In Their Own Words: Hispanic LGBT Older Adults by SAGE

In Their Own Words: a Needs Assessment of Hispanic LGBT Older Adults

JANUARY 2014

ACKNOWLEDGEMENTS The National Hispanic Council on Aging (NHCOA) — the leading national organization working to improve the lives of Hispanic older adults, their families, and caregivers — would like to express its gratitude to the individuals and organizations that contributed to the completion of this important project and the development of this report. In particular, NHCOA warmly thanks the Arcus Foundation for its generous support of the project and development of the report. Thanks to its unwavering support, NHCOA was able to conduct the needs assessment and produce this report. Several NHCOA staff worked on the development and implementation of this project. Maria Eugenia Hernández-Lane, NHCOA Vice President, led the development and implementation of the needs assessments project and the preparation of this report. Jason Coates, Public Policy Associate, conducted the literature review and provided important insight on the development of the moderator’s guide. Nataly Arce, Special Events Associate, provided assistance with forums, logistics, and participants’ recruitment. Martha Peredo, Editor, offered editorial oversight. We would also like to acknowledge Ivonne Rivera, President of the Rivera Group, for providing her expertise facilitating the forums and providing a topline report. We extend a special thanks to the focus group and in-depth interview participants – older adults, caregivers, and service providers – who gave their time and shared their personal experiences, stories, and perceptions. Their views will continue to serve as an important force for raising and addressing the needs of LGBT Hispanic older adults in the U.S.

FOREWORD From their respective experiences working with LGBT Hispanic older adults, Services and Advocacy for GLBT Elders (SAGE) and the National Hispanic Council on Aging (NHCOA) have long known that this elder population faces specialized challenges and is particularly vulnerable. Until now, however, that knowledge was limited to individual anecdotes; no research had intensively examined the needs of and interests of LGBT Hispanic older adults from around the country. With the release of this path-breaking report, NHCOA has changed that landscape and made a critically important – in fact, foundational -- contribution to building a body of knowledge on diverse older adults, including Hispanic elders who are LGBT. Many of the participants in this needs assessment report experiencing both racial/ethnic and LGBT-based discrimination in housing and the workplace, negatively impacting their chances of achieving the fundamentals of housing and income security. When older people are saddled with housing insecurity and cannot rely on a steady job in their latter working years, their ability to retire at an appropriate age diminishes and their risk for poverty during their elder years increases. This report demonstrates that discrimination on multiple fronts complicates the burdens facing LGBT Hispanic older adults and makes it even more difficult for them to age successfully. Equally important, in this needs assessment many LGBT Hispanic older adults report feeling excluded and isolated from their various communities – whether it is their families, their Hispanic community, or their LGBT community. The fact that many LGBT Hispanic older adults report both that they suffer from multiple layers of discrimination and that they cannot count on their communities and those who should be closest to them for support is particularly troubling and worthy of substantial attention. Social isolation is a phenomenon that affects many older people, and it’s especially pronounced when elders fear stigma, bias and discrimination even from their few sources of support and engagement. NHCOA’s report makes clear that facing multiple forms of discrimination and living in social isolation can have devastating effects on the lives and well-being of LGBT Hispanic older adults, and that we need multiple responses to support this marginalized community. As a result, the report makes a number of important recommendations, including promoting cultural and linguistic competence among aging and service providers, taking decisive steps to improve economic security, increasing this population’s access to health care, and producing more data and research on the lives of LGBT Hispanic older adults. With regard to the need for more research, it is worth noting that while this report makes a foundational contribution to building our knowledge of what happens at the intersections of the LGBT, Hispanic and aging experiences, much work remains to be done to deepen our understanding and to identify promising solutions. 3

After an eye-opening report like In Their Own Words: a Needs Assessment of Hispanic LGBT Older Adults, the question for policymakers, funders, and organizations like NHCOA and SAGE must be: What Now? Knowledge such as that contained in this report must be harnessed to make a positive difference in the lives of this especially vulnerable elder sub-population. In fact, to date very little has been done to address the specific needs of LGBT Hispanic older adults. SAGEâ&#x20AC;&#x2122;s outreach work to Spanish-speaking LGBT elders in New York Cityâ&#x20AC;&#x2122;s East Harlem neighborhood and similar work by the Azteca project in San Diego represent nascent efforts to address the substantial need for services, information and social connection documented here. In addition, SAGE and NHCOA have been working together with our partners in the Diverse Elders Coalition to begin exploring how federal aging policy can improve the lives of marginalized older people, including LGBT Hispanic older adults. As documented here, so much more must be done. And as evinced by the release of this path-breaking study, it is clear that the leadership of NHCOA and its wide Hispanic aging network is critically important. We at SAGE see In Their Own Words as a dramatic call to policymakers, funders and service and advocacy organizations like ours to rise to the challenge by forging and supporting powerful efforts to counter-act the discrimination and isolation LGBT Hispanic older adults face and by engineering new programmatic initiatives that are responsive to their acute needs. We congratulate NHCOA on this path-breaking report and on their determination to ensure that all Hispanic older adults, including those who are LGBT, can lead lives of dignity, respect and fulfillment in their later years. We at SAGE pledge to join in collaboration with NHCOA and other valued partners to improve the lives of LGBT Hispanic older adults. We strongly encourage policymakers, funders and all who can make a difference to do so by carefully studying In Their Own Words and committing to a significant and measurable contribution toward addressing the social problems that this report documents so effectively. Sincerely, Michael Adams Executive Director, SAGE

EXECUTIVE SUMMARY

he rapid aging of the population presents our country with the opportunity to embrace diversity as it appears at all stages of life. Hispanic lesbian, gay, bisexual, transgender (LGBT) older adults are not well understood by the nation’s service providers, or by local, state, and federal governments. There is limited available research on this diverse population. In order to better understand the reality of this diverse community, the National Hispanic Council on Aging (NHCOA) conducted a needs assessment comprised of a literature review, focus groups, and key informant interviews with LGBT Hispanic older adults and with the service providers who work with them. This research project was designed to assess the status of Hispanic LGBT older adults and understand the challenges they face. To develop a foundation of knowledge on which to base its research, NHCOA first conducted a literature review. NHCOA’s literature review documents some of the struggles of Hispanic older adults with diverse sexual orientations and gender identities. These older adults face substantial challenges to aging in dignity and the best possible health. As the older adult population becomes increasingly diverse, researchers must pay greater attention to all LGBT older adults. NHCOA’s review of the available literature, however, found that little was known about the experiences and challenges of the Hispanic population and that there are few organizations that specialize in serving Hispanic LGBT older adults. There is a dearth of research about Hispanic LGBT older adults. The research that is available comes from studies of the larger population of LGBT older adults. The literature review showed that Hispanic LGBT older adults often face challenges in the areas of economic security and health. Part of the reason for this is likely the lack of research on the needs and perspectives of this population. Knowledge about the specific health issues facing Hispanic LGBT older adults will allow healthcare providers to offer better service. Learning how policy decisions impact this population will allow decision makers to craft polices that help Hispanic LGBT older adults achieve economic security. NHCOA calls for more research as an important follow-up step to improving the status of Hispanic LGBT older adults. After establishing a foundation of knowledge and learning of the pressing need for more research, NHCOA held focus groups and key informant interviews. The focus groups and interviews were held in Washington, DC; New York City; Miami; and Los Angeles. Participants shared a wealth of knowledge and experience, as well as recommendations for professionals and the general public. Following is a summary of the findings of the forums and interviews. As they age, many LGBT Hispanic older adults feel excluded and isolated. This danger is compounded by the prejudice and discrimination that many suffer for being members of both a 5

sexual minority and an ethnically marginalized group. Hispanic cultures place a strong value on family, which is of central importance in the lives of many Latinos of all sexual orientations and gender identities. LGBT Hispanics, however, can become estranged from relatives who exhibit bigotry, condemn their sexualities on religious grounds, or simply fail to show understanding. Faith is likewise an important facet of many Hispanics’ lives, and, like one’s family, one’s religion can be a source of support or of alienation, depending on its stance towards LGBT people. Having a fulfilling job (or having had one, in the case of retirees) with a good salary and benefits, and having a safe, affordable place to live are both very important contributors to one’s economic security, health, and happiness. When denied either employment or housing, one’s overall wellbeing is in jeopardy. Participants in these focus groups reported experiencing discrimination in both areas because of their LGBT status. Though such discrimination is prohibited by law in some states and localities, it is still a fact of life for many people, and can occur in both overt and subtle ways that are hard to document and to address. An LGBT person’s quality of life is also affected by his or her relationships with social service and healthcare providers. It is therefore tremendously important that such providers have an understanding of the LGBT community, and demonstrate respect and cultural competency. LGBT people who are Hispanic face the same challenges as many other Latinos in the healthcare or social service setting, and these must also be taken into consideration by providers. Included in these challenges are issues of language accessibility, immigration status, and lack of government benefits. Like so many other seniors, Hispanic LGBT older adults grapple with issues of health, mobility, technology access, and housing security. Presented with this host of potential concerns, the social worker or healthcare provider has much to consider when working with Hispanic LGBT older adults. Participants in this needs assessment shared many recommendations, presented in the “Recommendations” section of this report, to help professionals serve the community most effectively. Overall, many factors can keep Hispanic LGBT older adults from accessing services. Since members of this population are often accustomed to being very self-reliant, they tend not to seek out services available to them. Fear of experiencing discrimination and the social isolation that it causes is another factor that makes accessing services difficult. Oftentimes, geographical isolation prevents Hispanic LGBT older adults from accessing services, as there are many places with health and social service providers that are unfamiliar with serving this population. However, Hispanic LGBT older adults will often accept and appreciate services that are directly offered to them. Outreach is critical, therefore, to inform members of the diverse LGBT Hispanic elder population of the services that are available to them. Above all, forum participants emphasized that education, understanding, and respect are the most important qualities to cultivate in service of the LGBT Hispanic older adult community. 6

Education is key, as it fosters other values. With education, understanding, and respect, service providers can make important strides to delivering services in a culturally-competent manner, and effectively addressing the needs of the diverse LGBT Hispanic older adult population.

INTRODUCTION

he National Hispanic Council on Aging (NHCOA) conducted a qualitative needs assessment to better understand the experiences of aging and socio-economic and health challenges facing the LGBT (lesbian, gay, bisexual, and transgender) Hispanic older adult community. Specifically, the research had the following objectives:     

Understand LGBT Hispanic older adults’ self-perceptions of the aging experience Identify LGBT Hispanic older adults’ health challenges and how they relate to their own circumstances Identify the socio-economic challenges that LGBT Hispanic older adults face Explore the culturally appropriate strategies to better serve LGBT Hispanic older adults Identify gaps in knowledge requiring further research.

This qualitative study comprised two interconnected parts: First, a desk review of the literature was conducted to ascertain what was already known about the struggles of a highly vulnerable U.S. population – Hispanic LGBT older adults. This review also identified gaps in the literature in terms of the coverage of topics and the lack of organizations specializing in serving Hispanic LGBT older adults. Second, LGBT Hispanic older adults’ perceptions and experiences of aging and socio-economic conditions were explored using focus group and individual in-depth interviews. A total of four focus group discussions and ten key informant interviews were held with Hispanic LGBT older adults and service providers. The interviews took place in Washington, DC; New York City; Miami, Florida; and Los Angeles, California. The focus groups in Los Angeles were conducted in English at the request of participants. The three other focus group discussions took place in Spanish. The key informant interviews were conducted either in Spanish or English, as preferred by the interviewees. The groups were selected based on the following eligibility criteria: 1. Age 55 years or older; 2. Self-identification as Hispanic LGBT or identification by a social service provider; 3. Willingness to participate in the needs assessment. The standard focus group guide and interview schedule were utilized for all focus group discussions and interviews (The Forum Moderator’s Guide is provided in Attachment 1, and the Key Informant Interview Guide in Attachment 2.) The findings of focus group discussions and the literature review guided the development of the interview schedule. Semi-structured interviews were used to examine issues related to the health and aging experience, social and economic challenges, as well as housing and civic engagement of Hispanic LGBT older adults. Interviewees openly spoke about their life experiences and health issues and also raised topics that were of particular concern to them.

Data from the focus group discussions and in-depth interviews were translated into English and analyzed separately. For each group, we organized data according to each topic discussed. Then we looked across all respondents and their answers to identify consistencies, differences, and the emerging themes/categories. Next, we looked for common elements to the themes and summarized data for each category. Quotes from the English transcripts that captured participantsâ&#x20AC;&#x2122; opinions were incorporated to support each theme. The following sections present the findings of the needs assessment, including the literature review of research on LGBT Hispanic older adults; results of the focus group and key informant interviews; and the analysis of findings and recommendations for social workers, policy makers, healthcare professionals, and the general public.

GLOSSARY OF TERMS For the purposes of this report, we use the terms “Hispanic LGBT older adult” for readability purposes. This phrase encompasses a wide variety of people that are diverse in race, ethnicity, country of origin, immigration status, and more – as well as being diverse in sexual orientation and gender identity. We recognize that people have multiple identities and often navigate spaces where they are not allowed to bring their full selves into the room. Our focus group participants come from all walks of life. Below is a glossary of terms for “Hispanic” and “LGBT.” Gay A word used to describe anyone, mainly men, who have primary physical, romantic, and/or emotional attraction to someone of the same sex, e.g. gay man, gay people. Many gay people prefer this term over “homosexual,” which retains negative connotations. Lesbian can be a preferred term for a gay woman. Bisexual, Bi An individual who is physically, romantically, and/or emotionally attracted to both men and women. “Bisexual” does not suggest a person has equal sexual experience with both men and women. In fact, some people who call themselves “bisexual” have not had any sexual experience at all. Lesbian A woman whose primary physical, romantic, and/or emotional attraction is to other women. Some lesbians may prefer to identify as gay (adj.) or as gay women. Many lesbians view “homosexual” as a derogatory term. Transgender An umbrella term for people whose gender identity and/or gender expression differs from the sex they were assigned at birth. The term may include, but is not limited to transsexuals and cross-dressers. Transgender people may identify as female-to-male (FTM) or male-to-female (MTF). It is important to use the descriptive term (transgender, transsexual, cross-dresser, FTM or MTF) preferred by the individual. Transgender people may or may not decide to alter their bodies hormonally and/or surgically. Hispanic and Latino People who identify themselves as being of Spanish-speaking background and trace their origin or descent from Mexico, Puerto Rico, Cuba, Central and South America, and other Spanish-speaking countries. People that are Hispanic or Latino can be of any race.

LITERATURE REVIEW In order to ensure that all the nation’s seniors have a high quality of life, it is imperative to understand the diversity of the population. This literature review examines research on Hispanic older adults, LGBT older adults, and LGBT Hispanics, to determine the scope “I think there is a huge of knowledge on Hispanic LGBT older adults and what research is needed in the future. Research on Hispanic problem with older LGBT older adults is scarce. No major studies focus persons, aside from exclusively on this group; the only information that is rejection. Nobody available comes from sources studying LGBT older adults wants to get near or overall. Consequently, this review analyzed studies that talk to an LGBT examine people at the intersection of diverse identities, for person, even if they are example, articles on LGBT Hispanics or LGBT older adults. Doing so revealed commonalities between LGBT in the same Hispanics, LGBT older adults, and Hispanic older adults place…There is a great and gaps where more research is required. The review also deal of rejection of old briefly describes organizations that specialize in serving persons. That is why Hispanic LGBT older adults, as they may be able to provide those old men and additional insight. The following literature review first identifies organizations that serve Hispanic LGBT older adults. Next, it provides a brief overview of the economic and health status of Hispanic older adults. It then looks in depth at the economic and health status of LGBT older adults and LGBT Hispanics. Finally, it discusses what current literature and research is able to tell us about the status of Hispanic LGBT older adults.

women do not have support groups even among themselves…We are persons who, because of who we are, people are not interested in…” - Study participant

Organizations Serving Hispanic LGBT Older Adults With the growing number of Hispanic LGBT older adults, there is a tremendous need for community-based organizations that serve them in a culturally- and linguistically-competent manner. The Azteca Project near San Diego, California, and the Harlem branch of Services and Activities for GLBT Elders (SAGE) are organizations dedicated to serving racially- and ethnically-diverse LGBT older adults. The Azteca Project is dedicated to providing support and referral services to Hispanic LGBT older adults (Azteca Project, a). The initiative, founded by activist John Acosta, organizes food and clothing drives and conducts efforts to educate the 11

public about issues affecting Hispanic LGBT older adults (Azteca Project, b). SAGE Harlem offers a variety services to connect LGBT older adults, many of them Hispanic, to available resources, legal assistance, and opportunities for social interaction (SAGE). Despite the need for organizations like SAGE and the Azteca Project across the country, there are few organizations that are dedicated to serving Hispanic LGBT older adults. There are some exceptions, with most such organizations working in parts of the country with large populations of Hispanics, like Southern California. Gay and Lesbian Elder Housing (GLEH) in Hollywood, California, specializes in serving lower-income LGBT older adults in need of housing (Gay and Lesbian Elder Housing). Organizations like GLEH have developed the capacity and expertise to work with Hispanic LGBT older adults through years of experience. As the Hispanic LGBT population grows and ages, similar organizations will gain such experience.

Hispanic Older Adults The rapid growth of the Hispanic population in the United States, including that of Hispanic older adults, is well documented (US Census Bureau, 2008). Hispanic older adults are a diverse population (Ennis, Rios-Vargas, & Albert, 2011) who face significant challenges in old age, primarily having to do with attaining financial security, maintaining health (Administration on Aging, 2010), and accessing needed services (Hispanics in Philanthropy, 2011). Economic Status Hispanic older adults face many challenges in attaining economic security in old age. Low levels of formal education (Administration on Aging, 2010), language barriers, and limited economic opportunities throughout life (US Bureau of Labor Statistics, 2010) all make affording secure retirement difficult for many Hispanic older adults. In general, higher levels of education lead to higher rates of employment and higher income (US Bureau of Labor Statistics, 2011). Although the Hispanic community is making great strides in educational achievement (Fry, 2009), Hispanic older adults have significantly lower levels of educational attainment than the general older adult population (Administration on Aging, 2010). Similarly, the Pew Hispanic Center notes that first-generation immigrants to the U.S. are less likely to speak English as well as subsequent generations (Hakimzadeh, Cohn, 2007). Because many Hispanic older adults are first-generation immigrants, many were disadvantaged in the job market by limited English proficiency (Hakimzadeh et al, 2007). The Bureau of Labor Statistics notes that Hispanics are overrepresented in generally low-wage positions and that, when they do have work in occupations that tend to pay more, they earn less than their counterparts in other ethnic groups 12

(US Bureau of Labor Statistics, 2011). These three factors – limited education, English proficiency, and job prospects – hold Hispanic older adults back from achieving economicallysecure golden years. Hispanics have less wealth saved and invested than the general population, another setback to economic security in retirement (Kochhar, Fry, & Taylor, 2011). Hispanic households possess less in home equity (Kochhar et al, 2011) and other investments (Kochhar, 2004). In 2009, the median value of home equity held by Hispanic households was $3,519 (Kochhar et al, 2011). Additionally, Hispanic households are less likely than the general population to own retirement accounts or other interest-bearing savings accounts (Kochhar, 2004). This lack of wealth makes economic security in retirement difficult. In recent years, funding retirement has been difficult for everyone, but Hispanics have been hit particularly hard by the economic downturn (Kochhar et al, 2011). For example, from 2005 to 2009, the median net worth fell 16% for non-Hispanic white households and 53% for black households; taking the largest losses, however, were Hispanic households, whose median net worth fell 66% (Kochhar et al, 2011). One of the major factors for these huge losses was that many Hispanics live in states like Nevada and Florida, where housing markets endured steep declines in value (Kochhar et al, 2011). This loss in wealth further limited the ability of Hispanics to prepare for old age. Maintaining economic security is especially difficult for Hispanics as older adults. According to the US Census Bureau, nearly 18% of Hispanic older adults lived in poverty in 2010 (DeNavasWalt, Proctor, & Smith, 2011). This number would be substantially higher were it not for Social Security, which is keeping more than ten million of the nation’s most vulnerable seniors out of poverty (DeNavas-Walt et al, 2011). For Hispanics, Social Security is particularly important; more than 40% of married Hispanic older adults and more than 60% of unmarried Hispanic older adults rely on it for 90% or more of their income (Social Security Administration, 2012). In 2010, the average annual Social Security benefit to Hispanic men was $12,815, and Hispanic women earned $9,605 from the program (Social Security Administration, 2012). Complicating the challenges Hispanics face in achieving economic security is the fact that Hispanic older adults often have difficulty in accessing community-based resources in this area due to language barriers and lack of cultural competence among service providers (Hispanics in Philanthropy, 2011). Health Status of Hispanic Older Adults As with economic security, Hispanic older adults face unique health challenges as they age. According to the Centers for Disease Control and Prevention (CDC), nearly 10% of Hispanics rate their health as “fair” or “poor” (Adams, Martinez, Vickerie, & Kirzinger, 2011). Hispanic older adults are likely to enter Medicare in worse health than the general population of older adults due to difficulty in accessing health insurance earlier in life (DeNavas-Walt et al, 2011). 13

Hispanics endure multiple health inequities. For example, the National Center for Health Statistics reports that they are about half as likely to receive a pneumococcal vaccination as nonHispanic whites (National Center for Health Statistics, 2010). The disparity in chronic diseases is even more troubling. Hispanic women are disproportionately afflicted with cervical cancer and are more likely to die from it, compared to the general female population (National Cancer Institute, 2008). Hispanics are more likely than non-Hispanic whites to suffer from diabetes (National Center for Health Statistics, 2010), and the National Hispanic Council on Aging has noted that this condition is particularly prevalent among the older adult population. Recent data shows that Hispanic men are more than twice as likely to die from HIV/AIDS as non-Hispanic white males and Asian-American males (National Center for Health Statistics, 2010). Access to healthcare is more difficult for Hispanics at all ages (DeNavas-Walt et al, 2011). Medicare provides health insurance in old age, but according to the most recent data, 30.7% of Hispanics lack health insurance, about 10% more than any other racial or ethnic group (DeNavas-Walt et al, 2011). This means that Hispanic older adults may be likely to enter Medicare in worse health than the general population. Further, although Medicare is helpful in providing access to healthcare, it does not pay all medical costs, and, on average, beneficiaries pay $4,586 out of their own pockets for healthcare (Nonnemaker, & Sinclair, 2011). These costs can be a burden for Hispanic older adults, even to the point that they may delay seeking healthcare (Administration on Aging, 2010). Linguistic barriers and lack of cultural competence on the part of healthcare providers also makes healthcare less accessible (National Alliance for Hispanic Health, 2001). Some Hispanics with limited English proficiency feel that they do not receive adequate care when they cannot understand an Englishspeaking healthcare provider (Livingston, Minushkin, & Cohn, 2008). The US Department of Health and Human Services recognizes the value of having healthcare providers who can interact with and treat patients with cultural competence, and has developed guidelines to improve care (National Alliance for Hispanic Health, 2001). Health inequities and financial and cultural barriers to receiving healthcare in later life all negatively affect the health of Hispanic older adults. As the country grows more diverse, health care providers and researchers will have to adapt in order to work effectively with diverse populations and develop the means to deliver the best possible healthcare.

LGBT Older Adults The population of Hispanic LGBT older adults is diverse, growing rapidly, and under-researched (Fredriksen-Goldsen et al, 2011). LBGT older adults face a unique set of challenges. For example, accessing community services and supports, and benefitting fully from Social Security, Medicare, and Medicaid, are more difficult for them than for other older adults. Economic Status of LGBT Older Adults The economic status of LGBT older adults is not well documented. Some studies indicate that they are poorer and less secure economically as compared to the general population of older adults (The Movement Advancement Project, & Services and Advocacy for GLBT Elders, 2010), while other studies indicate that their overall economic status is similar (FredriksenGoldsen et al, 2011, and Oâ&#x20AC;&#x2122;Brien, Wu, & Baer, 2010). Studies agree that LGBT older adults face many unique challenges to achieving economic security in old age. Employment discrimination and anti-LGBT bias experienced throughout life are barriers keeping many Hispanic LGBT people from getting and staying in a good job at all stages of life. These economic difficulties are compounded by the challenges of aging, and can keep LGBT older adults from living in economic security (Fredriksen-Goldsen et al, 2011). Social Security, Medicare, and Medicaid only offer full benefits to married couples, and because marriage equality is banned in most states, same-sex couples may not enjoy the full protection of these programs. Likewise, retirement benefits and health insurance often do not extend full coverage to the same-sex couples, posing a barrier to preparation for the economic challenges of later life. Overall, 29 states do

not prohibit discrimination on the basis of sexual orientation or gender identity.

Employment Discrimination Against LGBT Older Adults

Anti-LGBT discrimination can result in lower wages, which in turn harms economic security in old age (The Movement Advancement Project et al, 2010). There is currently no federal law that prohibits employment discrimination based on sexual orientation and gender identity. This means that employers, where not prohibited by state or local law, can fire or refuse to hire qualified, capable individuals based solely on their LGBT status. Overall, 29 states do not prohibit discrimination on the basis of sexual orientation or gender identity. Moreover, lesbian couples, because of the gender gap in wages as well as anti-LGBT employment bias, earn even less than married same-sex older adult male couples (The Movement Advancement Project et al, 2010). Gay men earn 10% less than straight men with similar qualifications (Grant, 2009). The transgender population is the most likely of all LGBT subgroups to earn wages at or below 200% of the federal poverty level (Fredriksen-Goldsen et al, 2011). Employment discrimination and other forms of anti-LGBT bias

endured throughout life have a negative economic impact on the LGBT population, and limit their economic security in old age. Lack of Full Social Security Benefits Because most states prohibit same-sex marriage, and despite the U.S. Supreme Court’s decision in United States v. Windsor, many LGBT same-sex couples are denied the survivor benefits, spousal benefits, and death benefits that are offered to Social Security beneficiaries in heterosexual marriages (The Movement Advancement Project et al, 2010, and Lambda Legal a, 2013). Survivor benefits entitle a widowed spouse to either his or her own Social Security benefits or 100% of the deceased spouse’s benefits. Additionally, Social Security offers a onetime payment to help meet funeral expenses. These features of the program are especially helpful to spouses of partners who had earned higher wages. Not extending these policies to include same-sex couples can mean a loss of thousands of dollars per year (The Movement Advancement Project et al, 2010). For an older adult living near the poverty line, such a difference in income can be the difference between life and death. Currently, same-sex couples, even if they are married or have been together for years, do not receive the Social Security spousal benefit if they live in one of the many states that prohibit marriage equality (The Movement Advancement Project et al, 2010, and Lambda Legal a, 2013). This benefit provides a spouse the larger amount of their Social Security payment or one half of their spouse’s benefit. Spousal benefits would be especially helpful to surviving members of LGBT couples in which one partner had foregone working outside the home in order to care for children – a situation that is more common among Hispanic same-sex couples (Cianciotto, 2005). Medicaid Asset and Income Limits Medicaid asset limits also put the economic security of same-sex older adult couples at risk. Although many people will need long-term care during old age, few have insurance or adequate savings for such needs (The Movement Advancement Project et al, 2010). Medicaid, a meanstested program, pays for most long-term care in the U.S. (The Movement Advancement Project et al, 2010). Although the benefits it provides are valuable, Medicaid’s policies on exempting assets and income from means testing can significantly harm same-sex older adult couples. When qualifying for Medicaid, same-sex couples in some states do not enjoy the same asset protection policies as married couples (The Movement Advancement Project et al, 2010, Lambda Legal b, 2013). After the Windsor decision, the Centers for Medicare and Medicaid Services (CMS) issued guidance to states on qualifying for Medicaid. CMS encourages all states to recognize legally married couples for purposes of Medicaid qualification. States that recognize marriage equality must allow all married couples to qualify and enroll in Medicaid as married couples. States that do not recognize marriage equality, however, are not required to allow people in same-sex marriages to qualify for Medicaid as a married person. Thus, some states do 16

not extend the asset and income protections of Medicaid to married same-sex couples. Married couples are allowed to keep the greater of all assets up to around $22,000 or half of all assets up to around $110,000 (The Movement Advancement Project et al, 2010). In contrast, in states that do not recognize same-sex marriage, LGBT older adults apply for Medicaid as individuals, and thus may only retain $2,000 in assets (The Movement Advancement Project et al, 2010). Their partners do not enjoy any of the asset protections afforded to married couples (The Movement Advancement Project et al, 2010, and Lambda Legal b, 2013). This policy harms same-sex couples when one partner has greater savings than the other and is forced to spend it all to qualify for Medicaid, whereas married couples may retain more assets to provide for the partner not enrolled in the program. Married Medicaid beneficiaries can set aside some of their income to provide for their spouses, but this protection is not available to same-sex couples in states that prohibit marriage equality (The Movement Advancement Project et al, 2010). LGBT Medicaid beneficiaries in states that prohibit marriage equality are required to spend nearly all of the income they receive on health care. As with the asset protection provision, this policy does the most to harm lower-earning members of same-sex couples, whose income may not have been counted on as a living wage for support earlier in life. Health Status of LGBT Older Adults Like other diverse populations, LGBT older adults face distinct health inequities and challenges in accessing healthcare. HIV/AIDS, mental health problems, and substance abuse all affect LGBT older adults disproportionately (Mayer, Bradford, Makadon, Stall, Goldhammer, & Landers, 2008). Many healthcare providers are unfamiliar with the unique care needs of the LGBT population (Mayer et al, 2008). An older adultâ&#x20AC;&#x2122;s decision not to seek needed medical treatment or to disclose his or her LGBT status can be another barrier to achieving the best possible health (Mayer et al, 2008, and The Movement Advancement Project et al, 2010). LGBT Hispanics endure the same health inequities present in the LGBT older adult population as a whole. For LGBT Hispanics, however, these inequities are felt at a disproportionate rate. HIV/AIDS For many years, LGBT health research focused on HIV/AIDS (Mayer et al, 2008). Gay and bisexual men disproportionately deal with HIV (Centers for Disease Control and Prevention, 2010). In 2007, the Centers for Disease Control and Prevention estimated that gay or bisexual men were 44 to 86 times more likely to have HIV when compared to other men (Centers for Disease Control and Prevention, 2010). According to the U.S. Senateâ&#x20AC;&#x2122;s Special Committee on Aging, by 2015, half of all Americans with HIV will be age 50 and older (Fredriksen-Goldsen et al, 2011). Currently, about 31% of those living with HIV are 50 and over, and about 15% of all new HIV infections develop in this age group (Fredriksen-Goldsen et al, 2011). 17

Recent research shows that HIV infection is associated with increased risk for other chronic health conditions (Fredriksen-Goldsen et al, 2011, and The Movement Advancement Project et al, 2010, and Mayer et al, 2008). Fredriksen-Goldsen found that, compared to LGBT older adults without HIV, those with HIV are more likely to be in poor physical and mental health and to be disabled. They are also more likely to have hepatitis and cancer (Fredriksen-Goldsen et al, 2011). Other researchers have found abnormalities in lipid levels (Mayer et al, 2008), kidney disorders, and osteoporosis (The Movement Advancement Project et al, 2010). LGBT older adults with HIV are also less likely to have social support, more likely to live alone, and more likely to experience victimization than HIV-negative LGBT older adults (Fredriksen-Goldsen et al, 2011). They are also more likely to be denied healthcare and to have difficulty paying for prescription medications (Fredriksen-Goldsen et al, 2011). Although these studies have yielded valuable findings, researchers do not have a complete understanding of how HIV impacts the aging process (The Movement Advancement Project et al, 2010). Mental Health and Substance Abuse Researchers are also now focusing on mental health inequities (Mayer et al, 2008). Compared to the general population, gay and bisexual men are twice as likely to struggle with mental health concerns, and lesbian and bisexual women are three times as likely (Grant, 2009). Fredriksen-Goldsenâ&#x20AC;&#x2122;s study of 2,560 LGBT older adults found that 31% of participants have symptoms of depression (Fredriksen-Goldsen et al, 2011), and that 39% have thought of taking their own lives (FredriksenGoldsen et al, 2011). The transgender population has higher reported levels of depression, anxiety, and suicide attempts (Fredriksen-Goldsen et al, 2011). A California study of LGBT older adults found that they were more likely to live alone (Wallace, Cochran, Durazo, & Ford, 2011), and about twice as likely as heterosexual older adults to need help with mental health and emotional issues (Wallace et al, 2011).

Compared to the general population, gay and bisexual men are twice as likely to struggle with mental health concerns, and lesbian and bisexual women are three times as likely.

It is likely that LGBT older adults have higher rates of substance abuse than the general population (Mayer et al, 2008), and researchers closely link this to mental health issues (The Movement Advancement Project et al, 2010, and Grant, 2009, and Mayer et al, 2008). More research is needed to determine whether LGBT older adults disproportionately abuse substances. Researchers have found disparate rates of substance abuse in the LGBT population overall (Grant, 2009). For example, LGBT people suffer from addiction and use illegal drugs at higher rates than the non-LGBT population (Grant, 2009). Use of tobacco products is also more 18

prevalent in the LGBT population than among the general population (Mayer, 2008). These health disparities are largely a result of stigmatization and the stress it causes (Mayer, 2008). Fredriksen-Goldsen’s study is one of the first to examine substance abuse among LGBT older adults. It noted that 12% of participants used illegal drugs in the past year (Fredriksen-Goldsen et al, 2011), a level more than twice as high as the Substance Abuse and Mental Health Services Administration’s finding of 5.2% illegal drug use in the general population of adults 50 and over (The Substance Abuse and Mental Health Services Administration, 2011). It also found high rates of excessive drinking among the LGBT older adult population. Among LGBT older adults, 17.13% of gay and bisexual men and 7.88% of lesbian and bisexual women drank alcohol excessively in the preceding year, compared to 11.12% and 4.61% for heterosexual men and women, respectively (Fredriksen-Goldsen et al, 2011). Researchers are just now beginning to turn their attention to substance abuse in the overall population of older adults (The Substance Abuse and Mental Health Services Administration, 2011), and the disproportionately high rates in the LGBT community identified by Fredriksen-Goldsen suggest that more research is also needed for this population. Mental health issues and substance abuse are not an inherent part of being an LGBT older adult; however, anti-LGBT bias and its broad effects have a strong negative impact on mental health (Mayer, 2008). When many of today’s LGBT older adults were born, LGBT status was considered a mental illness (Grant, 2009), and many are still reluctant to disclose their status to healthcare providers due to fear of discrimination (Mayer, 2008). Overall, disclosing LGBT status has a positive effect on mental health (Fredriksen-Goldsen et al, 2011). It can also lead to more appropriate health care, because the provider will have more information about the patient. Health care providers often discriminate against LGBT older adult patients, however (Fredriksen-Goldsen et al, 2011). Training health care providers for cultural competence can help reduce this discrimination. It is important for health care providers to ask patients about sexual orientation and gender identity, but these questions should be phrased properly and paired with proper instruction and training. Overall, a lifetime of discrimination is harmful to mental health (Grant, 2009, and FredriksenGoldsen et al, 2011), and rates of victimization are high (Fredriksen-Goldsen et al, 2011). Of the participants in Fredriksen-Goldsen’s study, 82% were victimized at least once in their lives due to their LGBT status (Fredriksen-Goldsen et al, 2011). Additionally, LGBT older adults with lower incomes are more likely to report experiencing bias and to report lower levels of social support (Fredriksen-Goldsen et al, 2011). Researchers and practitioners have more work to do to discover the best approach to reducing mental illness and substance abuse in the LGBT older adult population. Overall, efforts to make society more tolerant and accepting of the LGBT community will help improve mental health in this population.

LGBT Hispanics The LGBT Hispanic population is large, diverse, growing, and under-researched. Most research focuses on health inequities or conditions that disproportionately affect a segment of the population. Researchers use the data available to them from the U.S. Census and surveys that include information on “same-sex unmarried partners” to draw inferences about the broader LGBT population. These new Census- and survey-based studies yield valuable information about the economic status of LGBT Hispanics, though it has limitations. The characteristics of same-sex couples might be different than those of single LGBT people. Also, the data from these studies only includes couples willing to acknowledge their relationship and be “out” for a survey. The Census also does not include questions for transgender people or those who identify as “queer.” As more people “come out,” collection of accurate data on the LGBT population is more important than ever. Economic Status of LGBT Hispanics Housing, income, educational attainment, and parenting status all have an impact on economic status. A 2005 study by Jason Cianciotto examined the results of the 2000 Census to find out about Hispanic same-sex households (Cianciotto, 2005). In 2000, there were 105,025 Hispanic same-sex households in the U.S., compared to 770,000 Hispanic opposite-sex couple households (Cianciotto, 2005). Forty-six percent of Hispanic male same-sex couples and 50% of Hispanic female same-sex couples owned their own homes, compared to 60% of married Hispanic opposite-sex couples and 30% of Hispanic heterosexual cohabiting unmarried couples (Cianciotto, 2005). Like the general Hispanic population, Cianciotto found that LGBT Hispanic couples live throughout the country, but are most concentrated in Arizona, California, Florida, Texas, and the New York City area (2005). According to Craig J. Konnoth of the Williams Institute, these residence patterns remained the same in 2011 (Konnoth, 2011). Additionally, LGBT Hispanic households tended to be located in Hispanic communities, rather than LGBT communities (Grant, 2009). Income in Hispanic same-sex households was similar to income in Hispanic opposite-sex households. Hispanic male same-sex couples had an average annual income of $49,800, and Hispanic female same-sex couples had an average annual income of $43,000, while Hispanic married opposite-sex households earned $44,000 on average (Cianciotto, 2005).

A quality education and good job are vital pieces of economic security in later life. In the households Cianciotto studied, 71% of individuals reported having full-time employment; this number is similar to that of non-Hispanic white same-sex households, where 74% of individuals are employed full-time, and it is slightly higher than the employment level of Hispanic heterosexual couples (67%) (Cianciotto, 2005). Although these employment numbers are encouraging, educational attainment was significantly lower in Hispanic same-sex households than in non-Hispanic white same-sex couples. Only 23% of individuals in Hispanic same-sex households had completed some level of education beyond high school, compared to 66% of individuals in non-Hispanic white same-sex couple households (Cianciotto, 2005). Seventy-two percent of individuals in households in which one of the partners was Hispanic had completed education beyond high school (Cianciotto, 2005). Addressing the disparity in educational attainment between Hispanics in inter-ethnic relationships and Hispanics in same-sex relationships with other Hispanics will likely have positive outcomes for Hispanic LGBT older adults. Like Hispanic households overall, Cianciotto found that Hispanic same-sex couple households are likely to raise children (Cianciotto, 2005). Seventy percent of married Hispanic households were raising children 18 years of age or younger (Cianciotto, 2005). Hispanic same-sex couples showed similar, though lower, rates of child-rearing. Fifty-eight percent of Hispanic male couples raised children, and 66% of Hispanic female couples raised children (Cianciotto, 2005). These percentages of child-rearing are much higher than those of non-Hispanic white same-sex couples, where 19% of male households and 32% of female households raise children (Cianciotto, 2005). A recent study by the Williams Institute indicates that children growing up in Hispanic LGBT households are more likely to live in poverty than their counterparts in married, opposite-sex couple households (Albeda, Badgett, Schneebaum, & Gates, 2009). As people age, however, adult children often take a caregiving role (Feinberg, Reinhard, Houser, & Choula, 2011); the relatively high numbers of households raising children in the Hispanic LGBT community could help ease the burdens of aging when compared to other LGBT populations. Cianciotto found that female Hispanic same-sex couples are more likely to have used public assistance programs than married Hispanic households and non-Hispanic white same-sex households (Cianciotto, 2005). Eight percent of Hispanic female same-sex couple households reported that they received public assistance, like Temporary Assistance for Needy Families, compared to 4% for Hispanic married heterosexual couples and 5% for Hispanic male couples (Cianciotto, 2005). Information on the economic status of LGBT Hispanics is valuable, but limited. Cianciottoâ&#x20AC;&#x2122;s study does a good job of describing the economic status of LGBT Hispanics, but the information is now dated and it applies only to LGBT Hispanics who have established households. Researchers should further study the economic status of this growing population group.

Health Status of LGBT Hispanics Income and accumulated wealth are closely related to health status, regardless of age, race, ethnicity, sexual orientation, or gender identity (Braveman, Egerter, & Barclay, 2011). Many more factors contribute to the health of LGBT Hispanics, however. Jeff Krehely, of the Center for American Progress, argues that health inequities among LGBT populations of color are largely a product of unaffordable health insurance, lack of cultural competence among healthcare providers, and prejudice about race and ethnicity (2009). Other researchers have examined the impact that anti-LGBT bias, race, poverty, and social support have on the health of LGBT Hispanics (Diaz, Ayala, Bein, Henne, & Marin, 2001, and Cochran, Mays, Alegria, Ortega, & Takeuchi, 2007). Mental health issues (Diaz et al, 2001), substance abuse, and HIV (Krehely, 2009) all affect LGBT Hispanics at disproportionate rates. Studies show that poor mental health often takes the form of depression, suicidal ideation, and social isolation (Diaz et al, 2001, and Cochran et al, 2007). Compared to heterosexual Hispanics, lesbian Hispanics are more likely to experience depression, and gay and bisexual Hispanics are more likely to have attempted suicide (Cochran et al, 2007). Compared to the general LGBT population, LGBT Hispanics have the poorest selfreported status of mental health (Fredriksen-Goldsen et al, 2011) and are more likely to experience depression and higher levels of stress (Fredriksen-Goldsen et al, 2011).

“One of the challenges for the current LGBT population is that they are not screened on a regular basis for sexually transmitted diseases, simply because the age stereotype applies to them as well… And if they are sexually active, they do not think they are at risk and a lot of the symptoms of sexually transmitted diseases mimic the symptoms you have when you are aging.” - Study participant

Substance abuse is a health issue among LGBT Hispanics (Krehely, 2009). According to Krehely, 60% of LGBT Hispanics abuse alcohol (Krehely, 2009, and Cochran et al, 2007). LGBT Hispanics, particularly females, are more likely to suffer from the ill effects of substance abuse than the general population (Cochran et al, 2007). LGBT Hispanics, particularly gay Hispanic men, also have a high rate of HIV infection as compared to other LGBT populations (Grant, 2009, and Kuhns, Vazquez, & Ramirez-Valles, 2008, and Ceballos-Capitaine, Szapocznik, Blaney, Morgan, Millon, & Eisdorfer, 1990). Anti-LGBT bias and racism have a negative impact on health (Diaz et al, 2001). LGBT Hispanics experience bias throughout life in the form of verbal harassment, employment discrimination, and even physical violence (Diaz et al, 2001). One of the first studies of LGBT older adults that also studied the 22

population by race and ethnicity found that Hispanic LGBT older adults had lower levels of social support (Fredriksen-Goldsen, 2011) and higher levels of victimization and neglect (Fredriksen-Goldsen, 2011) than the general population of LGBT older adults. Diaz found that, during childhood, 70% of respondents felt that their sexual orientation harmed their family (Diaz, 2001). This is particularly troubling, because in the Hispanic community, family is often a source of support and strength (Kaminsky, Kurtines, Hervis, Blaney, Millon, & Szapocznik, 1990). Racism can separate LGBT Hispanics from the non-Hispanic white LGBT community, cutting off a potential source of support (Diaz et al, 2001). Diaz also found that poverty exacerbates the impact of racism and anti-LGBT bias in ways that are detrimental to mental health (Diaz et al, 2001). Retaining LGBT Hispanics in long-term health studies is difficult (Kuhns et al, 2008). Cultural and linguistic barriers, high mobility, and distrust of unfamiliar institutions can all limit the ability of a researcher to maintain contact with an LGBT Hispanic study participant (Kuhns et al, 2008). Kuhns et al successfully maintained contact throughout a long-term study, but had to collect many pieces of contact information, vary contact methods depending on the study participants’ city of residence, and work to develop a personal rapport with each participant to achieve a successful study follow-up (2008). Although Kuhns et al were successful in reconnecting with study participants, they stressed that their methods and results may not be possible to duplicate in other locations and among other populations of LGBT Hispanics (2008). Cultural and linguistic differences make accessing care difficult, and make that care less effective, for LGBT Hispanics (Krehely, 2009). Researchers identified the role of family (Kaminsky et al, 1990, and Ellison, Acevedo, & Ramos-Wada, 2011), views of gender identity, LGBT status, HIV status (Kuhns et al, 2008, and Flaskerud, Nyamathi, & Uman, 1997), and methods of communication (Marin, 1989) as cultural barriers that prevent LGBT Hispanics from receiving effective healthcare. To address health inequities in this population, culturally- and linguistically-competent health interventions are needed (Flaskerud, et al, 1997, and Kaminsky et al, 1990, and Marin, 1989). The Department of Health and Human Services’ Office of Minority Health defines cultural competence as “a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among professionals that enables effective work in crosscultural situations” (The Office of Minority Health, 2011).

Researchers and service providers have developed some successful health promotion programs for LGBT Hispanics. Such programs incorporate families (Kaminsky et al, 1990) and recognize them as a valuable resource in transmitting health information (Marin 1989). Additionally, they work to dispel the stigma and address the seriousness of HIV among Hispanics (Kaminsky et al, 1990). Successful health interventions also recognize the importance of forming a personal relationship with participants (Kuhns et al, 2008). These techniques are a valuable foundation on which to base further research. The ability to afford and access preventive treatments is another area of difficulty. Of all LGBT populations, Hispanics are the least likely to have a regular source of healthcare (Krehely, 2009). Medicare insures most older adults, but Hispanics are less likely to be able to afford prescription medications than the non-Hispanic white LGBT population (Fredriksen-Goldsen et al, 2011). In accessing preventive care, Hispanic LGBT older adults are less likely than the non-Hispanic white LGBT population to receive screening for osteoporosis (Fredriksen-Goldsen et al, 2011). Improving economic security and increasing access to affordable healthcare will be key challenges to ensuring that Hispanic LGBT older adults can age with dignity.

SUMMARY: WHAT WE KNOW ABOUT HISPANIC LGBT OLDER ADULTS

vailable research has a few key pieces of information about older adults who have lived with the experience of being both Hispanic and LGBT. Research shows that, in early life, LGBT Hispanics endure mental health issues, challenges and bias associated with HIV, racism, and anti-LGBT bias at even higher rates than the general LGBT population. As discussed above, in later life LGBT Hispanics suffer from poorer health, including higher incidence of HIV, diabetes, asthma, and impaired vision (Fredriksen-Goldsen et al, 2011), as a result of poor health earlier in life. With the lowest access to health insurance of all racial and ethnic groups, Hispanic people are more likely to enter old age, and Medicare, in poor health. Making matters worse, Hispanic LGBT older adults are less likely to have social support (Fredriksen-Goldsen et al, 2011) and more likely to endure victimization (Fredriksen-Goldsen et al, 2011), neglect, and mental health problems (Fredriksen-Goldsen et al, 2011) than the general LGBT older adult population. LGBT Hispanic older adults likely face the most severe health burdens of the LGBT, Hispanic, and older adult populations. Hispanic LGBT older adults face economic difficulties, which can also have a negative impact on health. They are less likely than other LGBT older adults to be able to afford prescription medication (Fredriksen-Goldsen et al, 2011). While heterosexual married couples are able to make health decisions in the case of one partnerâ&#x20AC;&#x2122;s incapacitation, same-sex couples often need 24

complex legal arrangements to do so. Hispanic LGBT older adults are less likely to have made these arrangements (Fredriksen-Goldsen et al, 2011), and this could lead to adverse health outcomes. Hispanic LGBT older adults also show signs of resilience, however. They are more likely than non-Hispanic white LGBT older adults to be caregivers (Fredriksen-Goldsen et al, 2011). Difficulties earlier in life reportedly help them face the challenges of older adulthood (Grant, 2009). Overall, more information is needed about diverse LGBT populations and LGBT older adults – and particularly Hispanic LGBT older adults. Researchers and healthcare providers should also closely follow the recommendations of the Office of Minority Health to develop the most culturally-competent and accessible healthcare.

RESULTS Focus Group Discussions Focus group discussions, which took place in the summer of 2012, resulted in rich data comprising perceptions and experiences of the LGBT community and their social services providers. Accordingly, the findings were organized in two parts: One reflects perspectives of LGBT older adults and the second – perspectives of their service providers. While NHCOA spoke with a wide variety of individuals, the comments below only come from people in four cities: New York City, Miami, Los Angeles, and Washington, DC. They provide a valuable insight but are not representative of the entire country.

Perspectives of LGBT Hispanic Older Adults Four central themes/categories emerged from the focus group data: (1) Perceptions of diversity among Hispanics; (2) Aging experience of the LGBT community; (3) Social support/family ties; and (4) Challenges resulting from institutional and/or cultural discrimination. The latter category was broken down into three subcategories: Faith/religion; Economic challenges; and Health challenges. A brief description of each theme, including quotes from the focus groups, follows: Perceptions of Diversity among Hispanics According to the focus group participants, Hispanics in general do not readily accept diversity, especially with respect to sexual orientation and gender identity, and often to do not accept or associate themselves with people who are different from them.  “I believe that there is sexual diversity but the subject is taboo. There is a lot of rejection, fear… It is not the same to live life in the closet than to live openly gay. I have seen in the gay community, especially among gay youth, that there is a lot of rejection against them

because they are gays, bisexuals, transvestites; in other words, all the names that are used to describe this community.”  “… my opinion is that we Hispanics are wonderful, we are enchanting, love family, love unity, all those things, but we are very conservative at heart…Here, in the USA, there are different levels of conservatism, more so in some places than others. But Hispanics have that tendency; we have a tendency to be conservative, a tendency to be discriminating and tendencies to do all of those things.” Some participants thought that there was a higher degree of awareness of the existence of LGBT communities in big cities, such as New York or Los Angeles. However, many believed that there is a lack of understanding of different types of sexual orientation among Hispanics and even within the gay community of what it means to be lesbian, gay, bisexual, transgender or a questioning person.  “…you live in New York, and here, the LGBT community is more accepted.”  “Sexual diversity is so large that if we studied each category, tendency, or like of a person, we would never finish.” Some participants said that they themselves did not know what the terms meant and that they could not associate their own sexuality with any of the terms. However, many said that with time things are changing and the new generation, specifically college students, are increasingly more aware of what the terms in LGBT mean:  “…I think the college students are a little more conscious about the terms, what the different identities consist of. I think that, when we are looking at the family, the father, they are not aware of what LGBT is, and in their defense, they are coming from a country where such identities are repressed, so I think they just use the term gay.”  “…Times have changed. Thirty or 40 years ago they would have crucified you…”  “And many killed themselves because of parents…Many died.”  “Things have changed, but they have feelings that have not disappeared, there is a bit more flexibility from society, but it is not something that was eliminated. It is not looked at as a normal thing – something that is your own choice, which you decided, no.” Other participants mentioned that there are differences in terms of acceptance of diversity among Hispanics born in the US versus Hispanics who immigrated to the US. Other participants stressed that acceptance was easier if one did not reveal his true identity:  “Latinos are the most closeted of all. They come over here – for example, the parents – but those who were born here are more open. Much sex education is necessary for those [who are born abroad]. The people who are born here [in the USA] are more informed. ”  “If you don’t say it, people will accept you. It is like a secret understanding. Everyone knows that that person or that person is or is not and people know, inside our Latino community there is a group who is discriminated against more than others. Even in our 26

LGBT community when there is someone who says, “Yes, I am bisexual,” people say, “Ay no, you are crazy or confused.” I think that there is much discrimination within our community, but as long as you don’t say who you are, things are fine.” According to the focus group participants, there is also a difference in perceptions of the LGBT community between Hispanics and other non-Hispanic communities in the USA. The latter appear to be more accepting of populations with a diverse sexual orientation:  “The Latino is inclined to criticize, as we are here among Latinos, and it is the reality. You enter, for example, an African-American or Anglo-Saxon community and you are one more person. There is no problem.” Aging Experience of the LGBT Community Some participants felt that the experience of getting older among LGBT individuals was not different from that of the general population. Some even felt that with aging there is more selfacceptance, particularly if an older person is financially secure:  “I agree with the opinion that there is more self -acceptance. There are people who say, “I don’t have my parents anymore or anyone to whom I owe an explanation:” When you are economically independent, as our colleague said when he got here, “Now I am going to be free.”  “It is age and I think that it is in all cultures. From what I’ve seen, when you are older, it does not matter whether you are gay or not. It’s the same from what I’ve seen. It is not worse to be gay than to be old.” Other focus group participants stressed that in a youth-oriented culture growing older was not an easy experience, especially for the gay male population, which emphasized the importance of virility and viewed aging as being “less sought after:”  “One of the great challenges that we have here is that you have the factor of being invisible in LA because not only you have ageism, you have the LGBT community, where being old is not looked upon well, especially with men. And then you have Los Angeles, which is very anti-age, you know.”  “I think there is a huge problem with older persons, aside from rejection. Nobody wants to get near or talk to an LGBT person, even if they are in the same place… There is a great deal of rejection of old persons. That is why those old men and women do not have support groups even among themselves… We are persons who, because of who we are, people are not interested in…” Social Support/Family Ties Family support is the most desirable relationship that occurs though Hispanic older adult’s social network. However, for the LGBT community these ties are often broken. Some participants 27

expressed feelings of social isolation within their own families, because of their identities as LGBT people. Others had better experience with their families, although all participants agreed that there was a dire need for more information and education for families to better understand sexual and gender diversity.  “Acceptance is very difficult among us Latinos, maybe because of our nature. For example, when a mother divorces and she wants to remarry, the children won’t accept it. The same thing is with homosexuality. The thing is to orient people bit by bit and find ways to prepare oneself, introduce this to each person and see if they are accepting.”  “The families are the most important nucleus in society. From our family we receive understanding, love and affection. If we don’t receive that, other factors happen, like depression or suicide. Or the person falls apart when does not have close family ties. If someone from your family rejects you, there are problems…”  “[Education] is important for prevention because when we are educating, we are preventing the break-up of the family. To have our families close by and not have them move far away or kill themselves or become depressed or use drugs because, when someone comes out, it’s not easy. There are people who are 90 years old and have never said they are gay. They are bearing the cross because their family cannot accept that. And there are gay men who are married and have children, and women who are married and are obliged to the relationship.” Some LGBT Hispanic older adults who do not face prejudice from their family or community, still face problems of rejection and emotional and psychological abuse (including from social service organizations) and low self-esteem. The participants felt that rejection by family members could be very painful, but societal rejection even more so, as it causes an even greater degree of isolation.  “…In my opinion, the rejection is more from society than from the family. Of course, there are exceptions, but society’s rejection is worse… It [society] is the one that marginalizes.” Some participants felt that they faced a dual discrimination as Latinos and as members of the LGBT community.  “It is one more stigma, being Latino.” Others emphasized the need for building a higher self-esteem and self-reliance to stand up to societal pressure:  “I think it has to do with one’s own sense of security. Because I am a lesbian and I feel good about myself, I don’t care what others say or think. I am clear, I am like that. But there are many people who hold back because they have been raised dif ferently. They are fearful or they are frustrated.” 28

Challenges Resulting from Institutional or Cultural Discrimination Faith/religion Many LGBT Hispanic older adults have mixed experiences with religion and faith. Many of the respondents are religious and attend church regularly, while others do not believe in organized religion and cultivate their own spirituality privately. Some have found that they are discriminated against by members of specific religious institutions, such as by members of the Catholic Church and fundamentalist Christian churches, while others have found great support in those same institutions. Some participants reported that they had found support in the Episcopal, Lutheran, and Universalist churches. “The Church is very tough on this issue because they interpret the Bible in a fundamental way. That’s the way it is for them. And for them, the Bible condemns it. It makes you feel worse. I participate in a Lutheran Church and the minister is very open to us. We have meetings with the gays and with the transgendered and we go to the same church service. But we go to church and, when we leave, we feel filled with a sense of spirituality. That is something that we were missing, but we found it, because someone understood us.” “Unfortunately, I don’t believe in any religion as an institution. In our community, certain people were altar boys when young. But when they grew up, they were thrown out of these same churches and that was traumatic. Those same people in whom you believed for such a long time, kicked you out. The ones who kick you out are those who run the church. But those who are rejected, believe it’s God who is throwing them out.” Economic challenges LGBT Hispanic older adults in this research project face challenges related to their income, employment, housing, access to social services addressing their needs, partner benefits, and obtaining food. Many are poor, earning income at about half of the federal poverty level, and this is insufficient to cover their basic living expenses. These interviews also took place before the United States Supreme Court’s decision to strike down Section 3 of the Defense of Marriage Act (DOMA), which harmed the economic security of LGBT individuals across the country. It is also important to stress that many social service programs the group relies on for survival, are being defunded or closed.  “In this economy, many of the groups or programs for LGBT people are being cut. And for many who are older, we are socially conscious and we share with these groups.”  “I say that Social Security must be profoundly reformed because it is a fallacy for them to say that after 70 years of age any person of whatever gender can get a job anywhere.” To make matters worse, some benefit recipients are unable to seek employment, even part-time, because of federal requirements that require agencies to reduce some benefits based on the 29

amount of employment income they receive. Due to state bans on marriage equality, members of same-sex couples are not recognized as surviving spouses or dependents, barring them from receiving surviving spouse benefits if their partners die. Although the invalidation of Section 3 of DOMA ends this problem in states that recognize the equality of same-sex marriage, state bans on marriage equality frequently force surviving partners to give up their residences, as they are unable to afford keeping them on their single and very limited incomes.  “…If you come to a household of seniors and you become a one-income household, the government does not recognize the retirement, Social Security, so there are no benefits for the surviving partner. And so they may go for a household income of three or four thousand dollars a month down to $700 and that’s just in general, for the LGBT community. And the fact that they are Hispanic, or any people of color, is likely to put them in the position to make less money through their working years.” (editor’s note: This statement was made before the Supreme Court ruled DOMA Section 3 unconstitutional. The federal government now provides full Social Security benefits to same-sex married couples in states that recognize same-sex marriage.) LGBT seniors may qualify for some existing housing programs if they meet income, age, and disability requirements. There are very few such programs, however, and there is a need for many more. Few LGBT Hispanic older adults qualify for Section 8 housing, but are unable to receive it, as many lack immigration status documentation or Social Security registration. Some LGBT Hispanic older adults who live in shelters are placed on waiting lists for subsidized housing, but are not advanced on the list if they are ill. Social service organizations offer support, and centers in Washington, DC and New York City offer services specifically to LGBT Hispanic older adults. In many other areas, however, LGBT aging services are not available. Some participants also identified shortage of information in Spanish as a barrier to the utilization of services. Some of the programs mentioned that aid LGBT Hispanic older adults include Andromeda, La Clinica del Pueblo, and Casa Ruby in Washington, DC. Casa Ruby does not receive government funds and is able to serve everyone, regardless of their immigration status. Andromeda focuses on providing mental health and HIV services for LGBT people. La Clinica del Pueblo is limited to accepting only HIV patients who have Social Security benefits. Health Challenges Among the many health challenges that Hispanic LGBT older adults face, the participants mentioned (1) limited affordability of services, when the utilization and degree of satisfaction differ depending on older adults’ insurance coverage; (2) low availability of culturally appropriate services; (3) overall poor physical and mental health status, including higher rates of substance abuse, depression, alcoholism, chronic diseases, such as diabetes and cancer, lack of medications, loneliness, isolation, lack of exercise, and a higher risk of HIV infection and STDs. 30

Some participants expressed concerns that older adults were not receiving STD screening due to bias toward their age.  “Loneliness is one thing. Illnesses, physical or mental, wear down a person. That is what older people are struggling with.”  “One of the challenges for the current LGBT population is that they are not screened on a regular basis for sexually transmitted diseases, simply because the age stereotype applies to them as well… And if they are sexually active, they do not think they are at risk and a lot of the symptoms of sexually transmitted diseases mimic the symptoms you have when you are aging.” Focus group participants stressed that, in their opinion, society in general is not doing enough to be inclusive of LGBT people. They felt that a better understanding of the contributions of the LGBT population would lead more members of the general public to oppose government actions to reduce or eliminate their benefits. Overall, the participants emphasized that it is very important to develop resources and provide more support for LGBT Hispanic older adults and help them live with dignity and comfort.

Perspective of Social Services Professionals The two major themes that emerged from the focus group discussions with social service providers were: (1) The need for education and awareness of their rights among the LGBT community; and (2) The need to develop culturally appropriate strategies to better reach out to the LGBT community. The Need for Education and Awareness of Their Rights among LGBT Communities Social service professionals participating in this research reported that LGBT Hispanic older adults are frequently unaware of how the “system” works. They do not know how to ask for help, do not have access to written materials explaining the availability of services, and are unaware of their rights to certain benefits.  “They do not know very well how the system works. They do not know how to ask for help either – the language is part of that – until they get to a hospital. I know people like that. There are no campaigns or materials to distribute.”  “I think they are open to the help, but they do not necessarily seek it. I believe it could be a cultural repression they group up in. When they become seniors, they are entitled to reduced phone bills, for example, or things like that. They seemed surprised that it’s available to them. They are happy to take it – they are very grateful. But they are not necessarily aware and they don’t seek like, “What else can I get? What else is there?”… I think it’s cultural, because of the time in which they grew up – nothing was given to them.”

Some participants stressed that people who provide services to LGBT Hispanic older adults also need more information about their clients’ rights and eligibility for various social services.  “I believe that there are three important factors that each social work er must understand: the economic situation, the health, and the benefits. These factors need to be handled for the LGBT seniors.”  “They should give me a directory to refer those people for housing, health problems – where they can be seen directly and not referred somewhere else. It needs to be a national directory. For example, if I am in Houston, where do I need to go.” Culturally Appropriate Strategies to Reach Out to LGBT Communities Some respondents stressed that although all LGBT people are likely to experience some form of discrimination due to their sexual orientation, the transgender community is the one most discriminated against. As a result, they rarely participate in community events or other programs for LGBT individuals, and therefore, it can be very difficult to conduct needs assessments or provide services to them. Several participants suggested accommodating many transgender people’s preference for nighttime appointments.  “…There is a lot of discrimination of the LGBT community overall. Nevertheless, the transgender one is much more discriminated against. It is much more difficult to bring to the table a transgender person, especially when events are held in the daytime. It is a community that feels much discrimination; it feels totally marginalized; much mistreated by all sectors, including the governmental and medical sectors.” Other strategies proposed to facilitate the outreach to the LGBT community were to have advanced training courses for LGBT individuals, so they can develop professionally and plan for the future. Others suggested “sensitivity” training workshops to be offered to schools, companies and families, so they would understand how to deal with the LGBT community. Some suggested language training to overcome linguistic barriers to obtaining services. Several participants raised the issue that the LGBT population should not be served exclusively by caregivers from the same community. These respondents felt that heterosexual caregivers are equally capable, as long as they understand and respect the people to whom they provide services.  “The agencies – I say it because I have seen it – the agencies that work with lesbian people, you go to seek help at that agency and all you see are lesbians. But why? They could have heterosexual people working there! They need to help that community feel whole, full of everyone…”

Key Informant Interviews The focus groups allowed for a broad-range exploration of key issues, while in-depth interviews placed those discussions in a broader context. All interviews were recorded, translated where necessary, and transcribed. Content analysis was conducted, exploring both emerging themes and pre-identified key issues. Overall, ten in-depth interviews were conducted with ten key informants and included the following themes: (1) Perceptions of aging; (2) Economic challenges; (3) Health challenges; (4) Civic engagement; and (5) The need for continuing research on the LGBT population. Perceptions of Ag ing Most participants noted that aging is a difficult experience in the LGBT Hispanic older community. Many felt that unlike in Latino cultures, LGBT elders are marginalized and forgotten as they age in a community that puts so much value on youth and physical attractiveness.  “To be honest, it is not something that they view in a good way, because elderly people are isolated. I see this a lot more in LGBT, because there is nothing that embraces this population – and specifically, the Latino LGBT aging population. Overall, there is a lot of disrespect, because for LGBTs, aging starts a little earlier. In the culture, you are considered somehow elder like once you hit 35. You are considered older because of the standards that are set in the LGBT population. You are supposed to be young, beautiful. You are supposed to be full of life. Even the word “gay” means outspoken, full of energy.” Participants felt that aging in this community is associated with loneliness, illness, and loss of economic opportunities, particularly for those older adults who did not enjoy the support of their families and did not have children to take care of them.  “Our Hispanic community simply fears the thought of growing old, because many times people know that after a certain age they may not be able to advance professionally or may not be able to compete in the job market. There are also psychological and emotional concerns about health, housing and family.” Some interviewees also noted that there are not enough gathering places for the older LGBT community to socialize, in contrast to the numbers of programs and centers for LGBT youth and the availability of senior centers for the elderly Spanish-speaking community. This is particularly important since, as some participants mentioned, LGBT older adults are often being “rejected by their families for being gay.”

Economic Challenges All participants, except for one, believed that the economy was not improving in the United States or was getting worse. In terms of economic challenges, the majority of interviewees stressed the difficulty in obtaining affordable housing and employment. There was a widespread belief that Hispanic older LGBT adults are experiencing discrimination for being LGBT, Hispanic and older. In addition, many who are immigrants and don’t have an American education, do not qualify for well-paid jobs. Further, undocumented migrants have problems accessing housing.  “I think that [LGBT] community faces disadvantages in three different ways, in that they are older, they are gay, and they are Latino.”  “Although they say there is no hiring discrimination, believe me that if two heterosexuals show up and two from the LGBT community, they’re going to give preference to the heterosexuals.” Hispanic LGBT older adults cannot find housing that is affordable and safe, due to high rent and lack of good employment. As a result, they either have to live in crowded conditions with families (if the families accept them) or with friends, or become homeless.  “They go from couch to couch to friend to friend…and not only are these people gay, but also old. Chances are that families do not want them close.”  “[They] do housework in exchange for housing. They are homeless, and there is a particular place where they meet. In DC, there is a bridge where they stay, under the bridge… because they like the coolness when it is very hot outside.” One respondent from New York mentioned that when housing is not accessible, older adults seek help from the city, but unfortunately, there are not enough shelters to satisfy the high demand. Others commented that to get low income housing there are many requirements and long waiting lists, with seven, ten, or 15 years of wait. A respondent from Miami said that the only affordable housing is government subsidized Section 8 accommodation, which is of very poor quality and not always available.  “They go to shelters. Or maybe they spend a night or two at a friend’s home. There are city housing projects but… there is not enough for the number of people who need apartments.” To avoid living in shelters, some older LGBT adults often sacrifice the basic necessities, such as a nutritious diet, and buy less food to be able to pay the rent. The respondents mentioned that there were no incentives for older adults to supplement their low incomes by trying to find a job, since they are afraid of losing Supplemental Security Income payments. In the end, some older adults resort to work “under the table” to make extra income, which is illegal.

 “At their age and because of their language, they cannot really get a job that pays well, and they don’t do it (get a job) because they fear losing their Social Security check (editor’s note: Supplemental Security Income can be lost if a beneficiary exceeds a certain amount of income, but after full retirement age, Social Security retirement benefits will not be reduced by earning wages) …Some may work “under the table,” which is illegal because they don’t pay taxes or report their income. That is something that depresses them because they are people who have worked hard and honestly for years, and at the end of their lives, they have to do something illegal.” Health Challenges The participants’ perceptions of the LGBT Hispanic older adult community healthcare needs and the barriers to services centered around the following themes: (1) Lack of affordable healthcare services; (2) Lack of availability of culturally-competent services and linguistic barriers; (3) Lack of information on the services available to LGBT individuals; (4) Legal barriers for LGBT partners to access their health insurance; (5) Unique health needs. (1) Lack of affordable healthcare services - Many interviewees emphasized lack of adequate funds to access quality healthcare. The issue is particularly problematic for undocumented immigrants. Some respondents also noted that services are more accessible in cities, but less so in rural areas.  “When they are retired and receive Social Security, the money is not sufficient. And Medicare and Medicaid don’t provide adequate healthcare coverage and the doctors they have to see under those programs are not the best.”  “From what I see in the Los Angeles metropolitan area, they have great services. I don’t think they have any problem accessing healthcare. What it is, is purely economic. Now the ones that are here illegally, their only way is though clinics funded through donations.”  “When a client does not have Medicare, it is many times hard to get medication… The type of health insurance policy that covers medications for HIV infection does not cover other medications if you need something for depression or anxiety or sleep.” (2) Lack of availability of culturally-competent services and linguistic barriers – All interviewees believed that culturally appropriate services were not available to the LGBT community. Most healthcare providers are not optimally trained to provide culturallycompetent care to an overlooked segment of the aging population. This was particularly problematic for transgender individuals:  “The older LGBT don’t feel comfortable with sharing their sexual orientation with their provider. In the case of the transgender, they are diagnosed in advanced stages of syphilis or AIDS because they never got into testing, because the medical providers just pay attention to whatever the patient was complaining [about], but they never check all the other problems they might have.” 35

 “Doctors who don’t have an education about the LGBT community are a major systemic barrier. In the schools of medicine there are doctors who are homophobic… A lot of doctors don’t want to touch HIV-infected patients.”  “…They ask questions about husbands, their relationships, etc., that are not applicable. They don’t even realize how insensitive they are.” Accessing formal healthcare services for Hispanic older adults is often impeded by language barriers. Lacking English proficiency to communicate with health professionals poses a serious hurdle for older adults who do not speak English:  “The challenge is to train in our native language the communities or the centers that, in one form or another, are going to provide those services.” (3) Lack of information on the services available to LGBT individuals – Several respondents stressed the need to make information on the availability of services easily accessible to LGBT seniors. The lack of information impedes access to and utilization of services, which may have detrimental effects on this population’s health.  “There is a lack of information and knowledge about where services are located. There is also a difficulty speaking about one’s own health, as well as a language barrier. This community is not used to speaking about its health, body, or sexuality.” Another respondent thought that some older adults may feel disadvantaged because they are immigrants and not entitled to certain services. Federal and state laws deny or limit immigrants’ ability to access many of the benefits that are available for citizens.  “…the majority of Hispanics think that as immigrants they don’t have rights to certain services. Perhaps access is not such a problem as lack of information.” One participant also raised an issue that using computer technologies could be an additional barrier to accessing valuable information by older adults, not only for the LGBT community:  “I don’t think just the LGBT community, but all elderly persons, have a hard time with new technology, new advances in information and accessing that information.” (4) Legal barriers for LGBT partners to access health insurance – An informant from Washington, DC mentioned that due to the fact that same-sex marriage is not legal in all states, it creates legal barriers to partners’ abilities to access their partner’s healthcare insurance policy and hinders their ability to be effective caregivers, not only to each other, but to each other’s families as well.  “…That’s why we live in the District of Columbia. We have those policies around domestic partners, same-sex marriage. So we’re different in DC…The challenge we may be facing is like either my mom or my partner’s mother and we have to make decisions. Chances are that if my partner is not here, I may not be able to sign papers for her mother because I am not [legally] her relative…It would be easier if I was her daughter-in-law.” 36

Other participants commented that some employers may allow partner’s access to health insurance, but they would still require legal documents:  “It depends where they are working. Nowadays, there are some businesses that allow it, but they need to have written and legal documents.” Even when the domestic partnership laws are being implemented in some states, employers still have the right not to offer insurance to partners at their discretion. (5) Unique health needs – One respondent mentioned that people in the LGBT older community are likely to suffer from high blood pressure and from abusing drugs, which increase sexual activity and hence, the risk of sexually transmitted infections, because they do not use condoms. They also suffer from poor diets, lack of exercise, depression and anxiety. These problems were repeatedly mentioned by the focus group participants as well.  “People feel pressured by others who are sexually active and without thinking , they begin to abuse medication so they can compete with the group…” Civic Engagement Almost all participants were passionate about causes ranging from same-sex marriage and affordable housing and nutrition to educational opportunities to LGBT and civil rights and access to services. However, many felt that there were a number of barriers to volunteering. There was a fear of rejection, linguistic barriers and a lack of knowledge about their rights:  “There is a fear of rejection, lack of orientation, fear of not knowing how to be fully involved and not knowing their rights. But more than anything is the language barrier.” Others mentioned linguistic barriers and immigration status as possible barriers to the LGBT community becoming more active in society. The participants stressed the need for education of the public in general about issues of different sexual identities to overcome the barriers to LGBT individuals’ civic engagement.  “What we need to do is educate our community about issues of sexual orientation. There is a lot of prejudice.” Need for More Research A respondent from Washington, DC, who works with LGBT Hispanic older adults, highlighted the need to study this neglected group and generate evidence that will become the basis of better public policies and dissipate public prejudices against LGBT people.

 “They are not counted. It’s like they do not exist. And [then there is] this perception, even in general media, of being gay and being seen as HIV positive…We start acknowledging that they exist, including them in surveys. We need to focus on their needs. For example, a health survey. There has never been a needs assessment for this population in DC…They need to be a part of the population agenda for Hispanics."

DISCUSSION

his needs assessment documented well that LGBT Hispanic older adults suffer social and economic disadvantage as a result of historical discrimination, social stigma, age, and a lack of legal recognition of same-sex relationships and gender identity.

Sexual orientation and gender identity can be less visible subjects in U.S. Hispanic culture compared to the culture of the U.S. as a whole. All participants indicated that understanding of sexual diversity is an issue in their own families and/or other families they knew. This can be partly explained by religion/faith, with the majority of Hispanics being members of the Catholic Church. The experiences with the religion have been mixed, however. Some participants were able to find a Catholic church that accommodated their needs, while others had better experiences with the Lutheran or Evangelical churches. Most of our research participants considered faith an important part of their spiritual lives, although some admitted that organized religion was not something they believed in. The intensity of homophobia and transphobia is no stronger in Hispanic than in black or Anglo-Saxon cultures in the U.S., however. In fact, a recent study by Social Science Research Solutions found that Hispanics are more likely to support marriage equality and are more tolerant of LGBT individuals than the general population (Social Science Research Solutions, 2012). Hispanic culture places a very strong value on family. A large family means more human power and economic prosperity. Men and women are expected to get married and have children, who will take care of them in old age. However, LGBT status is in conflict with the traditional gender roles and family structures. Even when LGBT older adults have children, they may have been rejected by them due to their sexual orientation or gender identity, which increases their economic vulnerability. Many respondents mentioned the feeling of being isolated from family and friends, and/or the experience of significant stress or problematic alcohol and drug use which have dire consequences for their health and exacerbate depression and anxiety. Moreover, the existence of transgender communities challenges traditional norms about gender that assume a static, binary identity of either male or female.

It is important to emphasize that many challenges faced by aging LGBT Hispanic older adults are similar to those faced by non-LGBT seniors, such as chronic disease, loneliness, dependence on social service programs, lack of exercise, difficulty of accepting loss of youthful appearance and depression. LGBT Hispanic older communities have additional health challenges, however. They face disproportionate risk of contracting STDs and HIV/AIDS. High rates of tobacco use and alcohol and drug abuse also require culturally- and linguistically-competent strategies for diagnosis and treatment. Stigma and discrimination in healthcare affect LGBT older adults in many ways and lead to delays in accessing health services. The participants stressed their experience of “insensitive” healthcare services and exposure to discrimination and poor clinical care, which included providers’ lack of attention to health concerns of LGBT individuals because of stereotypical thinking, lack of understanding of unique challenges they face (e.g. screening for STDs, mental health challenges) and lack of knowledge and sensitivity regarding the cultural concerns of LGBT Hispanic older adults. The study documented well the vulnerability of LGBT Hispanic older adults due to their age, sexual orientation, and ethnicity, as well as immigration status and linguistic barriers, but the most commonly experienced challenge frequently noted by participants was economic insecurity due to their status. The LGBT Hispanic older adults shared remarkably similar experiences related to cultural rejection, stigma, and lack of social support, as well as discrimination in employment and housing and the high cost of healthcare services and medications. They also lacked information on health and social services available to them, resulting in even greater social isolation of this already marginalized group. The fear of discrimination and rejection was also frequently cited as a barrier to civic engagement, even though almost all participants were passionate about various causes and had a desire to do volunteer work. The participants widely expressed the need to have a “safe space” where LBTQ identities are acknowledged and respected. Though experience of discrimination due to age, sexual orientation, and ethnicity was common, the experiences also reflected the different life experience of different groups within the LGBT community. For example, there was a widespread perception that the transgender community is the most discriminated against. It is important to acknowledge that LGBT communities are not necessarily a cohesive group, and may not all see themselves as having a common identity or being part of a community of interest. The transgender community itself includes a variety of individuals and identities, and this diversity needs to be considered when referring to a broader group. 39

NHCOA’s needs assessment identified many areas where policy, social, and scientific changes could improve the lives of Hispanic LGBT older adults. Policy makers can reform Social Security to provide full benefits to LGBT married couples in all states. Local, state, and federal government can take a stand by promoting civil rights for LGBT individuals and by facilitating access to available benefits, like Meals on Wheels. Educational reforms can dispel stigmas around sexual diversity and better equip health care providers to treat LGBT patients. Organizations that already serve LGBT communities can join the effort by empowering their older adult members and helping them take advantage of available economic opportunities. As the first “out” generation comes of age, researchers should turn their attention to this new wave of diverse older adults. It was widely acknowledged that there are no definite data in relation to the size and composition of the LGBT Hispanic community, and their needs have been largely undocumented.

RECOMMENDATIONS

n part because of the difficulties they face earlier in life, many Hispanic LGBT older adults show signs of resilience. There remain, however, many problems to be solved. Based on the areas of change proposed by the study participants, the following recommendations have been developed and directed towards policy makers, service providers and the public in general. 1. Social workers and other professionals who provide support to Hispanic LGBT older adults need to take a holistic approach to understanding each person’s circumstances and experience. The key areas to consider include:  Economic status  Eligibility for government benefits  Employment  Health  Housing situation  Immigration status  Language proficiency  Social and recreational needs  Discrimination based on sexual orientation or gender identity  Caregiving supports and definitions of “family” 2. Professionals should conduct active outreach whenever possible, since some LGBT Hispanic older adults may be reluctant to come forward and ask for available services. When conducting outreach, one should be aware of the diversity of the LGBT community and therefore the diversity of their interests and needs. Hence, different groups within the LGBT community may not be reachable at the same public venues. For example, as study 40

4. 5.

participants pointed out, older LGBT people may not feel comfortable at common social gathering places such as bars and dance clubs. Targeted outreach strategies need to be devised for transgender communities. Transgender people may feel more marginalized than other groups within the LGBT community and feel uncomfortable with coming forward to seek services. Some of the strategies to effectively reach them may include extending the hours with an organization providing services open to the public, as well as nighttime availability to accommodate some clients’ preferences. Social service organizations should have both LGBT and heterosexual staff and volunteers to make sure all participants feel welcomed and included. Improving economic security and increasing access to affordable healthcare will be key challenges to ensuring that Hispanic LGBT older adults can age with dignity. Thus, in healthcare, there is a need to recognize the unique challenges that LGBT Hispanic older adults are facing and revise clinical practice, informational brochures and other materials (e.g. office forms) to be more inclusive of LGBT Hispanic older adults. In this regard, it is important to train students and doctors to improve their cultural competence with LGBT older adult minority groups, facilitate better provider-patient communication, particularly in relation to unique healthcare needs of LGBT older adults, and also recognize the diversity among LGBT groups. Researchers and healthcare providers should closely follow the recommendations of the Office of Minority Health to develop the most culturally appropriate and accessible healthcare. Some examples of culturallyappropriate practices include: asking patients about “relationship status” instead of “marital status” in order to be inclusive of same-sex relationships not recognized by the law in most states; asking if a patient prefers to be referred to as “he” or “she,” and when asking about gender identities, offering options of male, female and transgender on forms; asking thorough questions about STDs and/or mental health issues in an openminded manner, so a doctor can learn crucial information that might not otherwise emerge in the conversation. Bilingual services should be available in healthcare and other social service organizations. Ideally, healthcare professionals should possess at least a basic knowledge of Spanish or, when this is not the case, make fluent interpreters available to the patients who need them. The interpreters working with the LGBT community should be trained to project a caring, non-judgmental attitude. Apart from medical care, there is a need for health promotion for LGBT Hispanic older adults. The public health interventions should address enhanced needs for behavioral health services, increased prevalence of alcohol and substance abuse, need for mental health services, social service needs, public safety concerns and support group opportunities targeted to Hispanic older LGBT adults. There are examples of successful health promotion programs for LGBT Hispanics to emulate. Such programs incorporate families as a valuable source in communicating health information. 41

8. The need to educate healthcare providers, government policymakers, the Hispanic community, families and the public in general has been widely emphasized. Religious conservatism and lack of understanding of LGBT needs often lead to the ostracizing of sexual minorities. Focus group and key informant interview participants suggested including a sexual orientation and gender identity dimension in the education of children and healthcare professionals and conducting workshops for families and the public on the importance of tolerance and embracing diversity. Other recommendations included public campaigns that emphasize the contributions of LGBT people, fostering support for organizations, such as Services and Advocacy for Gay, Lesbian, Bisexual, and Transgender Elders (SAGE) and its National Resource Center on LGBT Aging and Parents and Friends of Lesbians and Gays (PFLAG), and featuring more LGBT people â&#x20AC;&#x201C; as well as Hispanics and older adults â&#x20AC;&#x201C; in positive roles in entertainment and media. Greater social understanding of the LGBT community has the potential to decrease employment discrimination, housing discrimination, and religious and familiar ostracism. 9. The opportunity to use LGBT Hispanic older adults as educators themselves should be seized. They already do this in their everyday lives, but they can also serve as educators in more formal settings. As people that express multiple, diverse identities, they can share what it means to be lesbian, gay, bisexual, or transgender, what it means to be Hispanic, and what it means to be an older person, as well as the lessons they have learned overcoming prejudice. Older adults have a lifetime of experience to share with younger people, and older people who are also Hispanic and diverse in terms of sexual orientation and gender identity have a uniquely important story to tell. 10. There is an urgent need for more data and research about the experiences and needs of LGBT Hispanic older adults to document the challenges they face across multiple identities. Research is necessary to assess the impact of legal and policy changes, and to identify how policy and service provision can have a positive influence. It is important to underscore that a major methodological challenge may be the reluctance of many LGBT people to disclose their sexual orientation for fear of stigmatization due to religious, cultural or political beliefs, but the problem is not insurmountable. The government has to commit to take action towards the provision of legal protection and safety guarantees to this group. 11. A broad research agenda should be developed through a series of discussions involving LGBT Hispanic older adults themselves, reflecting a need to learn more about LGBT life, experiences, economic, health, and other challenges and circumstances. The importance of building trust is critical, as is developing the partnerships approach when LGBT older adults, government agencies, and organizations attending to the needs of this community, share the ownership of this agenda. 12. The importance of recognizing the role of organizations providing information about the needs of LGBT Hispanic older adults cannot be underestimated. These organizations, like SAGE and its National Resource Center on LGBT Aging should be further empowered 42

and resourced to contribute to research on LGBT older adults and to use research and evidence in developing their services.

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