However, the equation of homosexuality exclusively with sexuality does Lesbian and Gay male elders a very grave disservice. It erases two key components of Gay life that have everything to do with how well these elders are served by aging providers in general and by adult protective services in particular: their relationships, and their social, psychological, and legal environment. This article seeks to outline how being a Lesbian, Gay male, or Bisexual elder may impact on that elder’s need for — and willingness to accept assistance from — adult protective services. It will also discuss some strategies adult protective workers may want to adopt to ease these elders’ fears.

Lesbian and Gay male elders have been called an “invisible” population (Cruikshank, 1991). If they are invisible, then transgendered elders have been inconceivable. Many adult protective services workers do not even realize such elders exist. This article therefore also explores transgender issues and identity vis-a-vis elder abuse and adult protective services.

Unfortunately, due in large measure to our society’s still-pervasive social prejudice against and ignorance about sexual orientation and gender minorities, there have been few studies of this population of elders, and virtually no one has examined how this population’s culture affects its experience with elder abuse. This paper is thus only a beginning, speculative venture into this realm. It is based primarily on my personal knowledge of Lesbian and Gay male elders and younger transgendered persons and on my discussions with social workers serving older Lesbians and Gay men and with domestic violence specialists serving older women or Lesbians, Gay men, and transgendered persons.

Sexual Orientation and Gender Identity

It’s often said that Americans are obsessed with sex. Unfortunately, that obsession has not translated into accurate and complete information about sexuality and gender. Therefore, before we can begin discussing elder abuse in relationship to this population, we need to define who they are.

Sexual Orientation

Sexual orientation refers to whether someone is sexually and/or emotionally attracted to: someone of the same gender (Lesbian, Gay male, Gay or Homosexual [both referring to either men or women]); someone of the opposite gender (heterosexual or “straight”); or both (bisexual). It’s impossible to determine how many people are Lesbian or Gay, since social prejudices dictate that many people will lie about this aspect of their identity. Those who have estimated percentages have produced numbers everywhere from 2% of the population to 20%, with 5-10% being the most popular estimates (Buxton, 1994).

Gender Identity

Gender identity refers to whether you perceive yourself to be male, female, both, or neither. Most of the time people who perceive themselves to be male are born with male genitalia, and those who perceive themselves to be female are born with genitalia labelled female. The exceptions are transgendered persons, who will be discussed in more detail below. There are nocredible estimates of how many Americans are transgendered.

The Intersection of Gender Identity and Sexual Orientation Sexual orientation and gender identity are wholly separate characteristics, like age and race. Most Lesbians feel fully female and most Gay men never question their maleness. Transgendered individuals may be heterosexual, homosexual, bisexual, or asexual. Lesbians, Gay men, and transgendered persons are found in every racial and cultural group. Therefore, it’s possible for an individual elder to face abuse and prejudice based on her age, her race, her gender identity, and her sexual orientation. While such multiple-jeopardy situations are not uncommon, this paper will focus only (and separately) on how Lesbian or Gay sexual orientation and transgendered identity intersect with elder abuse issues.

The Social, Psychological, and Legal Environment of Lesbian and Gay Male Elders

Homophobia

For the generations of Lesbians and Gay men who are now elders, the larger social environment in which they’ve existed can be summed up in one word: homophobic. Homophobia is fear of and/or hatred toward homosexuals. When those who are now elders were growing up, discovering their sexuality, forming relationships, and making a living, homosexuality was viewed as criminal, sinful, and sick. Those known to be homosexual were often fired from jobs, thrown out of their apartments, kicked out of the military, disowned by their families, and beaten by strangers. Businesses known to cater to Gay men and Lesbians were frequent targets of police harassment. Gay men and Lesbians who were working class and/or adopted manners of dress deemed that of the “opposite” sex were particularly brutalized (Marcus, 1992). Lesbian and Gay relationships were (indeed, in most ways still are) completely denied the rights and recognition routinely granted heterosexual marriages.

A few brave Lesbians and Gay men confronted the larger society’s disparagement (Marcus, 1992), but most learned that in order to survive, they must hide their identities and relationships. Indeed the stigma of being Gay or Lesbian is so great for these generations of elders that many of them refuse to label themselves as such. “We identify simply as two women living together in a primary relationship,” said one 75-year-old who had been partnered for 41 years (Johnson, 1991, p. 26). Adelman (1991, p. 30) interviewed another elder who said, “I never wanted to identify with a lesbian group. I just like being with women.”

Social condemnation of people who have relationships or sex with persons of their own gender is so strong that even those who do not identify themselves as Gay or Lesbian, those who do not associate with other known Gays or Lesbians, and those who “come out” (realize they are Gay) late in life nevertheless adopt many of the same protective behaviors and social adaptations as those who have long labelled themselves Gay.

Some of these adaptations are helpful. Some researchers believe, for instance, that Lesbians and Gay men may actually adapt to aging better than some of their heterosexual peers because they’ve learned to build close networks of friends and have a greater range of daily living skills due to their rejection of social gender task proscriptions (Friend, 1991).

Unfortunately, some of these adaptations make older Gay men and Lesbians morevulnerable to abuse, neglect, and exploitation. And none of the adaptations spares Lesbian and Gay male elders from the abuse all elders are vulnerable to, or from the threat of homophobic abuse.

Abuse of Lesbian and Gay Male Elders

Homophobic Abuse

The stories abound. One researcher discussed an older resident of a nursing home whom staff refused to bathe because they didn’t want to touch “the Lesbian” (Raphael, 1997). A social worker reported a case where the home care assistant threatened to “out” her older Gay male client if he reported her negligent care (Roosen, personal communication, May 12, 1997). Older Lesbians and Gay men who choose not to or do not succeed at hiding all traces of their sexual orientation are also subject to street harassment and violence (Visano, 1991).

Domestic Violence

Homophobia also plays a part in domestic violence within Lesbian and Gay couples. A therapist who works with Gay male batterers reports that “the majority…[of the men referred to him] have manifested a negative self- concept related to being homosexual, as well as negative feelings about who they are as a person.” (Byrne, 1996, p. 110) Homophobia is often used as a tool of batterers, who threaten to out their lovers to family or employers (Elliott, 1996).

Fear of Authorities

Most importantly, however, homophobia serves to keep victims from seeking help. Such a move (particularly if the abuser is a lover) might require outing oneself and facing possible hostility from the very people who are supposed to help. If seeking help involves — or might involve — the police, Lesbians and Gay men are especially likely to demur, because being Gay is still illegal in many states and because virtually every older Lesbian and Gay man knows of instances of police brutality against homosexuals (Marcus, 1992).

Legal Barriers

Legal discrimination against Lesbian and Gay male couples makes it harder for elders to afford to leave an abusive relationship. Whereas a heterosexual wife usually has access — albeit sometimes hard-to-obtain access — to her husband’s pension and (in community property states) to half of the couple’s assets regardless of whose name is on the title or account, Lesbians and Gay men have no such rights. An older Gay man who does not have sufficient pension income of his own has no right to a portion of his lover’s, and an older Lesbian whose abusive partner put all their assets in her name (a scenario that is fairly common among couples with an abusive, controlling partner) will lose everything she has worked for her whole life if she leaves.

Self-Neglect by Lesbian and Gay Male Elders

Every state that includes self-neglect in its definition of elder abuse reports that self- neglect makes up a large proportion of the elder abuse problem (Tatara, 1994). In fact, one study (Duke, 1990) found that self- neglect made up 79% of substantiated elder abuse cases. Judging from the experiences of Ruth Morales and George Roosen, caseworkers for San Francisco’s Gay and Lesbian Outreach to Elders, it seems possible that Lesbians and Gay men make up more than their “fair share” of this population. They have several reasons why they believe this is so (personal communication, May 12, 1997).

Internalized Homophobia

All Lesbians and Gay men must struggle to define themselves as worthy and decent human beings in the face of social prejudice that says they are emphatically not worthy and decent (Adelman, 1991). Some never successfully achieve a positive self-definition. Others, facing increasing disabilities, the deaths of lovers and friends, and other drains on their emotional strength, may find their psychological defenses against homophobia disintegrating as they age. Elders who have internalized homophobia come to believe that they are not worthy and respectable people and consequently deserve loneliness, ill health, and poor living conditions. Lacking self- esteem, these elders may be unable to ask for help, and unwilling to accept any help that is offered.

A History of Hiding

The current generations of Lesbian and Gay male elders almost invariably have histories of protecting themselves from social prejudice by hiding who they are. Some contracted heterosexual marriages or took opposite-sex friends to work-related social events. Others “simply” pretended to be single or lied about their hobbies and interests. Many turned down jobs and other opportunities that threatened their efforts to appear heterosexual. Roosen believes that some Lesbian and Gay male elders have so routinely taken extraordinary measures to protect their privacy that the prospect of allowing someone into their homes to provide personal care is unthinkable.

The Value of Independence

Ironically, one of the most adaptive consequences of learning to deal with societal homophobia — cultivating the skills and attitudes to sustain independence — can end up being counter-productive when an elder becomes frail. Because so many Gay men and Lesbians are disowned by family members who learn of their homosexuality and because they are legally deprived of rights to their partners’ earnings and pensions, Lesbians and Gay men tend to highly value self-reliance. Older Lesbians, in particular, often take pride in their ability to be self- supporting. Unfortunately, this independent streak can make accepting help in old age anathema. Consequently, some Lesbian and Gay male elders, Morales believes, simply vastly prefer self- neglect to “becoming dependent.”

Fear of Encountering Homophobia

Finally, Lesbian and Gay male elders may end up self-neglecting in order to protect themselves from others’ homophobia. Isolation is widely viewed as one of the primary risk factors for elder abuse and neglect (Wolf, 1996). Unfortunately, the services set up to connect isolated older people with others are shunned by many Lesbians and Gay men. Morales and Roosen report that many of their clients refuse to attend senior centers or nutrition sites or move into senior housing because they have “nothing in common” with heterosexual peers, whose conversations often include discussions of grandchildren and spouses. They also tend to refuse home care services, fearing that a worker might realize they are Gay and become abusive or try to blackmail them.

Transgendered Elders

Definitions

It is highly unlikely an adult protective services worker will ever encounter an elder who calls him- or herself “transgendered.” This term is relatively new, and its definition is contested. However, it is a useful umbrella term for several types of gender-related identities.

Transsexual. A transsexual is a person assumed to be female at birth who now lives full- time as a male (female-to-male or FTM), or a person assumed to be male at birth who now lives full-time as a female (male-to-female or MTF). Transsexuals may be post-operative, which means they have had one or more surgeries to alter their primary and/or secondary sex characteristics. They may be pre-operative, in that they intend to have one or more surgeries in the future. And they may be non-operative, which means they do not intend to have any gender-related surgeries. Although most transsexuals take hormones to help their bodies visually conform to their gender identity, some do not. Legally, transsexuals may have changed all, some, or none of their identity papers to reflect their “new” gender and (if appropriate) name.

Cross-dresser or transvestite. A cross-dresser or transvestite is a person who dresses part- time or full-time in clothing his or her culture deems as “belonging” to the “opposite” gender. Some people cross-dress as part of a performance, and may be called drag queens or drag kings.

Intersexed (intersexual) or hermaphrodite. Intersexuals (formerly known as hermaphrodites) are persons born with genitals that are not clearly “male” or “female,” or do not look like “typical” genitals.

Transgender(ed). This term is a catch-all for all of the above and for people who feel they cross or blur gender lines, are both female and male or neither. “Butch” Lesbians and “effeminate” Gay men are sometimes included in this category.

Non-congruent Bodies

What nearly all transgendered elders have in common is a body that does not “match” their clothing, presentation, and/or identity. Transsexual genital surgeries only began in the 1940s and 1950s, are extremely expensive and seldom covered by insurance, and — especially in the case of female-to-male transsexuals — have often produced less-than-satisfactory results. Therefore, even transsexual elders are likely to have genitals and (perhaps) other physical features that are not congruent with their sense of who they are. That means transgendered elders will tend to be extremely reluctant to use services — even emergency medical care — that require disrobing.

Transphobia

Social prejudice against transgendered persons (transphobia) is, in many cases, even more intense than that directed against Lesbians and Gay men. Surveys of transgendered persons consistently show an extremely high rate of violent victimization, including higher-than-average rates of street violence and of childhood violence perpetuated by parents and caregivers (Bowen, 1996; Courvant, 1997; Wilchins, 1997). Transgendered persons face prejudice from family members, employers, the general public, and “helping professionals.”

Law enforcement. Like Lesbians and Gay men, transgendered persons generally avoid contact with the police. Transgendered persons have often been the victims of police brutality and negligence, and many stories circulate about what happens in jail when a transgendered person is placed in a sex-segregated group cell.

Health care professionals. Transgendered persons are also subject to health care provider ignorance and prejudice. Even those who specialize in treating transgendered persons often require them to lie and hide. For decades these doctors and therapists required transsexuals to divorce loving spouses, move to new states, and fabricate whole new “life histories” in order to qualify for hormones and surgery. Even today, some surgeons refuse to operate on transsexuals who reveal facts like having borne or sired children. Health care providers who do not specialize in treating transgendered persons are, for the most part, completely ignorant about their health care needs and concerns (Morton, Lewis, Hans and Green, 1997).

Effects of transphobia. Because they face similar social prejudices and degradations, it is likely that transgendered elders face the same elevated risks of elder abuse and self-neglect as their Lesbian and Gay male peers. They may frequently internalize the prejudice against them and come to believe that they are not worthy of decent treatment. Greg Merrill, Director of Client Services at the Community United Against Violence, reports that transgendered victims of domestic violence are the least likely to leave an abusive lover, since they often believe their abuser’s taunts that no one else will ever love and accept them as they are (personal communication, June 17, 1997).

Like Lesbian and Gay elders, transgendered elders may frequently refuse services. They, too, will be exceptionally protective of their privacy. Because of past negative experiences, they may be particularly resistant to dealing with health care professionals, law enforcement, and agencies that may question their legal identity.

Implications for Adult Protective Services

Adult protective services workers, no matter how skilled and caring, cannot begin to negate or compensate for the violence and prejudice Lesbian, Gay male, and transgendered elders face. What they can do is try to be more aware of the perhaps-hidden realities of clients’ lives, and be more skilled at addressing clients’ fears and needs.

Identifying Lesbian and Gay Male Elders

Adult protective services workers do not have to positively identify who among their caseload is Gay in order to properly serve them. Indeed, many Lesbian and Gay male elders would feel distinctly uncomfortable if they felt they were “read” (identified as Gay), and some might deny it if asked. One Gay social worker even recommends not coming out to a suspected Lesbian or Gay male elder if you yourself are Gay, as it puts the elder in the uncomfortable position of feeling pressure to also self-disclose (Roosen, personal communication, May 12, 1997).

Recognize Relationships

Instead, be aware that not all couples are heterosexual. If there is evidence an elder lives with another adult, gently probe as to the nature and length of the relationship. Echo the elder’s language. Is this “friend” or “roommate” someone the elder can count on for care? For financial assistance? If there appears to be a partnership of some sort, you need not determine whether it’s sexual. Simply begin asking the type of questions you would ask a married couple rather than the type of questions you’d ask about a neighbor.

Be Aware of Legal Realities

At the same time, if the client appears to have a same-sex partner, be aware of the lack of legal protections and assumptions these couples have. If the client and partner want the partner to have something as simple as hospital visiting privileges or something as complex as an inheritance, special legal documents may have to be drafted. Even then, the couple may need help getting such documents honored: one lawyer who specializes in elder law and Lesbian and Gay issues reports that a nursing home refused to honor the Power of Attorney he drew up for the Gay lover of a resident (private conversations held at Joint Conference on Law and Aging, 1994).

Listen Especially Carefully

It was easy for the social workers who work with Lesbian and Gay elders to recite instances where adult protective services workers made situations worse. In one case, an older Gay man was moved out of a “dangerous” neighborhood to “nice senior housing.” All of this man’s friends and social contacts were young Gay male hustlers who abandoned him once he moved out of their neighborhood and into a “secure” building, effectively isolating him among people with whom he had nothing in common (Roosen, personal communication, May 12, 1997).

Similarly, what may look to an outsider like an exploitative relationship may, in fact, be quite an acceptable exchange to the people involved. Many older Gay men, in particular, couple with much younger men (Steinman, 1991; Visano, 1991). In one instance reported by Roosen, an older Gay man took in a much younger, Gay addict living with AIDS. The younger man was abusive and exploitative, but after his death the older man reported that he was prouder of having helped that young man than of almost anything else he’d ever done.

Find Respectful Service Providers

Just as an elder from a racial minority culture needs to have service providers who are respectful of her beliefs and practices, Lesbian, Gay male, and transgendered elders need providers who will treat them respectfully. If you suspect an older client is Lesbian, Gay, or transgendered, make sure you find or train service providers who will not denigrate them. In the case of transgendered elders, it is crucial for everyone who comes into contact with the elder to always address them by the name and pronoun they use, regardless of that elder’s genitals or legal identification.

Connect with the Client

One of the interesting findings of Bozinovski’s study of self-neglecting elders (1996) is that many of these elders were strongly identified with their past professions. This seems a fruitful rapport-building area to explore with suspected Lesbian and Gay elders, as these elders often invested a lot in their professional lives (Johnson, 1991). Further rapport can be developed by addressing “friends” or “roommates” as one would a spouse, and by noticing and asking about personal effects such as pictures (just don’t assume the young man in a picture is the client’s son!). If it will work in smoothly, talk about the variety of persons your agency serves.

Connect the Client to the Community

If you get any indication that a client is willing to talk about being Lesbian, Gay, or transgendered, be prepared to assist her or him in locating appropriate resources. Although there are very few programs specifically for Lesbian and Gay elders and none for transgendered elders, there are more and more “Gay retiree” groups, and hundreds of communities have Gay-oriented churches or social groups and/or transgender support groups. The pastors of such churches or leaders of such groups may be willing to arrange for an informal friendly visitor if the elder is homebound. A list of such resources is included below.

Conclusion

Given how much prejudice and violence Lesbian, Gay male, and transgendered elders face, there can be no question that any given APS caseload will include such elders. These clients are likely to be more resistant than other clients to accepting services, due to their fears of being victimized or ridiculed again and of losing especially-valued independence and privacy. When APS workers become more aware of the existence and circumstances of Lesbian, Gay male, and transgendered elders, they should be better able to build rapport with these clients and assist them in getting the services and assistance they need.

References

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Bozinovski, S.D. (1996, November). Self-neglect among elders: A struggle for self- continuity. Paper presented at conference of the National Association of Adult Protective Services Administrators, Austin, TX.

Buxton, A.P. (1994). The other side of the closet: The coming-out crisis for straight spouses and families (revised edition). New York: John Wiley & Sons, Inc.

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Johnson, S.E. (1990). Staying power: Long term lesbian couples. Tallahassee, Florida: The Naiad Press.

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Morton, S., Lewis, Y., Hans, A., & Green, J. (1997). FTM 101 — The invisible transsexual. (Available from FTM International, Inc., 1360 Mission Street, Suite 200, San Francisco, CA 94103)

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2000, amboyz.org