‘I don’t want to go back into the closet just because I need care’: recognition of older LGBTQ adults in relation to future care needs

ABSTRACT

There is increasing awareness in research about the social service needs of older LGBTQ adults. However, there are few studies that deal with differences in this community regarding elder care services. As a rule, transgender individuals are not included in these studies. This study focuses on how older Swedish LGBTQ adults reason about openness in an elder care context concerning their future needs for services and adopts Nancy Fraser’s theoretical framework of recognition. The material consists of fifteen semi-structured interviews with older LGBTQ adults. The results indicate that the main concern for older LGBTQ individuals is being accepted for their preferred sexual orientation and/or gender identity in elder care. However, there were differences regarding that concern in this LGBTQ group. There were also a variety of approaches in the group as to preferences for equal versus special treatment with respect to their LGBTQ identity. In addition, there were differences as to whether they prefer to live in LGBTQ housing or not. The findings contribute to existing knowledge by highlighting the diverse views on elder care services in both this group of interviewees and its subgroups. These findings emphasise the importance of the social work practice recognising different preferences and having an accepting approach. The results can further provide guidance on how to design elder care services for older LGBTQ adults.

ABSTRAKT

Inom forskningen finns idag en ökad medvetenhet om HBTQ-äldres behov av äldreomsorgsinsatser. Få studier har hittills belyst skillnader inom gruppen gällande önskemål av framtida insatser från äldreomsorgen. I dessa studier är transpersoner ofta inte inkluderade. Föreliggande studie fokuserar på hur svenska äldre HBTQ-personer ser på öppenhet i ett framtida äldreomsorgsammanhang samt hur detta relaterar till önskningar om behov av insatser. Studien utgår från Nancy Frasers teoretiska resonemang om erkännande. Materialet består av femton semi-strukturerade intervjuer med HBTQ-äldre. Resultaten visar att de flesta äldre HBTQ-personerna vill bli accepterade för den egna sexuella läggningen och könsidentiteten/könsuttrycket i ett framtida äldreomsorgssammanhang. Hur denna önskan ser ut skilde sig dock åt inom HBTQ-gruppen. Det fanns också olika uppfattningar om man huvudsakligen föredrar likabehandling eller om man istället vill att särskild hänsyn ska tas till den egna HBTQ-identiteten. Även inställning till huruvida man föredrar att bo på ett HBTQ-boende eller inte delade gruppen av intervjuade. Resultaten bidrar till existerande forskning om äldre HBTQ-personer genom att synliggöra de skillnader som finns inom gruppen gällande inställning till att använda framtida äldreomsorgsinsatser. Vidare påvisar resultaten vikten av att det sociala arbetet har ett öppet och erkännande förhållningssätt för olika preferenser. Resultaten kan vidare bidra till vägledning kring hur man utformar äldreomsorgsinsatser för HBTQ-äldre.

KEYWORDS:

• LGBTQ
• older adults
• elder care
• gender/sexuality
• social work

NYCKELORD:

• HBTQ
• äldre personer
• äldreomsorg
• genus/sexualitet
• socialt arbete

Introduction

Older LGBTQ¹ individuals are rather invisible in society in general and in the debate about elder care in particular. Their invisibility in elder care is due to their experience of discrimination but also to the prevailing heteronormativity in healthcare and social services (Addis, Davies, Greene, MacBride-Stewart, & Shepherd, 2009; Brotman, Ryan, & Cormier, 2003). There are also inequalities in the health status of older LGBTQ adults compared to non-LGBTQ adults since there is a greater likelihood that this group has poor health status, with problems such as depression (Fredriksen-Goldsen et al., 2013; Fredriksen-Goldsen et al., 2014). The concept of minority stress is used in describing unique stressors that can have an adverse effect on the health of LGBTQ individuals and also older LGBTQ adults, such as experience of discrimination or victimisation, internalised stigma or concealment of sexual orientation/gender identity (see Hoy-Ellis & Fredriksen-Goldsen, 2016, 2017; Meyer, 2003).

Several studies highlight how social policy and social work practice should work to challenge oppression and how older LGBT adults should be included more in healthcare and social services (Concannon, 2009; Hughes, Harold, & Boyer, 2011). According to Gratwick, Jihanian, Holloway, Sanchez, and Sullivan (2014), this is a question that needs increased visibility; social work should strive to equalise the services provided for this group. It is therefore important to investigate how older LGBTQ adults reason about future services when they enter elder care. It is also an essential question for shedding light on within social work research.

Research on the views and opinions of older LGBTQ adults concerning elder care

Older LGBTQ adults, besides being older, also have a previous history of marginalisation that affects the group. Studies highlight the importance of enabling older LGBTQ adults to be open and be themselves in an elder care context (Brotman et al., 2003; Jihanian, 2013). Other issues are the need for elder care providers to be LGBTQ-welcoming, for example, by having staff use inclusive terminology (Simpson, Almack, & Walthery, 2016: Hughes, 2007), demonstrating knowledge about LGBTQ issues (Croghan, Moone, & Olson, 2015; Willis, Maegusuku-Hewett, Raithby, & Miles, 2016) and recognising same-sex relationships (McFarland & Sanders, 2003; Croghan et al., 2015; Hughes, 2009). Croghan et al. (2015) examined what LGBT seniors consider to be signals that elder care providers are LGBT-inclusive, which were primarily associated with the staff’s behaviour. McFarland and Sanders (2003) also highlight how older lesbians and gay men wanted social workers to have more knowledge about LGBT issues.

Although previous research has shed light primarily on the invisibility of older LGBT individuals, Leyerzapf, Visse, De Beer, and Abma (2016) note that heteronormativity not only puts LGBT individuals at risk of being invisible, it can lead to them being excessively visible, with too much focus on their LGBT identity. Several international studies stress that LGBTQ individuals in need of healthcare and elder care are concerned about having to hide their LGBTQ identity due to a fear of disclosure (Brotman et al., 2003; Gardner, de Vries, & Mockus, 2014; Stein, Beckerman, & Sherman, 2010).

Age is seen as one factor in their openness, with older LGBTQ adults apparently less likely to be open than younger ones. Younger individuals report being interested in using LGBT-friendly or LGBT-specialised services to a greater extent than older LGBT adults (Gardner et al., 2014; Jenkins-Morales, King, Hiler, Coopwood, & Wayland, 2013). The issue of services tailored to the LGB population, for example special LGB housing, is another theme in research (see for example Westwood, 2016), with studies showing that older LGBTQ adults prefer LGBTQ-targeted or LGBTQ-friendly services to mainstream ones (Gardner et al., 2014; Stein et al., 2010). Sullivan (2014) have shown that LGBT seniors in special housing expanded their social network. Some experienced meaningful social relationships for the first time and described having created family-like relationships with other residents (ibid.). Studies also highlight the importance of mixed groups in elder care in order to challenge stereotyping and heteronormativity (Leyerzapf, Visse, De Beer, & Abma (2016). Leyerzapf, Visse, De Beer, and Abma (2016) believe that separate LGBT activities are important, but they also emphasise that this can lead to increased segregation.

LGBTQ individuals but not as much on treatment preferences or specific services such as how personal care could be performed by staff in an elder care context. The interest has been in understanding how previous experiences of discrimination and marginalisation still affect older LGBTQ adults, which leads to concerns when they need care or social services. Instead of talking more generally about acceptance, which has been the case in previous research, in this article we use Fraser’s theoretical framework of recognition. This enables us to analyze how interviewees consider their future situation in elder care and how they are to be included and achieve recognition in these settings. Focusing on recognition also allows us to discern differences and similarities in the LGTBQ group interviewed regarding how they want this to be achieved in terms of their preferences in a future elder care setting. Despite increased interest in identifying similarities and differences in views about elder care, research has not focused specifically on the LGBTQ community as a whole. This article therefore aims to provide an understanding of what older LGBTQ adults consider important aspects to promote recognition and inclusion on equal terms as those of other older adults in a future elder care context.

Theoretical framework

We consider Nancy Frazer’s status model of recognition to be particularly valuable in understanding how older LGBTQ adults formulate claims. Fraser argues that equal participation is the basis for understanding issues concerning justice, and creating participatory parity is the most crucial element for her (Fraser, 2000). She distinguishes between inequalities based on the socio-economic structure and those due to cultural value structures in dealing with issues concerning redistribution for the former and recognition for the latter. She stresses the importance of understanding that these inequalities are closely intertwined in reality and that both dimensions should be taken into account² (Fraser, 2007, 2011). However, in this article we will focus only on recognition. Recognition is seen as a solution to cultural inequalities and she stresses the importance of recognising misrecognised identities and changing cultural value systems to enable all individuals to participate in social interaction on equal grounds (Fraser, 2000, 2007). According to Fraser, there is a risk of emphasising minority cultures as a counterweight to the dominant culture, which puts pressure on members to adapt to a group culture identity. This can lead to consolidating stereotypes for minority group identities and result in an increased risk of misrecognition (Fraser, 2000). Fraser argues that redistribution or recognition refers to the empirical phenomenon and the category in focus. The category of class mainly refers to redistribution while the category of sexuality instead mainly refers to recognition. The categories of gender and ethnicity refer to both redistribution and recognition (Fraser, 2007). We argue that Fraser's concept of recognition can be used to study how older LGBTQ adults formulate their claims in an elder care context with respect to perceived wishes of service needs. According to Fraser, there are two solutions to deal with inequalities. Affirmation involves strategies that do not affect existing structures, as opposed to transformation, which is also aimed at changing underlying structures (Fraser, 2011). One affirmative solution for homophobia is a homosexual identity politics that enhances the homosexual identity, while one transformative solution, according to Fraser, is queer politics, since it strives to deconstruct the categories of homosexuality/heterosexuality (Fraser, 2003). An identity politics with respect to homosexuality results in increased differentiation between groups, whereas queer politics destabilises differentiation. In other words, differences between groups are reinforced through affirmation, while differences between groups are counteracted through transformation (ibid). Fraser’s concepts of affirmation and transformation will therefore be used to interpret arguments and to understand the variety of claims put forth.

Method

The empirical data consist of 15 semi-structured interviews with adults 65 years and older who identify as LGBTQ.³ The interviewees lived at home and two of them had previous experience with elder care services. Three lived in an LGBT senior housing facility. The first author conducted the interviews.⁴ The interviews lasted between 45 minutes and 2 hours and 20 minutes and comprised four different themes.⁵ The interview guide consisted of open questions which resulted in differences in the length of the interviewees’ answers. Of the 15 older adults who participated, five were bisexual/lesbian women, five were bisexual/gay men⁶ and five identified themselves as transgender.⁷ The interviewees lived in large and medium-sized cities in both the north and south of Sweden and were born between 1939 and 1950.

In order to reach interviewees, contact was made via several channels: pensioneŕs organisations; LGBTQ organisations, including organisations for older LGBTQ adults;⁸ one LGBT senior housing facility; and LGBT-certified retirement homes/home care services. The first author also recruited some interviewees through a Pride festival. Information about the project was also spread via organisations’ websites. In addition, a snowball sampling procedure was used, where interviewees were asked for further recommendations of potential participants (Silverman, 2005).

Hyden (2014) mentions that interview situations should be seen as a process created between the researcher and interviewee. Although the interviews conducted were semi-structured, the interview guide was used rather flexibly. There was room for the discussion to take other turns during the interview, based on what was brought up in the conversation. The interviewees chose the location for the interviews, which took place in their home or in cafés, libraries and park settings. The interviews were recorded and all of them were transcribed by the first author. As a method of analysis, a thematic approach has been used to identify themes and patterns in the material, but also to make interpretations of the material (Braun & Clarke, 2006).

In the first phase, all of the interviews were read through carefully a number of times. Data processing and encoding of the material were carried out in NVivo. All of the material was divided into different text segments and given specific codes in NVivo. After the sorting process, the analysing process entailed manually recognising themes that could be identified from the codes. In this phase, some codes were also decoded into more suitable ones. Braun and Clarke (2006) argue that a theme must be relevant in relation to the aim of the study, contain meaning and recur in the material – requirements that guided us in this phase. The subsequent process of analysis focused on reviewing the themes identified in relation to how well they fit the data set and the overall aim. This process also included discussions about whether themes should be split or merged. In the work to evaluate themes, we used peer-debriefing sessions in which both authors interpreted the material individually and then met to compare understandings of the material (Creswell, 2000). The peer-debriefing procedures were used to achieve increased reliability in the analysis.

For the presentation in the findings section, interviewees were anonymized and given fictitious names. The differences acknowledged in the findings section below mainly concern differences between older transgender and LGB adults since there were too few bisexuals in the material to distinguish between homosexuals and bisexuals.⁹ Nor could we discern any clear differences between lesbians and bisexual women or between homosexual and bisexual men, which could be a result of the small sample size. However, this classification may seem reasonable because one concerns sexual orientation, the other the desired gender expression, which is one distinctive difference between them.

Findings

The following section presents the findings for the three different themes that emerged in the material. First, the theme of openness and recognition is introduced, since this was the most prominent theme in the interviews. The second theme concerns how the interviewees expressed their desires for the way they want to be responded to socially and behaviourally in an elder care context and the need for knowledge about LGBTQ issues. The third and final theme describes the issue of dedicated LGBTQ housing. All three themes highlight the interviewees’ perceptions and descriptions in relation to recognition of these issues. The analysis is illustrated by quotes that best describe their particular view and reasoning. As a result, not all of the LGBTQ group will be represented equally in each section.

Openness and recognition

In the interviews, there is a shared view that everyone wants to be recognised and accepted for their own identity in an elder care context, but there are differences in what is considered important in reaching this goal. Attitudes among the interviewees varied in terms of how much attention they want paid to their identity and how open they want to be in different social settings. One fact that probably affects their attitude and view of openness may be how visible they are with their LGBTQ identity. Transgender individuals are often more visible (if they do not pass using the preferred gender expression) than LGB individuals, and this leads to differences in whether individuals themselves can decide to be open or not. The transgender individuals noted to a greater extent that they need to stand up for themselves and this could be one reason for their position. Older LGB adults instead indicated the importance of being able to talk about themselves, including important aspects that concern their sexuality, and of not assuming that everyone is heterosexual. One interviewee said that she would be careful and choose a staff member who seems trustworthy before deciding to be open:

I suspect that in any case you have to sound people out a little before you start talking about how you live. That’s what I feel. And that you don’t. I’m the kind of person who’s cautious but then if I were to seek help and things like that, then I wouldn’t say anything the first day. I wouldn’t do that but would instead get a sense of the atmosphere and pick out someone who seems like level-headed and would take it well and all. (Agneta, lesbian, born in 1945)

This excerpt shows the difficulty that older LGBTQ adults may experience if or when they disclose their LGBTQ identity. The lack of implementation of LGBTQ issues in elder care practice in general could lead to older LGBTQ adults feeling that they have to rely solely on individual employees to treat them in competent and affirmative ways, which could lead to uncertainty and insecurity, as we see in the example above.

In the interviews, it appears that being recognised in one’s LGBTQ identity in an elder care context is relevant in some cases but not others. Some of the interviewees have been open for a long time, while others have had more difficulties with this. This probably affects how comfortable individuals are with being open and in what contexts. Although the interviewees expressed different views about being open, they either implicitly or more explicitly addressed the connection to heteronormative and gender-binary norms. For issues related to openness and acceptance, a key concern is to not make individuals who deviate from heteronormativity or gender-binary norms invisible. This could also be understood in terms of Fraser’s ideas of recognising misrecognised identities (see for example Fraser, 2003). As Fraser emphasises, it is important to foster cultural values that enable all individuals to be seen as equal participants in social interaction. We understand the interviewees’ statements as they long to feel included in elder care and have all issues, questions and experiences be considered equally important.

One of the interviewees considered the possibility of being open about one’s personal life story as an older LGBTQ adult:

Most people agree today about it one way or another. And that you open up in a good way to take an honest life-story, a history from that person. It’s a pretty big thing to bring up that you’ve lived life as a lesbian and your real experiences, right. And to deal with someone based on that too. With total respect, I think that’s also important. (Elisabeth, lesbian, born in 1941)

The example above illustrates how important the interviewee considers it to enable older adults to talk about life stories that do not follow heteronormativity. She stresses the importance of staff being comfortable talking about these topics with older adults, thus capturing the real stories about how people have lived their lives. The interviewees also mentioned concrete measures that would promote this welcoming, inclusive environment and encourage individuals to be open. Using Fraser’s (2000) theory, we can understand this in terms of dismissing cultural value systems that do not lead to equality in elder care. One first step to change the cultural value system and ensure equality would involve placing these issues on the agenda. For example, having visual markers and using language in a more affirmative way can help challenge heteronormativity and CIS norms and make elder care settings more inclusive for older LGBTQ adults.¹⁰

Preferences regarding how to be treated in elder care

Another theme highlighted by the interviewees was how they want to be treated in an elder care context. There were different views discernible in terms of their preferred desires for the staff’s responses. Some of the interviewees¹¹ emphasised that they consider equal treatment problematic and instead want attention paid to their specificity. The person below talks about what is important in treating LGBTQ individuals in elder care:

Yeah, but you try to see each person as an individual and try to put yourself in their situation. And it’s obviously difficult if you don’t have enough staff and things like that. But you can have a vision that people should show consideration to each and every one. We’re all individuals and we’re all different. You have to show consideration to everyone. And some people need to act or think in one way. And other people think in another way. And that means you can’t treat everyone the same because it’s wrong somehow. I don’t know if it’s difficult. But obviously it’s these ways of thinking that you can at least have a discussion about in this kind of group working with older people so that everyone is aware somehow. And then if it works in practice. It could work sometimes, sometimes not. But you somehow have that idea. (Agneta, lesbian, born in 1945)

As we see in the example above, this person emphasises the importance of understanding that LGBTQ individuals can be different from non-LGBTQ individuals. Arguments supporting treatment based on an ideology of differences stress that there are the problems with treating everyone equally. Instead, what is brought up in the interviews is that particular attention should be paid to the qualities of individuals, their LGBTQ identity and unique life story. As Simpson et al. (2016) highlight, the idea of treating everyone the same has some negative consequences since this leads to inequality and exclusion when a heteronormative and CIS-gender norm is assumed. Implicit in the arguments in the interviews favouring this view is the risk of making LGBTQ adults invisible when the issue is not specifically addressed. The excerpt above can be understood in line with Fraser’s (2003) concept of affirmation. We see how the interviewees highlight the importance of addressing specific qualities in the identities of different individuals. But this can also be understood as emphasising how all different aspects of identity should be recognised and accepted.

In the interviews, there are also arguments in favour of equal treatment.¹² Interviewees stressed that they want to be treated like everyone else and without too much focus on their LGBTQ identity. Below is an example in which the interviewee talks about the subject of equal treatment:

And if they ask, they’re not hurting any one’s feelings. A polite question is always OK, right. And that of course means I care and I want this to be as good as possible. But you can’t say that. I don’t know anything about this – you can teach me. They’re not allowed. We’re so tired of instructing people who are going to take care of us. Not so that they don’t ask but what do you want us to do so that it can work. That’s the question they should ask if they’re uncertain – nothing more than that. We don’t come from another planet. We’re normal people and just happen to have this little extra thing. (Lena, transgender, born in 1939)

In this example, the interviewee expressed the opinion that LGBTQ individuals should be dealt with and treated like everyone else. Throughout the interviews, similar arguments were presented – how individuals wanted to be themselves but that it should not involve anything other than respect for their individuality. As for the interviewees’ views about equal or preferential treatment, on the question of how they want to be addressed it was not possible to clearly distinguish a particular subgroup within this LGBTQ group that preferred one approach or the other. However, in the case of the older transgender adults interviewed, they may have expressed stronger support for equal treatment argument in their communication. This could be discussed in relation to Fraser’s (2003) transformative solution to cultural inequality since that could be connected to the interviewees who said they preferred equal treatment. They want to be themselves but not have to act in line with heteronormativity or gender binarism. They are instead interested in questioning and destabilising binaries associated with sexuality and gender since they want more room for flexibility in distinctions such as homosexuality/heterosexuality and CIS gender/transgender. The latent meaning can be seen to deconstruct distinctions altogether.

The common attitude expressed in the interviews is that respecting personal integrity and individuality is important, whether it is a matter of sexuality or gender expression/gender identity, regardless of whether that person wants equal treatment or not. Respect and acceptance of one’s individuality are given particular prominence, and one way to achieve this, which is noted in the interviews, is through education on these issues. Below is an example of this:

Yeah, that I am treated with respect. And that they know what I want. That they understand how I want it. And I naturally respond by treating them with respect as well. Respect is the most important thing, I think. And that they’re familiar with this. That they’re familiar with the fact that they have to be LGBTQ-certified if they’re going to the home of someone who is LGBTQ. They should know what they’re doing. They should know what … how a person like that works and why. There’s a lot of stigma and different things, for instance, if someone is infected with AIDS or something where there’s a lot of stigma in this. (Gösta, gay man, born in 1940)

The interviewees noted that increased knowledge¹³ about LGBTQ issues is crucial for contributing to increased visibility for LGBTQ individuals in an elder care context and for creating a good response when LGBTQ adults enter elder care. LGBTQ certification provided by the Swedish Federation for Lesbian, Gay, Bisexual, Transgender and Queer Rights¹⁴ is also mentioned as something positive. However, this entails problems, which the interviewees noted, since the process is costly and everyone working in human service professions needs training on LGBTQ issues. Regardless of how people learn about these matters, the interviewees want increased understanding about what may be particularly important to take into account in dealing with LGBTQ individuals.

LGBTQ housing

In the interviews, different opinions were expressed concerning the question of whether older LGBTQ adults prefer LGBTQ housing or not when they are in need of elder care.¹⁵ At first glance, there do not appear to be any sharp divisions in the LGBTQ group between those who prefer special housing or not. However, the transgender people are interested in LGBTQ housing to a slightly lesser extent, since they more clearly expressed in their arguments why they preferred not to live in such accommodations. The older LGB adults who want to live in specialist LGBTQ housing were primarily the ones who were single. Here is an example of an interviewee who currently lives in senior housing for LGBT individuals and explains why he prefers this accommodation:

Yes, my background and what I went through in the 60s and how I was treated by my father. And how people viewed things then. Also maybe that I. There were a lot of things. We don’t all socialize together, but you meet people here and you have some people you talk with about things. They’ve been through similar things. Many of the people who live here today were young in the 60s, 50s, 60s or 70s. So then you’ve experienced similar things. And you can also talk about that. (Gösta, gay man, born in 1940)

For this person, it is important to feel a sense of belonging to others, he feels connected to and to share similar memories with them. The example highlights how older LGBTQ adults can feel a need to be with people like themselves, who have lived a life not in line with societal norms of heteronormativity. Three of the interviewees currently live in senior housing for LGBT individuals, and it emerged in the interviews that this can make it easier to be open and be one’s self. For one of them, it was the first time in his life that he could be open about his sexual identity. Another of the interviewees finds it convenient to live in LGBT housing because there is no need to come out as an LGBTQ person to other residents. The interviewees’ reasons for why they want to stay in LGBTQ housing can be interpreted using Fraser’s (2003) concept of affirmation. There are ideas expressed about wanting to be with others like themselves, preferring a practice or politics that separates individuals from the majority group and instead staying in the LGBTQ community.

The interviewees not interested in special housing gave reasons such as everyone should be able to be who they are no matter where they live, or people do not want to be seen as deviant or abnormal. One of the interviewees who did not want to stay in special housing noted:

I think it’s really great that these LGBTQ accommodations exist but I think it’s wrong to bring everyone together in one place just because they’re LGBTQ. Instead I think everyone is entitled to be who they are anywhere, no matter what senior housing facility or nursing home or wherever you end up in so that they receive good care no matter what kind of place. But I wouldn’t prevent them from existing and I think it’s good that they’re available for people who want to live there. But I feel no desire to get in there. (Anne, transgender, born in 1949)

The example above illustrates someone who is not personally interested in living in special housing for older LGBTQ adults. She does not want to be put in special accommodations based on her LGBTQ identity but realises that others might prefer this. That sort of argument can be interpreted by means of Fraser’s concept of transformation (2003) since these individuals seem to strive more for inclusion in the majority group. These arguments question people’s preferences for housing options based on whatever group they belong to, for example, as a heterosexual or homosexual, a CIS person or transgender person. Instead, they want to deconstruct identity groups based on the distinctions homosexual/heterosexual and transperson/CIS person. It is worth noting that the interviews make clear that the attitude towards special housing is not a simple matter and that the issue has been given a great deal of consideration. Even individuals who are not interested in staying in such accommodations mention how it may be beneficial for some older adults to live in these kinds of accommodations.

Discussion

In this article, we have examined how older LGBTQ adults view future elder care services by focusing on differences and similarities in our LGBTQ group¹⁶ through Fraser’s lens of recognition and also by analysing how this can be accomplished from the interviewee’s point of view. The question of recognition is addressed in interviews since a common concern for all interviewees was that they wanted to be accepted for their identity. These findings correspond to results from other studies, which highlight the importance of acceptability (see for example McGovern, Brown, & Gasparro, 2016; Sullivan, 2014). The interviewees expressed ideas that could be understood as them wanting recognition for their individuality and their identity in a future elder care context, although this was expressed somewhat differently in the LGBTQ group. Older LGB adults emphasised how they want to be included and understood in terms of the way they had lived their life outside heteronormative conventions and to feel included in talking, for example, about previous experiences and same-sex partners. Transgender individuals want to be able to perform their gender in the way they prefer and with an understanding that they do not have to act according to gender binarism. To sum up, the older LGBTQ adults want elder care services that recognise and accept all aspects of their identity and, to use Fraser’s ideas, want cultural value systems in elder care not to make LGBTQ issues something that is invisible or deviant.

We have distinguished two different viewpoints, with some interviewees wanting equal treatment and others stressing the importance of understanding that one’s LGBTQ identity entails significant differences compared to that of non-LGBTQ individuals in an elder care setting. Previous research has not paid much attention to the issue of equal treatment. Cronin, Ward, Pugh, King, and Price (2011) notes that there is a tendency towards blind spots in healthcare and social work, of not noticing sexuality issues, with an underlying assumption that it is important to treat all older adults equally. The authors believe that this may increase inequalities between different older adults when differences are not taken into account. Examining the issue of equal treatment or special treatment based on Fraser's concepts of affirmation and transformation, we see that some individuals advocate the inclusion of the LGBTQ group in existing structures, while others instead argue that it is crucial to appreciate the distinctive characteristics of the group to a greater extent (Fraser, 2003). These two different approaches to changing cultural value systems lead to different consequences, but they both highlight the need to take these issues into account regardless of how that is achieved. The question of equal versus special treatment and the question of housing should also be understood based on how older LGBTQ adults perceive their belonging to the LGBTQ community more generally and also in a wider societal context. It is likewise important to understand the differences in views concerning whether individuals want changes made that comply with a queer politics that deconstructs structures and distinctions or that can result in reinforcing differences. But as Fraser also points out, in reality the outcomes of these two solutions are not as clear as they seem. Even if what Fraser calls strategic essentialism – in other words, an affirmative strategy – is used, in the long run this can result in transformative changes (ibid.). It is therefore possible to take affirmative steps in order to include minority groups, which could help to overcome differences between groups.

It is worth noting that, when the interviewees talked about differences in the LGBTQ community, they mainly talked about differences between transgender and LGB individuals. It is also noted in the interviews that the trans issue has been raised mostly in recent years and that there is not the same general awareness about transgender individuals. Most of the transgender individuals interviewed came out rather recently compared to the older LGB adults, which may affect their view on the subject. Trans issues have not been discussed to the same extent as issues relating to sexual orientation. According to Bailey (2012), transgendered individuals are increasingly visible due to changes in legislation and medical advances. The increased number of older transgender adults will probably also lead to greater demands for elder care to include this group. We furthermore think that it is crucial to understand the relationship that transgender individuals have to the LGBTQ community. It is likewise important to understand that different societal norms affect older LGBTQ individuals in various ways. Gender binarism and heteronormativity affect older LGBTQ individuals differently, including in how they perceive their opportunities for using elder care.

Implications for practice

Our study shows that there is nonetheless great diversity in the group of older LGBTQ adults as well as in different subgroups regarding recognition and how they believe services should be provided. These results are perhaps not surprising since there is a lack of knowledge among staff in elder care about issues concerning the recognition of special needs among different groups of older adults. This issue has been highlighted especially in research about staff members’ interpersonal encounters with older adults suffering from dementia (Baker et al., 2015; Hughes, Bagley, Reilly, Burns, & Challis, 2008). However, there is not much focus on sexuality and gender issues among different older groups. Some suggestions that could bring social work closer to achieving its task in developing services in the future for older LGBTQ adults are: Extending the research agenda in terms of both content and methodology to more comprehensively capture the entire LGBTQ community’s experience of services to meet elder care needs. Translating research findings into training programmes for staff in elder care needs to be built on knowledge about how to reduce minority stress – that is, how to enable all individuals to feel safe and welcomed to show all sides of their identity. These measures would promote the development and design of new options for specialised services in both specific and generalist elder care practice. This would hopefully further ensure that older LGBTQ adults can be included more and recognised as individuals in a social work context.

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes on contributors

Jenny Löf is a Ph.D. Candidate in Social Work at the Department of Social and Welfare Studies at the University of Linköping Sweden. Her research focuses on LGBTQ-questions within the social work sector and more specifically the inclusion of older LGBTQ-adults in eldercare. Furthermore she is interested in how older LGBTQ-adults observe and construct themselves in relation to the societal context. Other areas of interests are related to gender theory, queer theory and intersectionality.

Anna Olaison is an Assistant Professor in Social Work at CESAR Centre for Social Work, Uppsala University, Uppsala and the Department of Social and Welfare Studies at the University of Linköping Sweden. Her research concerns institutional interaction between the welfare state and citizens in social care services. Recent work has concentrated on social workers’ documentation practices as well as needs assessment practice involving people with dementia. Her interests also include questions concerning the impact of social policies on communities and services for older people.

Notes

1 We use this acronym in the findings section when we talk about the group as a whole, which also correlates with the empirical material since the majority of interviewees talk about LGBTQ issues. One person also sympathises with queer as an identity, namely the idea of a non-binary, fluid identity construction. When we refer to other studies more generally, we will also use the same acronym. However, if we refer to specific studies, we will use the same acronym that the authors have used.

2 She also develops a third level, the political dimension in which she talks about representation (Fraser, 2011).

3 This study has been reviewed and approved by a Swedish Regional Ethics Committee (doc. no. 2016/125-31).

4 The first author has prior experience from participation in the LGBTQ community, however this was not addressed in the majority of interviews. It might however lead to an increased pre-understanding of terminology and knowledge about the community.

5 The interviews addressed four different themes: the first was about everyday life and aging, the second was about social attitudes and norms; the third concerned the issue of elder care and the fourth concerned social relations and networks.

6 They were all CIS-women/CIS-men.

7 All of them were designated male at birth. Trans-identities included transvestites, transsexuals and also more fluid trans- identities. One of them identified also as a lesbian.

8 Gayseniorerna, Golden Ladies and HBT-seniorerna.

9 One of the women identified as bisexual. Two men said they were a mix of bisexual and homosexual.

10 There are initiatives trying to improve the inclusion of older LGBTQ adults in elder care for example the Pink Passkey in Netherlands. This is a certification that elder care providers can undergo to ensure to be LGBTQ-friendly and is symbolised with a pink key (Roze50plus.nl, 2018).

11 Six of the people interviewed expressed views in line with the argument above; four of them were LGB – two women and two men – and two identified as transgender.

12 Seven interviewees emphasise such an attitude – two of the bisexual/lesbian women, two of the bisexual/gay men and three of the transgender individuals. In two of the interviews it is not possible to determine whether the interviewees would opt for equal or preferential treatment.

13 In 13 of the 15 interviews, it is mentioned that greater knowledge is needed in elder care to gain understanding and to eliminate stigma, discrimination and negative attitudes. Of the two interviewees who did not mention this, both identified as LGB, one man and one woman.

14 RFSL started issuing LGBTQ certificates in 2008. Organisations and companies in the private and public sectors complete the certification process especially to educate and inform people about LGBTQ lives and how LGBTQ individuals are affected by societal norms, while also addressing various grounds for discrimination (RFSL, 2016).

15 Nine of the interviewees emphasised that they want to live in specialist LGBTQ accommodation because they could understand the feeling of belonging to a community, share the same experiences and feel safer. One of the interviewees said he would like to live in such accommodation if he was single which he was not at the time for the interview. Five of the interviewees noted that they were not interested in staying in special accommodations. Of these, two were older transgender adults, two identified as bisexual/lesbian women and one identified as a bisexual/gay man. One of the transgender individuals expressed an interest in housing specifically for older transgender adults, while the other transgender person favouring such housing was also a lesbian.

16 Some of the limitations of the study is the relatively small sample-size, with only a few representatives from each subgroup in this LGBTQ group. This means that if we have had more material, we may have been able to identify clearer patterns in the variations or similarities observed. Another major limitation in the study was that no individuals identified as transmasculine.