Successful Aging For Canada's LGBT Older Adults
Submitted by Tosh Reed
Tags: aging caregiver discrimination gay health care professionals lesbian LGBT LGBTQ mental health nursing older adults
Canada is a country made up of all cultures and it prides itself on the diversity of its citizens. As the baby boomer generation begins to enter the later stages of life, many health care professionals are discussing how to help aging Canadians achieve "successful aging". As defined by Rowe & Kahn, "successful aging is more than absence of disease, important though that is, and more than the maintenance of functional capacities, important as it is. Both are important components of successful aging, but it is their combination with active engagement with life that represents the concept of successful aging most fully (1997). I think that successful aging is something everyone in our society is entitled to, but it can be hard to attain for people that live within vulnerable populations. It can be even harder to age successfully if you live within a vulnerable population that is invisible to mainstream society.
Topic of Interest
My topic of interest is successful aging within members of Canada's LGBTQ community. LGBTQ is an acronym for lesbian, gay, bisexual, transgendered and questioning. It is used to replace the term gay when in reference to the group of people who identify as members of that community. I have been proud to have family and friends that identify as members of the LGBTQ community for my entire life. When I was growing up in a small town on Vancouver Island, I remember people's attitudes towards homosexuality being so extremely negative that it was violent in some situations. I remember when a family friend was dying of AIDS, he visited us in our town and I vividly recall how people seemed afraid of him, while others judged that he deserved his fate because of his sexual orientation. When I was attending the Gerontological Nursing Association of Canada conference in Vancouver this year, I met a nurse who worked with an organization in Victoria, BC that was dedicated to improving gerontological care for older adult lesbians on Vancouver island. She told me that their recent studies had shown that an overwhelming number of lesbians went back into the closet when they reached a point where they were admitted to long term care environments. This shocked me and has made me want to learn how nursing staff can help to improve care for older adults of the LGBTQ communities here on Vancouver Island. This topic is important for all nurses who want to improve the care that is delivered to the Canadian public. Increasing cultural sensitivity training in health care providers can improve the health outcomes of patients from different minority groups (Majumdar, Browne, Roberts, Carpio, 2004).
Question of Inquiry
The question that I wanted to ask within this paper is "how can nurses and other health care professionals adapt practices to reflect the cultural safety and life experiences of LGBTQ older adults in Canada?" This paper will discuss some current literature on the topic and show how nurses can develop cultural sensitivity towards the LGBTQ. It will also discuss nursing considerations when caring with older adults within the community and about how to assist clients that identify as LGBTQ that are facing discrimination. I believe that this question is of value to the nursing profession as it can help members of this community feel more comfortable when seeking out medical care. Many nurses may argue that since the legalization of gay marriage in 2005, this topic has become a non-issue. The reality is however, that because members of the LGBTQ community "have historically been socially defined within medical terms as mentally ill, the health care system has been one of the primary arenas through which control over their lives was exerted" (Brotman, Ryan & Cormier, 2003). The Canadian Psychiatric Association removed homosexuality from its list of mental disorders in 1982. For all older adult LGBT, this means that they can quite clearly recall a large percentage of their lives when their sexual orientation and way of life was called a mental illness by the country they were a citizen of. They also may be old enough to remember when homosexuality was outright illegal and deemed a criminal offense under Canadian law, which existed until the law was abolished in 1969. Brotman, Ryan & Cormier, (2003) stated that because of the length of time that elderly LGBTQ "have been managing stigma, health care professionals should be particularly concerned about potential effects on their health status" (p. 192). They go on to say that because of this, they "are less likely to seek out health care services or identify themselves as gay or lesbian to health care professionals when they do" (p. 193). It is for these reasons I believe this question of inquiry is valid and it is why I believe it is of value for nurses to learn about and take into consideration in their own practices.
Successful aging within the LGBTQ community
With regards to successful aging for the LGBTQ community, the article “I'm still raring to go”: Successful aging among lesbian, gay, bisexual, and transgender older adults, examines the "successful aging" term and have elaborated about which patterns of successful aging may differ in older LGBTQ adults as opposed to their heterosexual counterparts such as; the distinctiveness of the LGBT experience in older adults, and the health of LGBTQ older adults (Van Wagenen, Driskell & Bradford, 2013). This article articulates the ways in which the successful aging framework can be modified to describe experiences of aging in a sample of LGBTQ elders, a minority subgroup, sharing experiences of stigma related to their sexual orientation and/or gender identity. The authors argue that since coping with adversity is a common experiences in the lives of many minority groups, these modifications of the successful aging framework may be particularly relevant to describe the experiences of LGBTQ older adults (Van Wagenen, Driskell & Bradford, 2013). LGBTQ older adults that have been successful at coping with the adversities and discrimination that they have faced in their lives, may be even more successful in aging than their heterosexual counterparts because of an increased resilience.
A lack of studies on the topic of LGBTQ older adults
While reading through the literature that I have selected, themes of patient isolation, lack of studies targeting the population group, memories of past discrimination, and fear of future discrimination, became apparent. In the USA, the National LGBT Health and Aging Center performed the first national federally-funded project examining LGBT aging and health in 2011. their findings showed 13% have been denied healthcare or provided with inferior health care and that 21% do not disclose their sexual or gender identity to their physician (Fredriksen-Goldsen et al., 2011). In LGBT Aging and Rhetorical Silence, author Maria T. Brown comments that "LGBT elders have been excluded [the studies regarding the] LGBT community and from gerontology" (p. 65). She goes on to say that " the exclusion of LGBT elders from queer theory and gerontological theory has resulted in the silencing of LGBT older adults and their lived experiences. (p. 66). One of the problems of this kind of silence with regard to minority groups, is that the mainstream society tends to not realize there is a problem or a potential problem. Brown draws the connections between this silence and health care workers, saying that "LGBT elders historically have had to deny their sexual and gender identities to gain access to the social and material supports available to older adults through traditional human service networks" (p. 68).
This is something that younger LGBTQ may not need to face when they are older adults due to the recent changes in Canadian law, but it is still something that merits attention right now in our medical system and for the immediate future. Brown also stated that "rather than lie about who they are or risk being ostracized if their secrets are discovered, they may choose not to ask for the social and material supports available to heterosexual or non-transgender older adults" (p. 68). This is a very important reason why nurses and other health care professionals need to be more aware of the issues that these older adults may be going through so that we can provide culturally safe care. If a person is too uncomfortable or too scared to go to the hospital when they need care, the outcomes that are seen can be disastrous.
In Gerontological Nursing & Healthy Aging (2013), the authors state that "knowledge based on research is lacking about aging LGBT(Q) individuals. Reasons for this include difficulties in studying the LGBT(Q) population because of problems with definition, differences in self-identification, societal attitudes, and a lack of support for research with this population" (p. 408). An article that describes some of why members of this community may feel uncomfortable or scared in regards to seeking medical treatment is one written on the subject of "Minority stress". Defined as "being the chronically high levels of stress faced by members of stigmatized minority groups" (Kuyper & Fokkema, 2010). This information in this article is useful in that it articulates how minority stress can affect the mindset of someone already experiencing a depression/loneliness in their mental health state. In their conclusions, the authors stated that minority stress was a factor that was increasing the loneliness felt by older LGBTQ persons in the study (Kuyper & Fokkema, 2010). They also described how bisexual individuals had higher levels of internalized homonegativity and concealment of one’s sexual identity than homosexual participants did, while homosexual persons had more often encountered negative reactions on their same-sex attractions (Kuyper & Fokkema, 2010). I believe that this article is relevant to nurses because I feel minority stress plays a huge role in increasing loneliness in long term care settings for older adults of all minority groups as well as those in the LGBT community.
How to educate nurses
In the guidebook Inclusive Questions for Older Adults (National Resource Center on LGBT Aging, 2013), the authors state that "by creating a welcoming, safe and LGBT-affirming space—which includes asking demographic questions about sexual orientation and gender identity—service providers will be better able to provide culturally competent care and encourage honesty and trust so that clients can be their authentic selves" (p. 4). This guidebook contains some very useful information directly related to healthcare workers. In the section on data collection, they state that "given the unique barriers and challenges many LGBT older adults face, omitting explicit mentions of sexual orientation and gender identity from client demographic information limits the ability of service providers and healthcare professionals to address the complete needs and issues of LGBT older adults" (p. 6). The guide also has a section that addresses common questions and misconceptions related to older LGBTQ. These questions are relevant to health care workers as it outlines many of the typical responses to this topic of interest, as well as my question of inquiry in very direct and easy to understand language. The authors end with providing samples of questions to ask LGBTQ patients about their sexual orientation in ways that are culturally safe. This guide was written in the USA but the information they are sharing is just as relevant in Canada. The questions they offer as examples for how to initiate discussion with LGBTQ older adults are as useful to Canadian nurses as they would be to nurses anywhere in the world.
Rob O'Flanagan, of the Guelph Mercury newspaper, reported on a healthy aging forum where B.J. Caldwell, an educator spoke about to the crowd of health care professionals about ways to change their communication and assessments, stating that "using expanded, inclusive language to address their needs is a must", and "simply asking someone "who is your family?" is a much more open-ended question than asking if they have a husband or wife." (O'Flanagan, 2013) Caldwell also stated (as quoted in O'Flanagan, 2013) "It's the LGBT and the sexual-orientation, gender-identity issues that people often don't think about. It is about just broadening your scope of how you are approaching and how you are communicating with a person you are caring for" (O'Flanagan, A1, 2013). Nursing practice in Canada currently advocates for the use of open ended questions during assessment and when working with patients. Utilizing open ended questions encourage the patient to express the problem or health need in their own way, reflecting their own individual life experience while freeing the patient from feeling as if they are being directed or led by the nurse, thus helping them feel more in control (Arnold & Boggs, 2011).
In The Health and Social Service Needs of Gay and Lesbian Elders and Their Families in Canada, (Brotman, Ryan & Cormier, 2003), the authors discuss that the education of health care professionals is an important step to the creation of culturally safe environments for older LGBTQ, stating that this education is an " important way of raising awareness and improving services for aging gays and lesbians." (p. 198) They go on to state that during their study, "the most frequently mentioned issues were those related to the development of supportive and safe environments and improvements to the ways in which professionals collect information. It was felt that improving communication and support would best facilitate trust-building for gay and lesbian seniors" (p. 198). Aside from communication teaching for the health care staff, a major conclusion that Brotman, Ryan & Cormier discussed was that older LGBTQ would "benefit immensely from the added protection of policy initiatives that incorporate homophobia as a grounds of elder abuse" (p. 198).
Dealing with discrimination
"Homophobia has been variously described as ‘fear and hatred of gay and lesbian people and of their sexual desires and practice or as an irrational fear and dislike of lesbian, gay, bisexual and transgender people which may lead to hatred and result in physical or verbal abuses" (Irwin, 2007). This definition is something that could be included as grounds for elder abuse in my opinion as they are very similar in my mind. Irwin, (2007) mentions that homophobia "need not be conscious or intentional" (p. 72) and that it "may affect policies and attitudes indirectly and unintentionally by, for example, defining LGBT health issues as marginal, or less important, because they affect only a small majority of the population and are therefore, marginal to the concerns of the broader population" (p. 72-73).
I have heard classmates and other nurses say things along these lines, which I say not to cast blame, but to state that I have witnessed this behaviour and have believed it to be totally unintentional. I thought this article had value for nurses in that it lists some real examples of things that can be changed to provide more culturally safe care. Irwin discusses hospital admission forms and suggests that they "assume next of kin is either a spouse or a member of the patient or client’s biological family" (p.73), and that the forms "are particularly worrying for LGBT people because this type of information determines who may be granted visiting rights; given access to important information about the health status of the patient; and be involved in the decision‑making processes." (p. 73). She further states that "in the case of LGBT people, many are estranged from their biological families so families of their choice become very important to their wellbeing" (p. 73). Changing the hospital admission forms is something that can be done relatively easily and can help older LGBTQ feeling isolated and marginalized when they need to access care.
In the article Coming Out to Care: Caregivers of Gay and Lesbian Seniors in Canada, the authors describe some of the discrimination that LGBTQ elders face can face in their lives. One of the ways I think this article is excellent for health care professionals to read is that the authors give an explanation of terms such as Homophobia, Heterosexism and "coming out", which are useful for the reader who may be unfamiliar with these concepts to gain a bit more depth to the issues that are present in Canada and around the world. The authors also discuss that the current generation of LGBTQ older adults face discrimination in two articulated ways. "The first was the actual discrimination that these populations encountered in the health care system. The second was the anticipation of discrimination experienced by seniors prior to accessing health services that mediated their willingness to come out to health care providers or to access services altogether" (Brotman et al., 2007).
Discussed in this article are real examples of this kind of discrimination, such as health care workers in home support care outright refusing to work with patients because the patient identifies as LGBTQ (p. 497). These stories of real discrimination are presented for health care professionals to read so that they can see that this type of thing is still occurring. This discrimination not only harms the patient, but also their partner who may feel unable to leave their loved one in a medical system they feel would be marginalized in and treated poorly simply because they were not heterosexual. In my opinion, nurses can benefit from an increase awareness of these issues so that they can prevent themselves from coming across to LGBTQ patients as homophobic whether it be intentional or unintentional. For nurses to come to an understanding of the realities that some patients and their primary caregivers face when accessing the medical system here in Canada, we must encourage more sensitivity training in this area. Brotman et al., (2007) discussed their study where caregivers were asked to share their experiences of caring for LGBTQ older adults and their results showed that all of the caregivers highlighted a need for increased "education and training of health and social service professionals in hopes that these practitioners could learn acceptance, address heterosexist assumptions, and con- front homophobia" (p. 500). The caregivers also described how they felt that "individuals who work with seniors in the health and social service sector would benefit from learning to identify the more subtle clues behind individuals’ reluctance to access services so that they may proactively address potential problems, concerns, or needs" (p. 500-501). Receiving this type of feedback from LGBTQ caregivers and patients can help nurses and other health care professionals to improve the ways in which care is provided.
The literature also speaks to how LGBTQ older adults are affected when discrimination happens, and the effect that has upon their mental health status. This information is useful as it can raise health care professionals awareness of the mental health issues that the current generation of older LGBT face as they move through the transitions of older adulthood. In my opinion, as the baby boomer generation moves forward to older adulthood there will be a more vocally identified portion of LGBT needing care. In the article Aspects of mental health among older lesbian, gay, and bisexual adults, the authors discuss how shedding light on the issues that LGBTQ older adults face, will help care providers deliver better and more holistic care (D'augelli, Grossman, Hershberger & O'connell, 2001). I found this article to be of value to my own nursing practice as it examined older adults interpretations of their sexuality in relation to their past, and current mental health, especially in relation to depression. If "depression in older adults is exacerbated by loneliness and by declines in self- esteem, power, income, and number of friends" (D'augelli, Grossman, Hershberger & O'connell, 2001), then the feelings of isolation and fear for discrimination that older LGBTQ are reporting will surely compound on any already existing depression in their lives.
When I consider the history that many in this community have lived through, with the illegality of homosexuality, as well as the society deeming it a mental illness, I found the article by D'augelli, Grossman, Hershberger & O'connell very enlightening because I can keep these connections present in my mind when working with older adult populations as this may be still be a source of pain, depression and anger. I believe that having to repress part of one's self can lead to a lot of potentially disastrous mental health complications later in life and it is good to see research like this showing the potential mental health connections between lived experiences of older LGBTQ and existing mental health challenges such as depression and suicidal ideation. One thing that this article touches on was something I could not find in a lot of other literature which is why I included it even though the article is from 2001. It describes feelings of "personal homonegativity, which they define as a sense of personal discomfort about their sexual orientation (D'augelli, Grossman, Hershberger & O'connell, 2001). This can arise from societal pressure to conform and a personal desire to feel a sense of normalcy in congruence with the rest of society. Most of the literature I have read does not speak to the topic of personal homonegativity, instead looking at the more broad topic of societal homonegativity. Also of value in this research article is the topic of suicide-related homonegativity, which "describes suicidal thoughts and actions directly linked to dissatisfaction about sexual orientation".
Suicide is not a topic that is widely covered in the literature but is something that health care professionals should consider when working with older LGBTQ community members as "up to 75% of older adults who die by suicide, visited a physician within one month before death" (Touhy & Jett, 2012). In Gerontological Nursing & Healthy Aging (2013), the authors state that "contrary to popular opinion, the majority of older people who committed suicide were not physically ill" (p. 440). The authors discuss how the majority of older adult suicide is linked to mental illness such as depression (Touhy & Jett, 2012). The authors provide a useful side box that provides suicide risk factors among older adults (box 24-7, p. 440). For health care professionals such as nurses, it is very useful to know the risk factors so that when these people access health care services, health care staff can detect them and intervene for the patients safety. It is easy to see how feelings of discrimination, marginalization and homonegativity can contribute to older adult suicide and how they can be detected if health care staff are educated on the subject. The authors of Gerontological Nursing & Healthy Aging (2013) also provide sources for detailed interview questions and assessment tools for older adults at risk for suicidal ideation and behaviour such as the Registered Nurses' Association of Ontario's "Best practice guideline on assessment and care of adults at risk for suicidal ideation and behaviour" (p. 441). This textbook is probably the most useful resource I have found to date for information regarding working with older adult populations. The information is very well laid out and is full of resources, assessment techniques and interventions for nurses to make use of in their daily practice.
Creating services to work with older LGBTQ adults
As many older LGBTQ simply choose to not access health care services, it is useful for health care providers such as nurses to begin adapting preventative care and health promotion to be more inclusive of this community. In the article One Facility's Experience Using the Community Readiness Model to Guide Services for Gay, Lesbian, Bisexual, and Transgender Older Adults, the authors describe a "Community Readiness model" that is designed to guide long term care facilities in their care of older LGBTQ adults. The CRM examines six dimensions of readiness known to be key factors in a community's ability to initiate and sustain positive change. (Carlson & Harper, 2011). In the article, the authors state that the "CRM helped one long-term care facility critically examine their practices and culture with the goal of improving care for LGBT older adults" (Carlson & Harper, 2011). Creating systems and models that improve care in prehospital and community environments can be very helpful in improving patient outcomes and learning about these recommendations can help nurses build trust and connections with older LGBTQ adults.
In Lesbian and gay elders: Connecting care providers through a telephone support group, the author, Wayne Moore discusses his study focusing on the development of a telephone support group for rural lesbian and gay elders caring for their life partners with Alzheimer’s disease or related dementia in north western North Carolina.(Moore, 2002) This article is relevant to nurses in that it discusses the lack of support that gay and lesbian older adults face in rural communities when caring for life-partners living with dementia. Moore states that "the local chapter of the Alzheimers association was reluctant to expand its programs to be inclusive of LGBT participants because of concerns about professional appearance, propriety, and fund-raising" (Moore, 2002). This is the kind of story nurses need to be aware of so that they can gain an awareness that even though we have made steps to further equality in North America, there are still issues and situations where this community is being marginalized. Moore concludes the article by stating "that the support group was a success and in the feedback he received, he stated that "participants reported that the experience decreased their sense of isolation and increased their social support system, affirmed their determination to continue in the caregiver role, and strengthened their decision and confidence to maintain their life partner in the home as long as possible" (Moore, W. 2002). I thought this article was informative for health care professionals as it creates an awareness of ways to combat feelings of isolation and discrimination in this population.
LGBTQ older adults and end of life care
An area of discussion that is receiving attention recently is caring for older LGBTQ adults that are entering the end stages of life. In the nursingtimes.net article Bid to improve end of life care for gay people, Steve Ford writes that there is now "published guidance on care for lesbian, gay, bisexual and transgender people at the end of their lives" (Ford, 2012). The guide discussed in this article also highlights for nurses "the importance of avoiding the assumption that someone is heterosexual and avoiding the common misunderstanding that next of kin must be a person related by blood or marriage" (Ford, 2012). This is important as many within the LGBTQ community have families of choice and not necessarily ones based on the more traditional family structure of blood relation or marriage. It is of value for nurses to be aware of the potential challenges in care delivery faced if a patient has not previously “come out”, as well as the value in recognising that LGBTQ people that have “come out” may have become isolated from their families of origin and former communities in the process and therefore rely on new and alternative support networks (Ford, 2012). This article is from the United Kingdom but the information discussed in it is useful to nurses and other health care professionals in Canada and around the world as end of life care is free from boarders, although it may have different considerations depending on culture or spiritual views.
Also discussing end of life care for LGBTQ older adults is a report written by Lienert, Cartwright & Beck (2010). Discussed in this report is how "Advance care planning was seen as a mechanism that could improve end-of-life care" (p. 43). Across the literature, I found one of the main barriers to caring for LGBTQ older adults has been the lack of recognition of same-sex relationships in the eyes of the society and in the health care system which can lead to "the subsequent failure by family and health care professionals to acknowledge the appropriate substitute decision-maker at the time when it was needed" (Lienert, Cartwright & Beck, 2010). Being aware of the end of life considerations for LGBTQ older adults is especially important for nurses because end of life care is something we only have the opportunity to do once and though the patient dies, the family will always remember how the health care team treated their loved one. The described fear of discrimination by health care staff is shown across the literature to result in a failure to access health services when needed which "can lead to isolation, late presentation, the need for crisis management and premature hospitalisation or institutionalisation, and are predictors for problems in end-of-life care including elder abuse and neglect" (Lienert, Cartwright & Beck, 2010).
Improving rights and freedoms may improve health statuses
A recent study that used data from a nationally representative survey of US adults found that LGBTQ respondents living in states that passed constitutional amendments banning same-sex marriage during the 2004 elections had significant increases in mood, anxiety, and substance disorders. In contrast, lesbian, gay, and bisexual individuals living in states without these amendments did not experience an increase in psychiatric disorders (Hatzenbuehler et al., 2012). This speaks to the impact the society has on the mental health and well-being of members of the LGBTQ communities. This is more of an issue politically in the USA as opposed to Canada where gay marriage is now legal in every province and territory. The similarities however are that members of LGBTQ communities in Canada are still affected by discrimination and marginalization by society to such an extent that they feel unable or unwilling to access health care services. Hatzenbuehler et al., (2012) discuss that the improvement of LGBTQ rights and changes in policy to be more sensitive to the needs of the LGBTQ community can actually decrease health care costs in those communities (p. 289). This appears to me to hold true to much of what the literature I have chosen says. If health care providers are able to make LGBTQ older adults feel safe and respected when they access services, then those in the community will be more likely to access the services earlier, and thus the medical issue may be able to be prevented or diagnosed at an earlier and more easily treatable stage.
This paper discussed some current literature on issues that LGBTQ older adults face, as well as offering suggestions on how nurses and other health care professionals can develop cultural sensitivity towards the LGBTQ. The literature addresses the question of inquiry and offers real world examples of how nurses and other medical staff can improve care such as; more community supports such as the telephone support group, more culturally safe environments in existing programs such as adapting long term care environments to models like the community readiness model, sensitivity training for employees across all health care environments, particularly for nurses, and policy changes on the institutional level to reflect the unique life histories and ongoing challenges and diversities that LGBTQ older adults face. The literature showed how studies are being done that may suggest improving rights and freedoms for LGBTQ communities may actually decrease future health care costs. Throughout much of the literature that I found, were themes of fear and anger towards the medical system, an institution that once existed as a form of control over this population. One of the best things that nurses can do to help older LGBTQ adults is to act with kindness and compassion. Everyone in the profession can work towards erradicating homophobia and discrimination of all forms in our facilities and the community. If older LGBTQ adults no longer have a reason to fear seeking out access to medical attention, then the medical outcomes in those situations will be greatly improved.
- Rowe, J. W., & Kahn, R. L. (1997). Successful aging. The Gerontologist, 37(4), 433-439.
- Brotman, S., Ryan, B., Collins, S., Chamberland, L., Cormier, R., Julien, D., Meyer, E., & Peterkin, A. (2007). Coming out to care: Caregivers of gay and lesbian seniors in canada. The Gerontologist, 47(4), 490-503. doi: 10.1093/geront/47.4.490.
- D'augelli, A., Grossman, A., Hershberger, S., & O'connell, T. (2001). Aspects of mental health among older lesbian, gay, and bisexual adults. Aging & Mental Health, 5(2), 149-158.
- Brotman, S., Ryan, B., & Cormier , R. (2003). The health and social service needs of gay and lesbian elders and their families in canada. The Gerontologist,43(2), 192-202. doi: 10.1093/geront/43.2.192.
- Moore, W. (2002). Lesbian and gay elders: Connecting care providers through a telephone support group. Journal of Gay & Lesbian Social Services, 14(3), 23-41. doi: 10.1300/J041v14n03_02 Loneliness among older lesbian, gay, and bisexual adults: The role of minority stress. Archives Of Sexual Behavior,39(5), 1171-1180. doi: 10.1007/s10508-009-9513-7.
- Van Wagenen, A., Driskell, J., & Bradford, J. (2013). “I'm still raring to go”: Successful aging among lesbian, gay, bisexual, and transgender older adults. Journal of Aging Studies, 27(1), 1-14.
- Carison, L., & Harper, K. (2011). One facility's experience using the community readiness model to guide services for gay, lesbian, bisexual, and transgender older adults. Adultspan Journal, 10(2), 66-77.
- Hatzenbuehler, M. L., O’Cleirigh, C., Grasso, C., Mayer, K., Safren, S., & Bradford, J. (2012). Effect of same-sex marriage laws on health care use and expenditures in sexual minority men: A quasi-natural experiment. American Journal of Public Health,102(2), 285-291.
- Brown, M. T. (2009). Lgbt aging and rhetorical silence.Sexuality Research and Social Policy Journal of NSRC, 6(4), 65-78. doi: 10.1525/srsp.2009.6.4.65
- Ford, S. (2012, 6 12). Bid to improve end of life care for gay people.
- O'Flanagan, R. (2013, 06 22). Health care must meet needs of lgbt seniors, forum told: Homes, hospitals to face complex social and health needs. The Guelph Mercury.
- Fredriksen-Goldsen, K. I., Kim, H.-J., Emlet, C. A., Muraco, A., Erosheva, E. A., Hoy-Ellis, C. P., Goldsen, J., Petry, H. (2011). The Aging and Health Report: Disparities and Resilience among Lesbian, Gay, Bisexual, and Transgender Older Adults. Seattle: Institute for Multigenerational Health.
- National Resource Center on LGBT Aging. (2013, 03 14). Inclusive questions for older adults: A practical guide to collecting data on sexual orientation and gender identity.
Lienert, T., Cartwright , C., & Beck, K. (2010). The experiences of gay, lesbian, bisexual and transgender people around end-of-life care . A report for the Aged Services Learning and Research Centre (ASLaRC), 1-52.
- Irwin, L. (2007). Homophobia and heterosexism: implications for nursing and nursing practice. AUSTRALIAN JOURNAL OF ADVANCED NURSING, 25(1), 70-76.
- Touhy, T. A., Jett, K. F., Boscart, V., & McCleary, L. (2012). Ebersole and hess' gerontological nursing and healthy aging. (1st Canadian Edition ed., pp. 408-409). Toronto: Elsevier Canada.
- Majumdar, B., Browne, G., Roberts, J., & Carpio, B. (2004). Effects of cultural sensitivity training on health care provider attitudes and patient outcomes. Journal Of Nursing Scholarship, 36(2), 161-166. doi:10.1111/j.1547-5069.2004.04029.x
- Arnold, E. C., & Boggs, K. U. (2011). Interpersonal relationships: Professional communication skills for nurses. (6 ed., pp. 181-182). St. Louis, Missouri: Elsevier Saunders.