The lack of understanding and knowledge about older lesbians impacts the ability of advanced practice nurses (APNs) to provide appropriate, responsive health education and counseling. Traditional health care bias bases treatment and interventions on the assumption that all women are heterosexual (Roberts & Sorensen, 1995; Stevens, 1995). That bias fails to provide a safe climate, one without discrimination and negativism, toward lesbians. Lesbian, for the purposes of this article, is defined as a woman who prefers to partner with a woman for an intimate loving relationship. Advanced practice nurses are instrumental in providing a safe, accepting, and knowledgeable health care environment. The purpose of this article is to provide information about older lesbians and potential issues that may arise in providing care.
Although there is no reliable data, gay men and lesbians are believed to comprise between 6% and 10% of the total population in the United States (Jacobson & Grossman, 1996). Between 1980 and 1990, the older population - those older than age 65 - grew from 25.5 to 31.2 million, with women outnumbering men 3 to 2 (Schick & Schick, 1994). Using those figures, the estimated number of lesbians older than age 65, is 1.87 to 2.14 million. That figure will continue to grow as the population of older people grows with the baby boom generation reaching age 65. It is reasonable to believe that many APNs are caring for older lesbians and are not aware of it.
There is little information available about the health practices of lesbians age 60 and older. Few researchers report information about health issues of the lesbian population. Usually, older lesbians are ignored in studies concerned with women's health (Quam & Whitford, 1992) and lesbian health care (Buenting, 1992; Lucas, 1992; Trippet & Bain, 1993). Stevens (1992) identified 28 studies published between 1970 and 1990 relating to lesbians' health care experiences. Of those, one dealt with older lesbians. Only 3.1% of the 1,917 study participants in the National Lesbian Health Care Survey, conducted between 1983 and 1988, were lesbians older than age 55, although more than 20% of women were in that age bracket (Bradford, Ryan, & Rothblum, 1994). The literature available is scattered in nursing, sociology, psychology, feminist, lesbian, and women's studies journals. Over the past 30 years, only 13 empirical studies have been conducted in lesbian gerontology (Gabby, 1997).
One nursing study (Deevey, 1990) was designed to obtain information about the health-seeking behaviors and life experiences of older lesbians. The findings were based on 78 surveys completed by lesbians between the ages of 50 and 82, a 58% return rate. More than one half (n = 45) were from women between the ages of 50 and 59. The reported potential health problems included:
* High alcohol consumption.
* Extra weight.
* Infrequent breast self-examination.
* Skepticism toward health promotion and traditional health care.
Mental health was reported to be excellent, and attitudes toward aging were positive for approximately 80% of respondents.
Deevey 's (1990) study does not completely correlate with two sociological studies done by Kehoe (1986, 1988). Kehoe limited the sample (n = 50) to women older than age 65 in the first study and age 60 (n = 100) in the second study. The purpose of those studies was to gather information about older lesbians. In the sample (Kehoe, 1988), the typical woman older than age 60:
* Experienced good health.
* Had a history of a major surgery.
* Had minor attacks of arthritis.
* Was a social drinker.
* Was a nonsmoker.
* Had never been in therapy.
* Had no physical handicap.
* Wore glasses.
* Had no foot problems.
* Had her own teeth.
* Considered herself well adjusted.
The most common physical problems reported were arthritis and cardiovascular, which was the same as their heterosexual cohort. More than 70% of subjects were without mental or physical health problems; 35% did not drink alcohol; 66% did not smoke; and 58% exercised daily. Deevey and Kehoe used convenience samples, with self -reports of physical and emotional health, and were limited in the inclusion of lesbians living in rural areas and having diverse ethnic backgrounds. Findings of these three studies provides some insight to this heterogeneous group of people who are difficult to access and survey.
Lesbians older than age 60 have been labeled the invisible minority (Deevey, 1990; Kehoe, 1986). This invisible status of older lesbians is attributed to three factors: gender, sexual orientation, and age. Even with direct questioning, women may or may not disclose their sexual orientation. Many older lesbians choose not to be recognized and remain silent for many reasons, including their religion and family. Others do not want to be described simply by sexual orientation (Kehoe, 1988). The choice of nondisclosure may be related to the climate in which they grew up. For example, a woman who is 70 years old has experienced times when homosexuality was a reason to be placed in an institution for the mentally ill, and during the McCarthy era, subversion and homosexuality were linked (Fassinger, 1991). In 1973, homosexuality was de-classified as a mental illness by the American Psychiatric Association. It was not until 1986 that homosexuality was removed from the Diagnostics and Statistical Manual of Mental Disorders. The Gay Liberation movement that began in 1969 has not protected these women from discrimination in employment or housing nor has it allowed them to marry their life partners. The hiding of ones' sexual orientation has been a survival strategy for some lesbians because no one was available for financial support and maintaining employment was paramount to being self-sufficient.
Advanced practice nurses caring for older lesbians may discover sexual orientation only through subtle messages. Examples include:
* Having the same roommate for 20 years.
* Having a roommate as the emergency contact^ although there is a child available.
* Making a statement of being different using "women like us," or a similar term to refer to themselves.
Denial of being a lesbian may occur with direct questioning (Deevey, 1990). In some cases, the attitude displayed by practitioners may prevent older lesbians from raising the subject, and in turn, women will not seek health care when required (Kehoe, 1988). Confidentiality is of great importance, and many lesbians do not want their sexual orientation documented in their medical records. This is because of the fact that medical records are read by many people, and negative sanctions may result if that information goes outside the medical community (Smith, Heaton, & Seiver, 1990).
Some studies indicated that the stress of dealing with their sexual orientation has made aging less difficult and distressing for older lesbians than for heterosexual women (Deevey, 1990; Kehoe, 1988; Quam & Whitford, 1992). Kimmel (1993) pointed out that the major life crisis for older lesbians was dealing with their sexual orientation earlier in life. Dealing with that crisis, which is likely to involve family disruption and intense feelings, provides a perspective on the major life crises and a sense of crisis competence. Friend (1991) theorized that the flexibility in gender roles allows older lesbians to adjust more effectively to the socially constructed attitudes and beliefs of aging and being older. That ability to adjust is due to the development of psychological skills learned in the management of their sexual orientation throughout their lifetime and dealing with the nontraditional roles required to manage daily living.
Anxiety about aging is low and life satisfaction is high for older lesbians that have a positive sense of self and a developed social support system of gay men and lesbians (Quam & Whitford, 1992). Their concerns about aging are the same as their heterosexual cohort: health, loneliness, and income. Older lesbians without a developed social support system and positive sense of self express increased fear and anxiety of aging. Some of those additional fears are:
* Rejection by adult children and grandchildren.
* Poor quality of care from longtime health care providers.
* Discrimination in housing and long-term care.
The fear of additional losses may cause some older lesbians uneasiness with aging.
The ability to deal with aging does not protect older lesbians from ageism. The younger lesbian community is as likely as the general population to discriminate against older lesbians (Kehoe, 1988). In the 1980s older lesbians began organizing and confronting ageism and demanding recognition in their communities (Faderman, 1991). Old Lesbians Organizing for Change is one such group. The American Society on Aging has a network specifically organized to examine issues, seek solutions, and raise awareness about aging lesbians and gay men. Also many larger communities now have support services for older lesbians and gay men. Senior Action in a Gay Environment (SAGE), established in New York 20 years ago, began as a social outreach program that now offers multiple services. There are currently 20 affiliated SAGE groups providing services for older lesbians and gay men throughout the United States (Yoakam, 1996). There are other organizations in addition to SAGE that provide services for older lesbians. Advanced practice nurses can find local organizations in their communities by contacting the local lesbian or gay resource center.
Most older lesbians do not live lonely, isolated lives (Kimmel, 1992). The families of older lesbians may not be related by blood. Lesbians usually live in a self-created network of significant others and friends. These created families are especially important because they are viable support systems. The support systems are valuable when lesbians cannot rely on their biological family members for care. Having less family support than heterosexual women, the social support of friends balances the overall support network (Dorf man et al., 1995). For many older lesbians, denial of the relationship and support of their significant others, with whom they have been partnered for many years, can be detrimental to their health and wellbeing.
Dorrell (1991) provided insight into the support network of an 84year-old, terminally ill, single lesbian. A group of seven lesbians with varying backgrounds took turns taking her to doctor appointments and leisure activities, coordinating the access to needed services, and talking with her about her life, politics, and dying. The primary physician, a woman with a specialty in geriatrics, became part of the network by responding to calls from the group, making home visits, and supporting their roles as caregivers. As death neared, 1 year later than expected, the woman withdrew from the group and made arrangements to die where she wanted. It is possible that APNs will be called on to provide similar services to those of the physician in that situation. Understanding and being sensitive to families of older lesbians, who may need assistance with care, will allow APNs to mobilize resources with which the women feel most comfortable. In some cases, this may mean establishing a care network for them and tapping lesbian and gay resources in the community.
HEALTH CARE INSTITUTIONS
When older lesbians are hospitalized and fear of discrimination becomes an issue, stories may be created to enable their partners to visit unrestricted and unquestioned. Partners may become sisters or cousins. The fear of not receiving appropriate care is well supported by Stevens's (1994) research. Although Stevens's study did not include older lesbians and the oldest woman included was age 56, the findings clearly documented the lack of understanding and sensitivity by health care providers when dealing with lesbians in general. Many nurses are homophobic and have difficulty providing the same standard of care to lesbians (Irwin, 1992). Compounding homophobia is the age of older lesbians. The myth of older people not being sexual remains for some people. The holding of hands, hugging, or kissing are comforting actions during times of distress; yet older lesbians may not be allowed that comfort.
Another issue arising with hospitalization is the decision-making process regarding treatment for women who cannot make their own decisions. A durable power of attorney for health care may or may not be in place. The legal ramifications of the lack of such a document can be devastating. Blood relatives, who may have no knowledge of the relationship or be against the relationship, can control visitation, treatment options, discharge planning, and can completely exclude the partners. The additional stress created when blood relatives interrupt their relationships will affect lesbian dyads and may increase health problems and impact outcomes. It is the responsibility of APNs to inform all older adults, especially lesbian couples, of the importance of planning for decision making in the matters of health care.
Skilled nursing faculties, retirement homes, and assisted living facilities are other areas that increase the vulnerability of older lesbians. When women can no longer care for themselves and require outside assistance, fear of not receiving the needed care may become a reality. Lesbian couples who want to live together and share a room in nursing homes or retirement centers may be denied. It is the APN's responsibility to ensure that the couples' relationships are supported in those institutions. The approach is the same as that taken with older heterosexual couples - keep the couples together as long as possible. It also may become the APN's responsibility to educate facility staff caring for older lesbians, with respect to their lifestyle and culture. This includes reminding people that sexual orientation is only one minor component of the women and not their whole identity. Another APN responsibility is to ensure the care provided meets nursing standards. Monitoring the care for older lesbians is especially important because of the increased risk of substandard care being provided due to prejudices and homophobia. A few larger communities have coordinated home sharing and permanent housing for older lesbians in an attempt to keep them in a friendly atmosphere. One goal of lesbian and gay communities is to provide retirement and nursing homes for those older men and women in their communities (Kehoe, 1988).
AU adults may have a difficult time dealing with the loss of their long-time companions. It is not easy to predict who will experience pathological bereavement and move into a state of depression or other illness. The loss of a long-time partner can be especially difficult for older lesbians who have not built support systems outside their relationships. Lack of counseling and support opportunities, which are readily available within the heterosexual community, make it difficult to work through the loss. That loss may become even more difficult to resolve if the families of the partners do not understand or acknowledge the significance of the loss. Lesbians may be excluded from visiting the mortuary and attending the funeral. If the living partners are still working, their coworkers and employers may not understand why they are having a difficult time dealing with the loss, because they see it as just a friend. Other problems can arise with inheritance and legal rights. Couples may have failed to adequately plan for transfer of estate and inheritance. Surviving partners may be evicted from the homes they have lived in for many years or see treasures collected during their partnerships leave with relatives. Advanced practice nurses who are sensitive to lesbians' lifestyles may be the only people the partners are able to confide in regarding the significance of the loss. If living partners are willing to mobilize the lesbian community resources to find lesbian or lesbian-sensitive psychologists to assist with the bereavement process, it will likely prevent a pathological process from occurring. If grieving partners are not willing or capable to make the contacts, responsibility lies with the APN to make referrals when unable to provide care on their own.
PROVIDING HEALTH CARE
The assessment and management of medical conditions is the same for older lesbians as it is for heterosexual women. However, the likelihood of older lesbians to be nulligravida is higher. Preventive care includes addressing the increased risk of breast, endometrial, and ovarian cancers for these women. Recent research indicates that the incidence of depression in older lesbians is no higher than their heterosexual cohorts (Dorfman et al., 1995). The most important aspect of providing care for older lesbians is recognizing and addressing one's own prejudices and attitudes. If it is impossible for the APN to overcome homophobic feelings, then it is best for older lesbians if other health care providers are located and referrals are made. There is no reason for older lesbians not to have the same standard of care provided to all other people in any practice setting. All that is asked is that lesbians are treated with the same sensitivity, respect, and caring as other health care recipients.
Although there are unique issues to address when caring for older lesbians, those issues are not dissimilar to learning and knowing about ethnic, cultural, and other social diversities of people in general. This is a heterogeneous minority population. Societal and religious rules have caused additional stresses in their lives, but those who have lived to be considered older are survivors. Sensitivity to the differences in aging, social supports, and interactions with the health care community by APNs is necessary for providing quality care to this population. Their lives have not been the same as younger lesbians, whom researchers have been able to access and study.
Lesbians older than age 60 have seemingly adjusted to life's changes as well as, if not better than, their heterosexual cohorts. Despite older lesbians* ability to adjust to aging, the potential for their health and well-being to be negatively affected when interacting with the health care community remains. The health care heterosexual bias strains lesbian interactions with the health care community and impacts the quality of care. Advanced practice nurses can make a difference in older lesbian health care by being open, sensitive, and understanding of social support needs and by navigating the system to ensure needs are met.
There is little nursing or medical research about this population of older women, and the research that is available in other fields has been limited by access to a population that does not easily participate in full self -disclosure. Yet, it has been clearly documented that the health care needs of this population is a priority for them. Perhaps when society becomes more accepting, health care providers will be able to learn more about the specific health care needs of older lesbians. Until then, APNs must depend on gerontoiogists, social workers, and psychologists to gain insight competently and without judgment in response to older lesbians' health care needs.
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