The concept of holistic care demands that we as health professionals treat clients as individuals, taking into account very personal attributes and characteristics such as diet, exercise, sexual habits, and chemical /drug abuse. A barrier to this are the myths concerning homosexuality that still persist in the American health care system. By discussing research findings about aging homosexual men, a minority within a minority, and suggesting ways in which health care professionals can provide meaningful care, it is hoped that aging homosexuals will be able to maximize their potential as individual members of society.
The value of describing a minority is a questionable task. On the one hand, labeling people as "aging" and as "homosexual" indicates that there are certain characteristics attributable to them. This may lead to stereotyping, loss of the individual's uniqueness, and loss of the openness to learn the truth.
On the other hand, knowledge of the characteristics of groups, based on scientific data, can be useful. Insight into value systems, beliefs, and lifestyles are important considerations for health care professionals dealing with individuals in a holistic way.
In 1973, Marmon addressed the American Psychiatric Association regarding homosexuality. He stated:
Surely the time has come for psychiatry to give up the archaic practice of classifying the millions of men and women who accept or prefer homosexual object choices as being, by virtue of that fact alone, mentally ill. The fact that their alternative life style happens to be out of favor with current cultural conventions must not be a basis in itself for a diagnosis of pathology.1
Consequently, homosexuality was removed from the list of psychiatric disorders. The fact that the American Psychiatric Association included homosexuality on 'the list of mental disorders until 1973 surely underscores the fact that many health professionals practicing today were educated in relative misunderstanding and prejudice concerning homosexuality.
In Society and the Healthy Homosexual, Weinberg addresses the issue of the homosexual problem, stating that the "problem is one of condemning variety in human existence. If one cannot enjoy the fact of this variety, at the very least one must learn to accept its existence, since obviously it is here to stay."2
HOMOSEXUAL OR HETEROSEXUAL?
Although there are myriad popular myths about the choice of being homosexual or heterosexual, there seems to be only one differentiating characteristic. This difference is sexual preference for partners of the same sex in homosexuals and sexual preference for partners of the opposite sex in heterosexuals. There are no other characteristics that distinguish the two groups as a whole. Weinberg notes that even sexual activity with same sex partners is not the differentiating characteristic. There are gay and heterosexual celibates who, were they not sexually inactive, would still prefer sexual partners of the same sex or the opposite sex, respectively.2
In 1978, Bell and Weinberg published the results of a large-scale descriptive study of many aspects of homosexuality. They found little that distinguishes the abilities of homosexual men to adjust sociologically and psychologically from heterosexual men. They did find a full gamut of adaptation among different typologies of homosexuals but conclude that:
. . .homosexual adults who have come to terms with their homosexuality, who do not regret their sexual orientation and who can function effectively sexually and socially are no more distressed psychologically than heterosexual men and women, (p. 216)
Those who can come to terms with their sexual identity, do not have trouble expressing it, and can function effectively in society will be more healthy than those who have problems with sexuality.
AGING IN THE GAY COMMUNITY
When aging begins is of universal concern and a rhetorical question. In the predominantly heterosexual society of the United States, some see retirement as the beginning of old age and others associate aging with sickness and inability to maintain useful functioning in society. The state oî being old is a value perception and is measured, probably wrongfully so, on the loss of ability with regard to a value perception and is measured, probably wrongfully so, on the loss of ability with regard to health, work, or status that is present in younger members of a society.
In the gay community, physical attractiveness and youth are highly valued.3 Based on research studies, it was found that "old age" in the gay community seems to begin at a much earlier chronologic age. Many previous studies regarding age and homosexuals have grouped subjects past the ages of 40 to 46 as old. '3^ Society in general extolls the greatness of being young, wrinkle-free, and in good physical condition. Homosexual men take great pride in maintaining their physical appearance and being, therefore, sexually attractive. Whether this is a reflection of the values of the dominant society or a true characteristic of the gay minority is a question open to debate. Harry and DeVaIl suggest that it is not a matter of age but a reflection of the gay man's marital status.3 They state that although homosexual partnerships are on the increase, in general, homosexuals are more often single than they are married. Most singles' cultures, heterosexual or homosexual, value physical attractiveness and presentation of the cosmetic self to potential partners.
The fact that gay research itself is limited in its findings about older gays to those who are over 40 to 45 years of age has done little to dispel the myths about older homosexuals. There is no evidence that homosexual men die younger than heterosexual men and the question of what happens to older gay men (65+ years) only recently has been addressed.
Almost all researchers agree that compiling information about older gays is problematic. None of the studies cited in this paper were able to use non-probability samples to collect data. Samples of gay men usually are obtained through organizational resources in the gay community such as gay baths and gay bars. Since these also are known as places to meet new sexual partners, and knowing that youth and attractiveness is valued in these places, finding older gays is a difficult task. Another problem may be a generational difference. Younger gays do not face the intensity of societal discrimination that the older gays have experienced and may be more willing to be "found" by research investigators.
Ignorance about aging homosexuals has led to exaggerated stereotyping of them by society in general, homosexuals themselves, and even the scientific community. People have combined all the stereotypes of being old with all the stereotypes of being homosexual and have deduced that the aging gay is a pathetic figure.
RESEARCH ABOUT OLDER HOMOSEXUALS
Although limited, the descriptive research to date does not support this stereotype of older gays.
In 1978, Laner studied the theoretical notion that although older gays still wanted sexual partners and/or relationships, nobody wanted them.5 To try to avoid defensiveness that might be encountered by using questionnaires or interviews, the data were collected from personal ads in two magazines, one geared to heterosexuals and one geared to homosexuals, that asked for dates, sexual encounters, and or relationships. In comparing these two sources, the researchers found no difference in the numbers of older heterosexual and older homosexual advertisers and no special or particular interest of older gays for younger men. These findings do not indicate where older male partners are found, but do not support the use of personal ads for this purpose.
In a pilot study, Minnigerode and Adelman found that older gay men still desire and have sexual relationships with other men.6 Although homosexuals did express some concern in finding available partners, they were satisfied with their sexual activity.
Kelly's findings, based on interviews with 43 homosexuals over 65 years of age, dispel the stereotype of aging homosexuals.7 He summarizes his findings and offers a composite picture of the older gay:
The composite older man in this study does not frequent tearooms (public toilets) but occasionally goes out to bars, particularly those that serve his peer group. . . the extent of the typical older man's participation in the gay world is low to moderate and based largely on his individual desires. . .no one over 65 indicated that he had disengaged from activities in the gay world. . .he has many gay friends and fewer heterosexual friends. . .The sex life of the older man is characteristically quite satisfying, he desires sexual contact with adult men, especially those near his own age. . .The typical older man in this study neither considers himself effeminate nor likes to define himself in terms of gay age labels.1
PROBLEMS FOR OLDER HOMOSEXUAL MEN
Bell and Weinberg address the issue of aging homosexuals. "The homosexual who is afraid that he might end up a 'dirty old man,' desperately lonely, should be assured that such a plight is not inevitable and that given society's failure to meet the needs of aging people, heterosexuality hardly guarantees well being in old age."1
The question of sexuality in aging people is clouded by ageist beliefs that sex belongs to the younger generation. Many older people have been acculturated to believe they cannot, and should not, be sexually active.8 Whether this applies to aging homosexuals is not known but, given that society in general denies sexuality as an integral part of an individual over 65, it can be assumed that a denial of over-65 homosexuality most certainly exists.
Kelly states that society discriminates against gays on the basis of sexual preference.7 He cites several areas in which older gays, although fairly able to adjust to changes associated with aging, face society's inability to adjust to them. For instance, life insurance policies may be withheld once a person is discovered to be homosexual, and wills that name homosexual "marriage" partners can be contested successfully by surviving family members. Even hospital visiting rules often discriminate against visits by a homosexual partner or lover who is indeed a significant part of the gay man's support system.
HEALTH CARE IMPLICATIONS
The health care delivery system is one part of a predominantly heterosexual society into which most homosexuals will enter. This experience can be positive and rewarding and may even lead to maintaining or improving the health of the homosexual and increasing understanding and acceptance of sexual differences among people by the providers. Experiences with health care delivery systems also can be devastating. Denying or refusing to accept a person's sexuality leads to giving less than total care of homosexuals. A homosexual who has experienced being labeled, has overheard jokes or comments about his being different, or has been denied visitation from his homosexual partner may be very bitter and less able to maximize his health potential. At the very least, he is likely to think twice before returning to such a system when medical problems arise in the future.
Assessment of all older clients should include a sexual history.8 This should be done in a nonassuming, nonjudgmental manner. Brossart suggests that open-ended questions regarding the area of sex are the least threatening; not assuming that a man has sex exclusively with his wife or some other woman can be done by using nongender nouns and referring to his sexual "partner."9 Most homosexuals desire medical treatment or health care that will assist them in returning to a desired state of well being. If sexual preference influences attaining this goal, it must be dealt with.
Determining next of kin or asking for names of family members who can be contacted or who will be part of the client's support system during recovery may not permit the homosexual client to name his partner, since he is not a blood relative or even legally recognized as next of kin. Explaining the purpose for wanting this information from a homosexual client and asking for names of persons who the client wants notified or involved in his care will be easier questions to answer.
In planning care, a homosexual's identified partner can be used as a resource person, especially if the aging client is unable to speak for himself. Lifestyle considerations, previous medical history, and coping mechanisms can be identified by the homosexual's partner or significant other.
If assessment and planning have taken into account the person's sexuality, implementing care will become an easier task. In an atmosphere of openness and trust, the aging homosexual will be able to discuss his concerns more freely with those providing care. Knowing that a client is and/or desires to be sexually active will influence the teaching and support given by nurses. The effects oí certain disease processes on sexual ability should be discussed. The effects of medications such as antihypertensive drugs and major tranquilizers that affect sexual performance ability need to be discussed with the client before decisions are made to use them as part of a treatment plan.10 Recognizing the significance of the aging homosexual's partner is of utmost importance; the partner should be included in discussions that will lead to choices of treatment plans and their consequences.
In evaluating nursing care, emphasis on how the person as a whole "survived" the encounter with health care should be determined. A client whose appendectomy was successful but who suffered needless shame because of his sexual identity did not receive optimal nursing care.
Nurses have the unique opportunity to give care holistically, considering all aspects of a person, and planning care to meet the whole person's need. There is no need to wait until more complete research has been done to decide on how best to meet the needs of aging homosexual men. Nonjudgmental attitudes and trusting relationships with clients will allow the nursing process to flow toward the ultimate goal of quality patient care.
- 1. Bell AP, Weinberg MS: Homosexualities. New York, Simon & Schuster, 1978.
- 2. Weinberg G: Society and the Healthy Homosexual. New York, St. Martin's Press, 1972.
- 3. Harry J, DeVaIl WB: The Social Organization of Gay Males. New York, Praeger Publishers, 1978.
- 4. Weinberg MS, Williams CJ: Male Homosexuals: Their Problems and Adaptations. New York, Oxford University Press, 1974.
- 5. Laner MR: Growing older male: Heterosexual and homosexual. Gerontologi 1978, 18:494-501.
- 6. Minnigerode FA, Adelman M: Elderly homosexual women and men: Report on a pilot study. The Family Coordinator 1978, 27:451-456.
- 7. Kelly J: The aging male homosexual. Gerontologist 1977, 17:328-332.
- 8. McCarthy P: Geriatric sexuality: Capacity, interest, and opportunity. Journal of Gerontological Nursing 1979, 5:20-24.
- 9. Brossart J: The gay patient, what you should be doing. RN 1978, 42:50-52.
- 10. Finkle AL, Finklc PS: How counseling may solve sexual problems of aging men. Geriatrics 1977, 32:84-89.