Closet Doors Can Swing Both Ways: LGBTQ+ Elders in Long Term Care

June 2021. It’s Pride Month, and to mark the occasion Michael Hannah, a student on our MSc in End of Life Studies, draws on the concept of ‘social death’ to reflect on his own fears for what later life might bring.

Contribution by Michael Hannah:

It’s sometime back in the winter of 1979 and I am standing on a tenement close in St Andrews. I’m at the door of a perfectly ordinary flat and I’ve been invited there to a meeting and after party by members of one of the University’s student societies. 

But I hesitate. I feel physically unable to ring the doorbell because going into that flat, to that party, will mean “coming out”. The society was “St Andrews GaySoc” and by accepting the invitation and crossing that threshold, I knew I would be publicly acknowledging some deep part of my identity. The Minutes Book of that organization is now kept in the archives of the Glasgow Women’s Library. The entry for 14th November 1977 says simply “A Talk on Coming Out”. It was a key issue for the gay community back then and has remained so over these years.

Coming out of the closet has always been at the heart of the modern gay experience. Some choose to come out to everyone, some just to friends, some cut all ties and move to the big city to start a new “out” life. Yet however limited and partial the coming out might be, it marks a vital part of a new identity – and of belonging to a community. But what happens if people are forced back into the closet, particularly as they age? 

I am now 61 and this January I enrolled on the End of Life Studies MSc at the University of Glasgow, so this issue is important to me both personally and academically. LGBTQ+ people grow old just like anyone else. However, surveys suggest that LGBTQ+ elders are much more likely to live alone and without close family [1]. This means they may be more likely to have need of formal long term care. For LGBTQ+ people, there is a fear that their ageing and end of life will be lived out in an environment that is indifferent, ignorant, or even openly hostile to their identity.

Readers of this blog may be aware of the theory of “social death” that was developed from American studies of hospital dying in the 1960s which found that staff treated low status patients approaching death as simply bodies; as socially dead before physiological death [2]. This term has grown to include ideas of the cessation of the individual as a meaningful ‘social actor’, or as an active agent in other people’s lives [3, 4]. Learning about the concept raised a question for me: Given that LGBTQ+ elders are situated at an intersection of double discrimination of ageism and homo/transphobia, could that lead to the potential for “double social death’ within care institutions as they near the end of life? 

Many community-dwelling LGBTQ+ people believe older residents are discriminated against because of their sexual orientation or gender identity [5]. Hospitals and long-term care environments are sexually normative spaces where heterosexual relationships, norms and milestones are routinely privileged over other sexual identities and desires, and LGBTQ+ people can experience dual discrimination in these environments, including as they near the end of their lives [6]. This can result in concealment of sexual orientation, staff devaluation of relationships, reluctance to self-disclose health issues as a self-protective practice because of past experiences (or expectations) of mistreatment, and LGBTQ+ partners being offered less bereavement support [7-9]. 

Such fears of discrimination, and in response slipping back into a long abandoned closet, are very real to me as I live through my seventh decade and begin to contemplate other thresholds such as long term care and end of life. Compromising my gay identity really does feel like a social death. At the same time, I am left wondering about the extent to which the evident and documented fear that LGBTQ+ elders have of the prospect of long term care is matched by actual lived experience. There are clear examples of discrimination and bad practice. But are there also examples of modern and enlightened policy offering safe and affirming spaces for LGBTQ+ elders? Studies with older LBGTQ+ adults indicate that they desire inclusive care settings that provide two affirmative components of care: the local skills and knowledge of the caregivers in relation to LGBTQ+ ageing, as well as the overarching values and mission of the organization [10]. What then is the impact of explicitly LGBTQ-run or at least “friendly” facilities? And if there are good examples, can we measure any positive impact this may have on the wellbeing of residents and their eventual death? The work I did in the first MSc semester on the Continuum of Ageing and Dying sparked a strong interest for me in these issues of identity and social death. Now I am aiming, through research and study, to explore further these topics that are of such importance to LGBTQ+ elders as the end of life nears.

Back in 1979, after waiting on the cold stairs for far too long, I did in fact ring the bell and join the party. It was just a typical student get together, but it changed my life. Maybe my job now is to help ensure that LGBTQ+ elders waiting in fear at the door of long term care find acceptance and affirmation on the other side.

References

[1] Stonewall, 2011. Lesbian, gay & bisexual people in later life. London: Stonewall.

[2] Sudnow, D., 1967. Passing on: The social organization of dying. Upper Saddle River, NJ: Prentice-Hall. 

[3] Borgstrom, E., 2015. Social death in end-of-life care policy. Contemporary Social Science. 10(3), pp. 272-283.

[4] Mulkay, M. & Ernst, J., 1991. The changing profile of social death. European Journal of Sociology/Archives Européennes de Sociologie/Europäisches Archiv für Soziologie. 32(1), pp. 172- 196.

[5] Mahieu, L., Cavolo, A. & Gastmans, C., 2019. How do community-dwelling LGBT people perceive sexuality in residential aged care? A systematic literature review. Aging & Mental Health. 23(5), pp. 529–540.

[6] Willis, P., Maegusuku-Hewitt, T., Raithby, M. & Miles, P., 2016. Swimming upstream: the provision of inclusive care to older lesbian, gay and bisexual (LGB) adults in residential and nursing environments in Wales. Ageing & Society. 36, pp. 282-306.

[7] Almack, K., 2018. ” I didn’t come out to go back in the closet”: ageing and end of life care for older LGBT people. Older lesbian, gay, bisexual and trans people: Minding the knowledge gaps.

[8] Harding, R., Epiphaniou, E. and Chidgey-Clark, J., 2012. Needs, experiences, and preferences of sexual minorities for end-of-life care and palliative care: a systematic review. Journal of palliative medicine, 15(5), pp.602-611.

[9] Stinchcombe, A., Smallbone, J., Wilson, K. and Kortes-Miller, K., 2017. Healthcare and end-of-life needs of lesbian, gay, bisexual, and transgender (LGBT) older adults: A scoping review. Geriatrics, 2(1), p.13.

[10]  Putney, J.M., Keary, S., Hebert, N., Krinsky, L. and Halmo, R., 2018. “Fear runs deep:” The anticipated needs of LGBT older adults in long-term care. Journal of gerontological social work, 61(8), pp.887-907.