Learning to Deliver Affirmative Care to LGBTQ+ people in later life

A learning framework for LGBTQ+ Ageing

In March 2023, Skills for Care, England launched its new learning framework on knowledge, skills, and values for working affirmatively with LGBTQ+ people in later life. This capitalises on what is now a substantial, rich, cumulative, and growing body of evidence which speaks to the experiences of lesbian, gay, bisexual, trans, queer and questioning people (LGBTQ+) in later life.  The evidence reveals a range of concerns and challenges for people who identify as Lesbian, Gay, Bisexual, Trans, Non-Binary and Trans and other sexual and gender minoritised groups as they move into their later years. It also documents the strengths, contributions of the community and their recommendations for what can be done to support the workforce in developing and improving affirmative LGBTQ+ ageing care.

“Thank you, Professor Trish Hafford-Letchfield, for telling us more about this new framework that aims to help the social care workforce work affirmatively, inclusively, and effectively with individuals from gender and sexually diverse communities. SWU is publishing this on the International Transgender Day of Visibility to reaffirm our support of the transgender and non-binary community, and to raise awareness of this freely available new resource which can be used to improve support for LGBTQ+ people in later life,” said SWU Communications, Policy, and Engagement Officer Dr Shawn Major who is Co-Chair of the BASW UK & SWU LGBTQIA+ Action Group

BASW Cymru Professional Officer Narinder Sidhu who is also Co-Chair of the BASW UK & SWU LGBTQIA+ Action Group said, “I am delighted to see this framework being shared across the health and social care sectors. I hope it will lead to a better understanding and more effective support for LGBTQ+ people in later life. The UK has a growing ageing population, and we must do better to understand their needs. This journey begins by understanding the challenges, barriers and poor outcomes that people who identify as LGBTQ+ experience when accessing health and social care so we can improve our current practice and systems. This framework offers safe and effective practice guidance which can be applied throughout the life cycle of people we support.

“I hope practitioners will take the time to digest the framework which has been co-produced with people with living experience. The framework adopts a person-centred and humanistic approach which will hopefully fill in some of the gaps that currently exist in social work education and training. I agree with Trish Hafford-Letchfield (Professor of Social Work at the University of Strathclyde) that this framework will equip Social Workers and the health and social care workforce with enhanced knowledge, skills, and confidence on LGBTQ+ issues in ageing and how to address heteronormative and cisgendered assumptions which are deeply embedded in many services across the UK.”

What is unique about LGBTQ+ identities in later life?

Whilst we often talk about the ‘challenges’ of a growing ageing population, we tend not to talk about the diversity of experiences. LGBTQ+ people in later life report poorer health than the general population and significantly worse experiences of care. This is irrespective of whether they are accessing cancer, palliative/end-of-life, dementia and/or mental health services. For example, a meta-analysis of 29 datasets on health or care indicators on LGBT+ people revealed that (LGB) men and women experiencing poor self-rated health 1.2 times higher than for heterosexual people.  This type of analysis confirms how cumulative health inequalities are a strong predictor of future mortality, and poor outcomes for people’s health, disability and life expectancy and certainly merits concerted action.

LGBTQ+ people in the UK and in many other countries have witnessed transformative legal, political, and social changes during their lives, including rights in adoption (2002) the introduction of civil partnerships (2005), and the legalisation of same sex marriage (2014), alongside measures to tackle discrimination in employment, crime, and healthcare (Equality Act, 2010).  Today’s older LGBTQ+ people came of age as homosexuality was partly decriminalised (in 1967), and in the 1970s engaged in or supported  political and social movements such as radical feminism, followed by  the global AIDS crisis in the 1980s.  In the 1980s, the government also banned sexual diversity being discussed in schools (through Section 28).

Trans issues however have a longer and more complex history in the UK, which is helping shape the present legal landscape. It is only since 2000, that the legal rights of trans people have started to be addressed in UK law and there are still serious concerns about their rights as exemplified in the more recent Governments failure to legally ban conversion therapy in the UK. Non-binary people as a distinct group are not protected to the same extent as trans by UK legislation as under the Gender Recognition Act.

In most parts of the UK, the Gender Recognition Act 2004 is in urgent need of reform, to remove the dehumanising and demoralising medicalised system and barriers to a system of self-declaration. Some trans people do not seek a Gender Recognition Certificate (GRC) as the whole process is long winded, complex, and intrusive.  For those seeking gender affirming interventions, the waiting period is more than 5 years. There is, however, no age limit for someone striving to be their authentic self and many people are taking up private healthcare options in the face of these resource restraints, poor professional knowledge and in the face of attitudinal barriers to them accessing gender identity services.  

So, despite advances in the UK and elsewhere however, many older LGBTQ+ adults have faced rejection by family members or live in fear of losing family connections and/or live a hidden life as a result. Many have cultivated alternative support structures  known as “friendship families,” or “families of choice”.  Maintaining these networks can become more challenging in later life leading to greater potential for loneliness and isolation, which is also associated with poorer mental and physical health and avoidance of accessing support in time.

Gender diversity and ageing

Trans and gender diverse community networks and care practices are not always addressed in discussions of LGBTIQ+ ageing.  The focus is often on gender affirming interventions with little focus on individuals’ unique ageing experiences and needs when accessing social work services. Trans people’s healthcare needs are, in general, like those for other people but may need extra support and advocacy in accessing health in areas that need specific consideration or sensitivity (for example gynaecological health needs in trans men or prostate cancer risks for trans women as well as monitoring the long-term effects of hormone medication).

Trans and gender diverse older people may be at exceptionally high risk of social rejection and isolation, material risks and fear of being misgendered and exposed to ignorance and hostility, all of which can inform individual’s perception of care.  

One survey of 895 people in the UK of people who identified as non-binary, genderqueer, trans, gender fluid and agender revealed several concerns. These included being told that services did not know enough about non-binary people to help them and even refusing services. Respondents felt erased by the complete lack of representation in service literature, which impacted on them by feeling isolated, excluded, with low self-esteem, poor mental health and invalidated.  More work is needed to include non-binary and gender non-conforming people in later life.

Concerns about the respectful provision of intimate personal care is a key concern given the potential time for discrimination^. An example could be sensitivity about surgical scars and inappropriate questioning or ridicule by care workers and other service users, particularly in residential care. Other aspects of personal care such as attention to appearance and access to hair removal can be crucial to respecting dignity and choice.

Leaving needs unmet or not providing accessible formal services in the community may lead to premature admission to residential care. Being prematurely admitted to residential care is often reported as a key concern of older trans and gender diverse people. One comment has always stayed with me from an older Trans woman during our research of LGBTQ+ experiences during the pandemic:

 “I would much rather kill myself than go in a care home.  I have written ‘Do Not Resuscitate’ on the wall above my bed so the ambulance people know what I want.”

This individual had become isolated from her normal advocacy and support network and was extremely fearful of care services.

Social workers need to be able to work collaboratively with older trans and gender diverse people to overcome past negative experiences accessing formal support, particularly those of culturally and linguistically diverse backgrounds and to recognize the resources and capabilities they draw upon. This involves more than awareness, but active engagement with learning about trans care, being an advocate and fostering reciprocity in how to work with trans social networks in service planning and services themselves. Significant others, chosen family, friends, and extended networks may represent significant community relationships and can be engaged in helping to meet the need of trans and gender diverse older people.

How can the Skills for Care (SfC) LGBTQ+ learning framework help?

A key and consistent message from the research literature concerns the gaps in education and training needed to equip the care workforce with better knowledge, skills, and confidence on LGBTQ+ issues in ageing and how to address heteronormative and cisgendered assumptions in care provision.

The SfC learning framework for knowledge, skills, and values for working affirmatively with LGBTQ+ people in later life therefore identifies and articulates the key topics that should underpin best practices with LGBT+ older people and their carers in social work and social care.  Level 2 and 3 address specific learning outcomes for social workers in different services and roles. There are nineteen topics across four domains which can be integrated into other learning programmes to diversify and enrich learning and to make sure that these are always inclusive of LGBTQ+ lives. 

These 19 topics can be used in different contexts. In Higher Education, it can form part of the curriculum or stand alone in the form of a module or programme of modules.  They can also be tailored for different professional groups in training.  The topics and accompanying resources can also be used as a source for self-directed learning for example, logging your learning activities to meet CPD requirements in professional registration.

Teams can use the topics for peer and group supervision. Training providers can use the framework to underpin the core knowledge requirements for training on equality and diversity and map these to qualification frameworks. The framework is highly flexible and adaptable.  Whilst trans and non-binary affirmative care is embedded across all nineteen subjects, Subject 12 on page 62 outlines more specific consideration and additional guidance.  

The underpinning values of the framework concern person centred support informed by a lifecourse approach which recognises the circumstances, strengths, resilience, and cultures of an individual person, their families of choice, their advocates, friends, and community networks. Indeed, the learning framework and many of the resources signaled in the framework were co-produced and developed from research findings, and as a means of exchanging research knowledge with those in practice. The resources give particular emphasis to the personal stories and narratives of people with lived experience and are co-produced with LGBT+ older people and their advocates.  Pauline, one of the trans women involved, tells us what this meant to her personally:

Taking responsibility for learning collaboratively and in partnership with LGBTQ+ communities

As social workers, our values embody being sensitive to the assets older LGBTQ+ people and their networks already bring to their experience of care, the willingness to challenge and address inequalities based on sexual and gender identities and becoming confident is speaking out.  We must take responsibility for being familiar with how LGBTQ+ identities intersect with other inequalities and showing active commitment to LGBTQ+ advocacy, allyship and community support.

The framework offers us an opportunity to identify and articulate more systematically, key topics that should underpin best practices with LGBTQ+ older people and their carers in social care.  It helps to drills down to the specific issues, nuances, and differences to tailor support.

Whilst a framework can’t cover everything, it directs us as learners, educators, leaders, practitioners, providers, and commissioners in social care, to the essential knowledge, skills and values that help to underpin and enable better engagement with the delivery of more affirmative inclusive care for LGBTQ+ people in later life.  This is an ongoing conversation for continuous improvement and can be expanded and embedded further.  As we witness another celebration of the International Day of Transgender Visibility, let’s all make a conscious and active decision to listen to those voices embedded in the learning framework and commit to actions that recognise and champion equalities for gender diverse people in later life.

Having been active in developing and launching the framework, I will be continuing some work with Skills for Care to enable and encourage people to interact with the framework and evaluate its impact over the coming year.  I therefore welcome contact via trish.hafford-letchfield@strath.ac.uk if you want to find out more and/or discuss how your organisation or teams might use the framework to improve your services for LGBTQ+ adults. 

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