Okpodi Julius*1 and Emmarex Okhakhu2
Received: October 13, 2018; Published: October 17, 2018
Corresponding author: Okpodi Julius, Registered Social Worker and a PhD in Health Sciences with a research focus on breaking the inequalities and biases in healthcare provision
Researchers and practitioners of an aging world are increasing studying issues of the aged, the aging process, and the fears and worries of older adults. However, there are some studies that neglect to consider aging concerns and the identity of the lesbian, gay, and bisexual (LGB) older adults. Ageism is one of the concerns; it is associated with stereotypes and prejudice against older adults. As LGB older adults continue to age, their needs for quality social and healthcare services will grow. This is the focus of this qualitative research. The data gathered from this research were interpreted through the lens of thematic analysis and were used to identify emerging themes. While participants’ narratives overlap and reinforce each other, thematic approach provides a way of understanding how LGB older adults construct meaning to their perceptions and experiences of services received within British Columbia Northern Health Authority boundaries. The findings from this research present multiple health and social issues begging for greater understanding and integration to support the LGB older adults living within the studied area. The findings also seek to identify perceived social inequalities, understand the problems caused by those inequalities, and construct meaning to rectify those inequalities. Further, the findings developed from this study allows for a deeper understanding of sexual minority older adults and the need for the field of gerontology to increase research on this population.
Keywords: LGB Older Adults; Ageism; Bed Blocking; Qualitative Research; Thematic Analysis
The most significant change occurring in Canada today is the growing number of older adults. In Canada, the percentage of older adults aged 65 and over outweighs the population of children under the age of 15 (Canadian Broadcasting Corporation News, 2015; Statistics Canada, 2016). Researchers and practitioners of an aging world are increasing studying issues of the aged, the aging process, and the fears and worries of older adults. However, there are some studies that neglect to consider the identity of the lesbian, gay, and bisexual (LGB) older adults. As older adults continue to age, they will likely witness ageism. Ageism has a negative connotation and it is associated with stereotypes and prejudice against older adults . Revera’s report  on ageism reveals that six in ten (63%) older adults, defined as those aged 66 and older, have been unfairly treated in one way or another because of their age. Also, the report reveals that one in three (35%) of Canadians concede to having treated older adults differently because of their age.
LGB older adults face many of the same challenges in adapting to aging as their heterosexual counterparts, but they also have issues specific to their sexual identity and gender identity. Some of the issues identified in the LGB aging literature include ageism, discrimination and stigmatization, housing and social service needs [3,4]. Thus, discussing ageism and life style perceptions would help reduce ill treatment and stigma associated with social and healthcare services received by older adults. The next heading establishes a theoretical framework for this study.
There are many theoretical influences on the successful aging of LGB older adults. To address ageism as it affects LGB older adults, social constructivism theory is used to understand the meaning created in the minds of LGB older adults. Constructivism theory as learning theory acknowledges that reality is a construct of human intelligence and understanding of the world [5,6]. Constructivism suggests that individual learners create their own understanding and knowledge through personal experiences and perceptions of the real world. Constructivist theory is of relevance because it is a theoretical approach that acknowledges people construct knowledge and/or contribute to knowledge development through their experiences and perceptions of reality as constructed in their minds. With constructivism, the research participants can recount their perceptions and lived experiences as their reality [7,8]. In this research, constructivism allows research participants to communicate what they already know and believe and create knowledge from the experiences. This knowledge construct is not about creating artifacts (objects that are tangible/real) or engaging in an experimental learning but rather about retaining ideas read or heard and deliberately making or creating meaning out of the process . Constructivism is about framing the participants’ thoughts and constructs of their world, for meaning-making.
Constructivism is relevant to this research as it helped the researcher to formulate appropriate topic related open-ended questions which elicit meaning-making from the perceptions of the research participants. Constructivism helps participants to create new knowledge out of their experiences. For example, when a participant is asked: Can you tell me about your experience of growing older as an LGB person? This question invites the participant to share their unique experiences and perceptions, which makes meaning of their reality. In this instance, the participants respond reflectively about experience to the research questions. The theory of constructivism promotes meaning-making and knowledge construction as the underlying values. This theory considers contemporary knowledge as “temporary, non-objective, internally constructed, developmental, and socially and culturally mediated” . Other researchers see constructivism as the process through which the cognitive structures that shape our knowledge and perception of the world evolve through the interaction of environment and subject . The next heading discusses the literature review for this study.
The definition of the term “older adult” varies across disciplines. While gerontologists tend to define older adults as individuals who are 60 years of age or older, the federal government uses the ages 60– 70 as a marker for the Canada Pension Plan (CPP) . Older adults may remain in the workforce and continue to contribute to the CPP until the age of 70, which does not negate the fact that some older adults may choose to stop contributing to the CPP at age 65 . Researchers often identify subgroups of older adults as younger old (ages 65–74), older old (ages 75–84), and oldest old (85+) . These criteria are different from the federal government’s pension eligibility because, subjectively, many older adults may not label themselves as “old” and may not be prepared for retirement even in advanced age . As people age, they continue to grow, gain knowledge, become active in their families, create and engage in healthy activities, or stay active in their communities. However, older adults may also show some mental decline. As people age, their physical and mental characteristics do not change at the same sequential age for every individual. Each individual is unique and old age varies between individuals [13,14].
This research focused on the LGB Culture, yet it is acknowledged that these terms may extend to the transgender, queer, and queer+ within these sexualities (LGBTQQ+). The LGB culture is the predominant group culture with almost parallel sexual experiences. In the transgender culture, hormonal therapy may help in further qualifying the specific sexual identity of the individual. An element in the Q and Q+ cultures borders on physical/sexual behaviours of persons in this group. In fact, “Q” stand for “questioning” or “Q” stands for “Queer” which means the individual is uncertain of his/ her sexuality. This means that their identity may shift overtime. These distinctions appear settled in the LGB culture. Nonetheless, this study may have implications for the other cultures outside of the LGB culture.
The LGB acronym codifies the sexual orientations in a blanket fashion, which accrues from sexuality and gender definitions . LGB is used in this study as a descriptive condensation of the lesbian, gay, and bisexual populations. Most of the authors reviewed here have assumed that the LGB term and the minority sexual identity and gender descriptions are discrete categories , while the analysis of the concerns, experiences, and realities of LGB people remain unexpressed  indicate that sexual identity can change over time. This acknowledgment admits fluidity in the described sexual identity, pointing to current shifts in language and thinking, challenging the notion that sexual identity is fixed and immutable . The search for meaning through the concepts of categorization, to put things in square boxes and discrete classifications, makes researchers operate on the assumption that these three identities (LGB) do indeed comprise the full universe of sexual identities . If so, how do we explain pansexual, fluid, bi-curious, or those who simply refuse any kind of label? However, the recognition of more sexual variability and the possibility of change over time does not undermine the case for equal rights or our tending to the aging needs of LGB older adults.
Ageism has a negative connotation in Canada, especially in terms of how we view older adults. Revera’s report  on ageism reveals that six in ten (63%) older adults, defined as those aged 66 and older, have been unfairly treated in one way or another because of their age. Also, the report reveals that one in three (35%) of Canadians concede to having treated older adults differently because of their age. Moreover, the report states that half (51%) of Canadians agree that ageism is the most accepted social discrimination when likened to gender, race, class, and other isms . Older adults in the United States and Canada tend to be marginalized, institutionalized in nursing homes, stripped of responsibility, control, and their selfworth .
The problems LGB older adults’ faces are often similar to those faced by their heterosexual counterparts: ageism, physical and mental healthcare, legal rights, transportation, finances, and housing . However, Kimmel and his colleagues  noted that LGB older adults face the double stigmatization and oppression of age and sexual identity. Research on LGB aging is limited . In 1973, the American Psychological Association and American Psychiatric Association declassified homosexuality as a personality disorder  noted that older lesbians and gay men were not included in the studies on aging due to the ignorance and denial of their existence. The literature on LGB aging found that LGB older adults had many of the same challenges in adapting to aging as their heterosexual counterparts, but they also had issues specific to their sexual identity and gender identity.
However, ageism has been called the final prejudice, the last judgment, socially normalized discrimination, and the harshest rejection . As with heterosexual age peers, family and friends are crucial to LGB older adults. Offering support in the form of social interaction and connectedness may reduce the impact of ageism and isolation, as well as assist older adults with daily chores of living. Yet, the problems of ageism continue to be on the rise when such support may be lacking for LGB older adults, who are often single and without children . Subsequently life partners and children play a significant role in caregiving, and many LGB older adults may face isolation. On the contrary, heterosexuals can turn to family members and partners for informal support [20,21]. LGB older adults who are partnered struggle with discriminatory practices that arise from the lack of formal recognition of their relationships. LGB partners may face unequal treatment in hospital visitation, health decision-making, and housing rights, and a host of other issues that affect their financial security, health status, and quality of life . The next segment discusses the methodology used in this study.
This qualitative research used a semi-structured, in-depth, face-to-face interview tool to gain an understanding of underlying reasons, experiences, opinions, and perceptions of the research participants . Further, it provides insight into participant’s narratives and uncovers trends in thought and opinions, and probes deeper into the phenomena . The qualitative data collection method varies using semi-structured techniques. Such techniques include focus groups, direct participation/ observations, individual interviews, artifacts, documents, educational records, visual materials, and personal experiences [23,24]. Furthermore, qualitative research is multimethod in focus, using an interpretive and naturalistic approach (qualitative researchers study things in their natural settings, attempt to make meaning of, and interpret the phenomena as presented by the participant). Qualitative research aims to understand the social reality or cultures as presented by study participants. Typically, qualitative research samples are small in size, and respondents are selected to fulfill a given quota [23,24].
The in-depth interview process was the primary data collection technique for gathering data in this qualitative study. Detailed data were gathered through open-ended questions that sometimes provide direct quotations, since such direct quotations help to articulate the questions and keep the response in perspective. Each participant was given a copy of the questionnaire on hand and was encouraged to answer the questions serially, for easier re-mapping and analysis by the researcher.
Thematic analysis is a broadly used qualitative analytic method . This type of analysis is very inductive; i.e. the themes emerge from the data and are not imposed by the researcher. Thematic analysis is a qualitative analytic method that aims to uncover patterns or stories in data . Further, thematic analysis offers organization to the data analysis and helps the researcher to understand the potential of any issue more widely . This thematic analysis was conducted over several stages. A set of codes was defined and each data item was labeled with one of these codes. The code schemes were checked to determine if they were balanced, repeatable, and unambiguous. The codes were refined and reviewed until the researchers reached a pre-determined agreement rate.
The value of qualitative research is determined by methodological considerations. Creswell  noted that the quality of qualitative research could be increased through rigorous methods and by building the credibility of the researcher. This qualitative research was conducted rigorously. We utilized several methods that supported research rigour. These methods included reflexive journaling, candidness, and feedback. Personal reflexivity is a significant aspect of this research. Also, we kept an audit trail and coding checks to ensure the trustworthiness of the study. Constructing meaning is learning and empowering .
The member checking approach was used after data transcription and analysis to improve the accuracy, credibility, validate, and transferability in this study. Member checking is a form of triangulation that involved having those who were studied review the findings to offer a measure of accuracy . After data transcription and initial analysis, the researchers gave participants both transcribed and analyzed sets of data to consider the findings critically and to comment on them. Participants were allotted two weeks to affirm that the summaries reflected their views, feelings, perceptions, and experiences. Also, participants were informed that failure to respond within the two weeks may imply the transcription and analysis accurately reflected their opinions. The findings in this research reviewed through the data analysis are presented below.
These findings were participants’ expressions of their experiences, opinions, and perceptions of the phenomenon being discussed. With the intent of developing knowledge from participants’ experiences and perceptions of the real world, it was essential for the researcher to remain faithful to the letter and spirit of every word uttered by the participants to ensure value sense making of how older adults interact and interface in the midst of ageism.
LGB research participants interviewed believe that ageism specifically targets older adults. Decreasing stereotypes and discrimination against older adults within the study area is as crucial as providing social and healthcare services that are discrimination free. As stated by Abraham: “I don’t see much activities for LGB persons, getting older and doing nothing really just puts us . . . what do you call it . . . something in the crank shaft that doesn’t make it roll or turn.” Aging in the north limits older adult’s ability to engage in social and physical activities. LGB older adults need social amenities and therapeutic recreational facilities to enable them to age successfully. This limitation can create isolation for any older adult. Ageism is prevalent within the LGB community. Justin, one of the participants, believed that once a gay person turns 40, he faces fears and concerns about losing his partner. Justin believes that such perceptions should change. In his own words: Certainly, age does seem to be . . . at about forty, this does change the dynamics for a lot of people. I know other gay men who have been affected when they’ve hit 40 and 45 years of age. This is very distressing because their own mortality is coming into play and as a gay man, it’s really difficult to find a partner unless you are perfectly fit, perfectly handsome, and you got all the latest gadgets and things like that. It’s a lifestyle thing for sure, and when people reach the age of 40, they are not prepared for that. I think it can be quite a shock.
The above participant’s narrated experience may resonate with many people, regardless of sexual identity; since many people face this existential crisis when they move into their late 40s and early 50s. People may become conscious of their mortality and reflect on choices they have made regarding partner or partners, career, and so on. Some people are petrified of being alone when they become older adults. The feelings described here are Justin’s feelings and fears but may also be feelings of many LGB people. Mackenzie  noted that as you age, people act as if they don’t have any interest in you, and that some young people don’t show respect or sympathy for older adults. However, we must reconstruct this meaning, knowing that growing older is not growing obsolete. Older adults are people with different attitudes, worldviews, and taste, and old age brings intelligence, experience, wisdom, and knowledge. This reminds us that mortality is near, and we must respect and cherish the knowledge and wisdom shared with us by older adults. Further, the lifestyle perceptions identified by Justin—“perfectly fit, perfectly handsome and having all the latest gadgets”—ought not to be a condition for expressing sexual desire towards another. Furthermore, these lifestyle perceptions may not support successful aging. Consequently, this may pose a shock and/ or become emotionally damaging to the older adult challenged by these perceptions.
Other participants view ageism as institutional practices and policies that perpetuate stereotypes about older adults. As Lovett and Carla described, once a older adult falls sick and is admitted to a care facility, he/she is asked to sign a form to ascertain the level of intervention required. This paperwork may become overwhelming for older adults, and they may not have the opportunity to question those papers before signing. Secondly, the realities of the paperwork centre on “do not resuscitate,” which makes it more challenging for older adult services. Some participants in this study were very concerned about this and stated that healthcare providers need to educate older adults on the implications of do not resuscitate before signing any form, and failure to do this may be categorized as ill treatment.
The concept of “bed blocking” was raised by one of the participants. This individual, Lovett, believes that healthcare systems are under pressure to move hospital patients out of beds and back into the community as quickly as possible. Lovett said, “bed blocking means . . . you don’t deserve to be in that bed because you are old. A younger, fit, healthy, productive person deserves the bed.” Older adults were once young adults who worked and contributed tremendously to society. Even the church, “makes me feel concerned and unwelcomed”. Labelling older adults, especially LGB people as bed blockers, is a subtle form of mental discrimination, not just because of their age but because of the sexual lifestyle. While this may be unfair and unfounded, such discrimination may still be common among healthcare workers [29,30]. Such experience may make the old/ LGB persons feel stigmatized and insulted and may shy away from healthcare providers. Healthcare workers’ perceptions can affect the care given to older adults if they are labelled as bed blockers. Apparently, there are not enough longterm care beds, long-term care facilities, geriatric day facilities, or rehabilitative services available for older adults (a place or a facility where older adults could step down from acute care into more rehabilitative care, which may be more suitable and easier to maintain). The research participant’s narration of a bed blocking experience illustrated one of the prejudices faced by many older adults who need to use hospital facilities within the healthcare system. The experiences shared by older adults indicate the need to expand and/or develop more care facilities to provide accommodations to meet the needs of an aging population. Other participants stated that the healthcare system warehouses older adults and makes assumptions or perceptions about them. Doris’s understanding was as follows: Right now we warehouse our old people. . .. I don’t know if we spent much time in our nursing homes, they’re deplorable . . . we stick people away and treat them like cattle. Everybody must be up at eight a.m. for their bath or they get fed or their meds and it’s on a schedule and routine.
Over time, older adults have been exposed to socially normalized discrimination and the harshest rejection. This is because at a point in time, everyone may become a target of ageism and may not be able to do anything about it. There is a need for optimal and holistic care. Patient should be allowed to make or create input in treatment (bath times, meals, and medications) for better care management. Putting older adults on a routine without patient input is not empowering, but reinforcing ageism and discrimination. Discrimination and stigmatization of this nature presented in this finding creates stereotypes for all older adults and may re-enforce isolation and fear for LGB older adults seeking services. The next heading presents the discussion for this study.
The analysis and interpretation in this study focused on the construction of knowledge, based on the meaning that participants gave to their perceptions and experiences. The knowledge created had a clear indication of how participants looked upon themselves as subjects and as older adults seeking respect, dignity, and autonomy. For instance, the attitude of some social and healthcare workers/caregivers can directly affect older adults’ meaning of identity and create fear, which may stop some older adults from seeking social and healthcare services.
Research participants struggle daily with ageism and homophobia. Gallicano  argued that this type of fear, stereotype, and prejudice against older adults may deprive them of their participation and involvement in an age-friendly society, driving them into social isolation or a self-destroying lifestyle. Ageism perpetuates stereotypes about older adults. These stereotypes and prejudices are not limited to historical and economic circumstances but also include fears and concerns about the vulnerability inherent in the later years of life . Ageism causes fear, and fear can pose a shock and/or may cause emotional distress to an older adult . Ageism is unfair treatment of older adults, and some participants call for a revolution in older adults’ social and healthcare services to bring about a change in policies and perception of people. Constructivism theory may help by promoting optimal and holistic care for older adults [30,31].
Further, the term bed blocking was identified from participants’ narratives. Older adult who witnessed such a derogatory statement from healthcare workers may feel sad and helpless, and such derogatory statements can affect the care given to older adults. Labelling may also dissuade older adult from seeking social and healthcare services. In this instance, the applicability of constructivism theory is justified as it aims to create positive meaning and/or provide professional competency (through training) in services and sensitivity to the client’s culture, history, and social factors, and to identify older adults’ choices and preferences [6,32]. Several researchers have argued that discriminatory treatment of a marginalized group like older adults is pervasive in our society, and it is detrimental to the people it targets .
Some participants identified unacceptable comments and behaviour on the part of healthcare workers, friends, families, and caregivers. Others talked about overwhelming paperwork, labelling older adults, and how they are warehoused in a facility. Social and healthcare providers should be cognizant of the fact that respect, freedom of autonomy, and personal space can foster growth and enhance the relationship between the provider and the service user. One participant was very concerned about the church; the participant felt unwelcome at the church because he is a gay. The participant found the church to be hypocritical, considering that the sign at the right wing of the church reads: “love the sinner and hate the sin.” The participant found that individuals/churches adopting such ‘love all’ biblical verses to be duplicitous, when in reality they do not want you in their ‘holy circle’.
Some of the ways to improve social and healthcare services that shows respect and dignity to LBG older patients include: providing mandatory and monitored socio-cultural training to employees and volunteers respect all sexualities, and training staff to provide affirming and non-judgmental service that acknowledges the role of LGB partners in healthcare decisions, and honoring gay relationships. This study is one of the first of its kind on LGB older adults within the study area. Further, this research is needed in order to have an in-depth knowledge and understanding of ageism as it affects LGB older adults.
Educating social workers, other healthcare providers, and caregivers would help create an awareness that supports ageism and the successful aging of LGB older adults. This support will help LGB older adults actualize successful aging, rather than warehousing, labelling, and using discriminatory terms to describe LGB older adults. This study has potential to raise consciousness about LGB older adults that can be explored in other descriptive studies or a larger ethnographic study. Some challenges that emerged from the analysis call for further exploration. First, across participants in the research, there was a denial of experience of discrimination, yet participants discussed many stories of homophobia and discrimination. Though these experiences cut across the lifespan of all older adults, the LGB population feels the pain especially because of their experience of discrimination due to their sexuality. This provides an understanding as to why some older adults may feel guilty calling attention to such marginalization and discriminatory experiences related to their sexual identity. The implementation of these recommendations would be an open invitation to aging LGB seniors to use existent healthcare facilities, resulting in a significant bottom-line improvement for these treating facilities.
Ageism as an institutional practice and policy perpetuates stereotypes and negative perceptions of older adults. Ageism practiced within social and healthcare institutions tends to encourage the warehousing of older adults and label them as bedblockers. Ageism, particularly among the LGB older adults living within the studied area, presents many social and health issues demanding attention. In this view, social constructivism theory sought to identify perceived social inequalities, understand the problems caused by those inequalities, and construct meaning to rectify those inequalities. This theory also aimed at creating understanding and knowledge of the real world, assisting, supporting, or enabling LGB older adults with the intention of improving social and healthcare services and human conditions [6,31]. Social constructivism, if applied, can bring about a change in attitude and behaviour towards LGB older adults; this is sought through the empowerment and emancipation of the group pursuant to increased awareness of and critical reflection on the oppressive social structure [34-36].
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