A law clinic at Wake Forest University informs medical providers about the rights and needs of their older lesbian, gay, bisexual and transgendered patients.
By Minali Nigam
Sitting in a doctor’s office, filling out a medical intake form, a patient could be asked about marital status, with the following options listed: ‘Married,’ ‘Single,’ ‘Widowed,’ ‘Divorced.’
“I just add another box and say ‘Partner’,“ said Les Geller, 70, program director for SAGE Raleigh, which provides services for LGBT senior citizens.
Geller is one of three million estimated Americans in the older LGBT population, those aged 55 years and older. According to a 2014 SAGE report, that number is projected to double in the next two decades as the baby-boom generation continues to reach retirement age.
Law students and professors at Wake Forest University’s Elder Law Clinic have been addressing these LGBT seniors’ growing health needs. Last August, the clinic received a $2,500 grant from the North Carolina Society of Healthcare Attorneys to fund community outreach programs on LGBT health-care rights.
Since then, medical providers and community members attending three outreach events learned about federal laws that recognize domestic partners as hospital visitors and end-of-life care decision makers, said Kate Mewhinney, a professor at the Wake Forest Elder Law Clinic.
The clinic has partnered with aging service providers and medical centers, along with community programs, Mewhinney said. The joint effort clinic has raised awareness about health-related challenges older LGBT people face, such as lack of health insurance, high rates of poverty, and the difficult transition into nursing homes.
“When people go into long-term care it’s very challenging for anybody,” Mewhinney said. “And to go in there feeling doubly vulnerable as a gay person, I think, would be extremely difficult.”
“I believe that if people know their rights, they can cope better with the challenges of aging.”
Lack of trust
“From the aging perspective, LGBT adults [tend to] be more likely to not have children and therefore tend to age alone,” said Jennifer Harriss, an ombudsman for the Piedmont Triad Regional Council: Area Agency on Aging.
Older LGBT adults also tend to have developed smaller support systems over time and often fear discrimination in housing and long-term care settings. This can prevent full disclosure and force some residents to return to the closet, Harriss said.
“They retreat and become isolated,” he said. “And don’t want to seek out health-care providers.”
In a 2014 Harris poll performed for the national SAGE umbrella organization, forty percent of LGBT people in their 60s and 70s responded that they did not disclose sexual orientation to their physicians.
“So, if they are folks who have been fearful of health-care providers throughout their adult life they may not have had the preventative care that hetero residents their same age might have had,” Harriss said.
“Or they may have undiagnosed illnesses because they haven’t had that trust or haven’t been seen by health-care providers.”
Although there are health differences between subgroups within the LGBT population, some major health concerns include HIV/AIDS, mental illness, and substance abuse, according to a Kaiser Family Foundation issue brief. The history of discrimination and stigma contributes to higher rates of mental illness, with studies finding LGBT people two and a half times more likely to experience depression.
Sitting at a coffee table at a local SAGE morning meeting in Raleigh, David Holmes described how mental health problems took a toll on him at a young age.
“Growing up, I always knew I was gay,” he said, “[At the time] I felt dirty about it.”
Holmes married, and stayed with his wife for 25 years, raising two children, before he filed for divorce.
“I was just constantly going to mental health places because I was so depressed about it, because I didn’t know how to fix it,” he said.
The week Holmes filed for divorce, he met Phillip at a local gay bar, he remembered. “Drove in on his Harley Davidson with leathers on, and that was it for me.”
David and Phillip Holmes are married and moved to North Carolina a few months ago from New Hampshire. Both said they had positive health-care experiences, but continue to have separate insurance plans, with David having Blue Cross Blue Shield and Phillip covered by the VA.
But some older LGBT people don’t have health insurance at all, Mewhinney said, partly because they have not had the opportunity, until recently, to be married.
“And a lot of people get [insurance] through their spouse, “ she said.
Since the Supreme Court legalized same-sex marriage in June 2015, health insurance coverage is expected to expand.
The older generation lived through a time when being gay could meant institutionalization for having a mental disorder, Geller said.
Harriss noted it wasn’t until 1973 that homosexuality was taken out of the Diagnostic and Statistical Manual of Mental Disorders (DSM), which has guidelines for the diagnosis of mental-health problems.
Before that time, it wasn’t uncommon for gays to be subjected to shock therapy or placement in psychiatric treatment, “trying to be changed through antipsychotics or things of that nature,” Harris said.
These experiences resulted in profound distrust of healthcare providers for some people.
For older transgender people who are considering transitioning to another sex, the social transition is a bigger concern for them than the medical risks, said Kerith Lawrence, a doctor at Carrboro Pediatrics and Internal Medicine.
“I’ve had people come to me and say I can’t live life any longer not being who I feel I am,” she said. “So they’re willing to take the medical risks.”
The first year of transition requires monitoring, Lawrence said, and patients have to get blood work checked every three months.
“The elder population that is afraid to disclose themselves to medical providers, they’re getting hormones off the internet,” she said, “People who come in to me want to [transition] as safely as possible.”
The office and staff work with transgender patients regularly, she said, and create a comfortable and respectful environment by asking open-ended questions. Patients are asked on the intake form about preferred pronouns, gender identity, and sexual orientation.
“There are all sorts of combinations that people can have on who they’re attracted to,” Lawrence said.