orientation, the impact of relationships, inside and outside home, with professionals, residents and family and the impacts of changing the environment, i.e., the transition between leaving home to be placed in a NH.
Mansilla CF, Rodríguez-Martín B. 2019. Espanha (32) . A study pointed out that, although some residents have never suffered prejudice, the possibility of such an attitude happening is enough to reproduce insecurities and fears. Being a LGBTI+ in a Long-Term Care Facility requires support from the community, residents and management of the facility itself (31) .
Some works cited narratives of LGBT-phobia committed by health professionals and other residents of NH. These infractions included the denial of the social name, delegitimization of the stable union, separation of the couple at the moment when both start to live in the same NH, where the health professionals put each partner in a different room, prohibiting demonstration of affection, prohibiting bathing with other residents of the same gender and disregarding their partners' opinions in decisionmaking regarding treatment. Among the most serious infractions, it is worth noting the lack of understanding of gender identity when the loss of autonomy due to neurological changes coexists associated with the increase in the degree of dependence in activities of daily living (24,30) . It is at that moment that individuals who identify with the gender opposite to the gender designated at birth start to be dressed and treated by cis-heteronormativity.
Being visible in shared residential environments is not, in itself, a sufficient strategy to change individual views and attitudes and promote more inclusive care environments (27) . Elders revealed that they preferred to live and be cared for in facilities that included people of all races, ethnicities, genders and sexualities (20) . There is an urgent need for research that examines the experience of LGBTI+ elders who have received or are currently receiving care in NHs (23) .

Professional training for dignified and inclusive assistance for Lesbian, Gay, Bisexual, Transvestite, Transsexual, Transgender, Intersexual elders
In this category, studies were included that investigated strategies aimed at training professionals working in NH, in order to promote awareness and approach of the LGBTI+ population in an inclusive and non-judgmental manner. Although the institutions affirm themselves to be inclusive, little is known about the strategies used for this purpose (18) , which supports the importance of presenting these findings.
A systematic review pointed to the need to promote changes in NH professionals' attitudes towards sexuality (32) . A strategy adopted to overcome this problem may be to personalize care to ensure respect for diversity and allow individuals to feel able to discuss their support needs with the staff, regardless of sexual orientation and gender identity (19) .
Furthermore, lack of training is consistent with the unfamiliarity of professionals with health problems and treatments related to the LGBTI+ population (25) . A study that conducted focus groups with NH professionals highlighted that the staff was looking for ways to learn how to be sensitive to LGBTI+ residents. However, they showed tension between wanting to provide an equal standard of assistance to all residents and fearing that they would show favoritism or special treatment, being considered non-professionals (26) . Lack of sex education and professional awareness reflects the need to train professionals to understand residents' sexual needs and effectively resolve conflicts or difficult situations (32) .
When analyzing the strategies for health education of professionals, one of the articles brings the study on the Health Education About LGBT Elders (HEALE), created and formalized by the Howard Brown Health Center, USA. The HEALE educational curriculum lists professional development for healthcare providers and care staff members who are interested in increasing their ability to care for LGBTI+ patients. The reports presented in the study, based on the training of 848 participating nurses, NH workers, demonstrated the course's effectiveness in informing, raising awareness, training and promoting changes related to health care provided to LGBTI+ elders, as they establish a standard of practice in nursing management to increase nurses' confidence to provide specific care to this population (21) .
Studies have pointed to the denial of the presence of LGBTI+ people and the imposing heteronormativity in NH. A study with NH professionals showed that the staff assumes that elders clients are heterosexual and non-transgender, and react in a discriminatory manner (28) . Professionals involved in long-term care for elders need to be aware of the historical legacy of discrimination against LGBTI+ people and how it can impact access to health services and social assistance or in residential environments (34) . Interviews with NH staff and managers pointed to the gap in the knowledge of specificities of care with LGBTI+ elders, since they reinforced the "equal treatment for all" discourse and the belief that elders should expose their sexualities so that the heterosexual presumption disappear (33) .
It was also observed that a main objective of education and training was to emphasize the fundamental importance that all LGBTI+ employees and service users receive the same dignified and respectful treatment offered to heterosexuals. Moreover, an example of how to achieve this result is the adoption of a logo or even the display of LGBTI+ posters and flags on site, indicating that the staff is well aware of lesbian, gay, bisexual and transgender clients' concerns (18) .
Co-production between academia and the community promoted discussion on public policies, ways of care and increased visibility, as it takes into account the experiences lived by LGBTI+ community members (17,23) . The need to disseminate knowledge about the specificities and particularities of care related to assistance to LGBTI+ individuals in health and institutional settings was also pointed out (21) .

DISCUSSION
The health field tends to follow a single direction, that of compulsory cis-heteronormativity. The assumptions, judgments and prejudices expressed by health professionals and institutions assume that all patients seen in the health system are configured as heterosexual and cisgender subjects (35)(36) , or that they are devoid of sexuality (37)(38) . However, health professionals and service providers are beginning to encounter a generation of politically engaged LGBTI+ elders who live openly and whose lifestyles and needs have so far not been properly included in social policies.
The articles included in this review, as well as studies from Australia (38) , Belgium (39) , Spain (40) and the United Kingdom (41) , pointed to the prejudice related to sexual orientation and gender identity in NH, which generates a feeling of fear and concern in LGBTI+ elders. A routine practice that transpires in healthcare environments, including in NH, is the obligation that elders find in "going back to the closet", hiding their gender identity and sexual orientation (24,38,(41)(42) . This has a negative impact on the quality of care provided, since the denial of identity leads to visible mental health problems in the assisted population. Depression, suicidal ideation, anxiety and social isolation are examples of mental disorders developed as a consequence of hiding sexual orientation and gender identity in institutionalized elders (13,43) .
The ambivalence in the judgment of NH resident elders' values about the fine line of taking on or not their gender identity and sexual orientation clearly reflects in the obstacles that this population faces during aging and in their old age. Even though in these places there is the possibility of aging together with other LGBTI+ people, sharing experiences and forming a support network (44) , it is necessary to modify the institutionalized approach models in health, as well as training and discussions about specificities of care crucial to care, thus preventing an increase in the rate of LGBT-phobia committed in NH.
In this setting, studies point out the dilemma between creating specific NH for LGBTI+ people in order to prevent LGBT-phobia, but with the risk of leading to segregation and accentuating the stigmatization of these elders. The ideal would be to invest in places where everyone is free to express their values, regardless of sexual orientation and gender identity (44) , which is still a challenging task in many countries. Another controversial point is the hiring of LGBTI+ people to work in these places, as long as they are empathetic in assisting this population (16,44) . Whatever the characteristics of NH are, it is essential to have institutional policies and concrete actions to train and develop professionals (45) able to assist LGBTI+ elders with quality and respect. Active Aging, marked by the preservation of autonomy and independence, shared by the World Health Organization in 2005 (46) , does not cover citizens in its entirety, as being a LGBTI+ elder means facing several barriers in politics, economy, social security, and health care. In addition to the discrimination due to fragility arising from aging itself, this population also faces greater difficulties in health care, since these care delivery environments are marked by the cis-heteronormative overview (47) .

Study limitations
This study had as limitations analyzing studies in Portuguese, English, and Spanish, which made it impossible to analyze studies in other languages, especially from countries with extensive experience with institutionalized elders, such as studies in German.

Contributions to nursing, health, and public policies
The findings of this review allow to give visibility to a theme that needs better exploration by public policies for healthy aging and NH managers. The results pointed to a serious problem of human rights, which calls for the LGBTI+ community's activism so that the theme is based on the deliberative spheres. It also brings relevant content of health education, with the inclusion of the topic in a professional training for the health staff.

FINAL CONSIDERATIONS
The studies in this review showed that NH are configured as hostile spaces, where elders can regress in their self-affirmation of gender and sexual orientation so that their care is adequate. The use of the title "treating everyone as equal" does not do justice to the equity of care, as it is systematized in the heterosexist perspective. We highlight the lack of professional training in assisting LGBTI+ old age and lack of knowledge of NH administrators and managers, considering LGBTI+ elders' health needs and demands.
Although the Brazilian gerontological studies of the last decade follow the international trend to include aspects of the development of sexual life in the itinerary of aging and old age processes, the heterosexual perspective is still mostly considered. Moreover, the difficulty of capturing how the topic has been approached in Brazil demonstrates the scarcity of national studies on institutionalized LGBTI+ elders.
Inserting gender aspects in debate and training of health and social care workers working in NH transcends biological issues of aging, reaching basic human rights of respect for identity, dignified treatment and the provision of a healthy environment and respect for residents.