Keywords

1 Issues for LGBTQ Elderly

Research focused on lesbian, gay, bisexual, transgender, and queer (LGBTQ) older adults has expanded over the past decade with significant attention to later stages of the lifespan. Witnessing this growing area in psychological research and practice, the field of gerontology has similarly expanded to meet the needs of policy and practice as an interdisciplinary enterprise (see Espinoza, 2016; Hash & Rogers, 2017; Porter & Krinsky, 2014; South, 2017). The significance of these advances has played an important role for two main purposes. The first impetus involves the combination of health professions (e.g., counseling, psychology, nursing) and disciplines (e.g., sociology, law, anthropology) attempting to meet the needs of older adults and to shift the discourse around gerontology and older adults within their respective professional communities (Adams, 2016; Linscott & Krinsky, 2016). The second motivation emboldens researchers to focus on this stage in the lifespan to illuminate opportunities for how older adults generally view themselves in light of their personal journeys and coinciding generational changes across time periods (Arthur, 2015). Both factors operate as a response to the growing stereotyping, bias, and negative responses toward older adults. Within LGBTQ communities, the plethora of social identities has not rendered the overall group immune to such issues of marginalization. In fact, LGBTQ elders frequently face a myriad of stressors that involve active and implicit forms of exclusion, harm, and violence, which tend to accumulate over the lifespan (Porter & Krinsky, 2014). Within an already marginalized group of identities, LGBTQ elders have been subject to horizontal aggression, namely involving ageism, and face backlash for negative societal responses to the aging process (Porter & Krinsky, 2014; Woody, 2014). Considering this stage in lifespan development, LGBTQ elders have likely endured multiple instances of trauma that overlap with incidents of oppression and violence (Woody, 2015) (Fig. 1).

Fig. 1
A close-view photograph of a woman with a fierce look posing to the camera.

A drag queen serving fierce looks in an LGBTQ Pride Parade. Photo by Tarek Mahammed

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Although research attempting to address the plight of LGBTQ older adults have several areas to cover with marginalization and health disparities, the platform to expand this area within psychology and other disciplines continues to receive extensive attention and motivates researchers and practitioners alike to shift affirmative practices in a profoundly meaningful way. Notably, the experiences of LGBTQ elders are not solely problem-centered, as researchers have elucidated significant findings that detail experiences of survival, cultural capital, community cultural wealth, and resistance in response to oppression (Chacaby & Plummer, 2016; Chaney & Whitman, 2020; Hash & Rogers, 2017). Conceptualizing this framework of practice for older LGBTQ elders, this population can benefit from honoring responses to both oppression and resilience. As this chapter unearths the complexity of these social and psychological experiences, several areas allude to meaningful affirmative and culturally responsive practices that can embrace a section for gerontology, older adults, and elders across LGBTQ communities. Under the premise of intersectionality, it will be important for psychology researchers and practitioners to continue exploring both areas of oppression and resilience for LGBTQ elders instead of relegating the population to one single set of experiences (Porter et al., 2016; Van Sluytman & Torres, 2014). Augmenting the goals of expanding culturally responsive and affirmative practices in psychology for LGBTQ elders, we attend to three main goals in the chapter: (a) an overview of contemporary research involving LGBTQ elders, aging, and gerontology; (b) theoretical underpinnings of intersectionality to reflect LGBTQ elders with other dimensions of culture and forces of oppression; and (c) considerations for practice and research areas with LGBTQ elders. For the purpose of the chapter, the use of LGBTQ is inclusive and involves populations minoritized across gender identity, gender expression, sexual identity, and affectional identity (Griffith et al., 2017). The use of elders and older adults is interchangeable due to differing illustrations across disciplines and their nomenclature in research and practice.

1.1 Minority Stress

Research on older adults features a plethora of issues that exacerbate psychosocial factors precipitating minority stress (see Correro & Nielson, 2020; Kim & Fredriksen-Goldsen, 2017). The Williams Institute, one of the largest community advocacy organizations focused on LGBTQ communities, took a unique interest in illuminating several issues among LGBTQ older adults (Choi & Meyer, 2016). In particular, researchers have taken note that LGBTQ older adults are generally at the margins in the broader landscape of behavioral health, mental health, and physical health research, which has essentially illuminated a constellation of health disparities (Foglia & Fredriksen-Goldsen, 2014; Goldhammer et al., 2019). Indeed, the chronic stress endured by LGBTQ older adults throughout the lifespan culminates in a predisposed risk for mental health issues, medical conditions, and disproportionate health disparities (Hash & Rogers, 2017). Compromised immune systems and medical issues have become an even larger focus for gerontological practitioners during the pandemic of COVID-19, given that the conditions of minority stress elicit a decrease in healthcare usage, access, and help-seeking (Jen et al., 2020; Meyer & Choi, 2020).

Researchers have taken a notable interest in identifying the needs of LGBTQ older adults from the standpoint of minority stress due to convergent forms of racism, genderism, heterosexism, and ageism (Arthur, 2015; Bettis et al., 2020; Choi & Meyer, 2016; Correro & Nielson, 2020; Woody, 2014, 2015). These overlapping forms of oppression do not preclude other structural inequities linked to classism and ableism, which likely exacerbate a number of preexisting conditions and access to care. Minority stress was initially conceptualized as a taxonomy of stressors, including events, people, and incidents, that predispose historically marginalized individuals to suicidal ideation, higher mortality rates, poorer physical health outcomes, and increased rates of mental health disorders (see Meyer, 1995, 2003). Meyer (2010, 2020) has advanced this model to illustrate how multiple marginalized identities may conflate the incidence of these risks for physical and mental health disorders. Additionally, Meyer (2020) has revamped this model to support resilience as an integral factor in ameliorating the risks of minority stress. Originally conceptualized in response to the experiences of LGBTQ communities, key components in classifying the definitions of minority stress are referred to as proximal stressors and distal stressors (Meyer, 1995). Distal stressors are defined as objective events that occur in the lives of historically marginalized communities, yet they are considered external to the individual (Douglass & Conlin, 2020; Meyer, 2003). For LGBTQ older adults, a distal stressor could be witnessing a verbal attack on another LGBTQ older adult in their housing environment. Conversely, proximal stressors are characterized as subjective events and reflect internalization of a stressor, such as a discrimination event (Correro & Nielson, 2020; Meyer, 2003). For instance, LGBTQ older adults could face the proximal stressor of negotiating fears of coming out in the workplace and internalized shame for being inauthentic to self.

There are significant connotations related to LGBTQ older adults that distinguish their experiences in the broad landscape of minority stress research. Namely, LGBTQ older adults face numerous events linked to past historical events and concurrent events of discrimination (Hash & Rogers, 2017). The chronic daily incidence of these events over a lifetime can potentially heighten rejection sensitivity and internalized stigma, which ultimately affect outcomes of mental health (Correro & Nielson, 2020; Meyer, 2020). Additionally, the subjective nature of proximal stressors for LGBTQ older adults can draw from a single or combination of discrimination events in one’s life, which means that the internalized response could emerge from a past experience, current experience, or combination of both. Different from the broad grouping of LGBTQ communities, minority stress affects the help-seeking and healthcare access of LGBTQ older adults (Choi & Meyer, 2016; Correro & Nielson, 2020). For many LGBTQ older adults, they may already face experiences of social isolation that heighten their hesitation to utilize medical and mental health care or lack the access needed to secure an affirmative provider (Bettis et al., 2020; Porter & Krinsky, 2014; Serafin et al., 2013). In the scope of minority stress, LGBTQ older adults may face accelerated negative outcomes of aging and disorders consistent with this stage of the lifespan, such as dementia (Correro & Nielson, 2020; Fredriksen-Goldsen et al., 2018; Yarns et al., 2016).

1.2 Social Determinants of Health

Combined with factors related to minority stress, a myriad of social determinants contribute to LGBTQ older adults’ access to care. In the frame of health equity, this issue is especially prominent for psychologists, mental health practitioners, counselors, and related healthcare professionals to examine as a public health issue (Espinoza, 2016; Yarns et al., 2016), given the way how multiple inequities can overlap at a single point in time and throughout the lifespan (Bowleg, 2017; Chan & Henesy, 2018). For this reason, specific regions already marred by mental health care shortages relate to the likelihood for whether older adults can access care, feel safe to do so, and find an affirmative provider (Bettis et al., 2020; Lecompte et al., 2020; Porter et al., 2016). Indeed, a number of these issues are pervasively affecting social conditions and psychosocial factors that exacerbate underlying medical conditions and mental health issues (Correro & Nielson, 2020; Yarns et al., 2016).

1.2.1 Physical Health and Mortality

Due to the relationship between psychosocial factors and underlying medical conditions, researchers have typically found that stressful events and their corresponding responses result in lower outcomes of wellness (Correro & Nielson, 2020; Meyer, 2020). The accumulation of these experiences leads researchers to links between health inequities and predisposing discrimination events. Numerous healthcare disciplines have identified concerns in their research about the overrepresentation of physical illness, underlying medical conditions, chronic illness, and obesity among LGBTQ older adults (Choi & Meyer, 2016; Kim et al., 2017). Of important note, physical and chronic illnesses are highest in older transgender adults, which warrants specific attention for practitioners and researchers (Fredriksen-Goldsen et al., 2013; Yarns et al., 2016). Healthcare workers and researchers have also distinctively found that sexual health concerns cannot be precluded, given that many LGBTQ older adults continue to remain sexually active throughout the lifespan (Brennan-Ing et al., 2020; Hillman, 2017; Schubert & Pope, 2020). Regarding promotion of sexual health, discrimination experiences and stereotypes may also challenge access to care and engagement in services for LGBTQ older adults living with HIV (Johnson Shen et al., 2019). Similar to indications of minority stress, LGBTQ older adults may be responding with their own historical trauma (Hash & Rogers, 2017) or internalize stigma about their sexual health in relation to heterosexism, genderism, and ageism (Brennan-Ing et al., 2020). For LGBTQ older adults, the constellation of stressors, medical issues, and mental health disorders increases the risk of mortality through physical health risks (Kim et al., 2017) and suicidal ideation (Brennan-Ing et al., 2014). Correro and Nielson (2020) elaborated further with examples of the physical effects and health disparities emanating from minority stress, such as hypertension, high blood pressure, cardiovascular issues, and diabetes. Kim et al. (2017), in particular, observed that health risks are exacerbated for older LGBT people of Color, specifically older LGBT Black and Latino populations. Results from the Choi et al. (2018) study also indicated that LGB Latino older adults reported more food insecurity, diabetes, and lack of health insurance.

At worst, LGBTQ older adults refrain from seeking care due to negative healthcare experiences or brace themselves for everyday discrimination in their healthcare experiences (Correro & Nielson, 2020; Foglia & Fredriksen-Goldsen, 2014). The culmination of discrimination experiences and overall lack of affirmative providers generally results in lower rates of help-seeking (Burton et al., 2020), and culturally responsive encounters can buffer the problematic experiences associated with negative healthcare encounters (Flynn et al., 2020; Porter & Krinsky, 2014). Instigated by these experiences, only a sample of practitioners are trained to work with older adults (Hash & Rogers, 2017) or covered by Medicare to provide mental health services (Fullen, 2018). LGBTQ older adults may not have the means for transportation to access medical or mental healthcare (Bettis et al., 2020), which is further complicated when they are living alone (Choi et al., 2018; Choi & Meyer, 2016). Burton et al. (2020) specifically suggested that the patient or client relationship is ultimately a crucial factor for LGBTQ older adults to access care. In light of the Burton et al. (2020) findings, trusting relationships and therapeutic alliances for mental health providers are consistently established as the most effective intervention in culturally responsive practices (Sue et al., 2019).

1.2.2 Mental Health and Substance Use

Numerous researchers have referenced the public health crisis related to mental health of LGBTQ older adults (e.g., Chaney & Whitman, 2020; Fredriksen-Goldsen et al., 2015; Yarns et al., 2016). McCann & Brown (2019), in particular, noted the global crisis indicating that LGBTQ older adults’ combination of mental health and discrimination concerns is not isolated to a single country. Correro and Nielson (2020) also documented the ramifications of minority stress and its cumulative effect on cognitive decline among LGBTQ older adults, which can potentially elicit more risks for dementia. Chronic incidents of discrimination, social isolation, and addressing societal expectations can lead LGBTQ older adults to serious psychological consequences (King & Richardson, 2017). According to Choi and Meyer (2016), LGBTQ older adults reported higher rates of mood disorders (e.g., anxiety, depression) and suicidal ideation in comparison to their heterosexual and cisgender counterparts. Notably, transgender, non-binary, and gender nonconforming older adults face higher rates in comparison to cisgender LGB community members (Hoy-Ellis & Fredriksen-Goldsen, 2017; Yarns et al., 2016), and bisexual individuals reported more incidents of psychological distress than gay and lesbian individuals (Choi et al., 2018). These studies further elaborate how LGBTQ older adults are uniquely situated at their stage of the lifespan not only with one single event of oppression, but rather, the overlapping psychosocial effects from oppression (Woody, 2014, 2015; Yarns et al., 2016). As a unique concern for LGBTQ older adults in comparison to LGBTQ individuals at other lifespan stages, LGBTQ older adults may be susceptible to heightened internalized stigma from longer histories of trauma, have fewer means to access mental health care, and face social isolation (Bettis et al., 2020; Choi & Meyer, 2016). Although LGBTQ individuals are similarly susceptible to the health disparities related to minority stress, practitioners must consider that decreased access to social networks can result in a lower likelihood of participating in mental health care (King & Richardson, 2017).

With the overview of risks, minority stressors, and potential social isolation experiences, multiple LGBTQ older adults may resort to substance use as a coping mechanism. Combined with managing psychologically distressing events, inadequate means to potential social networks for older LGBTQ adults could result in illicit substance use conflated with the lack of care and barriers to help-seeking. One primary risk pervasive to LGBTQ older adults is the potential social isolation, given a disconnection from friends and family, grief, and death of loved ones (Arthur, 2015; Burton et al., 2020; Goldhammer et al., 2019). Notably, Choi et al. (2018) noted that older LGB adults in California showed higher rates of smoking. Substance use research reflects these disparities as a major concern, given that many LGBTQ older adults access healthcare far less than their counterparts across cohorts of adults (e.g., emerging adults, midlife; Choi & Meyer, 2016). Talley et al. (2016) have raised attention to the comorbidity of substance use, underlying medical conditions, and mental health distress among LGBTQ older adults, where a lifetime of substance use coping mechanisms exacerbate the stress placed on preexisting medical conditions. Talley et al. (2016) also posited that chronic substance use to cope with psychological distress from discrimination can result in medical conditions and physical health issues later in life.

1.2.3 Housing, Eviction, and Financial Issues

Another significant area related to social determinants of health is food insecurity, financial issues, and housing for LGBTQ older adults. The housing issue layers into several social determinants of health, given that LGBTQ older adults may be living with caregivers, by themselves, or in nursing homes. Specifically in nursing homes, LGBTQ older adults may directly experience bigotry, incivility, and discrimination from other residents in nursing homes or nursing home workers (Hafford-Letchfield et al., 2018). A study by Putney et al. (2018) indicated that LGBTQ older adults’ fears about nursing homes and assisted living are primarily enacted through potential abuse, mistreatment, and identity concealment. Related to the Putney et al. (2018) study, Serafin et al. (2013) reinforced this claim by bringing more attention to LGBT elders and how they conceal their identities upon transitioning into nursing homes.

Unfortunately, LGBTQ older adults living among themselves or with caregivers are not immune to these deleterious effects. Choi and Meyer (2016) reported an increasing prevalence of LGBTQ older adults facing eviction from current housing, higher payments for housing and rent, or denial of housing applications. Although specific to California, the Choi et al. (2018) report indicated that LGB older adults, especially Latinos, were more likely to be food insecure. The accumulation of housing issues and food insecurity precipitate alarming concerns for LGBTQ older adults, as many transition into less income-earning and career opportunities later in life (Chaney & Whitman, 2020; Putney et al., 2018). Putney et al. (2020), in particular, identified that inclusive housing options for LGBTQ older adults are paramount to buffer the effects of isolation. As practitioners consider the implications of oppression specific to LGBTQ older adults, they could explore responses to potential discriminatory events and the cultural context associated with these housing environments (Goldhammer et al., 2019; Serafin et al., 2013). Additionally, practitioners could identify policies that protect or inhibit LGBTQ older adults in their housing conditions (Espinoza, 2016; McCann & Brown, 2019). As findings from the Putney et al. (2018) revealed, LGBTQ older adults are searching for housing with affirmative cultures and policies that embrace their identities.

1.3 Life Transitions, Trauma, and Surviving Multiple Eras

Within gerontological scholarly spaces, researchers and policymakers are focusing on LGBTQ older adults due to late adulthood transitions and distinct historical events that precipitate stress and resilience (Hash & Rogers, 2017; McCann & Brown, 2019). Practitioners should consider that the landscape has perpetually shifted for LGBTQ older adults, considering that they likely endured shifts in healthcare and mental health practices (Goldhammer et al., 2019). For some LGBTQ older adults, their sexual identity, gender identity, and gender expression was criminalized, despite the activism formed by previous generations of LGBTQ communities (Choi & Meyer, 2016; King & Richardson, 2017). Being gay, for instance, was considered a disorder in the DSM until 1973, and there are still major issues with the diagnosis of gender dysphoria (Hash & Rogers, 2017). Conflated with medical criminalization and ostracization, legislation in the United States and globally was rampant with sodomy laws that sustained long-term systemic harm for LGBTQ communities (Choi & Meyer, 2016). For some LGBTQ older adults, the timing of the HIV/AIDS pandemic left them with profound experiences of loss while simultaneously carrying homophobic and transphobic stigma over decades (de Vries & Herdt, 2012; Serafin et al., 2013).

Additionally, a rising number of recent research studies have revealed elder abuse and neglect among LGBTQ older adults to be a pervasive problem at this stage in the lifespan (see Bloemen et al., 2019; McCann & Brown, 2019; Robson et al., 2018). Given this alarming finding, mental health issues and traumatic stress can manifest in response to incidents of abuse (Westwood, 2019). Due to risk factors and discriminatory experiences, such as social isolation, LGBTQ older adults may underreport incidents of abuse or, in more dire circumstances, conceal their sexual identity and gender identity as a coping mechanism. There is an overwhelming fear of transitioning into healthcare settings, assisted living, or nursing homes as a result of abuse incidents instigated against LGBTQ older adults (Serafin et al., 2013; Witten, 2012). For LGBTQ older adults, practitioners and researchers can draw from a wider taxonomy in their conceptualization of abuse. Abuse can include interpersonal violence from caregivers, intimate partners, family members, healthcare providers, and other individuals within their living environments (Westwood 2019). Abuse can also be classified into elder abuse and neglect with LGBTQ older adults excluded from adequate care (Serafin et al., 2013; Westwood, 2019). Additionally, abuse can stem from systemic and epistemic violence through discrimination, explicit violence, and microaggressions (Choi & Meyer, 2016).

1.4 Caregivers and Social Isolation

For LGBTQ older adults, caregivers and social isolation have emerged as a significant priority for intervention, given that successful outcomes of health and wellness are tied to social networks. Researchers (e.g., Fredriksen-Goldsen et al., 2013, 2017; McCann & Brown, 2019; Putney et al., 2018; Yarns et al., 2016) have pinned social isolation as a pervasive issue for LGBTQ older adults, given that numerous LGBTQ older adults who self-disclose their identities or relocate may lose contact with critical networks. In turn, transitions among family and social networks alter LGBTQ older adults’ access to medical and mental health care. Isolation has also made LGBTQ older adults susceptible to increased mental health risks, psychological distress, and suicidal ideation (Goldhammer et al., 2019). The plight of isolation for LGBTQ older adults can manifest in feelings of loneliness, which compound with mental health disorders and symptoms (Yarns et al., 2016). The fear of isolation can incite an impending doom related to cognitive and physical decline and societal expectations on the aging process (Choi & Meyer, 2016; Zelle & Arms, 2015).

For LGBTQ older adults, families and kinship may be crucial factors in ameliorating the effects of oppression because these connections instill coping mechanisms and access to preventive care (Choi & Meyer, 2016; Yarns et al., 2016). LGBTQ older adults may be more apt to engage in counseling and mental health services with a stronger network of social connections. Similarly, social dimensions are characteristic of a holistic profile of wellness for LGBTQ older adults (Chaney & Whitman, 2020). Putney et al. (2020) highlighted these social bonds are interpersonal and contextual factors contributing to the overall safety and health of the population (Fig. 2).

Fig. 2
A photograph of Dr. Debra Joy and Billy Fields with their identity cards.

Dr. Debra Joy Perez and Billy Fields share amoment at the 2015 LGBTQ Scholars of Color National Conference inNew York City. Photo Courtesy of Riya Ortiz/Red Papillon Photography

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2 Intersectionality and Its Connection to LGBTQ Older Adults

Intersectionality has become a radical force across numerous disciplines, especially psychology and counseling, for its intuitive applications to practice, policy, and social justice (see Bowleg, 2012; Bowleg & Bauer, 2016; Chan & Erby, 2018; Grzanka et al., 2017; Singh et al., 2020; Warner et al., 2016). Notably, intersectionality plays a consistent role in examining multiple overlapping forms of oppression and how they conflate into larger systems of health inequities (Bowleg, 2017; Chan & Erby, 2018; Chan & Henesy, 2018; Hankivsky et al., 2014). Using the lens of intersectionality can serve as a catalyst for affirmative practices, specifically for LGBTQ older adults (Adams, 2016; Arthur, 2015), and raises the salience of policies and structural conditions affecting multiply marginalized communities (Crenshaw, 1989; Grzanka, 2020). Although intersectionality has been sourced to the work of Crenshaw (1989) and Collins (1986), intersectionality should be considered in the broader scheme of its intellectual forerunners (e.g., Anzaldúa, 1987; Combahee River Collective, 1995; Davis, 1983; Hooks, 1984; Lorde, 1984; Moraga & Anzaldúa, 1983). These intellectual forerunners drew from personal narratives that critically examined the clashes among their identities, the forces of oppression that culminated in these cultural clashes, and the opportunities to integrate these intersections (Chan & Howard, 2020; Moradi & Grzanka, 2017). Otherwise, intersectionality will be essentially reduced to a commodity of multiple identities or diverse identities without its premise in dismantling problematic power structures, a social justice ethos, and deconstruction of race (Chan & Henesy, 2018; Collins, 2015; Moradi & Grzanka, 2017). Too often, the approach is co-opted and erased from the genealogy of women of Color, queer women of Color, and Black feminism (Moradi & Grzanka, 2017), which first centered the movement in response to endemic racism within white feminist spaces (Collins, 2019; Crenshaw, 1989).

To effectively use intersectionality as an approach, scholars and practitioners must use several principles that continue to dismantle the inequities affecting LGBTQ older adults (Bowleg, 2017; Warner et al., 2016). Intersectionality is contingent on six themes from Collins and Bilge (2020) that demonstrate the depth of its framework: (a) power, (b) social context, (c) social inequality, (d) relationality, (e) complexity, and (f) social justice. Relationality and complexity work in tandem as these two principles characterize how individuals consist of multiple identities and carry unique experiences shaping each of their identities (Collins & Bilge, 2020). For LGBTQ older adults, using these two principles can reaffirm their experiences, capital, and integration of identities as protective factors and sources of resilience (Arthur, 2015; Woody, 2014, 2015). In the Woody (2014) study, aging African American lesbian and gay participants specifically reported that surviving multiple forms of oppression over several generations contributed to their resilience. Several scholars based in intersectionality have posited that intersectionality must draw from an analysis of power (Bowleg & Bauer, 2016; Collins, 2015) and structural oppression (Bowleg, 2017; Grzanka, 2020). Intersectionality represents a promising framework to elucidate the experiences of LGBTQ older adults, especially LGBTQ older adults of Color (Arthur, 2015; Bloemen et al., 2019). For instance, practitioners should consider structural forces, such as white supremacy, and how they foundationally undergird heterosexism, genderism, and ageism. Practitioners can contextualize how these forces impact LGBTQ older adults’ experiences over time and in the current state of society.

Although LGBTQ older adults are explicitly connected to heterosexism, genderism, and ageism, researchers and practitioners must unveil other intersecting forms of oppression, such as racism, classism, and ableism (Hash & Rogers, 2017; Johnson Shen et al., 2019). A plethora of researchers have commented that LGBTQ older adults of Color and racism must be further explored in the larger scope of gerontological research (Goldhammer et al., 2019; King & Richardson, 2017). Additionally, multiple researchers have noted the disparities associated with HIV exclusions in LGBTQ older adults, which illustrates an increased need to examine ableism within this population. Other than merely realizing multiple forms of oppression, researchers and practitioners must clearly foreground their practices of intersectionality in a social justice agenda (Collins, 2019). Using this mindset will reflect systematic changes that unsettle inequities and propels communities toward action (Bowleg, 2017; Hankivsky et al., 2014). This issue is especially relevant for policymakers who are unaware of the litany of injustices and health disparities facing LGBTQ older adults today (Espinoza, 2016; Hash & Rogers, 2017). Aside from empowering LGBTQ older adults with affirmative practices, practitioners should reflect their conversations on the possibilities for changing the cultural contexts affecting LGBTQ older adult clients.

3 Case Example

In this hypothetical case example, Mona is a lesbian 68-year-old Asian older cisgender woman with Indonesian and Chinese heritage and has accumulated a sizable amount of income due to financial planning within the last few years. Mona has recently retired from a successful position with her last company after a long-term leadership position in business. Mona uses the pronouns she, her, and hers. She has been living together with her partner who is also a lesbian cisgender woman, but with a white racial identity and a career in education. Her partner is still employed as a student affairs practitioner. They have been living in an urban city and have been married for several years with strong levels of marital, relational, and sexual satisfaction.

Upon retiring, Mona has changed her most recent medical provider to ensure that she is able to receive insurance coverage for the medical services. While visiting a new provider several times over the past few months, Mona has noticed that staff have foregone any discussions about her sexual health and generally meet with her for only 5 min. Mona has speculated that staff at the new provider have seemingly rushed her appointments and physically avoid her. At one point, she mentioned living with her partner to which the staff quickly shifted the topic of conversation. One day, the provider perpetuated a stereotype about Asian older adults and their usage of healthcare. The combination of these experiences has left Mona conflicted about continuing with this provider, although this provider is covered under her insurance and closest in location to her house. Mona tried to broach these issues among her friends and family, particularly white individuals in her social network, where many have dismissed the experiences or tried to explain the rationale behind their actions. Some friends, including her partner, suggested that the experiences may have been likely a result of heterosexist microaggressions. She has been working with a counselor for her own wellness over the past 2 years and bring these new life transitions to the counseling sessions (Fig. 3).

Fig. 3
A photograph of Dr. Barry Chung standing in front of a mic addressing the audience in the auditorium.

Dr. Barry Chung lecturing on his experiences as a gay Asian American before an captive audience. Photo Courtesy of Riya Ortiz/Red Papillon Photography

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4 Considerations for Reflecting Intersectionality in Practice

Within clinical practice, psychologists, counselors, and mental health practitioners are tasked with a responsibility to examine the accumulating effects sustained by health inequities and overlapping forms of oppression. There are three main areas related to intersectionality that are applicable to the case example. Given the potential health inequities and social determinants of health affecting LGBTQ older adults, practitioners can consider that a combination of factors might have been present in this case example. With LGBTQ older adults, they may face a variety of barriers in accessing healthcare, which may limit choices to access an affirmative provider. As demonstrated in the story, Mona has had several successes over her lifetime, including financial security, housing, and social connection. However, a life transition altered the pressures of finding another provider and shaped her choices for a healthcare provider. Social conditions and contextual factors influence the ability to seek certain providers, where specific providers may not institute the same affirmative approach. Although Mona’s past experiences with discrimination were not extensively discussed, practitioners must be attuned to the ways that life transitions may place a client at the nexus of multiple forms of marginalization (Arthur, 2015; Correro & Nielson, 2020). The contextual factors in this scenario alluded to the prominent issue that agencies, healthcare, and society are contending with gaps in training affirmative and culturally responsive practitioners (Hash & Rogers, 2017; McCann & Brown, 2019). Many training programs across healthcare disciplines are suffering from the omission of cultural aspects in the lives of clients, consumers, and patients (Lecompte et al., 2020), which render practitioners less likely to detect interpersonal and structural forms of marginalization (Choi & Meyer, 2016).

Although intersectionality highlights the constellation of oppression events that Mona could have encountered previously and currently, it behooves practitioners to address the strengths and resilience sustained over her lifetime (Chacaby & Plummer, 2016; Meyer, 2015). Given intersectionality’s focus on relationality and complexity, Mona’s experiences can map profound experiences of discrimination and resilience reflecting her multiple identities. Exclusively perceiving LGBTQ older adults in a deficit perspective can also be harmful (Arthur, 2015). However, this perspective does not mean that practitioners should diminish the cascading effects of oppression. Practitioners can incorporate Mona’s successes and responses to oppression as factors that ameliorate the psychological consequences with racism, heterosexism, and genderism throughout her life and specific to this incident (Choi & Meyer, 2016; Woody, 2014; Yarns et al., 2016).

The story of Mona is only a sample of the diverse spectrum of experiences among LGBTQ older adults. Researchers and practitioners must dedicate more efforts to tackling the epidemic and crises facing LGBTQ older adults of Color (Foglia & Fredriksen-Goldsen, 2014; Fredriksen-Goldsen et al., 2013, 2017; Kim et al., 2017; Van Sluytman & Torres, 2014), given the disproportionate amount of racism and white supremacy taking place over decades. In this scenario, Mona simultaneously experienced heterosexism and racism, which often manifested as a combination of implicit and explicit acts (e.g., avoidance, stereotypes, discomfort around sexuality). One element that should be highlighted was how individuals within Mona’s social network, particularly white individuals, perpetuated horizontal oppression (i.e., oppression within oppressed communities). By dismissing Mona’s experiences with her healthcare providers, the accumulation of these experiences may contribute to Mona’s likelihood of seeking help from future healthcare providers in the future (Flynn et al., 2020). Individuals in her own community overlooked the racism and racial microaggressions that could have played a distinct role in this incident. An apparent dynamic surfaced between Mona and her partner who also disregarded the racialized experience and focused primarily on the heterosexist act. Intersectionality provides a way to make sense of exclusionary practices and marginalization that takes place within historically marginalized communities (Chan & Erby, 2018).

5 Conclusion

Although researchers, psychologists, counselors, and mental health professionals are taking an interest in LGBTQ older adults and elders, the multitude of research studies in the past decade have demonstrated a more urgent need to increase research, practice, and policy supporting the population (Espinoza, 2016; Hash & Rogers, 2017). LGBTQ older adults may have overlap with youth and emerging adults, but in the context of lifespan development, practitioners and researchers must consider the historical events that precede stress and resilience experiences. Using intersectionality can be an effective approach to conceptualize the myriad forms of oppression and draw on multiple dimensions for cultural capital, knowledge, and wealth (Singh, 2019). For many LGBTQ older adults, their experiences with resilience and survival are likely contingent on integrating multiple dimensions of their social identities, becoming conscious about inequitable conditions, and affirming the intersections of their identities.