Lesbian,Gay,Bisexual,and Transgender Persons Aging in Rural Areas

The Case of Leslie Engels

Leslie is a 70-year-old Caucasian female who resides in a small, coastal town in the Southeastern United States. Leslie met and married her ex-husband, Dan, in college and they had three children together. They now have six grandchildren. Leslie’s mother is also still living but is currently receiving care in a memory care unit of a long-term care facility. Leslie recently retired from a long career as an elementary school teacher in a rural county. Leslie and Dan have maintained an amicable relationship in the last 2 years since their divorce and often spend holidays together with their children and grandchildren. In fact, she always felt like she and Dan were only friends for much of their marriage.

About 3 years ago, Leslie began spending more time with her best friend Emma and that friendship grew into a romantic relationship. By that time, Dan had already been sleeping on the couch and had also befriended Emma. He was not surprised when the two women shared their feelings for each other with him. Dan eventually moved to another house and began divorce proceedings.

Given her work history as a teacher in a very small and conservative community, Leslie felt the need to hide the nature of her relationship with Emma from former coworkers and friends. All but one of her children is supportive of her new lifestyle, and the unsupportive son has distanced his children from the couple. Leslie has felt increasingly ready to reveal her relationship with Emma so that they can start living more openly as a couple. She recognizes some of her friends might already suspect she and Emma are a couple given Emma’s recent social media postings of their trip together to the mountains.

Emma is also retired, does not have children, and is originally from the Netherlands, an open and supportive country that was the first national to legalize same-sex marriage. Emma has been out as a lesbian for most of her adult life. Although Leslie has had romantic feelings for other women in the past, she never previously acted on those feelings and never identified herself as lesbian Although Leslie feels uncertain of how to identify her sexual orientation, she is happier than she has ever been and feels like a teenager again.

Aging and LGBT People

Even though Leslie in the case study is uncertain of her identity, she is currently involved in a same-sex relationship. She could be considered a late bloomer in the LGBT community, meaning that she has come out later in life. The aging process for LGBT individuals is, in many ways, similar to the aging process of non-LGBT adults. Like other older adults, LGBT people cope with chronic health conditions, loss of independence, postretirement financial challenges, social isolation, and ageism (Hash & Rogers, 2013). Yet, older LGBT individuals also uniquely contend with social bias and stigma pertaining to their sexual orientation or gender identity. The convergence of ageism with heterosexism, homophobia, transphobia, and, in some cases, sexism and racism becomes cumulative and oppressive over time. The internalization of these biases by LGBT people over the years further impacts their self-image, openness about their sexual orientation and gender identity, and potential isolation in later life (Hash, Morrow, & Weirich, 2019; Morrow, 2006). The case study for this article reveals that Leslie has remained relatively hidden, or closeted, about her relationship with Emma and that she is now contending with the growing need to be more open and honest with others about her relationship. In having grown up in the more accepting Netherlands culture, Emma has more readily accepted herself as lesbian and has been more open to coming out, or disclosing, her sexual identity.

LGBT people also tend to have lower levels of health-care engagement compared with their heterosexual and cisgender counterparts (Fredriksen-Goldsen et al., 2014). Compared with heterosexual adults of similar age, LGB older adults have been found to have a higher prevalence of chronic health conditions such as low back pain, weakened immune system, stroke, heart attack, asthma, and arthritis (Fredriksen-Goldsen & Kim, 2017). Despite the prohibition of health-care discrimination against LGBT people under the 2010 Affordable Care Act, LGBT individuals report bias by health-care providers (Mirza & Rooney, 2018). The 2015 U.S. Transgender Survey (James et al., 2016) found that transgender individuals reported health-care discrimination related to insurance coverage for transition-related surgery and negative experiences with health providers because of their gender identity. The survey also found that transgender individuals tended to disengage from medical care for fear of being mistreated because of their gender identity. Coming from a heterosexual marriage, Leslie had not experienced discrimination in health care and other settings but now may be apprehensive about coming out to providers, such as listing Emma as her emergency contact or as a health-care decision maker for her. She may also need to decide whether to be open about her relationship with her mother and the staff at the memory care unit where her other receives care.

In the United States, the present generation of older LGBT people came of age in an era when same-sex intimacy was considered deviant and illegal (Hagai & Crosby, 2016; Johnson, 2009). In addition, they were prevented from serving openly in the military (the Don’t Ask Don’t Tell policy) and suffered great stigma and discrimination during the early AIDS crisis. Such stigma continues for midlife and older gay men suffering from the disease today (Centers for Disease Control and Prevention, 2018; Mattocks et al., 2013). Thus, hiding one’s minority sexual orientation or gender identity status was a common adaptation, even within one’s own family and community (Morrow, 2001, 2006). The U.S. Supreme Court ruled in the 1986 Bowers v. Hardwick decision that sexual intimacy between two men in the privacy of their home was illegal (Mucciaroni, 2009). The Defense of Marriage Act was passed by Congress in 1996 and defined marriage as being between one man and one woman (Clarkson-Freeman, 2005). Defense of Marriage Act excluded same-sex couples from federal benefits such as filing joint tax returns and securing survivor death benefits. It was not until 2003 that the Hardwick decision was overturned by the Supreme Court in Lawrence v. Texas (Hagai & Crosby, 2016). Then, in 2013, the Supreme Court ruled in United States v. Windsor that same-sex couples were entitled to marry under the equal rights clause of the Constitution (Silver, 2013). The Windsor ruling was a watershed civil rights moment for same-sex couples seeking legal recognition of their relationship through marriage. Even so, older LGBT individuals, such as in the case study about Leslie, have lived most of their lives under both legal and social discrimination because of their sexual minority status. Many LGBT individuals form non-kinship support networks (also known as families of choice) to compensate for rejection by their kinship families and home communities.

Aging in Rural Areas

In addition to aging as a lesbian or bisexual person, Leslie is also growing older in a rural area. Although almost a dozen different definitions exist for what is considered rural, the U.S. Census Bureau views it as an area that is not considered part of an urban area or cluster (Krout & Hash, 2015). In the United States, these rural areas tend to have a higher median age, and the older adult population accounts for a larger proportion of the population. As communities, rural areas often lack the continuum of health and social services that are afforded more densely populated areas. Advantages of living and aging in rural areas include lower crime rates, a lower cost of living, and often opportunities for outdoor recreation (Hash, Wells, & Spencer, 2015). Residents of rural areas are also typically more religious and politically conservative (Kellogg Foundation, 2001; Krout, 1986) and less accepting of LGBT people. Despite these characteristics, it is important to keep in mind that rural areas and their residents can be very diverse. In fact, Chuck Fluharty from the Rural Policy Institute warned, “If you’ve seen one rural community, you’ve seen … one rural community” (Lohmann & Lohmann, 2005, p. xxii).

Given that Leslie and Emma reside in a small community, they may feel intimidated about coming out to friends and neighbors for fear of not being accepted or being discriminated against. Since they are retired, Leslie and Emma could choose to relocate to a larger city that may be more accepting and that may offer greater opportunities to build a social network with other LGBT people. Some larger cities in the United States have specialized services and even housing for older LGBT people. They could also consider relocating to Emma’s home country, the Netherlands. Regardless of where they choose to live, Leslie may be interested in pursuing a more positive relationship with her adult son who has heretofore not been supportive of her relationship with Emma.

Recommendations

In considering the case of Leslie Engles and what is known about the challenges of LGBT adults aging in small towns and rural communities, a few recommendations can be offered to support these individuals and their families. First of all, the American Psychological Association (2011) published guidelines for assessment and intervention with LGB clients. Several of those guidelines are discussed here and extrapolated upon to address providing affirmative therapeutic services to older LGBT individuals. It is important that providers understand the context of time and era when working with older LGBT adults. The effects of physical, emotional, and mental trauma related to stigma and discrimination are significant for many older LGBT people and continue to inform their self-view. Also important is understanding the historical context of HIV/AIDS and the ways in which the epidemic influenced, and continues to influence, the health and wellness of gay men particularly. Recognition of workplace context is also important in understanding older LGBT people. One can surmise in the case study for this article that Leslie’s long-time career as a teacher likely influenced her decision to remain secretive, or closeted, about her sexual identity. Although it may be therapeutically tempting to push Leslie to become more open about her relationship with Emma, it is important to recognize and support a person’s choice on identity disclosure and management (Butler, 2017). It is also important that providers distinguish sexual orientation from gender identity in working with older LGBT individuals (American Psychological Association, 2011). Orientation and gender are separate and distinguishable identity descriptors.

Second, Fredriksen-Goldsen and Kim (2017) propose a Health Equity Model (HEM) for assessing and intervening with older LGBT individuals. The HEPM is particularly suitable to assessing older LGBT individuals because of its focus on a life course development perspective for identifying the issues and needs of LGBT clients. The model includes identifying positive and negative life experiences, both historical and individual, that impact a person’s capacity to “achieve their full potential for good health and well-being” (p. S2). Strategies for improving health and well-being arise from an understanding of individual and environmental context.

Finally, older LGBT adults receiving care in institutional settings including hospitals, assisted living facilities, and nursing homes are particularly vulnerable to ostracization and stigma by both staff and other residents in the facility. The federal 1987 Nursing Home Reform Act requires that nursing home residents be treated with dignity and respect (Kauber & Wright, 2001). SAGE (Services and Advocacy for Gay, Lesbian, Bisexual & Transgender Elders; 2010) offers recommendations for improving understanding and respectful care for LGBT individuals in residential care. For example, staff training on LGBT issues and resident rights can be helpful for creating a more respectful residential climate. In addition, facility operators can raise staff awareness by conducting self-assessments of faculty culture and quality of care. In addition, ombudsman programs can be a resource for LGBT residents who seek grievance about their treatment. Also, nursing home social workers should work with LGBT residents to ensure they secure legal documents such as a last will and testament, a health-care power of attorney, and a financial power of attorney. Such documents are important for LGBT people whose closest and most supportive contacts members may not necessarily be kinship or legal family. In the case study for this article, Leslie has a primary relationship with Emma. However, they are not legally married and there is no evidence that either has a will, health-care power of attorney, or financial power of attorney. In the absence of such documents, the decisions for Leslie’s health-care and financial decisions as well as her estate would revert to her children, should she become incapacitated or die. Emma, her spousal companion, would have no legal rights otherwise. Thus, it is vital to ensure that older LGBT individuals secure legal documents to ensure their wishes are honored in the event of incapacitation or death.

Conclusion

Older lesbian, gay, bisexual, and transgender adults face many challenges in aging, including coping with stigma and discrimination because of their sexual orientation or gender identity. In response to bias and rejection by family and community members, many older LGBT people have built strong support networks and personal resilience that offers protection to the risks and challenges of older adulthood. Despite the challenges of aging in small towns and rural areas, LGBT older adults continue to demonstrate resilience and dignity. Although not identifying as lesbian or bisexual during the majority of her life, Leslie must now decide not only whether or how to identify but also how to build and sustain resilience and navigate the challenges facing the persons in same-sex relationships living in small towns and rural areas.