Health care for LGBTI+ elders living in Nursing Homes

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.

Descriptors:
Sexual and Gender Minorities; Homes for the Aged; Delivery of Health Care; Nursing; Health Personnel

Databases	Serch strategy	Recovered studies	Selected studies
Virtual Health Library	“Minorias Sexuais e de Gênero” AND “Instituição de Longa Permanência para Idosos”	7	4
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

Author/Year/Country	Objective	Method	Participants	Results
Furlotte C, Gladstone JW, Cosby RF, Fitzgerald KA. 2016. Canada(16Furlotte C, Gladstone JW, Cosby RF, Fitzgerald KA. “Could We Hold Hands?” older lesbian and gay couples' perceptions of long-term care homes and home care. Can J Aging. 2016;35(4):432-46. doi: 10.1017/S0714980816000489 https://doi.org/10.1017/S071498081600048... ).	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 semi-structured questionnaire, telephone interviews and face-to-face 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.
Willis P, Almack K, Hafford-Letchfield T, Simpson P, Billings B, Mall N. 2018. United Kingdom(17Willis P, Almack K, Hafford-Letchfield T, Simpson P, Billings B, Mall N. Turning the co-production corner: methodological reflections from an action research project to promote LGBT inclusion in care homes for older people. Int J Environ Res Public Health. 2018;15(4). doi: 10.3390/ijerph15040695 https://doi.org/10.3390/ijerph15040695... ).	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.	37 participants (home staff, managers and community consultants).	The gain between training employees and managers of long-term care homes has reached debates about what the space needs are, to make it more inclusive for LGBTI+ elders.
Sussman T, Brotman S, MacIntosh H, Chamberland L, MacDonnell J, Daley A, et al. 2018. Canada(18Sussman T, Brotman S, MacIntosh H, Chamberland L, MacDonnell J, Daley A, et al. Supporting lesbian, gay, bisexual, & transgender inclusivity in long-term care homes: a Canadian perspective. Can J Aging. 2018;37(2):121-32. doi: 10.1017/S0714980818000077 https://doi.org/10.1017/S071498081800007... ).	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.	32 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.
Hafford-Letchfield T, Simpson P, Willis PB, Almack K. 2018. United Kingdom(19Hafford-Letchfield T, Simpson P, Willis PB, Almack K. Developing inclusive residential care for older lesbian, gay, bisexual and trans (LGBT) people: an evaluation of the Care Home Challenge action research project. Health Soc Care Community. 2018;26(2):312-20. doi: 10.1111/hsc.12521 https://doi.org/10.1111/hsc.12521... ).	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+.
Putney JM, Keary S, Hebert N, Krinsky L, Halmo R. 2018. United States(20Putney JM, Keary S, Hebert N, Krinsky L, Halmo R. “Fear Runs Deep:” The anticipated needs of LGBT older adults in long-term care. J Gerontol Soc Work. 2018;61(8):887-907. doi: 10.1080/01634372.2018.1508109 https://doi.org/10.1080/01634372.2018.15... ).	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.
Hardacker CT, Rubinstein B, Hotton A, Houlberg M. 2014. United States(21Hardacker CT, Rubinstein B, Hotton A, Houlberg M. Adding silver to the rainbow: the development of the nurses' health education about LGBT elders (HEALE) cultural competency curriculum. J Nurs Manag. 2014;22(2):257-66. doi: 10.1111/jonm.12125 https://doi.org/10.1111/jonm.12125... ).	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 post-training.	848 health professionals.	The study demonstrated the course’s effectiveness in informing, raising awareness, training and promoting changes in health care for LGBTI+ elders.
Committee AGSE. 2015. United States(22Committee AGSE. American Geriatrics Society care of lesbian, gay, bisexual, and transgender older adults position statement: American Geriatrics Society Ethics Committee. J Am Geriatr Soc. 2015;63(3):423-6. doi: 10.1111/jgs.13297 https://doi.org/10.1111/jgs.13297... ).	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.
Caceres BA, Travers J, Primiano JE, Luscombe RE, Dorsen C. 2019. United States(23Caceres BA, Travers J, Primiano JE, Luscombe RE, Dorsen C. Provider and LGBT individuals' perspectives on LGBT issues in long-term care: a systematic review. Gerontol. 2019;60(3):e169-e83. doi: 10.1093/geront/gnz012 https://doi.org/10.1093/geront/gnz012... ).	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.
Kortes-Miller K, Boulé J, Wilson K, Stinchcombe A. 2018. Canada(24Kortes-Miller K, Boulé J, Wilson K, Stinchcombe A. Dying in long-term care: perspectives from sexual and gender minority older adults about their fears and hopes for end of life. J Soc Work End Life Palliat Care. 2018;14(2-3):209-24. doi: 10.1080/15524256.2018.1487364 https://doi.org/10.1080/15524256.2018.14... ).	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.
Smith RW, Altman JK, Meeks S, Hinrichs KL. 2018. United States(25Smith RW, Altman JK, Meeks S, Hinrichs KL. Mental health care for LGBT older adults in long-term care settings: competency, training, and barriers for mental health providers. Clin Gerontol. 2018;42(2):198-203. doi: 10.1080/07317115.2018.1485197 https://doi.org/10.1080/07317115.2018.14... ).	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%).
Donaldson WV, Vacha-Haase T. 2016. United States(26Donaldson WV, Vacha-Haase T. Exploring staff clinical knowledge and practice with LGBT residents in long-term care: a grounded theory of cultural competency and training needs. Clin Gerontol. 2016;39(5):389-409. doi: 10.1080/07317115.2016.1182956 https://doi.org/10.1080/07317115.2016.11... ).	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.	22 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.
Willis P. 2017. United Kingdom(27Willis P. Queer, visible, present: the visibility of older LGB adults in long-term care environments. Hous. Care Support. 2017;20(3):110-20. doi: 10.1108/HCS-04-2017-0007 https://doi.org/10.1108/HCS-04-2017-0007... ).	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.
Jihanian LJ. 2013. United States(28Jihanian LJ. specifying long-term care provider responsiveness to LGBT older adults. J. Gay Lesbian Soc Serv. 2013;25(2):210-31. doi: 10.1080/10538720.2013.782834 https://doi.org/10.1080/10538720.2013.78... ).	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.	Seven LGBTI+ elders.	15 domains were identified corresponding to the needs of LGBTI+ elders, eight related to the types of knowledge needed, four to the idea of what attitudes NH providers need to have and three to the types of skills that are indispensable to assist these elders.
King A, Cronin A. 2016. United States(29King A, Cronin A. Bonds, bridges and ties: applying social capital theory to LGBT people’s housing concerns later in life. Qual Ageing. 2016;17(1):16-25. doi: 10.1108/QAOA-05-2015-0023 https://doi.org/10.1108/QAOA-05-2015-002... ).	To carry out a critical reflection, intervention and discussion about housing issues for LGBTI+ people during aging, according to the context of social capital theory.	A theoretical study based on an analysis of Robert Putnam and Pierre Bourdieu works. The author based himself on existing studies on housing for LGBTI+ aging, identifying the main concerns and framing those concerns around the social capital theory.	-	Service providers can be ignorant and discriminatory in the way they deal with LGBTI+ elders, especially with trans people. Heteronormativity and cisnormativity can distort the development of a bridge between social capital, bonds and, subsequently, affect well-being.
Benoit ID, Kordrostami E, Foreman J. 2020. United States(30Benoit ID, Kordrostami E, Foreman J. Senior sexual and gender minorities’ perception of healthcare services: A phenomenological approach. Int J Healthc Manag. 2020. doi: 10.1080/20479700.2020.1724437 https://doi.org/10.1080/20479700.2020.17... ).	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.
Green M. 2016. Canada(31Green M. The experience of living in long-term care for LGBT individuals: perspectives from residents and stakeholders [Internet]. Mount Saint Vincent University. 2016 [cited 2020 Mar 18]. Available from: http://140.230.24.101:8080/xmlui/bitstream/handle/10587/1750/MaureenGreenMAFSGNThesis2016.pdf http://140.230.24.101:8080/xmlui/bitstre... ).	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(32Mansilla CF, Rodríguez-Martín B. Professionals’ view of sexuality in institutionalized older people: a qualitative thematic synthesis. Gerokomos [Internet]. 2019 [cited 2020 mar 30];30(4):176-180. Available from: http://scielo.isciii.es/pdf/geroko/v30n4/1134-928X-geroko-30-04-176.pdf http://scielo.isciii.es/pdf/geroko/v30n4... ).	To analyze the existing evidence in the literature about the knowledge of professionals in Long-Term Care Facilities about the sexuality of institutionalized elders.	A systematic review. A search for qualitative studies, published in English or Spanish, was carried out in eight databases, in the gray literature (doctoral theses) and in the references of the included articles. 1,698 potentially relevant articles were collected and six articles were selected for this review.	111 professionals from Long-Term Care Facilities.	Seven categories emerged after the analysis of the included studies, of which the following stand out: the influence of negative stereotypes on the perceptions of professionals about sexuality in elders, the reactions and interpretations (positive and negative) of the professionals of Long-Term Care Facilities to the sexual expression of institutionalized elders and the residents’ need for privacy for the expression of sexuality.
Willis P, Maegusuku-Hewett T, Raithby M, Miles P. 2014. United Kingdom(33Willis P, Maegusuku-Hewett T, Raithby M, Miles P. Swimming upstream: the provision of inclusive care to older lesbian, gay and bisexual (LGB) adults in residential and nursing environments in Wales. Ageing Soc. 2014;36(2):282-306. doi: 10.1017/S0144686X14001147 https://doi.org/10.1017/S0144686X1400114... ).	To compare the expectations of LGBTI+ elders not living in NH with the findings of managers and health professionals working in these institutions.	A qualitative and quantitative study carried out through a semi-structured questionnaire applied to focus groups of NH workers, and semi-structured interviews conducted with LGBTI+ elders from the community in general.	70 participants, among them 14 were part of the NH professional staff, 27 were managers of these Long-Term Care Facilities, and 29 were LGBTI+ elders aged 50-76 years.	Interviews with LGBTI+ elders highlighted the desire not to reside in a NH for fear of discrimination. Moreover, they presented the idea of the need for specific institutions for the LGBTI+ community, in order to avoid the oppressions existing in heteronormative environments.
Willis P, Raithby M, Maegusuku-Hewett T, Miles P. 2016. United Kingdom(34Willis P, Raithby M, Maegusuku-Hewett T, Miles P. ‘Everyday Advocates’ for inclusive care? perspectives on enhancing the provision of long-term care services for older lesbian, gay and bisexual adults in Wales. Br J Soc Work. 2016;47(2):409-426. doi: 10.1093/bjsw/bcv143 https://doi.org/10.1093/bjsw/bcv143... ).	To understand how professionals who provide support to elders of different sexual identities can help to improve care environments.	A mixed study. Use of focus groups, semi-structured interviews and self-administered questionnaires.	62 participants formed the focus groups and 121 questionnaires were carried out.	Most of interviewees indicated tolerant attitudes towards elders’ sexual lives, but the results indicated gaps in the knowledge of changes in their sexual functioning and important aspects of the LGBTI+ history.

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[1] Corresponding author: Lucíola D’Emery Siqueira E-mail: luciola.demery@unifesp.br