The Perspectives and Experiences of Older LGBTI+ Adults About Long-Term Care: A Qualitative Systematic Review and Meta-Synthesis

Abstract

Background and Objectives

LGBTI+ older adults have experienced historical and systemic discrimination. Such discrimination has led to health inequities and avoidance of services. As LGBTI+ people age, they may need to access services, but information about this experience is situated in small-scale qualitative studies. As such this meta-synthesis aimed to bring together the perspectives and experiences of LGBTI+ older adults in literature about engagement with long-term care services.

Research Design and Methods

A meta-synthesis with a meta-ethnographic approach was conducted with qualitative published and gray literature. Findings were then confirmed through community consultation conducted with LGBTI+ adults aged 50+

Results

A total of 55 qualitative studies were included in the meta-synthesis. LGBTI+ older adults’ perspectives and experiences were synthesized into 4 key themes: (1) We see it as being heterosexualized, (2) With no one there to guard us, (3) You have to hide 90% of yourself, and (4) I don’t want a different service, I want a good service.

Discussion and Implications

Overarching heterosexism, experiences of discrimination, and complexities in maintaining identity all contributed to a predominately negative experience for LGBTI+ adults when engaging with long-term care. These experiences were found to align with “minority stress” theory. Our review found that a multilevel approach that included staff education, LGBTI+ affirmative care, and signs and symbols of inclusivity was required to reduce the impact of minority stress experienced by LGBTI+ older adults and to increase their engagement in long-term care services.

Our aging population presents unique challenges to health and long-term care systems. Populations living longer, with concurrent growth of health needs, increase the demand for long-term services (Australian Institute of Health and Welfare, 2022). Despite a lack of large-scale demographic data on the population of older adults who identify as Lesbian, Gay, Bisexual, Transgender, and Intersex (LGBTI+), it can be inferred that the LGBTI+ older population will also increase (Australian Institute of Health and Welfare, 2021). Long-term care is historically an environment that favors the heterosexual experience (Webb & Elphick, 2017), and currently most care institutions for older adults are run by faith-based organizations with histories of rejection of LGBTI+ individuals (Stinchcombe et al., 2017).

Older adults have reservations about receiving long-term care, due to concerns about loss of independence, quality of care, and institutionalization (Simpson et al., 2018). These reservations are magnified for LGBTI+ older adults who have a history of discrimination and abuse (Fredriksen-Goldsen et al., 2017; Fredriksen-Goldsen et al., 2023), especially by government, religious, and health care institutions. These damaging experiences included having their sexuality criminalized and pathologized (Webb & Elphick, 2017). In particular, homosexuality was considered a mental illness in the Diagnostic and Statistical Manual of Mental Disorders (DSM) (McHenry, 2022). In 1973, homosexuality was removed from the DSM; however, law reform was slow to follow with homosexuality remaining illegal in Australia until 1994 (Human Rights [Sexual conduct] Act 1994) and until 2003 in the United States (Kennedy et. al, 2003). Today, LGBTI+ individuals are more likely to experience mental and physical illness and financial hardship as they age (Crenitte et al., 2023; Fredriksen-Goldsen et al., 2012; Singleton et al., 2021). Furthermore, LGBTI+ older adults are more likely to lack familial supports, being more dependent on “family of choice” who are often comprised of peers also experiencing health and age-related changes (Ismail et al., 2020; Waling et al., 2022).

LGBTI+ people are often excluded in long-term care planning and service delivery (Peisah et al., 2018). The compounding effects of exclusion and previous trauma render the LGBTI+ population reluctant to engage with long-term care services or disclose their sexuality to providers (Alba et al., 2021; Kittle et al., 2022; Selix et al., 2020), making their LGBTI+ identity invisible in old age (Peisah et al., 2018). Such exclusion is problematic as LGBTI+ older adults not only experience health inequities but are more likely to require formal supports (Fredriksen-Goldsen et al., 2023). This systemic experience is best understood through Meyer’s (2003) minority stress theory which hypothesizes that sexual and gender minority groups will experience unique social stressors, particularly when exposed to heteronormative services. Minority stress has also been found to be compounded in the presence of intersecting vulnerabilities, such as ageism (Detwiler et al., 2022). The intersecting complexities of aging, being a minority group, reduced informal supports, and an inability to feel safe accessing care, is a reality for many LGBTI+ older adults, as such more support for this population is required.

To date, there has been no review to synthesize the qualitative literature exploring how LGBTI+ older adults have viewed and experienced long-term care. Therefore, this meta-synthesis aimed to answer the following question: What are the perspectives and experiences of LGBTI+ older adults about engagement with long-term care systems and services?

Method

Study Design

A meta-synthesis using a meta-ethnographic approach was conducted. The review was registered with PROSPERO (CRD42023431894). The protocol followed the eMERGE reporting guidance (France et al., 2019) as recommended by Cochrane (Noyes et al., 2022) and the PRISMA for systematic reviews (Moher et al., 2009).

Search Strategy

The search strategy was developed utilizing the SPIDER framework (Table 1) (Cooke et al., 2012). Search terms were developed by the first author (S. McMullen-Roach) in consultation with an academic librarian (see Supplementary Material Section 1). An initial search was conducted in Medline and then adapted for application to other databases. Seven databases were searched including Medline, CINAHL, PsycINFO, EMBASE, Emcare, Sociological Abstracts, and Scopus on June 6, 2023, and updated on May 9, 2024. To avoid publication bias, gray literature was included and identified through Google and Google Scholar searches (first 10 pages), and organizational, thesis, and government websites. Forward and backward citation was utilized for relevant reviews. Gray literature searching initially occurred between June 28, 2023 and September 29, 2023 and updated between May 9, 2024 and May 13, 2024.

Table 1.

SPIDER: Study Framework

(S) Sample	Older adults: 50 years+ who identify as lesbian, gay, bisexual, transgender, intersex, gender diverse, and/or asexual
(PI) Phenomenon of Interest	Engagement with aged care systems and services
(D) Study Design	Qualitative studies with any research methodology
(E) Evaluation	Views and experiences of aged care systems and aged care services
(R) Research Type	Qualitative or mixed methods where qualitative data can be independently extracted

Inclusion/Exclusion Criteria

Qualitative studies of any design were included. Studies with a mixed-method approach were included when qualitative data could be extracted. The inclusion and exclusion criteria are available in Table 2. When studies had some participants that met the inclusion criteria, then only the eligible data were extracted.

Table 2.

Inclusion and Exclusion Criteria

Inclusion criteria	Exclusion criteria
Qualitative or mixed methodology is used where qualitative findings can be extracted.	Quantitative methodology is used.
	Participants are aged <50 years
Participants are aged 50+	Participants do not identify as LGBTI+ or cannot be identified as LGBTI+
Where participants are of various ages, the data for those of 50+ can be separated.
	Perspectives of care providers
Participants identify as LGBTI+	Phenomenon is health care:
Phenomenon is aged care systems and services:	Acute health care
Community care	Hospitalization
Respite care	STI/sexual health
Aging at home	Study is written in a language other than English.
Home care services	Study is a review of literature.
Assisted living
Residential facilitates
Community health services
Adult day care
Convalescence home
Study is written in English
Any year of publication

Notes: LGBTI+ = Lesbian, Gay, Bisexual, Transgender, and Intersex; STI = sexually transmitted infection.

Study Selection

Results were imported into Endnote for de-duplication and then exported to Covidence for further duplicate removal. All citations were screened independently at title and abstract level by the lead author (S. McMullen-Roach) and one other author (C. Murray/S. Kumar), with the same process followed for review of the full-text articles. In instances where consensus was not reached, the decision was made by a third reviewer (C. Murray/S. Kumar).

Critical Appraisal

Included studies were critically appraised using the McMaster qualitative review form (Letts et al., 2007). A sample of 20 studies was appraised in duplicate by S. McMullen-Roach and C. Murray/S. Kumar. Discussions were held to identify discrepancies and guide decisions about the interpretation and thresholds for appraisal scoring. Once consistent standards were set, SMR appraised the remaining studies in consultation with C. Murray/S. Kumar.

Data Extraction

Data were extracted in two phases. In both instances, a data extraction tool was piloted and amended following extraction of a sample of 20 studies in duplicate by S. McMullen-Roach and C. Murray/S. Kumar. S. McMullen-Roach completed remaining extraction in consultation with C. Murray/S. Kumar. Initially extraction included the study characteristics and then study findings (see Figure 1).

Figure 1.

Data synthesis. LGBTI+ = Lesbian, Gay, Bisexual, Transgender, and Intersex.

Data Synthesis

The data synthesis followed Noblit and Hare’s (1988) seven-step method for conducting a meta-ethnographic synthesis (France et al., 2019). Steps 1 and 2, as identified in Figure 1, included the rationale and study selection process. Step 3 (Figure 1) enabled the extraction of first- and second-order constructs from the full primary studies; following this, the research team collaborated to identify how concepts were related within studies (Step 4), before reviewing how the studies translated into one another (Step 5). The process of translation incorporated both reciprocal (similar) and refutational (opposite) data, where the findings across multiple studies were able to be brought together to represent one concept. These concepts were then grouped by S. McMullen-Roach, C. Murray, and S. Kumar. Once this was completed, S. McMullen-Roach developed third-order concepts (Step 6), using concept maps, which were discussed and worked on collaboratively by the entire research team. Context, participant groups, and study aims were all considered within this process. The concept maps led to the development of initial themes and subthemes, which were discussed, modified, and re-created. Regular discussions were held with the research team and SMR kept a reflexive journal of decisions made and reasons for the decisions. Themes were further refined, and then Stage 7 (expressing the synthesis) was completed by means of a community consultation (Cahill et al., 2018). See Supplementary Material Section 2 for full details on community consultation.

Findings

Search Outcomes

There were 2,113 studies screened at title and abstract level in the initial search conducted in June 2023. After full-text screening, 51 studies remained. The updated search in May 2024 identified four studies (three from database and one from Google). In total, 55 studies were included in the review. Reasons for exclusion and sources of literature are identified in Figure 2. In two instances, research outputs were reported in duplicate as a publication (Dunkle, 2018b; Gabrielson, 2011) and a thesis (Dunkle, 2018a; Gabrielson, 2009); these studies were counted as a single study for the purposes of the review.

Figure 2.

PRISMA flow diagram.

Study Characteristics

Fifty-five (N = 55) studies were included from 11 countries, including United States (n = 18), Australia (n = 11), Canada (n = 9), United Kingdom (n = 6), Ireland (n = 2), the Netherlands (n = 2), Sweden (n =2), Sri Lanka (n = 1), Taiwan (n = 1), South Africa (n = 1), New Zealand (n = 1), and a collaboration between New Zealand, United Kingdom, Australia, and United States (n = 1) (Table 3). Studies were published between 2007 and 2024. The studies included over 3,072 LGBTI+ identifying older adults aged between 50 and 92 years. Studies that included lesbian, gay, bisexual, and transgender participants were the majority (n = 17), followed by lesbian and gay participants only (n = 11), lesbian participants only (n = 9), gay participants only (n = 5), and transgender and gender diverse participants only (n = 4). Nine studies did not provide information on participant-specific gender or sexual identity beyond LGBTI+.

Table 3.

Study Characteristics

Author (year), country	Age of participants	Number and identity	Aim of study
Adan et al. (2021), United States	Age range: 64–82	(19) 9: TM, 10: TW	Identify the needs of older transgender adults regarding aging and long-term care.
Barrett et al. (2015), Australia	Age range: 65–79	(12) 6: lesbian, 5: gay, 1: TW	Explore experiences of discrimination for olderc adults.
Barrett et al. (2015), Australia	Age range: 47a–79 (mean: 65)	(30): NRb	Explore needs of olderc adults living with dementia.
Barrett et al. (2014), Australia	Age range: 65–79 (median: 70)	(12) 6: lesbian, 5: gay, 1: TW	Give olderc people a voice in the development of campaigns and resources.
Benoit et al. (2021), United States	Age range: 61–77	(8) 8: gay	Explore olderc adults experience and perceptions of healthcare services.
Butler (2017), United States	Age range: 66–86 (mean: 71.9)	(31) 26: lesbian, 5: care workers	Explore relationships between lesbians receiving care and workers providing care.
Butler (2018), United States	Age range: 62–76	(31) 26: lesbian, 5: care workers	Explore experiences of lesbians with chronic conditions when accessing care.
Cloyes and Towsley (2023), United States	Age range: 55+ (mean: 70.62)	(13) 10: lesbian, 3: gay, 1: TGa	Describe olderc adults concern with communicating end of life preferences.
Czaja et al. (2016), United States	Age range: 50–89 (mean: 65.68)	(124) 32: lesbian, 92: gay	Understand the concerns and needs of lesbian and gay older adults.
Dilshani (2023), Sri Lanka	Age range: 60–65	(20) 2: lesbian, 18: gay	Examine issues faced by lesbian and gay older adults in Sri Lanka.
Dunkle (2018a, b), United States	Age range: 54–80 (mean: 65.65)	(31) 16: lesbian, 15: gay	Explore older lesbians and gays perceptions of funded long term care services.
Furlotte et al. (2016), Canada	Age range: 39a–75 (mean: 63.58)	(24) 16: lesbian, 8: gay, 1: TGa Note: all couples.	Explore gay and lesbian expectations about long term care homes and home care.
Gabrielson (2009, 2011), United States	Age range: 55–65	(10) 10: lesbian	Understand decision making processes and factors influencing lesbians’ perspectives of aged care.
Grant and Walker (2020), Australia	Age range: 57–70	(13) 13: lesbian	Explore perceived barriers and enablers for healthy aging for rural lesbians.
Green (2016), Canada	Age range: 50–73	(6) 2: lesbian, 2: gay, 1: bisexual, 1: NR	Determine experiences and perspectives of living in long term care for olderc adults.
Grigorovich (2015a), Canada	Age range: 55–72 (mean: 63.9)	(16) 7: lesbian, 2: lesbian and queer, 1: queer and dyke, 1: bisexual, 4: gay (F), 1: WLW	Understand impact of sexual minority identity on accessing long term care in the home.
Grigorovich (2015b), Canada	Age range: 55–72 (mean: 63.9)	(16) (as above)	Deepen knowledge of impact of sexual minority status with chronic illness.
Grigorovich (2016), Canada	Age range: 55–72 (mean: 63.9)	(16) (as above)	Investigate older lesbian and bisexual women’s perspectives on long term care in the home.
Guasp (2011), United Kingdom	Age range: 55+	(1036): NRb	Examine expectations of heterosexual and gay people about getting older.
Henderson and Khan (2020), South Africa	Age range: 50+	(22) 8: lesbian, 10: gay, 3: TW, 1: bisexual (M)	Explore the experiences of aging for olderc adults living in South Africa.
Higgins et al. (2011) Ireland	Age range: 55–70	(36) 13: lesbian, 22: gay, 1: bisexual and TW	To examine experiences and needs of olderc adults in Ireland.
Hoekstra-Pijpers (2022), Netherlands	Age range: 68–88	(10) 1: lesbian, 5: gay, 1: TW and lesbian, 2: bisexual (F)	Explore olderc peoples experience of caregiving when aging in place.
Hong (2024), Taiwan	Age range: 66–73 (mean: 69)	(5) 5: gay and/or bisexual (M)	Explore the perceptions, needs and willingness of older GBM to use long-term care.
Hosking et al. (2021), Australia	Age range: 50+	(111): NRb	To understand the experiences and needs of older LGBT people.
Hughes (2007a), Australia	Age range: 58–72 (mean: 66)	(14) 5: lesbian, 9: gay	Explore older lesbian and gay people’s experiences accessing health and long-term care.
Hughes (2007b), Australia	Age range: 58–72 (mean: 66)	(14) 5: lesbian, 9: gay	Explore older lesbian and gay people’s expectations of health and long-term care.
Jenkins et al. (2010), United States	Age: 78	(1)1: lesbian	Explore experience of an older lesbian managing disclosure.
Jihanian (2013), United States	Age range: 61–79	(7) 1: lesbian, 5: gay, 1: TW and Gay	Explore what constitutes as LGBT+ responsiveness by long-term care providers
Knochel and Flunker (2021), United States	Age range: 56–73 (mean: 63.46)	(24) 7: TW, 3: TM, 7: MTF, 1: FTM 1: NB, 1: TW and Gay, 4: TG (F)	Explore impact of gender identity on older TNB adults plans for use of long-term care.
Knocker (2012), United Kingdom	Age range: 64–81	(8) 4: lesbian, 3: gay, 1: bisexual (M)	Explore the views of olderc adults regarding getting older and accessing support.
Kortes-Miller et al. (2018), Canada	Age range: 57–78 (mean: 67.39)	(23) 23: NR	Examine fears and hopes of olderc adults regarding long term care.
Kushner et al. (2013), New Zealand	Age range: 65–81	(12) 12: gay	Explore aging experiences of gay men in New Zealand.
Lampkowski-Sowle (2018), United States	Age range: 51–67	(10) 10: lesbian	Understand impact of past experiences on lesbians’ feelings about senior housing.
Leyerzapf et al. (2018), the Netherlands	Age range: 55+	(18) NR	Understand experience and needs of olderc adults concerning care settings.
Lo (2015), Australia	Age range: 62–82 (mean: 68)	(14)14: gay	Explore needs of gay men in relation to long-term care service provision.
Lof and Olaison (2020), Sweden	Age range: 65+	(15) 5: lesbian and bisexual, 5: gay and bisexual, 5: TG	Understand what olderc adults consider important to promote inclusion and recognition.
National LGBTI Health Alliance (2019), Australia	Age range: NR	(NR) NRb	To provide a submission into the Royal Commission into Aged Care.
National Senior Citizens Law Center (NSCLC) et al. (2010), United States	Age range: 40a–89	(284): NRb	Understand the experience of olderc adults in long-term care settings.
Pang et al. (2019), Canada	Age range: 55–89 (mean: 70)	(24) 2: TM and straight, 4: TM and gay, 8: TW and lesbian, 2: TW and bisexual, 8: TW and straight	Explore how older transgender adults perceive late life care needs.
Putney et al. (2018), United States	Age range: 55–87 (mean: 67)	(50) 44: homosexual, 4: bisexual, 1: other, 1: TG and heterosexual	Gain insight into olderc couples needs and fears re residential care.
Rivera (2008), United States	Age range: 61–92 (mean: 70)	(15) 7: lesbian, 8: gay	Understand needs and preferences of gay and lesbian older adults regarding long-term care
Robinson (2016), New Zealand/United Kingdom/Australia/United States	Age range: 60–80+	(25) 25: gay	Examine concerns regarding aging and old age for gay men.
Sharek et al. (2015), Ireland	Age range: 50–74	(36) 11: lesbian, 2: lesbian and TG, 22: gay, 1: bisexual and TNB	Explore olderc adults usage, experiences and concerns with long-term care.
Siverskog (2023), Sweden	Age range: 67–85	(7) 2: lesbian, 1: lesbian and TW 4: gay (M)	Explore Swedish olderc peoples experience of long-term care.
Stein et al. (2010), United States	Age range: 60–84	(16) 4: lesbian, 12: gay	Identify psychological challenges faced by lesbians and gay men when accessing care.
Sussman et al. (2018), Canada	Age range: unclear	(9): NRb	Report on state of LGBT inclusivity in long-term care.
Tonic Living, Stonewall Housing, and Opening Doors London (ODL) (2020), United Kingdom	Age range: 50–80+	(624) 168: lesbian, 381: gay, 38: bisexual, 12: pansexual, 25: other	Capture voices of olderc adults regarding choices around long-term.
Versteeg (2016), United States	Age range: 58–87	(11) 3: lesbian, 5: gay, 1: gay and bisexual (M), 1: gay and TNB, 1: bisexual (F)	Explore impact of aging and homophobia on olderc adults.
Waling et al. (2020), Australia	Age range: 60–75	(10) 3: TW and lesbian, 1: TW and asexual, 1: TW and queer, 1: TW and pansexual, 3: TW, unsure, and DND, 1: TW and straight	Explore trans women’s perceptions of residential aged care in Australia.
Waling et al. (2019), Australia	Age range: 60–80+	(33) 19: lesbian, 14: gay	Explore perceptions and concerns of older gay and lesbian people regarding long-term care.
Westwood (2016), United Kingdom	Age range: 58–92 (mean: 64)	(60) 29: lesbian, 24: gay (M), 1: gay (F), 2: bisexual (F), 4: DND (F)	Explore aging, gender, and sexuality from an equalities perspective.
Westwood (2023), United Kingdom	Age range: 50–89	(70) 23: lesbian, 30: gay (M), 5: bisexual, 2: asexual, 10: other (pansexual, queer, MTF trans, asexual lesbian, not specified)	To explore delivery of long-term care services to older adults from religious care organizations and staff.
Williams et al. (2021), United States	Age range: 60–88	(11) 7: lesbian, 3: gay, 1: TG and gay	Examine experiences of olderc adults living in rural Appalachia.
Willis et al. (2016), United Kingdom	Age range: 50–76	(29) 18: lesbian, 9: gay, 1: bisexual (M), 1: dyke (F)	To examine older adults’ expectations for future home care and aged care.
Wilson et al. (2018), Canada	Age range: 57–78 (mean: 67.39)	(23): NRb	To understand the experience of olderc adults with the health care systems.

Notes: DND = did not disclose; F = female; FTM = female-to-male transgender; GBM = Gay, Bisexual and other men who have sex with men; LGBTI+ = Lesbian, Gay, Bisexual, Transgender, and Intersex; M = male; MTF = male-to-female transgender; NB = nonbinary; NR = not reported; TG = transgender (gender not specified); TM = transgender man; TNB = transgender nonbinary; TW = transgender women; WLW = woman loving women. Participants who are reported as gay are male unless otherwise noted.

^aData from participants under 50 excluded from analysis.

^bNot reported (NR) beyond LGBT.

^cOlder LGBTI+ adults.

Critical Appraisal Findings

The strengths of the included studies were reporting the study purpose, reviewing relevant literature, appropriate study design, and ethical approval (see Supplementary Material Section 2). Less than half (n = 26) of the studies reported their theoretical framework. Rigor was impacted by authors not identifying their own bias (n = 44) or providing inadequate description of the site (n = 14) and participants (n = 13). Sampling was often not done until redundancy (n = 43), which is to be expected when working with “hard to reach” populations.

Meta-Synthesis Findings

Themes

Findings were synthesized into 4 key themes and 13 subthemes (Table 4).

Table 4.

Themes and Associated Studies

Theme/subtheme	Studies included	Number of studies included
Theme 1: We see it as being heterosexualized		N = 36
1.1: It’s all geared to heterosexual people	(Barrett et al., 2014, 2015a; Cloyes & Towsley, 2023; Furlotte et al., 2016; Gabrielson, 2009; Grant & Walker, 2020; Grigorovich, 2015a; Guasp, 2011; Hoekstra-Pijpers, 2022; Hosking et al., 2021; Jihanian, 2013; Knochel & Flunker, 2021; Knocker, 2012; Kortes-Miller et al., 2018; Robinson, 2016; Sharek et al., 2015; Siverskog, 2023; Stein et al., 2010; Tonic Living, Stonewall Housing, and Opening Doors London (ODL), 2020; Versteeg, 2016; Waling et al., 2020; Westwood, 2016; Williams et al., 2021; Willis et al., 2016; Wilson et al., 2018).	N = 25
1.2: Could we hold hands?	(Cloyes & Towsley, 2023; Dunkle, 2018a, 2018b; Furlotte et al., 2016; Gabrielson, 2009; Grant & Walker, 2020; Green, 2016; Guasp, 2011; Henderson & Khan, 2020; Higgins et al., 2011; Hosking et al., 2021; National LGBTI Health Alliance, 2019; National Senior Citizens Law Center [NSCLC] et al., 2011; Putney et al., 2018; Sharek et al., 2015; Siverskog, 2023; Stein et al., 2010; Tonic Living, Stonewall Housing, and Opening Doors London (ODL), 2020; Waling et al., 2019; Westwood, 2016).	N = 20
1.3: I see only invisibility	(Barrett et al., 2014; Dunkle, 2018b; Furlotte et al., 2016; Green, 2016; Grigorovich, 2015a; Guasp, 2011; Henderson & Khan, 2020; Higgins et al., 2011; Hoekstra-Pijpers, 2022; Hosking et al., 2021; Knocker, 2012; Kortes-Miller et al., 2018; Kushner et al., 2013; Lof & Olaison, 2020; National LGBTI Health Alliance, 2019; Sharek et al., 2015; Siverskog, 2023; Stein et al., 2010; Tonic Living, Stonewall Housing, and Opening Doors London (ODL), 2020; Williams et al., 2021; Willis et al., 2016; Wilson et al., 2018)	N = 22
Theme 2: With no one there to guard us		N = 49
2.1: We are still considered less than	(Adan et al., 2021; Barrett et al., 2015a, 2015b; Dilshani, 2023; Furlotte et al., 2016; Gabrielson, 2011; Grant & Walker, 2020; Grigorovich, 2015a; Guasp, 2011; Henderson & Khan, 2020; Hosking et al., 2021; Hughes, 2007a; Knochel & Flunker, 2021; National LGBTI Health Alliance, 2019; Putney et al., 2018; Robinson, 2016; Waling et al., 2019, Waling et al., 2020; Westwood, 2016, Westwood, 2023; Wilson et al., 2018).	N = 21
2.2: You’re vulnerable to the people that are looking after you	(Adan et al., 2021; Barrett et al., 2014, 2015b; Butler, 2018; Dilshani, 2023; Dunkle, 2018b; Furlotte et al., 2016; Gabrielson, 2009; Green, 2016; Grigorovich, 2015a, 2015b, 2016; Guasp, 2011; Henderson & Khan, 2020; Knochel & Flunker, 2021; Knocker, 2012; Kortes-Miller et al., 2018; Pang et al., 2019; Putney et al., 2018; Siverskog, 2023; Stein et al., 2010; Westwood, 2016, 2023).	N = 23
2.3: I would sort of need to be on guard	(Barrett et al., 2014, 2015a, 2015b; Butler, 2017; Cloyes & Towsley, 2023; Czaja et al., 2016; Dilshani, 2023; Dunkle, 2018a, 2018b; Furlotte et al., 2016; Gabrielson, 2009; Green, 2016; Grigorovich, 2015a; Guasp, 2011; Hoekstra-Pijpers, 2022; Hughes, 2007a, 2007b; Jenkins et al., 2010; Knocker, 2012; Kortes-Miller et al., 2018; Kushner et al., 2013; Leyerzapf et al., 2018; Lof & Olaison, 2020; National LGBTI Health Alliance, 2019; NSCLC et al., 2011; Putney et al., 2018; Rivera, 2008; Sharek et al., 2015; Stein et al., 2010; Versteeg, 2016; Waling et al., 2019; Westwood, 2016; Willis et al., 2016; Wilson et al., 2018).	N = 34
Theme 3: You have got to hide 90% of yourself		N = 42
3.1: Ignorance at least, homophobia at worst	(Adan et al., 2021; Barrett et al., 2014; Butler, 2017; Cloyes & Towsley, 2023; Czaja et al., 2016; Dunkle, 2018b; Furlotte et al., 2016; Gabrielson, 2009; Green, 2016; Grigorovich, 2015a; Guasp, 2011; Hoekstra-Pijpers, 2022; Hong, 2024; Hosking et al., 2021; Hughes, 2007a; Knochel & Flunker, 2021; Knocker, 2012; Kortes-Miller et al., 2018; Leyerzapf et al., 2018; National LGBTI Health Alliance, 2019; NSCLC et al., 2011; Putney et al., 2018; Rivera, 2008; Sharek et al., 2015; Versteeg, 2016; Westwood, 2016, 2023; Wilson et al., 2018)	N = 28
3.2: Retreating into the closet	(Barrett et al., 2014, 2015a, 2015b; Butler, 2017; Cloyes & Towsley, 2023; Czaja et al., 2016; Dilshani, 2023; Dunkle, 2018b; Gabrielson, 2009; Grant & Walker, 2020; Green, 2016; Grigorovich, 2015a; Guasp, 2011; Henderson & Khan, 2020; Higgins et al., 2011; Hoekstra-Pijpers, 2022; Hosking et al., 2021; Hughes, 2007a; Jihanian, 2013; Knochel & Flunker, 2021; Knocker, 2012; Kortes-Miller et al., 2018; Kushner et al., 2013; Leyerzapf et al., 2018; Lof & Olaison, 2020; National LGBTI Health Alliance, 2019; NSCLC et al., 2011; Putney et al., 2018; Robinson, 2016; Sharek et al., 2015; Sussman et al., 2018; Tonic Living, Stonewall Housing, and Opening Doors London (ODL), 2020; Versteeg, 2016; Westwood, 2016, 2023; Willis et al., 2016; Wilson et al., 2018)	N = 37
3.3: I want to be myself	(Adan et al., 2021; Barrett et al., 2014, 2015a, 2015b; Butler, 2017; Cloyes & Towsley, 2023; Dunkle, 2018b; Furlotte et al., 2016; Gabrielson, 2009, Gabrielson, 2011; Grant & Walker, 2020; Green, 2016; Guasp, 2011; Henderson & Khan, 2020; Higgins et al., 2011; Hoekstra-Pijpers, 2022; Hosking et al., 2021; Knochel & Flunker, 2021; Knocker, 2012; Kortes-Miller et al., 2018; Kushner et al., 2013; Leyerzapf et al., 2018; National LGBTI Health Alliance, 2019; NSCLC et al., 2011; Putney et al., 2018; Robinson, 2016; Sharek et al., 2015; Tonic Living, Stonewall Housing, and Opening Doors London (ODL), 2020; Versteeg, 2016; Wilson et al., 2018).	N = 30
Theme 4: I don’t want a different service, I want a good service		N = 49
4.1: LGBTI+ specific aged care	(Barrett et al., 2014, 2015b; Benoit et al., 2021; Butler, 2017, 2018; Cloyes & Towsley, 2023; Dilshani, 2023; Dunkle, 2018b; Gabrielson, 2009, 2011; Green, 2016; Guasp, 2011; Higgins et al., 2011; Hong, 2024; Hosking et al., 2021; Hughes, 2007b; Knochel & Flunker, 2021; Knocker, 2012; Kortes-Miller et al., 2018; Kushner et al., 2013; Lampkowski-Sowle, 2018; Leyerzapf et al., 2018; Lo, 2015; National LGBTI Health Alliance, 2019; Putney et al., 2018; Rivera, 2008; Robinson, 2016; Sharek et al., 2015; Stein et al., 2010; Sussman et al., 2018; Tonic Living, Stonewall Housing, and Opening Doors London (ODL), 2020; Waling et al., 2019, 2020; Westwood, 2016; Williams et al., 2021; Willis et al., 2016)	N = 36
4.2: Affirmative care	(Barrett et al., 2014; Butler, 2017; Cloyes & Towsley, 2023; Dunkle, 2018b; Gabrielson, 2009, 2011; Green, 2016; Grigorovich, 2015a; Grigorovich, 2016; Guasp, 2011; Hoekstra-Pijpers, 2022; Hong, 2024; Hosking et al., 2021; Hughes, 2007a; Jihanian, 2013; Knocker, 2012; Leyerzapf et al., 2018; Lo, 2015; National LGBTI Health Alliance, 2019; Rivera, 2008; Sharek et al., 2015; Sussman et al., 2018; Tonic Living, Stonewall Housing, and Opening Doors London (ODL), 2020; Wilson et al., 2018).	N = 24
4.3: Knowledge is power	(Barrett et al., 2014; Butler, 2017, 2018; Cloyes & Towsley, 2023; Dunkle, 2018b; Green, 2016; Grigorovich, 2015a, 2016; Guasp, 2011; Henderson & Khan, 2020; Higgins et al., 2011; Hong, 2024; Hosking et al., 2021; Jihanian, 2013; Knochel & Flunker, 2021; Knocker, 2012; Lampkowski-Sowle, 2018; Lo, 2015; Lof & Olaison, 2020; National LGBTI Health Alliance, 2019; Putney et al., 2018; Rivera, 2008; Sharek et al., 2015; Stein et al., 2010; Sussman et al., 2018; Tonic Living, Stonewall Housing, and Opening Doors London (ODL), 2020; Versteeg, 2016; Waling et al., 2019, 2020; Williams et al., 2021; Wilson et al., 2018).	N = 31
4.4: Signaling inclusivity	(Adan et al., 2021; Barrett et al., 2015a; Benoit et al., 2021; Butler, 2017, 2018; Czaja et al., 2016; Dunkle, 2018b; Grant & Walker, 2020; Green, 2016; Guasp, 2011; Henderson & Khan, 2020; Hong, 2024; Hosking et al., 2021; Kortes-Miller et al., 2018; Lampkowski-Sowle, 2018; Leyerzapf et al., 2018; Lo, 2015; National LGBTI Health Alliance, 2019; Putney et al., 2018; Sharek et al., 2015; Tonic Living, Stonewall Housing, and Opening Doors London (ODL), 2020; Versteeg, 2016; Waling et al., 2020; Willis et al., 2016; Wilson et al., 2018).	N = 25

Note: LGBTI+ = Lesbian, Gay, Bisexual, Transgender, and Intersex.

We see it as being heterosexualized (Westwood, 2016, p. 157)

The findings indicated that care for older adults is underpinned by heterosexism. Heterosexism privileged the heterosexual experience and enforced gendered roles and assumptions. Such beliefs permeated the physical environment, the assumed dress and grooming standards, the activities engaged in, and the assumptions about relationships.

It’s all geared to heterosexual people (Westwood, 2016, p. 157).

Participants described heterosexism as influencing the support given for dressing and grooming and more pervasively, the activities available. Transgender participants were worried about grooming; “I’m mostly worried about shaving. If I can’t really shave myself, then I guess I’ll be a bearded lady or something” (Knochel & Flunker, 2021, p. 1545). They expressed concerns they “may not be able to fully express (them) self… as a transgendered person” (Sharek et al., 2015, p. 236) and would be told “No no no, you are really a male. You have to wear this. You have to wear that” (Waling et al., 2020, p. 1312). This trepidation was shared by lesbian and gay participants. One participant expressed concerns about a lesbian friend who had always worn trousers but in care was “put in a crimplene dress and given a standard ‘old woman’s perm” (Knocker, 2012, p. 12).

Heterosexism also led to exclusion from activities that enforced gender roles. Examples included “couples’ nights” (Kortes-Miller et al., 2018, p. 215) and “talking about their past, things that don’t relate to me as a gay man” (Westwood, 2016, p. 157). The design of these activities contributed to the sense of isolation older LGBTI+ adults experienced.

Could we hold hands? (Furlotte et al., 2016, p. 438).

This subtheme describes participants concerns about the acceptability of same-sex relationships in care. Participants described that their relationship “would not be respected” (Dunkle, 2018b, p. 447), that partners would be “rejected” (Higgins et al., 2011, p. 117), that residential care facilities would not “allow (them) to move in together” (Henderson & Khan, 2020, p. 103) and that appropriate next-of-kin processes would not be followed in an emergency.

Participants raised concerns about expressing their relationship free from judgment. This included being able to display a picture of their partner and showing affection; “Even holding hands is still unacceptable publicly between same-sex couples” (Guasp, 2011, p. 28). There were concerns raised about appropriate privacy for physical intimacy in residential care with participants identifying it “feels a bit tricky” (Siverskog, 2023, p. 8).

Participants described that talking about their current partner was seen to be pushing a homosexual agenda; “…if you say anything about your boyfriend, they say ‘oh you have to go on about being gay don’t you?” (Westwood, 2016, p. 157). One lesbian participant described a similar experience when told by faith-based providers: “you don’t need to share this [relationship] with everyone” (National LGBTI Health Alliance, 2019, p. 9). Those in same-sex relationships were met with disrespectful questioning such as “which one is the man and which one is the woman?” (National Senior Citizens Law Center [NSCLC] et al., 2011, p. 10). In instances where partners had passed away, participants felt they were robbed of the chance to grieve:

“the death of your significant other is not understood by others and that is really hard” (National LGBTI Health Alliance, 2019, p. 14).

I see only invisibility (Williams et al., 2021, p. 229).

The overarching heterosexism and disrespect for relationships left LGBTI+ individuals feeling invisible. Participants described being “totally ignored by mainstream providers” (Hosking et al., 2021, p. 19). This unwillingness to “acknowledge that such [LGBTI+] people exist” (Dunkle, 2018a, p. 446) resulted in participants feeling “entrapped in a heterosexual world” (Sharek et al., 2015, p. 236), which “forced” (Kushner et al., 2013, p. 3391) them to remain invisible.

“I visited a number of rehabilitative retirement homes and long-term care facilities and I (sigh) see only invisibility, expected invisibility on the part of LGBT people...” (Williams et al., 2021, p. 229).

Such invisibility left LGBTI+ people with no power to advocate for themselves or complain about substandard care.

“You learn to bury your feelings and honour theirs …. Well, I mean that just sums up what it is like to be a gay person in a straight world... You’re always the one who has to, you know, soften the corners, make things right.” (Furlotte et al., 2016, p. 439).

With no one there to guard us (Adan et al., 2021, p. 337)

LGBTI+ adults reported fear and a perceived lack of safety regarding care services. Such fears were reported in the context of historical discrimination, coupled with intersecting vulnerabilities of institutional control and care providers being away from the scrutiny of the public. Participants who were receiving services reported being hypervigilant about their safety due the compounding effects of feeling “less than” (Westwood, 2016, p. 157).

“… We don’t know what they would do to us in a nursing home with no one there to guard us” (Adan et al., 2021, p. 337).

We are still considered less than (Westwood, 2016, p. 157).

Participants “dread[ed]” (Grant & Walker, 2020, p. 2203) both implicit and explicit prejudice in care. They anticipated that pervasive societal attitudes toward LGBTI+ people would be exacerbated by “institutionalised prejudice” (Guasp, 2011, p. 21) and “homophobia” (Guasp, 2011, p. 23). There was concern that care staff would be “mean” (Grigorovich, 2015a, p. 956), “hostile” (Guasp, 2011, p. 28), and “abusive” (Hughes, 2007a, p. 176).

While discrimination from staff was most feared, fear of prejudice from service users was also identified. Participants feared that residents would be “looking down their noses because they could be of an age when it was taboo” (Barrett et al., 2015b, p. 138), “making fun” (Gabrielson, 2011, p. 336) of them, or that there would be “anti-gay bigots” (Guasp, 2011, p. 27). The sense of being “othered” was described to be worse than hostility.

“Even worse than hostility [would be] where you were the only gay couple perhaps in a village of heterosexuals and were treated sort of like the resident clown[s].” (Hughes, 2007a, p. 180).

Fear was described in detail and with gravitas. A fear so pervasive that participants identified extreme alternatives to long-term care including “liv[ing] on the street” (Henderson & Khan, 2020, p. 101), voluntary assisted dying, and suicide.

“I used to think that if I had to move into town or go to a nursing home, I’d just kill myself” (Grant & Walker, 2020, p. 2203).

Fear was exacerbated when referring to faith-based organizations: “…religious aged care providers have decided that Hell starts on entrance to their facilities” (Hosking et al., 2021, p. 15). Such organizations were described as the “last bastion (s) of discrimination” (Hughes, 2007a, p. 177) and were seen to “monopolise” (Hosking et al., 2021, p. 15) services.

You’re vulnerable to the people that are looking after you (Barrett et al., 2014, p. 27).

Participants described accessing long-term care as “a particularly vulnerable stage of life” (Guasp, 2011, p. 23), where people have “care and control over you, whatever biases they are carrying” (Knochel & Flunker, 2021, p. 1545). Participants who had experienced a lifetime of discrimination described that “racism, ageism, homophobia, sexism all wound (you) much deeper than they do when you’re younger” (Gabrielson, 2009, p. 74) and expressed a lack of energy to be “be fighting that kind of crap off” (Westwood, 2016, p. 159).

“…if we’re at the stage where we are moving into a facility, we may not be in a position that we are strong enough to fight back against it as much as we should” (Furlotte et al., 2016, p. 437).

While participants may have been “out” and advocated for their rights previously, it was seen that entry into care would be like starting this fight all over again.

“…you’ve created the life and have some comfort …then imagine that … there’s a whole other place where we are going to do the same work in. I mean I don’t have the energy to…” (Kortes-Miller et al., 2018, p. 216).

In many instances, the experiences of discrimination coupled with the lack of energy to fight led to a higher dependence on informal supports. Despite increased stress for carers, the use of informal supports was seen as a mechanism to avoid the “piece about the homophobia” (Grigorovich, 2016, p. 112).

I would sort of need to be on guard (Furlotte et al., 2016, p. 439).

A history of marginalization and discrimination within institutionalized care resulted in participants being “doubly-terri[fied]… about aged care” (National LGBTI Health Alliance, 2019, p. 9). This resulted in the need to be “on guard” (Furlotte et al., 2016, p. 439) and adopt a heightened level of protective vigilance when engaging with services.

Heightened vigilance was reported in residential and community facilities, resulting in participants concealing their sexuality, which included the need to “de-gay” (Butler, 2017, p. 387), “not be so obvious” (Barrett et al., 2015, p. 136), “straighten up” (Dunkle, 2018b, p. 448), and in some instances cutoff relationships with friends. Witnessing or hearing stories of discrimination increased participants perceived need for vigilance. Participants described how they were constantly monitoring staff and service users to “gauge the situation” (Grigorovich, 2015a, p. 952) and “pretty quickly learn[ed] to assess the risk” (Furlotte et al., 2016, p. 439).

To reduce the risk of being “found out,” participants employed strategies such as being “more quiet than usual” (Green, 2016, p. 79), talking to “less people” (Green, 2016, p. 79), and avoiding forming connections. This led to participants feeling “terribly isolated” (NSCLC et al., 2011, p. 7):

“I’m sure I am safer if nobody knows that I lived with my partner for 40 years. It would only make matters worse for me if others knew, and so I can’t speak about my life at all, can I?” (Stein et al., 2010, p. 430).

You have got to hide 90% of yourself (Butler, 2017, p. 387)

“Risky visibility” describes the complexity of maintaining one’s identity at the risk of being subject to homophobia and discrimination. While remaining visible and open about one’s identity was desirable; many participants found visibility compromised their safety to such an extent that they entered “the closet” when engaging with services.

Ignorance at least, homophobia at worst (Guasp, 2011, p. 22).

Participants who were or considering being visible in their sexuality or gender identity described experiences of subtle and overt discrimination. Subtle discrimination was characterized by ignorance and included limited eye contact “unfriendly attitudes” (Hong, 2024, p. 6), misgendering and stares for transgender individuals, subtle changes in tone of voice and body language, a lack of authentic engagement, or placing them in “shitty” living facilities (Dunkle, 2018b, p. 72). Such discrimination was also seen as a sense of “something missing” (Grigorovich, 2015a, p. 954), particularly avoiding asking questions about the older persons spouse or life history.

At times, participants felt staff were acting in ways that aligned with inclusive legislation but remained discriminatory toward them. Examples included forgetting about them “on purpose” (Leyerzapf et al., 2018, p. 361), “getting your cup of tea at the end of the line and its cold…” (Grant & Walker, 2020, p. 2203), seeming to resent same-sex relationships, enforcing heterosexual assumptions, not respecting preferred names or the “subtle, and problematic, aspects of prejudiced talk’ (Westwood, 2016, p. 157). Overt discrimination was perceived to be motivated by homophobia and included acts of verbal and physical aggression and suboptimal care. Specific examples of this can be seen in Table 5.

Table 5.

Participant Identified Experiences of Discrimination

Type of discrimination	Participant examples
Suboptimal care	“I was a friendly visitor for an older gay man who was in a nursing home. I witnessed discrimination against him and that was hard. He was not out at the nursing home, but people were aware, and nurse aids would not be appropriately caregiving for him because they were homophobic” (Czaja et al., 2016, p. 1112). “He was treated roughly. They knew he was gay” (Hughes, 2007a, p. 176). “This is one woman... she comes in, she’s got a bible and she’s telling me she’s not washing my clothes and I said, ‘Oh. Did I hear you correctly? You’re not washing my clothes?’ ‘Yes.’ I said, ‘Can you tell me why?’ ‘Because I don’t wash men’s clothes” (Grigorovich, 2015a, p. 954).
Verbal acts	“I think it’s just easier if you don’t … because my experience being in the medical field is I’ve heard how people talk behind people’s back, you know? Not that they don’t necessarily get the same care, but they do a lot of talking and joking and that sort of thing” (Furlotte et al., 2016, p. 436). “Well, not certainly physical. No assault or nothing like that. But I hear them talk. The staff talk. And I know how the situation is seen by certainly not everybody, but by a few, and like I say, I have no control or idea who’s gonna get me up the next day, so, so I shut up” (Green, 2016, p. 77).
Physical acts	“I’ve heard of an episode where one of the staff members came in and saw a photo that showed a man’s partner was male and they threw the photo away” (Barrett et al., 2014, p. 67). “…they shoved a face-cloth in her face and made comments about her being a dyke or something like that” (Green, 2016, p. 71).

Faith-based institutions, and workers’ religious beliefs were described as a catalyst for discrimination; “in the case of religious institutions, it seems to be legal to discriminate” (Czaja et al., 2016, p. 1112). Experiences included being thrown out of a nursing home, carers providing bibles and religious pamphlets to emphasize “homosexuality was a sin” (Butler, 2017, p. 389), and overtly praying for gay people which felt “like harassment” (NSCLC et al., 2011, p. 11). One participant described being tortured by a homecare worker:

“She began torturing me and repeating constantly that Satan was going to get me. I had to call the police” (Czaja et al., 2016, p. 1114).

Discrimination was also perpetuated from other service users. In residential care, a transgender participant described “when I walked by… the residents were calling out insults to me” (Sussman et al., 2018, p. 127). Similarly, a gay man reported that other residents “wouldn’t sit next to me... in the care home” (Leyerzapf et al., 2018, p. 361) and another that he was “avoided by the heterosexual men” (Hosking et al., 2021, p. 19). Such discrimination was seen in community settings, with participants reporting being treated “like the plague” (Hosking et al., 2021, p. 21) and having people “walk to the other side” (Gabrielson, 2009, p. 70) of a room.

Retreating into the closet (Westwood, 2023, p. 372).

Experiences of discrimination and hearing “horror stories” (Kortes-Miller et al., 2018, p. 216) from other LGBTI+ adults led to a return to “the closet.”

“I’ll have to go back into the closet… in order to be in a home, to be looked after…” (Kortes-Miller et al., 2018, p. 215).

“The Closet” was seen as a space to hide one’s sexuality, gender identity, and “shut down” (Higgins et al., 2011, p. 118) one’s life story. A return to the closet was described as a “first death” (Higgins et al., 2011, p. 118). While a return to the closet was motivated by fear of discrimination, participants wrestled with what “deny(ing)” (Guasp, 2011, p. 24) their identity would cost them emotionally. Some considered there to be “no point in living… if you have to be completely in the closet” (Willis et al., 2016, p. 293). As a population who had fought so hard for recognition and equal rights, participants were distressed by going back in the closet as it denied them their past victories.

“…you have to go back in the closet – deeply insulting to everything these people have achieved.” (National LGBTI Health Alliance, 2019, p. 9).

Discussions around “the closet” for transgender older adults differed, with some participants identifying that “they never had a closet” (Cloyes & Towsley, 2023, p. 7). Other transgender participants described a plan to conceal their identity and “lie about their preferred gender” (Hong, 2024, p. 8) or “revert to their birth gender to avoid harassment” (Kortes-Miller et al., 2018, p. 216). Some participants described the need to complete transitional surgeries in preparation for care to pass as cisgender.

“Hopefully...before I’m in one of them homes... I would have my surgery completed…” (Knochel & Flunker, 2021, p. 1546).

“I want to be myself” (Guasp, 2011, p. 29).

Despite the risk of homophobia, discrimination and substandard care participants expressed a desire to maintain their LGBTI+ identity as they age. Many recognized that their identity “took many years to achieve” (Guasp, 2011, p. 29) and was hard fought for.

“we’ve all fought for our identity you know? Like tooth and nail and … I know from my own personal experience that…Just how transformative it was, … and honest to God I would rather fucking(sic) die than go back.” (Wilson et al., 2018, p. 28).

Disclosure of sexuality and gender identity was a way to maintain identity and celebrate the struggle for equal rights, sexual liberation, and survival to older age. This was particularly true for older gay men who had survived through the HIV-AIDS pandemic and recognized themselves a “survivor[s]” (Dunkle, 2018b, p. 446) who deserved to “live a proud and open life” (Dunkle, 2018b, p. 446). Being one’s authentic self was associated with greater overall wellbeing. However, being able to remain out of the closet and live authentically into old age was something that many participates could “only hope” (Adan et al., 2021, p. 338) for in the context of long-term care.

I don’t want a different service, I want a good service (Knocker, 2012, p. 13)

A “good service” that affirmed and accepted the LGBTI+ identity was described by participants as “affirmative care.” Affirmative care was explored in the context of LGBTI+-specific care, factors that enhanced the care experience, the need for staff training, and the importance of signaling inclusivity.

LGBTI+-specific care

LGBTI+-specific long-term care was described on a spectrum. Participants associated LGBTI+-specific facilities with reduced risk of discrimination and an increased sense of community, inclusion, and safety.

While many participants viewed LGBTI+-specific care positively, there was a “dynamic tension… between mainstream and specialised services” (Waling et al., 2019, p. 1256), with complexities around “segregation” (Green, 2016, p. 94) in these facilities: “are we building a wall to keep them out or us in?” (Dunkle, 2018b, p. 447). Participants voiced concern that such an approach to care result in reduced tolerance of LGBTI+ older adults in mainstream care, unequal treatment, and the development of “gay ghettos” (Stein et al., 2010, p. 431).

The risk of LGBTI+-specific services being homogeneous was raised with participants identifying “homogenous services don’t suit us” (National LGBTI Health Alliance, 2019, p. 16). This was further emphasized by unique views, with many “cradle to grave” (Westwood, 2016, p. 159) lesbians stating that they would not like to deal with all the “gay male energy” (Gabrielson, 2009, p. 84). This sentiment was occasionally reflected by gay men identifying concerns with needing to “share it [care] with lesbians” (Lo, 2015, p. 219). Interestingly, the desire for LGBTI+-specific care was not discussed by transgender or bisexual individuals. Overall, participants would only choose LGBTI+-specific services in the absence of inclusive, mainstream LGBTI+ affirmative care.

“I am not looking for (gay) services. I want current community services to recognise that lesbian and gay needs may be different from hetero needs” (Lo, 2015, p. 223).

Affirmative care

Affirmative care moved beyond technical competence and into acceptance. Participants described that affirmative care enabled them to move from “feeling like a body to feeling like a whole person” (Sussman et al., 2018, p. 126). LGBTI+ affirmative care was based on staff being “accepting” (Dunkle, 2018b, p. 445), having some understanding of what it is to be LGBTI+, and treating LGBTI+ older adults “humanely” (Rivera, 2008, p. 52). Such care was experienced when participants were supported in their identity expression and were able to display “domestic materiality’s that signal values about LGBT(sic) life histories and identities” (Hoekstra-Pijpers, 2022, p. 37). Being able to curate an environment that “reveals…sexuality” (Siverskog, 2023, p. 7) was highly valued.

Supporting participants to remain “connected to LGBTI community” (National LGBTI Health Alliance, 2019, p. 14) and incorporating LGBTI+ activities into programs were also validating for participants. Staff who openly disclosed their sexuality created a sense of safety and connection in terms of shared culture.

“Just as it is important to have someone who speaks English or the same language as you… I need someone who can ‘speak lesbian’!” (Knocker, 2012, p. 11).

Knowledge is power (Williams et al., 2021, p. 231).

Participants identified that staff training was the most important thing to support LGBTI+ affirmative care. Participants reported being more likely to engage with services that provided staff training “at all levels” (Dunkle, 2018b, p. 448). Participants opined that care providers “need to know that the world’s not straight” (Jihanian, 2013, p. 26). This opinion was in recognition that “a very large percentage of the workers…are not particularly well-informed or intuitive about gay ageing people’s rights” (Higgins et al., 2011, p. 117) and lack understanding of “heterosexual privileges” (Jihanian, 2013, p. 220). Participants identified providers needed to be “educated in diversity” (Dunkle, 2018b, p. 448), the health disparities in the LGBTI+ community, the “care challenges” encountered (Hong, 2024, p. 9), LGBTI+ history, and the unique needs of older LGBTI+ adults.

Specifically, participants identified that long-term care staff are “not really educated” (Knochel & Flunker, 2021, p. 1545) in the care needs of trans individuals. The responsibility of ensuring providers were educated often fell to trans people who were not always comfortable to “stand up and tell service providers what they needed” (Barrett et al., 2014, p. 28).

It was anticipated that training would reduce the risk of systemic homophobia, while increasing dignity and respect for older LGBTI+ adults. Education was seen as especially important for workers that had immigrated from countries where homosexuality was considered “taboo” (Butler, 2017, p. 387), “evil or sin” (Rivera, 2008, p. 51), and where homosexual people were seen “as the devil” (Versteeg, 2016, p. 58).

Signaling inclusivity (Dunkle, 2018a, p. 77).

Participants identified need for “signals” of LGBTI+ affirmative care, including physical signage, openness of staff, imagery, and wording in forms and welcome materials.

Imagery that reflected the LGBTI+ community was seen to “open doorways” (Dunkle, 2018b, p. 449). The hoisting of the gay flag, written words, and symbolism also played a role in supporting participants to feel welcome “if they had… you know, a rainbow sign… you know, everyone would be welcome, and it would be much easier…” (Kortes-Miller et al., 2018, p. 219). Participants described the importance of inclusive paperwork in communicating how welcoming a provider might be. Having “no way to indicate sexual orientation on a form” (Dunkle, 2018b, p. 449) was seen as a barrier to inclusivity, that maintained the “we have no gay people here… façade” (Wilson et al., 2018, p. 28).

Organizations recognizing when they have LGBTI+ participants engaging in services communicated inclusivity. Participants reported visiting long-term care services to determine their suitability and often being informed “we don’t have any gay people here” (Kortes-Miller et al., 2018, p. 219). It was considered that such attitudes reflected people feeling unsafe to disclose their identity rather than an actual lack of LGBTI+ service users.

While signs of welcome were important, other methods for signaling inclusive and supportive care were also highlighted as an area that needed attention. Participants identified that the onus was on the provider to “come out” (National LGBTI Health Alliance, 2019, p. 14) as LGBTI+ friendly. Participants identified that this could be achieved through a “statement of inclusion” (Lampkowski-Sowle, 2018, p. 99), development of “directories” for “gay-sensitive agencies” (Butler, 2017, p. 392), or a “resource guide that has been vetted” (Dunkle, 2018b, p. 449).

Discussion

Findings from this meta-synthesis of 55 studies on how LGBTI+ older adults viewed and experienced long-term care services identified four key themes.

Heterosexism, described in Theme 1, pervaded long-term care, impacting on policy, service design, and delivery. Consequently, LGBTI+ older people continue to be excluded and rendered invisible. Minority groups who experience this when accessing services designed for the dominant culture are at risk of “minority stress” (Meyer, 2003; Turesky, 2022). Minority stress describes the experience of LGBT+ individuals across many sectors and has associated poorer health outcomes, such as reduced engagement in services (Mongelli et al., 2019). Our review findings reflect this in Theme 2, where LGBTI+ adults described drastic plans to avoid long-term care services. Those that accessed services did so feeling vulnerable, anticipating discrimination, and hiding parts of themselves as a form of protective vigilance. The idea of protective vigilance resonated with the lived experiences of the consumer reference group as they shared occasions of attempting to “blend” into the dominant culture to ensure their safety. The impact of minority stress was further found in Theme 3, through LGBTI+ older adults’ descriptions of experiences of being “out” when accessing long-term care. Participants described being met with subtle and overt discrimination, thus reliving traumatic experiences and, in many cases, causing them to return to the closet. Returning to the closet has been linked with worse mental health outcomes (Pachankis et al., 2020), and reduced ability to form meaningful connections, resulting in loneliness (Wright et al., 2024).

While heterosexism, discrimination, and invisibility all increase minority stress, Chaudoir et al. (2017) identified ameliorating factors that could reduce the impact of minority stress. These factors were structural, interpersonal, individual, and multilevel. Participants in our study identified that policy (structural), LGBTI+ affirmative care (interpersonal), and staff education (individual) all play an important role in reducing the impact of minority stress. At a structural level, laws and policies that protect LGBTI+ adults can reduce minority stress (Chaudoir et al., 2017). Most studies included in this synthesis were from countries where homosexuality was legalized, with the exclusion of Dilshani (2023). Despite differences in legislation and LGBTI+ protections, the perceptions and experiences of LGBTI+ participants remained consistent across studies, decades, and jurisdictions. This finding indicates that structural protections alone have limited reach for protecting against minority stress.

Contact between LGBTI+ individuals and heterosexual individuals is considered an effective “interpersonal” intervention against minority stress (Chaudoir et al., 2017; Smith et al., 2009). Participants in our review emphasized a preference for integrated, affirmative care. Participants were aware of the importance of being able to access “mainstream” services and engage with non-LGBTI+ providers and services users. Our consumer reference group supported this recommendation, identifying the importance of shared spaces for enabling inclusion.

Education is the primary “individual” intervention against minority stress (Chaudoir et al., 2017; Porter & Krinsky, 2014); this was reflected in our review. LGBTI+-specific training has been shown to enhance the provision of LGBTI+ affirmative care (Hafford‐Letchfield et al., 2018; Holman et al., 2020; Yu et al., 2023). Despite this, providers report they lack knowledge on LGBTI+ health issues and needs (Caceres et al., 2020; Skeldon & Jenkins, 2022; Willis et al., 2017). Multiple studies found that LGBTI+ training was often not engaged in during tertiary education (Smith et al., 2019) or once care workers were in the workforce (Bell et al., 2010; Donaldson & Vacha-Haase, 2016).

Our findings in Theme 4 support the importance of “multilevel” interventions, specifically signaling inclusivity (Chaudoir et al., 2017). These recommendations are supported in current literature, with signage, intake forms, inclusive language, public statements about staff training, and advertising materials all viewed as the most effective methods for communicating such inclusivity (Croghan et al., 2015). The concept of long-term care providers needing to “come out” and signal their inclusivity was strongly supported during the consumer reference group.

Strengths, Limitations, and Reflexivity

Use of eMERGE reporting guidance (Noyes, 2022), preregistration with PROSPERO, inclusion of gray literature, and large number of studies are strengths of this review, as is the consumer consultation process. The findings from consumer consultation strengthened the framing of themes and recommendations. Limitations to acknowledge are inclusion of literature originating from developed countries with most participants identifying as Caucasian, educated, and middle class. Similarly, no intersex participants were identified in the included studies. Finally, there is risk of language bias as only studies reported in English were included.

Implications

There are extensive data reporting mostly negative experiences of LGBTI+ older adults in terms of how they perceive and experience care. Experiences led to re-traumatization, protective vigilance, and stress for LGBTI+ older people. Globally, there have been reports and recommendations made; but this discourse needs to translate transparently into how services are signaled and provided for LGBTI+ older people.

Funding

Sarah McMullen-Roach is recipient of a Research Training Program from the Australian Government and receives a Commonwealth Scholarship Stipend.

Conflict of Interest

None.

Data Availability

The data are available upon reasonable request. As the review is secondary research, all data are available as published papers or online. Studies reported on in this manuscript were not screened for preregistration.

Author Contributions

Sarah McMullen-Roach (Conceptualization [lead], Data curation [lead], Formal analysis [lead], Investigation [lead], Methodology [lead], Project administration [lead], Validation [lead], Visualization [lead], Writing—original draft [lead], Writing—review & editing [lead]), Saravana Kumar (Conceptualization [supporting], Data curation [supporting], Formal analysis [supporting], Methodology [supporting], Supervision [lead], Validation [supporting], Writing—review & editing [supporting]), Maria Inacio (Conceptualization [supporting], Formal analysis [supporting], Investigation [supporting], Supervision [supporting], Writing—review & editing [supporting]), and Carolyn Murray (Conceptualization [supporting], Data curation [supporting], Formal analysis [equal], Investigation [supporting], Methodology [supporting], Supervision [supporting], Validation [supporting], Visualization [supporting], Writing—original draft [supporting], Writing—review & editing [supporting])