VOLUME 22

ISSUE 1

SPRING 2012

Published by the National Association of Professional Geriatric Care of Managers 3275 West Ina Road Suite 130 Tucson, Arizona Geriatric Care Management 85741 520.881.8008 / phone 520.325.7925 / fax www.caremanager.org

Older Adult Sexuality, Intimacy, and Sexual Orientation

Guest Editor’s Message: Addressing the Elephant in the Room: Dealing with Matters of Sexuality and Sexual Orientation in Care Management Practice...... 2 Lenard W. Kaye, DSW, PhD

Defining Moments: Sexuality and Care of Older Adults...... 4 Marilyn R. Gugliucci, MA, PhD, AGSF, GSAF, AGHEF and Shirley Weaver, MT(ASCP), MA, PhD, GCG

Intimacy in Later Life: Reflections on Love and Care...... 10 Amanda Smith Barusch, PhD

Addressing Diversity in Sexuality and Aging: Key Considerations ...... 13 for Healthcare Providers Nancy A. Orel, PhD, LPC and Wendy K. Watson, PhD

Older Lesbian Adults and Alcoholism: A Case Study for Practitioners...... 19 Noell L. Rowan, PhD, LCSW, CADC

Aging, Relationships, & Sexuality: Tools and Resources ...... 25 for Geriatric Care Managers Jennifer A. Crittenden, MSW and Lindsay Day, LSW of Geriatric Care Management Spring 2012

Guest Editor’s Message Addressing the Elephant in the Room Dealing with Matters of Sexuality and Sexual Orientation in Care Management Practice By Lenard W. Kaye, DSW, PhD

Talk about the proverbial informal models of service delivery emotionally charged and commonly elephant in the room! I would hazard are often entrenched in past societal avoided by our clients as well has only to guess that the prospect of dealing mores. These, too, warrant fresh served to feed this tradition of neglect. with matters of sexuality, intimacy, perspectives in order to encourage Our expert contributors will and love with your clients will give change and progress. broach the topics but no doubt realize virtually all of you pause no matter This issue of the Journal of that they can only scratch the surface how seasoned a mental health Geriatric Care Management will of such complex matters. I believe I professional you may be. Fear not – address highly relevant subject speak for them in expressing the hope you are not alone. These are issues matter dramatically impacting the that their presentations will encour- that the vast majority of helping lives of older adults that has been, age a beginning discourse on a set of professionals likely avoid addressing unfortunately, ignored by too many issues extremely relevant to more fully as a matter of course in their daily of us for far too long. Whether understanding the challenges impact- practices. we perceive matters of sexuality ing our older clients and patients. More than “correct” language is and intimacy to be controversial, Multiple dimensions of the needed to insure adequate levels of embarrassing, or socially taboo, we subjects of sexuality, intimacy, and understanding and informed care as have steered clear of addressing sexual orientation will be addressed we encounter issues of intimacy and them in our work with older clients in the pages to follow, including the sexual satisfaction expressed by older and patients and their families. The impact of physiological changes of adults. Tenets that guide formal and fact that these are matters that are aging on sexual expression and long-

EDITORIAL BOARD Rona Bartelstone, LCSW Fort Lauderdale, FL Cathy Cress, MSW Santa Cruz, CA Lenard W. Kaye, PhD Orono, ME of Leonie Nowitz, MSW, LICSW New York, NY Journal Emily Saltz, MSW, LICSW Newton, MA Geriatric Care Management Monika White, PhD Santa Monica, CA Published by the: National Association of Professional Geriatric Care Managers EDITOR-IN-CHIEF 3275 West Ina Road, Suite 130, Tucson, Arizona 85741 • www.caremanager.org Karen Knutson MSN, MBA, RN © Copyright 2012 Bryn Mawr, PA The Journal of Geriatric Care Management is published two times per year as a membership benefit to GRAPHIC members of the National Association of Professional Geratric Care Managers. Non-members may subscribe DESIGN to Journal of Geriatric Care Management for $95.00 per year. Send a check for your one-year subscription to: HagerDesigns Subscription Department, NAPGCM, 3275 West Ina Road, Suite 130, Tucson, Arizona 85741. Dallas, Texas

PAGE 2 of Spring 2012 Geriatric Care Management

Lenard W. Kaye, DSW, PhD, is Professor of Social Work at Multiple dimensions of the subjects of the University of Maine School sexuality, intimacy, and sexual orientation will be of Social Work and Director of addressed in the pages to follow, including the the University of Maine Center on Aging. A prolific writer in the impact of physiological changes of aging on sexual field of health care and aging, he expression and long-standing myths held of older has published approximately 150 journal articles and book chapters people, sex, and sexuality that are perpetuated and 12 books on specialized in our youth-dominated culture. topics in aging including home health care, productive aging, rural practice, family caregiving, controversial issues in aging, support groups for older women, standing myths held of older people, a useful framework for practitioners and congregate housing. His sex, and sexuality that are perpetuated to use that systematically considers pioneering research and writing in our youth-dominated culture. The ten cultural factors and personal on older men’s caregiving authors will examine why there is attributes that influence sexuality. The experiences and help-seeking discomfort with exploring this topic authors maintain that appreciating the behaviors, is widely recognized among many professionals and allied importance of these factors for their and frequently cited. His current health care providers. In addition, older patients will enable providers book project is a self-help manual issues of sexual identity among the to more appropriately and adequately for mid-life and older men on 60-and-over age group will also be meet their needs in the arena of healthy, active aging. Kaye sits on examined. Special attention will be sexuality and sexual health. the editorial boards of the Journal directed at the anticipated impact Finally, Noell Rowan addresses of Gerontological Social Work of having a dramatically expanding a rarely discussed issue in clinical and Journal of Geriatric Care cohort of lesbian, gay, bisexual, and practice -- the older chemically Management and is a Fellow of transgender (LGBT) baby boomers dependent lesbian and her health the Gerontological Society of using a wide range of health and and mental health needs. Rowan America. social services, including both considers the issues faced by older community and institution-based lesbians with alcoholism and further forms of care in the coming years. research necessary to enhance our Marilyn Gugliucci and understanding of the lived experiences Shirley Weaver set the context by of these individuals. She includes an presenting foundational information illustrative case study to demonstrate on the issues that affect both a variety of critical issues likely to be heterosexual and homosexual older faced by practitioners working with adults, including such matters as this client group. We very much hope terminology, stereotypes associated readers will want to read more about with aging in our society and with the topics raised in this special issue, older adult sexuality, as well as and to that end Jennifer Crittenden associated psychosocial factors, care and Lindsay Day have prepared strategies, and resources available to a compendium of professional providers and older adults. resources, information, consumer Amanda Smith Barusch, resources, and training materials on drawing on her research into elder love, relationships, and sexuality in romance and love, presents four older age. The authors have provided vignettes on late-life intimacy with them as a general starting point for direct implications for geriatric considering, discussing, and exploring care managers. She includes special issues of older adult relationships and attention directed at “Living Apart sexuality. Together” relationships, late-life infatuations, and the insidious effects of ageism on intimacy in late life. Nancy Orel and Wendy Watson explore the heterogeneity of the older adult population and provide

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Defining Moments: Sexuality and Care of Older Adults Marilyn R. Gugliucci, MA, PhD, AGSF, GSAF, AGHEF Shirley A. Weaver, MT (ASCP), MA, PhD, GCG

Summary such an issue. We are who Health care providers we are throughout life – are reticent to discuss “We are squeamish about the hopefully gaining wisdom as intimacy and sexual issues sex lives of the elderly we move through the ages, with their older adult but still the “same person” inside. This simple realiza- patients or the patients’ …even more so when those elderly adult children. This article tion could greatly aid us in is written with the provider are senile or our parents” providing positive descrip- in mind and presents tions of aging and a more foundational information —An Affair to Remember, realistic understanding of on older adult sexual health Henneberger, 2008 life-long issues of sexual- and intimacy issues that ity. This is something that affect both heterosexual we hope will become more and homosexual older prevalent as we advance adults. We begin with defining sex, and resources available to providers through the 21st century and welcome sexuality, physical and emotional and older adults. the Baby Boomers into older adult- intimacy; we then present stereotypes hood. As of January 1, 2011 between associated with aging in our society Introduction 8,000 and 10,000 people turn 65 years and with older adult sexuality. Once Temporal definitions tend to old each day and this will continue for this underpinning has been presented define old age in relation to a certain the next 20 years! (Love, 2010). This we introduce some of the psychosocial number of birthdays one has had. growth in our aging population impacts factors, care strategies, and resources Most commonly, in contemporary all aspects of society, including health available to providers and older adults. society, having reached the age of 65 care, social security, the work force, social services, education, and societal Many would agree with a person is considered to be in the views of aging. As health care provid- Henneberger. In our society it is rare young-old category. It is important ers, how well we address older adults’ to discuss the intimacy and sexual to note that regardless of age, there physical and emotional needs for sex needs or desires of older adults. It is are aspects of life, such as the basic and intimacy will, in large measure, rarer still for health care providers to drives, that continue unchanged. The determine their quality of life. discuss intimacy and sexual issues older adult, like the young adult, feels with their older adult patients or the the need for physical comfort, love, patients’ adult children. There is good and status. Habit systems persist with Defining Moments: What reason why this topic is often times great tenacity, as do characteristic is Sex and Intimacy? controversial or misunderstood in our ways of meeting frustrations, Little is known about the sexual society. In this article some of these personality patterns of dominance or behaviors and sexual function of older issues will be addressed as we present submission, and the individual’s whole people. While moral issues associated foundational information on the issues array of attitudes. As one elder woman with sex are the driving forces in our that affect both heterosexual and stated in a seminal study by Cavan, et culture, they will not be addressed in homosexual older adults. We begin al., 1949, “I see no change in myself this article. Sex often times is defined with terminology to ensure we are all as I enter the period of old age; I am using scientific terms leading it to be on the same page and then present the same self I always was” (pp. 1-2). considered as an act involving biologi- stereotypes associated with aging This sentiment continues to be stated cal and physiologic manifestation of in our society and with older adult by older adults in the United States. libido and hormones (Lindau, 2007). sexuality. Once this underpinning has With age perceived by the older However, for the purposes of this been presented we introduce some adult in this way, one could wonder discussion, a broader perspective is psychosocial factors, care strategies, why sexuality or sexual expression is necessary so as to include the social-

PAGE 4 of Spring 2012 Geriatric Care Management emotional conditions. There are four older adults are lonely, bored, or are not merely as a decline from youth, key terms we want the reader to be dissatisfied with life. Additionally, it but as an open-ended development familiar with -- sex, sexuality, physical is believed that all older adults are the in its own terms, which, in fact, intimacy, and emotional intimacy; we same (homogeneous), and as a group may be uniquely ours to define?” (p. chose the following definitions: (1) they encounter the same negative 192). She asserts that public policies Sex is defined as any mutually volun- health and psycho-social experiences. have reinforced the terror of age: the tary activity with another person that It is bad enough that society believes weak, catastrophic, victimized face of involves sexual contact, whether or not this to be true, but the real travesty age. Friedan set out to separate the intercourse or orgasm occurs (Lindau, is that it is often believed by older complex issues of biological aging 2007); (2) Sexuality, on the other adults themselves! This infusion of from aging as pathology. Her belief hand, is defined as an intrinsic lifelong negative beliefs and resulting inaction in the importance of maintaining aspect of being human and is not limit- or passivity in challenging societal control over your own life, remaining ed by age, physical appearance, health, impositions has a variety of historical viable, and employing open choices or functional ability (Stausmire, 2004); reasons. For example, one of the first could lead to transformation for older it includes “the capacity of the indi- “proven” theories of functional aging people. The fact remains that although vidual to link emotional needs with was entitled “Disengagement Theory,” many of us wish to support older adult physical intimacy” within the con- by Cumming and Henry (1961). empowerment, older adults often face straints of their ability (Gilley,1988, p. Disengagement theory proposed that additional challenges due to society or 367); (3) Physical Intimacy is defined starting in middle age the individual family pressure. as sensual proximity and/or touching was both accepting and desirous of When will our society, and more including an expression of feelings decreased interaction in old age. This specifically health arec providers, (such as close friendship, love, and/or was gradual and inevitable and led to a learn that old age and sexuality is sexual attraction and includes holding mutual withdrawal of the elderly from not just the sum of the parts of one’s hands, hugging, kissing, caressing, society and of society from the elderly. past; it is life as one has lived it and and sexual activity (Miller & Perlman, According to this theory, the process continues to live it. Older adults 2008); and (4) Emotional Intimacy, of change enabled the elderly to adapt dynamically integrate a wide range which is a dimension of interpersonal more successfully to the issues of of experience to construct a current intimacy that varies in degree and biological decline, physical decline, length of time, allows the ability to and viable identity; they do not think and losses in old age, which is the feel emotions and express feelings of themselves as purely “socialized” “functional” or “successful” basis for both verbally and/or non-verbally beings, learning and then acting out this theory. So, our take on this theory (Miller & Perlman, 2008). a set of socially appropriate rules of is that if you want to age successfully behavior; nor is their identity merely The medical field, however, sel- or functionally – and according to the sum of the parts of their lives dom reveals a broad conceptualization what is deemed best for the older (Kaufman, 1986 - seminal work). of sex or sexuality in relation to aging adult and society – then death would Age doesn’t need to imply a passive or older adults. Rather, health profes- be your best option. Although this decline and disengagement. Being sions training has narrowly focused on application may be absurd, an old is not a central feature of the self, factors which impact sexual perfor- historical and seminal theory such nor is it a source of meaning in and mance (intercourse or orgasm) for of itself. Older people do not relate older adults. It is important that health as this (later debunked, although is printed in textbooks), continues to to aging or chronological age as a care providers are able to discern the category of experience or meaning. importance of the differences between drive the beliefs about withdrawal and decline of older adults in our society. They know who they are and what sex, sexuality, and intimacy, and how matters to them now. They have an they impact quality of life for older Thirty years after the ascendency identity that maintains continuity adults. We advocate for health care of the Disengagement Theory, Friedan despite the physical and social that affirms the total self by promot- (1993) as an “older woman” and changes that may come with old age ing all older adults’ ability, regardless a researcher of aging stated in her (Kaufman, 1986). And so, as noted by of age or condition, to share love and book the Fountain of Age, that older Weeks (2003), an authority on older affection through either one or both adults have been posed with two adult sexuality, the most important forms of intimacy – physical and options: (1) they were either expected sexual organ is between our ears. The emotional. to disengage from life in order to way we think of ourselves, at any prepare for death (Disengagement point in our lives, but especially so in Stereotypes of Aging Theory) or (2) act “youthful” through our later years, will aid us in finding and Their Effect on remaining active or redefining another ourselves, our sexuality, and our place Intimacy mechanism to compensate for loss in this world. Weeks postulates that Negative stereotypes of older of youth. Friedan (1993) wondered, our sexuality is where we experience age persist in our society. Common “Why are we not looking at age as a ourselves as real people; it provides misconceptions continue such as new, evolving stage of human life – continued on page 6

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Defining Moments: Sexuality make a meaningful sexual relationship Elders (SAGE), American Association and Care of Older Adults impossible. The societal reinforced of Retired Persons (AARP), and the continued from page 5 disease/decline and withdrawal model Institute of Medicine (IOM) to educate of aging poses the contradiction that the public and providers on the issues us with our identities, our sense of older adults are either prudish and affecting the health and health care of self, men and women, regardless of asexual, or at the other extreme are LGBT older adults, stigmas persist. whether we identify as heterosexual or considered to be “dirty old men” homosexual at any given time (2003). Table 1 outlines the similarities as evidenced by the term “Condo and differences in social perceptions Older Adults and Sex/ Casanovas” that applies to men of the issues facing the older Intimacy who have multiple sex partners in heterosexual and homosexual adult. It condominium communities. becomes increasingly clear that older Human sexual behavior doesn’t Nowhere are the contradictions adults’ expectations of health care fit neatly within imposed societal, and confusions of competing providers’ accommodation of their cultural, or religious structures. notions of older adult sexuality more sexuality is emerging as an imperative. Regardless, when asked about evident than in the evolving social As health care providers, it is essential satisfaction in their sex lives, older acceptance of alternative life styles, for us to promote an atmosphere adults responded that they: (1) such as homosexuality, and rising of comfort, consciousness, and apply more open attitudes toward awareness of transgender health compassion so that communication sexuality; (2) rate their health better; issues. In 2001, the U.S. Office on is supported and understanding (3) participate in Internet dating; Aging recognized that Lesbian, enhanced. and (4) take advantage of available Gay, Bisexual, and Transgendered medications that address erectile (LGBT) elders are underserved by Nursing Homes dysfunction (Lindau, et al, 2007). the federally funded programs that (Residential Long-Term Both the Starr-Weiner Report (Starr receive support through the Older Care) & Weiner, 1981) and the Love, Sex Americans Act. The 2010 census This article will only whet the and Aging Consumer Union Report report, citing nearly a million same reader’s appetite regarding the topic (Brecher, 1984), were among the sex couples and changing geographic of sex within nursing homes. Briefly, first to include older adults in their living patterns, gives evidence to baby nursing home law states that nursing- research. They concluded that older boomers’ willingness to declare their home residents are guaranteed some people are sensual and have needs life style and suggests changing social small degree of privacy, along with for closeness and intimacy that attitudes. Yet, despite the considerable the right to “psycho-social well-being” included feelings of love, passion, efforts of organizations as diverse – this includes free sexual expres- and pleasure. It may seem odd to as Area Agencies on Aging (AAA), sion (Engbar, 2007). As a result, the cite research that supports a fact that Services and Advocacy for GLBT administrator must balance resident should be obvious, but earlier research contributed to the asexual stigmas associated with older adults. Whether it is physical or emotional intimacy, TABLE 1 older adults continue to have sexual activities (intercourse, masturbation, Issues for Older Heterosexual and Homosexual Adults mutual masturbation, oral sex) and the physical capacity for male erection Older Heterosexual Adults Older Homosexual Adults and male and female orgasm continue almost indefinitely. Older adults find Ageism Double stigma of homosexuality & ageism they have more time, more privacy, Depressed, isolated, desperate, and sexless is prevalent Depressed, isolated, desperate, and sexless is prevalent and less stress in their lives from when they were younger, all of which aid Empty nest syndrome – little family support Empty nest syndrome tempered by support of friends in increasing a feeling of comfort and and “chosen” family satisfaction. However, the “Love, Sex and Aging” research also revealed Health care system traditionally unresponsive Health care system traditionally unresponsive of the that older adults felt the need to keep person and lifestyle sex secret due to the response from Partnerships relied upon Partnerships not recognized society, their children and friends, and their health care professionals. Concerned about housing Concerned about housing that is sensitive to lifestyle There is no surprise that our World shrinks as age progresses World shrinks as age progresses and there are few re- society presumes that older adults have sources to either (a) meet supportive people or (b) ad- no interest in sexuality, that romance just to their reorientation for newly “out” LGBT adults and physical attraction decline, and that age-related physiological change Adapted from Raymond M. Berger (1996) Gay and Gray: The Older Homosexual Man. Haworth Press.

PAGE 6 of Spring 2012 Geriatric Care Management rights with their ability to consent “spouse” (LGBT included) may of others; (d) performance anxiety to sex. Ironically, there is a term lovingly apply lotion that creates (males performing “up to par”); referred to as “gray rape” that does an intimate if not sexual encounter. (e) lack of availability of a not apply to hair color or the age of Conducting staff training on older partner (35% of men vs. 70% of the population having sex. The term adult sex and intimacy is critical women do not have partners); (f) originated with the young adult to instituting an environment that attitudes towards and acceptance (college student) population and supports appropriate sexual health of alternative sexual activities; and applies to sex that falls somewhere and intimate behaviors. Establish- (g) reaction to environmental (adult between consent and denial. “Gray ing proactive policies in the home children, physician, institutional) rape” is even more confusing than will support administration and attitudes and opportunities for date rape because often both parties staff to proactively work with privacy (Thienhaus, 1988). are unsure of who wanted what. As residents and families throughout Role of Communication: such, the nursing home administra- the time they reside in the nursing Communication is essential in tor and staff need to ensure that home or skilled unit. any medical or health sexual encounters are not an care field. Seminal work elder version of “gray rape” published by Mehrabian and that consent is mutual. (1981) established Although numbers may vary With the aforementioned assumptions that communication from home to home, on aver- and stereotypes about older adults and effectiveness is reliant on age an estimated 50 percent three components – words, of nursing home residents are sexuality that are prevalent in our society, voice tone, and body diagnosed with some degree there is no wonder that something as language. Mehrabian of dementia, which, depending found that words on its severity, can make them vibrant as intimacy and sexuality would contribute to only 7% of unaware of their own behavior. be a struggling concept for health care what is communicated; Four (4) conditions affect- voice tone was responsible ing this population regarding providers to work with effectively. for conveying 38% of sexual activity were identified: the message, and body (1) certain kinds of cognitive language contributed to impairment can enhance sex 55% of communication. drive; (2) approximately 25% of Practitioner Approaches As health care providers discuss those with dementia lose interest With the aforementioned sex and intimacy with their in sex; (3) about 14% experience assumptions and stereotypes about patients, words may be important, a heightened libido; and (4) up to older adults and sexuality that are but it will be the combination 8% become unable to control their prevalent in our society, there is no of their body language (posture, sexual behavior, which manifests wonder that something as vibrant as incessant masturbation and facial expressions, appearance, as intimacy and sexuality would be repetitive sexual advances (Engbar, touch, body movements, “air” a struggling concept for health care 2007). Communicating about sexu- of confidence, hair style, body providers to work with effectively. ality/intimacy with older adults and position, breathing, eye contact) and There are three (3) key points for their families (significant others) as voice tone (voice cadence, pitch, providers to keep in the forefront a part of the standard admissions inflection) that will be responsible procedures is a proactive approach when working with older adult for creating an atmosphere of trust to supporting sexual health. Ad- patients: (1) knowledge of past and openness. Health providers ditionally, conducting a compre- psycho-social sexual health; (2) role of may think they have adequate hensive sexual history that includes communication; and (3) issues related training and tools to work with a medication review regarding the to medications. older adults regarding sexuality indications and contra-indications Knowledge of Past Psycho- and intimacy; however, words on sexual or intimate behavior for Social Sexual Health: Providers combined with voice tone and body each resident, will aid the home in may enhance effectiveness in language will speak volumes about being prepared. addressing sexual health and intimacy the providers beliefs, attitudes, A confounding issue in nursing for older adults through increased and values on sexual health when homes is personal care provided by understanding of their patients’ past conversing with a patient. In return, staff, with the need for resident/pa- experiences and attitudes, as these providers need to look, listen, and tient touch and intimacy. Such prac- could impact current issues. Psycho- consciously observe their patients to tices as putting lotion on a resident social indicators include (a) attitudes determine how best to proceed with or bathing can be sensual activities toward sex and intercourse; (b) communication on this topic. depending on how these are per- reactions to physiological changes formed and by whom. A resident’s and illness; (c) reactions to attitudes continued on page 8

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Defining Moments: Sexuality Conclusion benefit from choosing the definitions and Care of Older Adults that are congruent for the provider – an We have established that the continued from page 7 expression, if you will, of the provider’s topics of sex and intimacy are often level of self-awareness and comfort Issues Related to Medications: times controversial or misunderstood with the subject. There are a number It is essential for providers to at in our society. Many older adults of resources that support older adult least have a foundational knowledge continue to be sexually active and sexual health; some of the long standing or awareness of the effects that exhibit good sexual health. Of impor- resources are presented in Table 2. pharmaceuticals and poly-pharmacy tance for health care providers is the have on older adults. Social work knowledge that both emotional and In supporting the humanness of training rarely requires a pharmacy physical intimacies are accepted forms older adults, let’s not be ahistoric about course and certainly not a course of sharing love and caring. As there their desires (or lack thereof) and prior on older adult pharmacokinetics. It are many definitions for sex, sexual- intimacy practices. Inclusion of sexual is not the intention of this article to ity, and intimacy, a provider would history and current sexual/intimacy educate the reader behaviors of older adults will aid in about pharmacology, the comprehensiveness of care plans. but to note that drugs Ascertaining this information in an affect older adult In supporting the humanness of older environment and manner that promotes function, sexual or adults, let’s not be ahistoric about comfort and openness is essential. The authors are eager for the day that care otherwise. What their desires (or lack thereof) and prior is critical for the providers are taught proper sexual his- provider to know intimacy practices. Inclusion of sexual tory-taking and this practice becomes is that physicians history and current sexual/intimacy a standard component of promoting sexual health in all care settings. may not factor in behaviors of older adults will aid in the sexual health the comprehensiveness of care plans. of the patient when Footnotes prescribing drugs Ascertaining this information in an – prescription and environment and manner that promotes 1. The young-old are 65-74; the old-old are over the counter 75-84; and the oldest-old are 85 years of age and older (Rieske and Holstege, 1996). (OTC). At the core of comfort and openness is essential. “traditional” sexual 2. movement of drugs within the body. performance for men, certain drugs may affect erections and libido (sexual urge or desire); TABLE 2 for women, they may affect vaginal dryness and libido as Resources well. Certain psychoactive drugs, especially those prescribed for Resource Location Parkinson’s disease—can serve as National Institute of Aging - Age Page – http://www.nia.nih.gov/HealthInformation/Publications/sexuality.htm love potions (Engbar, 2007). Sexuality in Later Life (2010) Also printed in Spanish Some questions that will aid providers as they ponder and Safe (and Enjoyable!) Sex for Seniors: http://www.healthinaging.org/public_education/safe_sex_tips.php Tips from the American Geriatrics Society’s discuss sexual health issues with Foundation for Health in Aging (2008) their colleagues and older adult patients could include: How do American Journal for Hospice and http://ajh.sagepub.com/content/25/5/366.full.pdf+html we foster satisfaction and inti- Palliative Care: Is there a place for sexuality Provided by SAGE Journals Online Publications macy as one ages?; As health in the holistic care of patients in the palliative care phase of life? (Redelman, 2008) changes?; As a person’s world gets smaller?; As independence Beers’ Criteria for Potentially Inappropriate http://www.patientsafetysolutions.com/docs/ is compromised?; At the end of Medication (PIM’s) Use in Older Adults December_2011_Beers_Criteria_Update_in_the_Works.htm life? Providers that (1) apply the American Geriatrics Society List is in the process of being updated by the AGS, 2011 broadest definitions of physical The Health of Lesbian, Gay, Bisexual, and http://www.iom.edu/~/media/Files/Report%20Files/2011/ and emotional intimacy; (2) know Transgender People: Building a Foundation The-Health-of-Lesbian-Gay-Bisexual-and-Transgender-People/ their own attitudes and beliefs; for Better Understanding LGBT%20Health%202011%20Report%20Brief.pdf and (3) understand the stigmas Released: March 31, 2011 Consensus Report and societal stereotypes associ- US Department of Health and http://www.cdc.gov/std/see/HealthCareProviders/SexualHistory.pdf ated with older adults; will no Human Services, CDC. Can also be ordered as a spiral bound pocket book. doubt be best prepared to address A Guide to Taking a Sexual History these questions.

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References Rice, A.M. (2000) Sexuality in cancer and palliative care 2: exploring the issues. Dr. Shirley A. Weaver has a long Breecher, E. M. (1984). Love, Sex, and International Journal of Palliative Nursing, history of involvement in health Aging. Boston, MA: Little, Brown and Vol 6, pp. 448-453. professions education, both in Company. Berger, R.M. (1906) Gay and military and academic capacities. Gray: The Older Homosexual Man. New Starr, B.D. and Weiner, M.B. (1981) The York, NY: Haworth Press Starr-Weiner Report on Sex & Sexuality She was the founding director in the Mature Years. New York, NY: of the Maine AHEC System and Cavan, R. S., Burgess, E. W., Havighurst, McGraw-Hill. the Maine Geriatric Education R. J., & Goldhammer, H. (1949) Personal Center at the University of New Adjustment in Old Age. Chicago, IL: Stausmire JM. (2004) Sexuality at the end England College of Osteopathic Science Research Associates, Inc. of life. American Journal of Hospice and Medicine, and Associate Director Palliative Care. Vol 21, pp. 33-39. Cumming, E., & Henry, W. E. of the Harvard Geriatric (1961). Growing Old: The Process of Thienhaus, O. J. (1988) Practical overview Education Center at Brigham Disengagement. New York, NY: Basic of sexual function and advancing age. & Women’s Hospital. She has Books, Inc. Geriatrics, 43, 63-67. focused on workforce training and education issues at national Henneberger, M., (June 10, 2008) Slate Weeks, J. (2003) Sexuality (2nd edition). (a division of the Washington Post Oxford, UK: Routledge. and state levels to improve health Company); care for rural and underserved http://www.slate.com/articles/life/ communities, such as: improving family/2008/06/an_affair_to_remember. the distribution of health care html ; Accessed November 7, 2011. Dr. Marilyn R. Gugliucci providers, especially primary is the Director for Geriatrics care providers; increasing health Engber, D. (2007) Naughty nursing homes: Education and Research at the Is it time to let the elderly have more sex? career awareness and preparation SLATE Magazine, http://www.slate.com/ University of New England of rural and underserved youth; id/2174855/, Accessed October 30, 2011. College of Osteopathic Medicine preparing providers to care for (UNECOM), and Director of our increasingly older population; Friedan, B. (1993). The Fountain of Age. U-ExCEL (UNE~Exercise and and increasing rural veterans’ New York, NY: Simon & Schuster. Conditioning for Easier Living) access to care and services to Gilley J. (1988) Intimacy and terminal Fitness/Wellness Program for address special mental health care. Journal of the Royal College of older adults. Her Learning by needs. General Practitioners, Vol 38, pp: 121-122. Living© Research Project, a Lindau, S.T., Schumm, P. Laumann, E.O. UNECOM signature program, Levinson, W., O’Muircheartaigh, C.A. and “admits” medical students into Waite, L.J. nursing homes to live the life of an elder resident for 2-weeks. (2007): A study of sexuality and health in older adults in the United States, New She also conducts research England Journal of Medicine, pp762-774. on older adult function and standing balance control. Dr. Love, J. (2010) Approaching 65: A Survey Gugliucci is a Fellow of the of Boomers Turning 65 Years Old AARP American Geriatrics Society Survey and Statistics. http://www.aarp.org/ personal-growth/transitions/info-12-2010/ (AGS), the Gerontological approaching-65.html, Accessed November Society of America (GSA), and 17, 2011 the Association for Gerontology in Higher Education (AGHE). Kaufman, S. R. (1986) The Ageless Self: Sources of Meaning in Late Life. Madison, Dr. Gugliucci was recently WI: The University of Wisconsin Press, Ltd. awarded the 2012 Association for Gerontology in Higher Mehrabian, A. (1981) Silent Messages: Education Hiram Freidsam Implicit Communication of Emotions Mentorship Award for her and Attitudes (2nd ed.). Belmont, CA: Wadsworth.1981 excellence in mentoring students, faculty, and administration in Miller, R. & Perlman, D. (2008) Intimate the field of aging; and the 2012 Relationships (5th ed.). New York, NY: Harvard Pilgrim Health Care McGraw-Hill. and MaineToday Media, Inc. Mooradian, A. D. (1991) Geriatric Healthcare Hero Award as a sexuality and chronic diseases. Clinics in Health Care Educator. Geriatric Medicine, 7, 113-131.

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Intimacy in Later Life: Reflections on Love and Care By Amanda Smith Barusch, PhD

Summary Living Apart Together they’d see us coming hand-in-hand and they’d start humming or singing, This article draws from research In American culture, marriage ‘Here comes the bride.’ And they and literature to offer four vignettes is central to romantic aspirations tried pushing us to get married but of late-life intimacy with significant and experiences. The Census Bureau we decided to just be good friends.” reported that in 2009 approximately implications for care managers. At first Ginnie and Saul “very much” 85,807 Americans aged 65 years and Noting that intimacy in later life can wanted to get married. But in time, as over were married in the United States arise outside the context of marriage, Ginnie explained, they decided “it was (U.S. Census Bureau, 2011). This is we begin by considering “Living a good thing not to get married . . . he but the tip of the iceberg of romantic Apart Together” relationships and the didn’t want to put his health problems relationships among older Americans. challenges of talking about love. The – burden me with them – and I didn’t Beneath lie a variety of relationships article then turns to Henry Miller’s want to burden him with mine either.” that may not have legal sanction but late-life infatuations, both of which Given subsequent events we might are vital (as in life-sustaining) to the offer lessons in the complex dynamics also suspect they were also concerned participants. Some take the form that of this powerful aspect of romantic about the reactions of Saul’s children. love. Finally, consideration turns to sociologists in Western countries A few months before she and I ageism and its insidious effects on around the world describe as “Living Apart Together” (LAT) (Levin, met, Ginnie had what she called “a intimacy among older adults. 2004). California researchers Strohm, run in” with the youngest of Saul’s Despite its importance, late life Seltzer, Cochran, and Mays (2009) two boys. Saul had been in the intimacy has been neglected by geron- estimate that a third of Americans hospital for a few days, and when he tological researchers. Gerontologists classified as “single” are involved in was scheduled for discharge Ginnie have made considerable progress in LAT relationships. In these intimate mentioned to the doctor that he had the study of sex, but relatively little relationships, couples live separately been having trouble with his intestines in understanding romantic love and but consider themselves – and are and she thought he should be intimacy in later life. This led Robert perceived by others – as a committed evaluated before he went home. The Kastenbaum to observe that, “[W]e do couple. While most of the limited doctor agreed. But when the son found not have a comprehensive gerontol- research on this topic has involved out, “He said, ‘Who ordered that?’ and ogy unless we know something about younger adults, a few studies have he found out that I was the one that this realm . . . Loving is not encom- explored the LAT relationships of brought it up and got so mad he started passed by the frequency of reported older adults. For instance, studies yelling in the hospital and he started sexual interests and activities . . . All in Europe suggest that living in out the door and he turned around and he said, ‘And you, Lady! You stay the ‘dirty old men’ jokes in the world separate homes may confer freedom out of it!’” Saul told his son to leave do not dilute the poignancy of love and egalitarianism not available to and Ginnie took him home the next and sex in later life” (Kastenbaum, cohabiting couples (De Jong and day. Saul refused to let his son visit 1973). Gierveld, 2004). The arrangement might also avoid or mitigate the until he apologized to Ginnie. Finally Those seeking to understand concerns of adult children. the apology was offered but relations at the time of our meeting were still intimacy may benefit from the study The experiences of two older strained. After telling this story, Ginnie of poetry and literature. While adults whom I will call Ginnie and said, “I’m sure they’re very happy that behavioral scientists struggle to Saul illustrate some of the dynamics he’s not gonna get married.” “operationalize” love, poets seek to of LAT relationships. The two met evoke the experience. Consider, for in at a retirement home and fell in Four months before Ginnie’s instance, a definition of intimacy love when Saul was 88 years old and interview, Saul moved out of the offered by an anonymous poet: Ginnie, 78. They quickly became an retirement home. His caregiver had “Henceforth there will be such a “item.” As Ginnie explained, “So, moved, so he went with her to the new oneness between us – that when one we just got very close, and then it facility. Once they no longer lived in weeps the other will taste salt.” got so the help [staff], particularly, the same facility it was more difficult

PAGE 10 of Spring 2012 Geriatric Care Management for Ginnie and Saul to see each other – not understand professional jargon, suggests that, “A slight friendship not impossible, because Ginnie could so clients and managers can find developed during the more than a still drive. But they relied more on themselves talking at cross-purposes. year that he pursued her, and then fate phone contacts. Ginnie said, “Every Simple language choices can played into his hands. When he saw her morning . . . either I call him when I bridge this gap. Some older adults dismay upon hearing from the United get up, or he calls me, at 7:00 every refer to romantic partners as a “friend” States Immigration Service that her morning, and then we talk again just or a “special friend,” terms that might visa had expired and that she would before lunch, and then I go over there easily be adopted by care managers. have to leave the country, he explained usually around 2:00 and come back Strohm, Seltzer, Cochran, and Mays that married to him she would not have there at 4:30 and then we call each (2009) used a more long-winded ap- to leave” (p.328). In September, 1967, other about 7:30 at night” (Barusch, proach in their study of LAT relation- Tokuda became Miller’s fifth wife 2008). ships, asking “Do you have a main despite the objections of Miller’s adult children, ex-wives, and friends. As Although neither Ginnie nor romantic involvement – a (man/wom- others had predicted, Tokuda exploited Saul had a care manager, this case an) you think of as a steady, a lover, a Miller and made his life miserable until illustrates some of the challenges partner, or whatever?” Regardless of she moved out in 1974. Afterwards he posed by LAT relationships. First, the specific term, care managers owe wrote, “Everybody had her number, the care manager must be alert to the it to themselves and their clients to it seemed, except me. . . She was possibility that a client’s intimates develop a comfortable approach for like one of those numbers that are may not be his or her spouse. This discussing intimate relationships both in and outside of marriage. indivisible. She had no square root” underscores the importance of (Winslow, p. 330). discussing intimacy during assessment and care planning. Second, in LAT Dynamics of Infatuation This experience illustrates why relationships the extent to which Like many younger adults, Lois so many adult children object to their partners are willing and able to Judson (2009) had fairly limited parents’ new love interests. Aware contribute to caregiving varies romantic expectations for her old age: of the overpowering intensity of considerably – probably more than infatuation, they seek to protect their When I’m eighty – if I’m ever parents’ from suffering. Despite her in marriage relationships. Although eighty – I expect my shape . . . to Ginnie and Saul voiced the desire conflicts with Saul’s children, Ginnie be sad and droopy, the odd bumps was sensitive to another possibility – not to “burden” the other with their and wrinkles progressed past the that they were still grieving the lost illnesses, Ginnie was clearly involved power of cosmetics to soften them. parent. As she noted, “. . . it’s only in Saul’s medical care, which brings Sexual striving, with its undignified two years for them that their mother’s us to the final challenge illustrated explosions and tremors, will have been gone.” Of course, more selfish by this case – potential tensions with passed away, and I do not expect to motivations may also be in play. Robert adult children. Clearly a care manager miss it. All I will ask of my body then Butler suggested that “many adult must be able to successfully navigate is that it carry me to my garden and children continue to be bound by a the complex dynamics that arise back, and that it allow me to hold a primitive childhood need to deny their between a client’s LAT partner and his grandchild or two, and that it let me parents a sex life…” (Butler, 1988, p. or her adult children. see and smell and taste a few seasons 11). Clearly adult children’s reactions more (p. 280). Communicating About to parental love are driven by complex Intimacy Likewise, before his own late- motivations and histories. life infatuation, Tom Ireland thought Following his disastrous fifth Caught up in the physical he had “finally used up my lifetime marriage, Miller fell madly in love with needs of frail and vulnerable allowance of love…” (p. 287). These a young actress-playboy model, Brenda clients, care managers may find it beliefs are unnecessarily self-limiting. Venus. By this time, 81-year old Miller difficult to devote time and energy suffered from severe disabilities. to emotional needs, not the least Older adults can and do But he pursued this romance with of which is the vital need for love. experience intense infatuations. th characteristic vigor. It proved a marked Many professionals find it hard to Throughout his lifetime, 20 century contrast to his previous love affair. talk about intimacy. Some think literary giant Henry Miller was a In one touching scene, Venus told it unprofessional to ask clients poster child of infatuation (and lust). of an evening when they went out about love, preferring euphemisms At the age of 76, he became wildly for dinner on a rainy night. The only like “primary relationship” or infatuated with a 27-year old singer parking place they could find was far “attachment.” Love is complicated from Japan, Hiroko Tokuda. She sang from the entrance to the restaurant, and sensitive, so it is tempting to use in the bar of a Japanese restaurant, and Miller was unable to navigate the this jargon to maintain distance from and every night Miller would sit at a distance. Despite her high heels, she the lived experiences of clients, not to table and, as his friend and biographer “scooped up Henry and set off across mention the manager’s own romantic Kathryn Winslow put it, “gaze on her issues. Unfortunately older adults may until closing time” (p. 328). Winslow continued on page 12

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Intimacy in Later Life: limitations regarding what is and is with prevention of sexually transmitted Reflections on Love and Care not possible in old age. Ageism can diseases. Assuming these considerations continued from page 11 also rear its head when older adults have been responsibly addressed, fall in love. This may have especially professionals must help family members the broken parking lot” (p. 90). His dire consequences for those living in deal with their own concerns, both friend, Lawrence Durrell reflected on residential care facilities. founded and otherwise. the role Venus played in Miller’s last Melinda Henneberger told the four years: “Everyone was absolutely story of a couple she called “Dorothy” Conclusion delighted for him, not the least his and “Bob” (Henneberger, 2008). Bob The four vignettes presented here children and friends. . . He would have was 95 and Dorothy was 82 when they illustrate important themes for care been forced to drowse away his last met and fell in love. They were both managers to keep in mind regarding late years with the needle and knockout residents in an assisted-living facil- life intimacy. First, Ginnie and Saul’s drops for company! Poor Henry! As ity, and they both had been diagnosed LAT relationship was vital to them, it was, he lived them in an ecstasy with dementia. The situation exploded but might easily have been ignored in of love bequeathed, valued, and when Bob’s son walked in on the a traditional care management assess- reciprocated” (Venus, 1986, p. 9). couple enjoying a sexual moment in ment, which underscores the importance Miller’s experiences illustrate the privacy of Bob’s bed. The son of learning to talk about love with the complexities of late life was furious and demanded that staff older clients. Second, Henry Miller’s infatuation. While individuals seem make sure that Bob and Dorothy were problematic fifth marriage reveals the to have different tendencies towards never again left alone together. As a intensity and the self-delusion that can infatuation, no one is too old to result, Dorothy stopped eating, lost 21 be part of late life infatuation. On the become infatuated (Barusch, 2008). In pounds, and was treated for dehydra- other hand, the third vignette – his final the intoxication of early infatuation, tion and depression. When Bob was infatuation – conveys the life-giving the lover becomes obsessed with the eventually moved out of the facility, power of reciprocated passion. Finally, beloved and can (like Miller) be deaf Dorothy sat next to the window and the sad tale of Dorothy and Bob, points to voices urging caution. The Jungian waited for him. Her doctor suggested to the impact of ageism and the vulner- perspective holds that infatuation is that without the forgetfulness of Al- ability of intimate relationships among essentially a projection. I like to think zheimer’s, the loss might have killed adults in residential care. Love is a basic of it like a movie projected (by the her. Commenting on the story, one human need, and romantic love can lover) through mist against a screen reader said that “the idea of geriatrics arise at any age. With sensitivity, care (the beloved). In time, the mist clears having sex freaks people out.” She managers can tap into its power to en- and the projection fades. The lover called it “the ick factor.” This story hance the quality of life for their clients. does seem to clearly illustrate the faces the reality of his or her beloved References and with it the opportunity to convert destructive power of ageism. Other infatuation into lasting love. Typically issues may also be at play. Barusch, A. (2008). Love Stories of Later this happens 12 to 18 months after When older adults enter Life: A narrative approach to understanding romance. New York: Oxford University Press. the initial infatuation (Fisher, 2004). residential care they have a right to While some lovers navigate the privacy under federal law. If married, Butler, R.N. & Lewise, M.I. (1988). The transition with no problem, others they have a right to conjugal visits new love and sex after 60. New York: are surprised or displeased by what and if both are residents of the same Ballantine. they see and the relationship can face nursing home to share a room (Centers Centers for Medicare & Medicaid Services a crisis. Care managers can support for Medicare & Medicaid Services, (n.d.) Your Guide to Choosing a Nursing older adults and their families by n.d.). But, unmarried residents, Home. (http://www.medicare.gov/ understanding these dynamics and particularly those with cognitive Publications/Pubs/pdf/02174.pdf, accessed approaching late life infatuation with impairments do not have a right to January 11, 2012). the respect it deserves, but sometimes intimacy. This led Anne Holmes De Jong Gierveld, J. (2004). Remarriage, ageism gets in the way. (2008) to – perhaps facetiously – unmarried cohabitation, living apart suggest that older adults should have a together: Partner relationships following Ageism and Residential “sexual power of attorney.” bereavement or divorce. Journal of Marriage and Family, 66(1), 236-243. Care While it is tempting to attribute this to ageism and/or prudishness on Fisher, H. (2004). What wild ecstasy: Being Ageism, a negative attitude in love. In Fisher, H. Why We Love: The towards old people and the process the part of administrators and staff, nature and chemistry of romantic love. New of aging, permeates our personal and physical intimacy among residents York: Henry Holt, 1-25. cultural expectations of older adults. can pose risks. Staff and family members face the delicate question of Henneberger, M. (2008) An affair to Its impact on the romantic possibilities remember. Slate. (http://www.slate.com/ insuring that sexual activity involving of late life is not always readily articles/life/family/2008/06/an_affair_to_ apparent. It arises, for example, when a cognitively impaired older adult is remember.single.html, accessed Jan. 7, popular myths fuel self-imposed consensual. They are also charged 2012).

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Holmes, A. (2008). Love, romance may still flourish in the nursing home, but can an advance directive give residents the right to a sex life? Booomerlifestyle blog. (http:// Addressing Diversity boomerlifestyle.com/blog/love- romance-may-still-flourish-in-the- nursing-home-but-can-an-advance- in Sexuality and Aging: directive-give-residents-the-right-to-a- sex-life/ accessed January 7, 2012.) Key Considerations for Ireland, T. The woman in question. In Sy Safransky (Ed). The Mysterious Healthcare Providers Life of the Heart. Chapel Hill: Sun Publishing Company,285-291. Judson, L. (2009). I am not a sex Nancy A. Orel, PhD, LPC and goddess. In Sy Safransky (Ed). The Mysterious Life of the Heart. Chapel Wendy K. Watson, PhD Hill: Sun Publishing Company, 275- 280. Levin, I. (2004). Living apart together: Abstract A new family form. Current Sociology, The purpose of this article is 52, 223-240. to explore the heterogeneity of the You wonder if perhaps Strohm, C.Q., Selzer, J.A., Cochran, older adult population and to provide the other five patients S.D. & Mays, V.M. (2009). “Living a framework for systematically Apart Together” relationships in the considering factors that influence are also seeking United States. Demographic Research, sexuality and the importance of these medical attention due 13(21), 177-214. factors when assessing the needs of U.S. Census Bureau (2011). Marital older clients in the arena of sexual to issues surrounding Events of Americans: 2009. American health. The acronym ADDRESSING Community Survey Reports. By will be used to illustrate ten cultural sexuality and sexual Dianna B. Elliott and Tavia Simmons. factors and personal attributes that U.S. (http://www.census.gov/ health, but you quickly impact sexuality. To appropriately and prod/2011pubs/acs-13.pdf, accessed dismiss this thought. January 7, 2012). adequately serve older patients, health care providers must seek to understand Venus, B. Sindell, G.S. (Ed) (1986). the patient’s perspective and how each Dear, Dear Brenda: The love letters of of these areas of diversity bears on Henry Miller to Brenda Venus. New but to wonder what brings these five York: William Morrow & Co. one’s attitudes, experiences, and needs regarding sexuality and sexual health. individuals to the doctor’s office today. Winslow, K. (1986) Henry Miller: Although your appointment with the Full of Life. Los Angeles: Jeremy P. Introduction physician is to seek some type of relief Tarcher, Inc. for your painful and burning urination, Imagine yourself walking into a you doubt if this is the same issue for physician’s office. You check in with the other five patients. You attribute the receptionist and take a seat close your current health concerns to the Amanda Smith Barusch, to a window to wait for your name fact that you are 72 years of age and College of Social Work, to be called. As you get comfortable have just begun engaging in weekly University of Utah. Prof. in your seat, you glance around the sexual intercourse after being celibate Barusch has long been waiting room and take note of the for the past fifteen years. You wonder fascinated by romance and five other people also waiting to see if perhaps the other five patients are the meaning of love. Her their physicians. You immediately also seeking medical attention due book, Love Stories of Later assume that all five of the individuals to issues surrounding sexuality and Life: A narrative approach to are older adults, aged 60 or older. sexual health, but you quickly dismiss understanding romance was Their grey hair (or lack of hair), this thought. released in 2008 by Oxford wrinkled skin, “age spots” on their University Press. hands, and bifocals tend to confirm This scenario illustrates your assumptions. You also categorize the human tendency to make the waiting patients as two older generalizations and to categorize white women, a white older male, an people (especially older adults) African-American older woman, and a so that order can be given to vast Hispanic older man. You cannot help continued on page 14

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Addressing Diversity in cultural factors and personal attributes group and if reinforced by political, Sexuality and Aging: Key also contribute to the difficulty in economic, and social power lead to Considerations for Health- designing services and programs that “isms” (e.g., ageism, sexism, racism, care Providers would meet the needs of any specific etc.). Table 1 illustrates the ten cultural subgroup of older adults. Therefore, factors/personal attributes and their continued from page 13 programs that are available must be corresponding dominant discourse and amounts of information. However, mindful of the diversity that exists isms (where evident). the tendency to generalize and within groups based on these cultural categorize can also lead to bias, factors and personal attributes. Assessing the stereotyping, and/or marginalization. Drawing upon the work of Hays Differences in Older Inaccurate generalizations concerning (1996), the acronym ADDRESSING Adults’ Sexual Health sexuality and sexual health in later will be used to illustrate the cultural using the ADDRESSING adulthood have led to misperceptions factors and personal attributes that Framework and the exclusion of older adults influence sexuality in later adulthood A key task for health care from receiving adequate attention and the importance of these factors in practitioners when assessing the from health care providers. The health and health care. ADDRESSING sexual health of older adults is to purpose of this article is to explore diversity in sexuality and aging discover and determine what cultural the heterogeneity of the older adult requires practitioners to consider ten factors and personal attributes are population and to provide a framework primary cultural influences, namely, important to their lives and thus for systematically considering the Age and cohort effects, Degree of contribute to their sexual health and multiple cultural factors and personal physical ability, Degree of cognitive well-being. The ADDRESSING attributes that influence sexuality ability, Religion, Ethnicity and framework can assist practitioners and the importance of these factors race, Socioeconomic status, Sexual in making accurate assessments by when assessing the needs of older orientation, Individualistic life increasing practitioners’ awareness clients in the arena of sexual health. experiences, National origin, and of “specific cultural influences and An understanding of the diversity that Gender. In addition to recognizing minority identities that they might exists in the expression of sexuality these ten cultural factors and personal otherwise overlook” (Hays, 1996, p. would lead to sexual respect and attributes that influence sexuality, it 335) as well as decrease the likelihood dignity. is just as important to identify the that important aspects of the patients’ ADDRESSING “dominant discourse” of each of the lived experiences would be unnoticed, personal attributes in order to foster Framework ignored, or disregarded. Likewise, an understanding of the diversity that discovering the specific significance or Older adults are a diverse and exists in the expression of sexuality. salience of one personal attribute over heterogeneous group of individuals, The dominant discourse is a particular the others for any one patient requires with only age being the common way of conceptualizing or talking that practitioners possess “culture- denominator. There are cultural factors about a subject. In this discussion, specific knowledge and skills.” To and personal attributes that define their the dominant discourse refers to appropriately and adequately serve unique and varying subgroups. These biases that are held by a dominant older patients, health care providers must seek to understand the patient’s perspective and how each of these TABLE 1 areas of diversity bears on one’s attitudes, experiences, and needs Cultural Factors/Personal Attributes and regarding sexuality and sexual health. Corresponding Dominant Discourse and Isms Returning to the scenario Personal Attribute Dominant Discourse “ism” presented in the introduction, the waiting room patients were simply Age Youth Ageism identified as being two older white Degree of Physical Ability Able-bodied Ableism women, a white older male, an Degree of Cognitive Ability Able-minded Abelism African-American older woman, and a Hispanic older man. However, these Religion Christian five patients represent heterogeneous Ethnicity and Race European American Racism experiences that might impact their Socioeconomic Status Middle Class Classism views of sexuality and play a role in Sexual Orientation Heterosexual Heterosexism their sexual health histories. Consider Individual Life Experiences Expected Roles and Experiences the following additional information about the five patients: National Origin American Born Ethnocentrism Martha is a 75-year old Caucasian Gender Patriarchy Sexism widow who wants a complete physical

PAGE 14 of Spring 2012 Geriatric Care Management examination. She is dating again for return to his place of employment Age and Cohort Effects the first time in six years. Martha is a -- as a security guard in an in-patient Because of the dominate first generation American. Her family hospice care facility. discourse of “youth,” society emigrated from Italy in 1932. Martha Collectively, these five patients erroneously assumes that older was raped as a child and has never are specifically seeking either a adults are not sexually active, despite told anyone about this experience. comprehensive physical/cognitive current research that documents that She does not think of the rape often, examination or medical attention individuals continue to be sexually but it has colored her enthusiasm for for a specific health concern or intimate throughout the lifespan beginning a new sexual relationship. issue (e.g., hearing loss, erectile (DeLamater & Still, 2005; Lindau Eighty-five year old Odessa dysfunction, shortness of breath, et al., 2007). The myths surrounding was brought to the physician’s office chronic pain). The brief descriptions sexuality in older adulthood are by Marvin, her 68-year-old son. would lead one to believe that only generally unquestioned throughout the Odessa currently lives in a long-term Odessa and Marvin have identified United States. Researchers perpetuate care facility and the administrator concerns related to sexuality and these myths by excluding has requested that Odessa older adults in their studies be evaluated for dementia of sexuality, which in turn because she has repeatedly may result in physicians not made sexual advances Because of the dominate discourse conducting comprehensive towards staff and other sexual health histories with residents. Odessa has been of “youth,” society erroneously their older patients. There are brought against her will and assumes that older adults are not many physicians who hold refuses to be examined by the belief that sexual activity “those doctors.” sexually active, despite current is not important in later life Marvin (Odessa’s son) research that documents that and therefore they do not is a Caucasian male. He is a ask about sexual histories in Veteran of the Vietnam War individuals continue to be sexually patient assessments (Gott, and lives with his wife of intimate throughout the lifespan Hinchliff, & Galena, 2004). twenty-five years. Although Physicians who unknowingly (DeLamater & Still, 2005; Lindau et al., 2007). Marvin is in the doctor’s abide by these myths not only office because of his mother, exclude sexual intimacy as he has intentions of speaking an important aspect of the to the doctor about his older patients’ lives, but they hearing loss and erectile dysfunction, sexual health. However, every health also place older adults at risk by not both of which are interfering with his care practitioner should complete a informing them of safe sexual health relationship with his wife. Marvin comprehensive sexual health history practices. Although the experience of is also struggling to make ends meet with every patient. Societal ageism aging and the experience of sexuality financially. reinforces the stereotypes that across the lifespan are extremely diverse, the traditional view of Adrienne is a 64-year-old older adults are not sexually active, sexuality in later adulthood tends to be African-American woman who lives and thus comprehensive sexual negative. Conversely, with the advent with Ruth, her partner of 10 years. histories are not usually obtained of sexual enhancement medication Adrienne has two grown daughters for patients over the age of 50 (Gott, (e.g., Viagra), it is now assumed from a previous heterosexual Hinchliff, & Galena, 2004). As that older men must participate in relationship, and she is currently previously indicated, a key task for penetrative sexual activity. responsible for watching her three health care practitioners who are grandchildren (ages 11 months, assessing the sexual health of older Ideally, older adults will 2 years, and 4 years) while their adults is to discover and determine recognize that there is no correct mothers work. Adrienne has been what cultural factors and personal or clearly defined manner in which experiencing shortness of breath and attributes are important to their lives sexuality must be expressed in later fears that it may be heart-related. and thus contribute to their sexual adulthood (Hillman, 2008). However, health and well-being. Applying it is important to recognize that older Jack is a Hispanic male who the ADDRESSING framework, adults’ attitudes and definitions of appears to be much older than the each of these cultural factors and sexual relations have been shaped by 64 years indicated on his driver’s personal attributes that contribute their culture and the historical events license. Jack’s physical complaints to sexual health and well-being will related to sexuality. Table 2 illustrates are numerous. He has been be briefly discussed and the five a few of the historical changes that experiencing numerous bouts of the patients previously described used to older adults have experienced related flu, and is in chronic pain. Jack is illustrate the potential application of to sexuality and sexual health: demanding that pain medication be the framework. prescribed for him so that he can continued on page 16

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Addressing Diversity TABLE 2 in Sexuality and Aging: Key Considerations for Select Historical Changes Older Adults Have Healthcare Providers Experienced Related to Sexuality continued from page 15 From this brief listing of 1928 Margaret Mead concluded that attitudes toward sex are culturally prescribed. historical events related to sexuality 1949, 1953 Kinsey Reports on Male and Female Sexuality are published. that older adults have witnessed and 1953 Playboy and Cosmopolitan begin publishing. lived, it is evident that the current cohort of older adults is less likely 1960 Contraceptive pill is approved by the U.S. Food and Drug Administration (FDA). to have experience with birth control 1966 NOW (National Organization for Women) is established. (e.g., the pill, condoms) and safe sex Human Sexual Response, the Masters and Johnson research is published. practices. Additionally, the current cohort of older adults is less likely 1969 Stonewall Inn Riots – beginning of gay liberation movement. to openly discuss their sexuality 1970 Everything you Always Wanted to Know about Sex is published. and/or sexual orientation and have 1972 Joy of Sex is published. lower levels of education and financial resources when compared 1973 The Roe vs Wade decision guarantees limited right to abortion. to younger cohorts. Health care The American Psychiatric Association eliminates homosexuality as a mental disorder. practitioners must recognize that 1975 Against Our Will: Men, Women and Rape is published. older adults have been influenced by different political and historical The Equal Rights Amendment to the U.S. Constitution is passed by the U.S. Congress and defeated in states. forces, with distinctive sets of social 1976 The Hyde Amendment to the U.S. Constitution prohibits federal funding of abortion. attitudes and opportunities. 1979 The Moral Majority is established. Degree of Physical 1981 HIV/AIDS is identified among gay men. Ability 1987 The Gay March on Washington revitalizes the gay movement. Research indicates that 1992 The National Health and Social Life Survey – the first scientific study of U.S. sexual behavior is published. frequency of sexual activity, a good 1993 “Don’t Ask, Don’t Tell” policy in the U.S. Armed Forces. quality sex life, and interest in 1994 U.S. Surgeon General Joycelyn Elders is fired for recommending education about masturbation. sex are positively associated with health in middle and later adulthood 1996 The federal Defense of Marriage Act forbids gay marriages. (Lindau et al., 2007) and a satisfying 1997 Ellen Degeneres comes out on “The Ellen Show.” sex life among married couples may 1998 Viagra is approved by the FDA. delay mortality (Seldin, Friedman, & Martin, 2002). However, research 1999 The emergency contraception pill is approved by the FDA. has also shown that an older 2000 RU486 (medical abortion) is approved by the FDA. adult’s level of physical activity 2004 Eleven states pass amendments to define “marriage.” affects his/her sexuality. Chronic 2007 New England Journal of Medicine publishes A Study of Sexuality and Health among diseases, certain surgeries, certain Older Adults in the United States. medications, personal reactions to physiological changes, substance 2011 First baby boomers turn 65 years of age. use, incontinence, acute illness, etc. 2011 “Don’t Ask, Don’t Tell” policy is abolished. can individually and collectively affect sexual well-being (Hillman, 2008; Steinke, 2005). All of these Degree of Cognitive likely change in the sexual behavior health conditions and an older Ability of an older adult with dementia is adult’s ability to perform Activities An older adult’s level of cognitive indifference or apathy (deMederios of Daily Living (ADLs) must be ability affects his/her sexuality. et al., 2008). However, the majority taken into consideration when Mental health issues, issues related of research on dementia and the assessing sexual health. Because the to performance anxiety, dementia, expression of sexuality has focused attribute of degree of physical ability depression, attitudes toward self as on improper sexual behaviors among intersects with gender, practitioners a sexual being, and level of sexual older adults with dementia (Ward et must also be mindful of the research knowledge and comfort with intimacy al., 2010). As in the case of Odessa, that indicates that men lose more must be explored. Research also most health care practitioners will years of sexually active life as a indicates that cognitive impairment does request a psychological evaluation result of poor health than women not prevent sexual desire, but it may for an older adult who is displaying (Lindau et al., 2007). complicate its expression. The most “inappropriate sexual behaviors” and

PAGE 16 of Spring 2012 Geriatric Care Management rarely request an assessment if sexual (Cain et al., 2003). Health care categories are evaluated negatively, indifference or apathy is evident. practitioners must not resort to with flagrant acts of discrimination as- ethnic or racial generalizations or sociated with them. Because it is pos- Religion assumptions, as could be the case with sible to conceal sexual orientation and, Jack, a Hispanic older man. even to some extent, chronological age, When completing a sexual sexual orientation and age have similar health history with older adults it is Socioeconomic social constructions. For example, imperative that religious beliefs are Status (SES) recognized and honored. Limited “within an ageist and heterosexist There are markers of SES that research indicates that religious and culture, the phrase (and former policy) influence one’s sexuality. These spiritual beliefs play a significant ‘Don’t ask, don’t tell’ is applicable and include level of education, economic role in older adults’ view of sexuality often applied to both older adults and class, style of life, occupation, and (Stancil, 2004) and that religiously LGBT persons by those who would living conditions. Changes in living inclined older married individuals prefer that they remain invisible” (Orel arrangements (e.g., moving in with tend to have more pleasurable sex than & Fruhauf, in press). adult children, residing in a long-term nonreligious older married individuals care facility) can contribute greatly to (McFarland, Uecker, & Regnerus, Individualistic Life changes in levels of sexuality among 2011). However, the limited research Experiences older adults. on the role of religion in shaping Each older adult has personal sexual frequency and satisfaction Sexual Orientation life experiences that have influenced amongst older adults did not make their sexual beliefs and attitudes and distinctions among religious traditions. Although sexual activity and thus their sexuality. Most significant There are theological guidelines health among older adults is an under- is an older adult’s past history of regarding sex or sexual activities, but studied topic, even less is known sexual experiences and activities. there are considerable differences about the sexual health and well- This would also include a past history in sexual morality among followers being of lesbian, gay, bisexual, and of sexual abuse that may play a of different religious traditions. For transgender (LGBT) older adults. It is role in one’s ability to experience example, Christianity (the dominant extremely important to recognize that intimacy. Likewise, people who have discourse) sanctions sexual activity LGBT older adults came of age when experienced life-altering experiences mainly between a husband and wife, their sexual orientation was regarded (e.g., physical abuse, violence, trauma, and sex is seen as serving the purpose as a form of mental illness and that natural disasters) may find that these of procreation. Further research is sexual behaviors between individuals experiences affect their views about needed to explore how the connection of the same sex was considered illegal sexuality and intimacy. and/or immoral (for a comprehensive between religion and sexuality in A history of STIs/HIV/AIDS review of LGBT and aging literature, later adulthood varies by religious is another critically important life see Kimmel, Rose, and David, 2005). traditions, cultural factors, and other experience that can influence sexual Older adults who self-identify as personal attributes. beliefs and attitudes. This would LGBT have faced numerous challeng- include aging with HIV or contracting es due to the prevailing heterosexist Ethnicity and Race HIV in later adulthood. The emotional and homophobic attitudes within the There is limited research on impact of HIV and AIDS on the LGBT culture. Health care providers when the impact of race and ethnicity community cannot be understated, assessing the sexual health of older on sexuality and sexual health in yet many LGBT individuals also adults must refrain from heteronorma- later adulthood. However, Mahay, experienced resiliency in the face of tivity – or assuming that all patients Laumann, and Michaels (2001) have adversity. The LGBT community’s are heterosexual. This would only indicated that ethnicity and race work in developing effective HIV compound the invisibility of LGBT influences attitudes concerning sexual prevention education programs can older adults. A health care practitioner expressiveness. Likewise, sexual be models for developing effective working with Adrienne must listen norms, practices, and preferences are HIV prevention education programs for subtle messages concerning the shaped by race and ethnicity. Limited specifically tailored for an older adult salience of her sexual orientation on research indicates that because the population. The Centers for Disease her current health concerns. U.S. culture tends to depict older Control and Prevention (CDC) persons as being white, middle class, An exploration of the sexual currently reports that 24% of persons and male, the sexual experiences of health of LGBT older adults must living with HIV/AIDS are over age 50 minority elders are poorly accounted take into consideration the similari- (2008) and that by the year 2015, 50% for in research. Although the U.S. ties between the social construction of of those living with HIV/AIDS will be has a growing population of non- sexual orientation as a sexual minor- 50 years of age or older. Health care Caucasians, the vast majority of ity status, and the social construction professionals must obtain thorough research on sexual functioning has of aging. Kimmel, Rose, Orel, and sexual histories from their older adult been conducted among Caucasians Greene (2006) indicate that both social continued on page 18

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Addressing Diversity in Conclusions Gott, M., Hinchliff, S., & Galena, E. (2004). Sexuality and Aging: Key General practitioners attitudes to discussing Considerations for Health- An investigation of personal sexual health issues with older care Providers attributes and the dominant discourses people. Social Science, 58(11), 2093-2103). leads to a more comprehensive continued from page 17 exploration of issues surrounding Hays, P. (1996). Culturally responsive assessment with diverse older adults. patients and be willing to discuss sexuality and sexual health among Professional Psychology: Research and STIs/HIV prevention strategies. older adults. Health care practitioners Practice, 27(2), 188-193. and researchers must adopt a broader National Origin view of sexuality in later adulthood, Hillman, J. (2008). Sexual issues and aging one that more accurately reflects the within the context of work with older adult Attitudes and definitions of sexual patients. Professional Psychology: Research heterogeneity in the lived experiences relations are shaped by one’s country and Practice, 39(3), 290-297. of individuals. It is important to stress of origin. What is considered sexually that health care providers must not Kimmel, D., Rose, T., & David, S. (Eds.). desirable or appropriate behavior only consider each dimension, but the (2006). Lesbian, gay, bisexual, and within a particular culture depends on interaction of multiple dimensions. transgender aging: Research and clinical salient aspects of the culture. There perspectives. New York: Columbia Press. Research is needed on sexuality in is limited research that systematically later adulthood particularly in relation Lindau, S., Schumm, L., Laummann, E., explores cultural similarities and to the intersection of age, degree of Muicheartaigh, C., & Waite, L. (2007). A differences on beliefs and values physical/cognitive ability, religion, study of sexuality and health among older related to sexuality. What is reported ethnicity/race, socioeconomic status, adults in the United States. New England relates to sexual behaviors that are Journal of Medicine, 357, 762-774. sexual orientation, individualistic seen as being “positive” or “negative.” life experience, national origin, and Mahay, J., Laumann, E., & Michaels, S. For example, there is often a global gender. (2001). Race, gender, and class in sexual expectation that women should remain scripts. In E. O. Laumann & R. T. Michaels virgins until marriage. Likewise, Most importantly, health care pro- (Eds.), Sex, love, and health in America men are likely to have more freedom viders who wish to approach the topic (pp. 197-238). Chicago, IL: University of in expressing their sexuality than of STIs/HIV/AIDS with their older Chicago Press. women. patients will be more successful if they take into consideration the numerous McFarland, M., Uecker, J., & Regnerus, M. (2011). The role of religion in shaping sexual Gender variables that may contribute to risk frequency and satisfaction: Evidence from Gendered sexual practices taking behaviors, STIs/HIV/AIDS married and unmarried older adults. Journal and gendered sexual roles reflect a knowledge, and older adults’ desire to of Sex Research, 48(2-3), 297-308. patriarchal discourse. Interest in sex practice safe sex. Basic education on STIs/HIV/AIDS is needed for many Orel, N., & Fruhauf, C. (in press). Lesbian, among middle-aged and older men in Gay, Bisexual, and Transgender (LGBT) older adults, but before risk prevention the United States has increased since Grandparenting. In A. Goldberg & K. R. 2000 (Lindau et al., 2007). Overall education programs can be initiated, Allen (Eds.). LGBT parent families: men have a longer sexually active the personal attributes of the “student” must be known so that the program Innovations in research and implications for life expectancy and most sexually practice. New York: Springer. active men report a good quality sex can be tailored for a specific set of life. In contrast, only about half of values, norms, and beliefs. Peplau, L.A. (2003). Human sexuality: sexually active women reported a How do men and women differ? Current References Directions in Psychological Science, 12, good quality sex life. This disparity 37-40. and its implications for health require Cain, V., Johannes, C., Avis, N., Mohr, further exploration. Although greater B., Schocken, M., Skurnick, J., & Ory, M. Seldin, D., Friedman, H., & Martin, L. sexual satisfaction is associated with (2003). Sexual functioning and practices (2002). Sexual activity as a predictor of greater sexual frequency for men, in a multi-ethnic study of midlife women: life-span mortality risk. Personality and Baseline results from SWAN. Journal of Individual Differences, 33, 409-425. sexual satisfaction in women has been Sex Research, 40(3), 266-276. found to be more strongly associated Stancil, B. P. (2004). Sex and the elderly: with emotional factors. Women tend DeLamater, J., & Still, M. (2005). No laughing matter in religion. Journal of to emphasize the relationship-bonding Sexual desire in later life. Journal of Sex Religious Gerontology, 15, 17-24. Research, 42, 138-149. aspects of sexuality more than men Steinke, E. E. (2005). Intimacy needs (Pepleu, 2003). Women’s sexual DeMederios, K., Rosenberg, P., Baker, and chronic illness: Strategies for sexual desire in midlife and older adulthood A., & Onyike, C. (2008). Improper sexual counseling and self-management. Journal of also appears to be more dependent on behaviors in elders with dementia living Gerontological Nursing, 31, 40-50. the availability of a partner than for in residential care. Dementia and Geriatric Cognitive Disorders, 26, 370-377. Ward, K., Bosek, R., & Trimble, E. (2010). men (DeLamater & Still, 2005), and Romantic relationships and interpersonal women often express a loss of interest Gott, M. (2005). Sexuality, sexual health violence among adults with developmental in sex that coincides with the disability and ageing. Maidenhead: Berkshire. Open disabilities. Intellectual and Developmental or death of a spouse (Gott, 2005). University Press. Disabilities, 48(2), 89-98.

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Nancy A. Orel, PhD, LPC is Associate Professor and Director of Gerontology Program; Bowling Green State University, Bowling Green, Ohio. Dr. Orel received Older Lesbian Adults her BA from Bowling Green State University in 1978. She and Alcoholism: A Case received her Master of Science in Guidance and Counseling from the University of Toledo in Study for Practitioners 1983 and her PhD in Counseling Psychology from the University Noell L. Rowan, PhD, LCSW, CADC of Toledo in 1999. Dr. Orel’s professional background as a licensed professional counselor includes over 18 years of clinical Abstract dramatic increase in the number of older adults with substance abuse and experience working with older There is a significant gap in the chemical dependency issues predicted adults. Dr. Orel’s research and literature regarding older chemically in the near future, current rates indi- the publications of that research dependent lesbians and their health cate that up to 17 percent of adults age have focused on intergenerational and mental health needs (Satre, 2006; 50 and older may be struggling with relationships within diverse family Shankle, Maxwell, Katzman, & structures (e.g., multigenerational such issues; however, this problem Landers, 2003). This conceptual article caregiving families, grandparent area has not yet achieved prominence begins to address the issues faced by headed families) and the needs in the literature (Blow, 2000; CSAT, older lesbians with alcoholism and and concerns of vulnerable 1998; Rowan & Faul, 2007; Shibu- considers further research necessary populations of older adults (i.e., sawa, 2006). Lesbian, Gay, Bisexual, and to enhance understanding of the lived experiences of these individuals. A In each year from 1995-2002, Transgender [LGBT] elders, and alcohol was the most frequently re- older adults with HIV/AIDS). literature review of issues facing this population is provided, followed by ported primary drug of choice among focus on alcohol-related older adult those admitted to a treatment facility health concerns, discussion about (The DASIS Report, 2005). It is esti- mated that 4% to 20% of community- Wendy Watson, PhD is Assistant older lesbian adults, and a case study Professor Gerontology Program; to demonstrate issues for practitioners dwelling older adults abuse alcohol Bowling Green State University, and a summarization with implications (Shibusawa, 2006). These percentages Bowling Green, Ohio. Dr. for practice and research. translate to an estimated 2.5 million Watson received her BA from older adults with problems related to the University of Houston in Background and alcohol (Blow, 2000; CSAT, 1998). 1990. She received her Master Literature Review In health care settings, 6% to 11% of older adults exhibit symptoms of alco- of Science and her PhD in 2006, Alcohol and drug abuse and mis- both in Human Development and holism; in psychiatric settings, 20% of use among older adults is one of the Family Studies from Texas Tech older adults exhibit similar symptoms; fastest growing public health problems University. Dr. Watson’s past and in emergency rooms, 14% (Shibu- in America. Initial evidence demon- research has explored issues of sawa, 2006). Rates for alcohol-related strates that the upcoming generation dating, sexual decision-making, hospitalizations among older adults of older adults will have high levels of condom use, sexuality, and are similar to those for heart attacks. remarriage for women in middle health problems related to substance Forty-nine percent of older nursing and later life. Current projects abuse (Axner, 2008; Farkas, 2008). home residents show signs of alco- and research interests include For example, Watts (2007) noted an holism, some of whom may be using sex and sexuality, dating and increase in problematic alcohol con- nursing homes for short-term rehabili- remarriage, women’s identity sumption in older adults and warns of tation (Blow, 2000; CSAT, 1998). development, and HIV/AIDS the urgent need to provide competent prevention for older adults. Although these figures are assessment and treatment for im- of concern, they still represent an proved health outcomes. An estimated underestimation of the true problem. 1.7 million older adults (age 50 and It is challenging to obtain accurate older) are chemically dependent and statistics on the prevalence of this group is predicted to increase to alcohol dependence in older adults 4.4 million by 2020 (Gfroerer, et al., due to multiple factors, such as 2002; Korper & Rasken, 2003; Men- the stigma, nonspecific symptoms, ninger, 2002). In conjunction with the continued on page 20

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Older Lesbian Adults and assessment and intervention strategies. income and estate taxes or social Alcoholism: A Case Study Moreover, Wilsnack et al. (2008) security survivor benefits. for Practitioners reported elevated risks of hazardous The preceding paragraphs continued from page 19 drinking, depression, and history establish many of the challenges of childhood sexual abuse amongst multiple comorbid health issues, and that play a role in creating stress lesbian and bisexual women with inadequate screening among this within the older lesbian population. specific recommendations to health population (He, Sengupta, Velkoff, & Furthermore, older lesbian women and mental health care providers DeBarros, 2005; Hooyman & Kiyak, who are most at risk for alcohol and to assess the sexual orientation of 2008). Nonetheless, these estimated other drug problems appear to have women in an effort to design more figures have important implications for low self-esteem, anxiety, depression, effective treatment provisions. There social work practice with older adults. poorly developed social support is a growing body of literature which In addition, the subset population of networks or have lost once relied demonstrates that differences between older lesbian women with alcohol upon social networks, and have long heterosexuals and sexual minorities related problems presents particular periods of stress associated with aging in regard to substance use, misuse, urgency for more research due to (Satre, 2006). Of specific concern is abuse, and dependence extends into indications of greater physical and that compared to heterosexual women, middle age and late life (Anderson, mental health risks that substance older lesbians are more likely unable 2009; CSAT, 2001; Jones, 2001; Satre, abuse/dependence entails for this to curtail their substance use and 2006; Valanis, Bowen, Bassford, population (Gabbay & Wahler, 2002; are at greater risk for physical and Whitlock, Charney, & Carter, 2000). Satre, 2006; Shankle, et al., 2003). mental health problems (Satre, 2006; While older lesbians deal with the Moreover, the virtual absence of Wilsnack, et al., 2008), and other expected stressors of growing older literature about the lived experiences issues particular to sexual minority (i.e. physiological changes, retirement, of older lesbian women who have adults such as more severe substance and loss), which have been noted as alcohol addiction and their ability to abuse, greater psychopathology, and potential risk factors for developing sustain recovery necessitates further increased medical service utilization alcohol problems in late life (CSAT, research. (Cochran & Cauce, 2006; Jones, 2001) 1998; Satre, 2006), there are additional Compared to the general which provides a clear urgency to vulnerabilities amongst older lesbians. address this social problem. population, lesbian women and gay Older lesbian women may have come men have elevated rates of substance out before the sexual revolution and Finnegan and McNally (2000) abuse problems (CSAT, 2001; Hall, gay rights era, thereby experiencing described that chemically dependent 1996; Hughes & Wilsnack, 1997; more anti-gay discrimination, a lesbians in the late mid-life years of Matthews, Lorah, & Fenton, 2005; greater sense of isolation, and age 50-60, deal with critical issues McKirnan & Peterson, 1989; Ratner, additional pressure to conceal their of losing their former identities and 1988; Roberts, 2006). It is even more identity, resulting in considerable creating new selves in older age and difficult to ascertain precise incidence emotional stress (Anderson, 2009; the incredible sense of loss felt when and prevalence information about Finnegan & McNally, 2002; CSAT, realizing that they have missed out lesbian women due to the hidden 2001). They may also sense a lack of on life experiences while in the midst nature of this population, inconsistent acknowledgement in society for their of their addiction to alcohol or other methodologies across studies, and partner relationships, their concept of drugs. Dealing face to face with death lack of attention to sexual orientation family, and may face being “lesbian when struggling with alcoholism in epidemiological research (CSAT, widows,” and drinking alcohol or or drug addiction and subsequent 2001). using other substances may have been recovery takes its toll especially when Recent research has begun to a major part of their lives (Finnegan coupled with the complex issues of show an even greater health risk for & McNally, 2002; CSAT, 2001; aging as a lesbian and many life- chemical addiction amongst lesbian Jenkins, Rowan, & Parks, 2008; changing decisions that need to be women as they present for treatment McFarland & Sanders, 2003). Also, addressed during their mid-life and with more severe chemical abuse because older lesbians do not qualify later age years. histories, co-occurring mental health for federal privileges of marriage, As has been noted, little is known issues, and increased medical service their surviving significant others/ about older lesbians with alcoholism utilization rates (Anderson, 2009; partners typically suffer more financial who have attained sobriety and the Cochran & Cauce, 2006; CSAT, 2001; losses than do heterosexual widows outcomes of formal treatment and Gabbay & Wahler, 2002; Mercer (Anderson, 2009). More specifically, informal supports are missing from the et al., 2007; Wilsnack et al., 2008). lesbian widows are not automatically literature. While there are some studies Mercer et al. (2007) also indicated consulted with on important health that provide treatment outcomes that lesbian women are fearful of care or family decision-making and of older adults, sexual orientation disclosing their sexual identity to do not qualify for bereavement or information is typically omitted health providers, which emphasizes medical leave, nor can they file joint (CSAT, 2001; Satre, 2006). Moreover, a need for culturally sensitive tax returns or reap financial gain from there is a dearth of information as it

PAGE 20 of Spring 2012 Geriatric Care Management relates to what helps older lesbian which tend to mimic other problems changes. Contrasts may be noted adults obtain and sustain sobriety that are common among older between older and midlife lesbians of specifically from a perspective about adults. Vague symptoms such as today given more public awareness of resiliency and overall quality of life. irritability, stomach upset, weight lesbian mothers, grandmothers, more Due to the history of socializing in loss, malnutrition, depression, and visible media, and the debates in the lesbian and gay bars, the ability to insomnia may be the first signs of media about same-sex marriage and form safe, supportive community a problem. In subsequent years, health care provisions with health care networks that do not involve drinking evidence of liver, kidney, and heart surrogate policy changes. There is a alcohol or using other drugs has disease, osteoporosis, incontinence, need for more research about older been particularly challenging for and pancreatitis may become apparent. lesbian women in an effort to increase this subset of older adults (Satre, Problems associated with the misuse the understanding of various health 2006). In addition, the negative of benzodiazepines overlap with those and life span concerns. attitudes and heterosexism as noted of alcohol abuse and may include The incidence of alcoholism in prior studies can create a complex drowsiness, sedation, confusion, among older lesbians is difficult to memory loss, falls, and other types of situation when older lesbian adults pinpoint because many studies do not accidents. When used in combination, present for treatment for alcoholism include data on sexual orientation. (Eliason & Hughes, 2004). Therefore, the adverse effects of alcohol and According to the available research, more needs to be known about the benzodiazepines may be severe the National Gay and Lesbian Task lived experiences of older lesbian (Finfgeld-Connett, 2004). Force (2005) estimates that three to adults with alcoholism in an effort to Most common causes of death in five percent of women in America inform practice with older adults. An older substance abusers include cirrho- overview of the health issues that face identify as lesbian or bisexual. sis of the liver, cancers of the mouth, According to the updated report older adults with alcohol problems is esophagus, pharynx, lung and liver; presented next in an effort to provide (2010), there are almost 38 million breast cancer in women; and trauma specific focus areas for geriatric health Americans over 65 or 12.6 percent (Fingerhood, 2000). Gastrointestinal care practitioners. of the population. This is predicted and liver diseases are the main com- to nearly double by 2030, when there Health Concerns about plications of alcohol use with older will be an estimated 72 million people Older Adults with adults. Esophagitis, ulcer disease, and over age 65. Since the lesbian and Alcohol Problems gastritis are all more common in the gay population is estimated to be older drinker; and aspirin and other between five and ten percent of the Health-related consequences of nonsteroidal anti-inflammatory drugs general population, this means that acute alcohol intoxication are more commonly taken by older people add today, 1.4 to 3.8 million lesbian and severe with older adults. Changes per- to the risk of these alcohol-related taining to physiology of aging occur gay Americans are reaching standard problems. Alcohol is also the second retirement age with an estimated 3.6 to in the older adult that account for the leading cause of acute pancreatitis in development of problems secondary to 7.2 million projected to be 65 or older older people behind gallstone disease alcohol use even when the older adult in 2030. and is the cause of chronic pancreatitis does not increase the amount of alco- in many cases. The complications hol intake over the years. A significant Case Study associated with alcohol use in older problem is the decreased absorption As a way of illustrating some of adults are no different than in younger rate in the gastrointestinal system, the points made in this article about people. However, the complications occurring as a result of decreased the need to understand more about may be more severe and occur at blood flow to the gastrointestinal the lived experiences of this subset lower levels of alcohol consumption system. Therefore, alcohol remains in of older adults, preliminary findings than in younger people (Fingerhood, the body longer and at higher rates of from the first case of current phe- 2000). These concerns emphasize concentration. Reduced hepatic blood nomenological research are discussed the importance for practitioners to be flow and decreased enzyme efficiency in the next section. The case serves mindful of pertinent health issues in diminish the liver’s functional capac- to strengthen the points made in the ity to metabolize drugs and alcohol. older adults that may be complicated description of older lesbian adults Hence, older adults keep an increased by alcoholism. with alcoholism by providing specific amount of drugs in their body for lon- examples of how one participant de- ger periods of time. The mortality rate Older Lesbian Adults: scribes her dealings with the intersec- for cirrhotic liver disease in the aged is What Do We Know? tion of identity in dealing with having about twice the mortality rate for the Lesbians from varying alcoholism, being lesbian, and aging. general population (Menninger, 2002; generations have lived and developed The phenomenological approach was Benshoff & Harrawood, 2003). in many different social environments selected in an effort to more fully un- There are multiple consequences with influences from a range of derstand the lived experiences of this of alcohol and other drug abuse political, historical, and civil rights continued on page 22

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Older Lesbian Adults and crucial in her decision to listen to the it’s just really hard to step out especial- Alcoholism: A Case Study therapist’s grave concerns that she ly if you’ve been heterosexual and mar- for Practitioners address her alcoholism. Dot related ried and had children.” She continues continued from page 21 that she had developed a nurturing and by stating, “the need for a listening ear subset population of older adults. The supportive relationship with the thera- and guidance and direction [is impor- study was approved by the Institution- pist that she did not want to lose. It tant] if you run across somebody who al Review Board of the researcher’s was during this time that she became is chemically dependent and lesbian… university and informed consent was sober in Alcoholics Anonymous. don’t be afraid to tell them to go to get obtained prior to involvement in the Her involvement with Alcoholics help.” three-part series of in-depth interviews Anonymous was described as very Needed programs or (Seidman, 2006). A combination of helpful and life changing as she services for older lesbian purposive and snowball sampling has maintained continuous sobriety adults with alcoholism methods were used to identify indi- for 22 years. She emphasized the viduals involved in the study. empowerment in learning that she There was an emphasis in the could rely on the support of others, first participant interview on the A description of the first that AA is a “we program” which she establishment of needed programs or participant described as a huge relief to not have services for this subset population of The participant, Dot (a pseud- to try to attain and maintain sobriety older adults. Dot stated the importance onym) is a 63-year-old African by herself. She reported, “I spent of creating settings where assistance American lesbian person who lives a lifetime trying to take care of me is provided for “help with socializing, in Kentucky with her partner of ten trying to do things by myself and not knowing what’s appropriate, how to years who is Caucasian and fourteen letting anybody in.” She described her be around many different situations, years younger. With some college, current life as beyond her imagination with other lesbians…[introduction to] she worked most of her adult life and with a large support system in place lesbian retirement communities.” Given continues to work in mostly clerical primarily from her involvement in that Dot admittedly had not developed positions. Alcoholics Anonymous and other social skills and was coming out as 12-step support groups as well as a lesbian in later life, socialization History with alcohol and involvement in a church community. opportunities wherein she could learn the transformation to She also described a strong faith in to interact without drinking alcohol and recovery God as helpful in difficult times. Dot other drugs was important to her ability reported, “I believe that no matter to sustain sobriety and a meaningful Dot lived in a heterosexual mar- what comes down the pike that God quality of life. She found the ability riage for twenty years reportedly is gonna be there.” In addition, she to socialize through her new-found drinking in “secret” to “take away all credited both her involvement in connections in 12-step groups that of my feelings just to get me in a place professional therapy individual and were lesbian and gay friendly as well where I felt okay about me ‘cause I group sessions along with 12-step as through a lesbian and gay affirming wasn’t okay about me.” She began support groups as key situations to her church community. Dot stated that if going to therapy and Adult Children of attaining and maintaining sobriety. practitioners could assist with a social Alcoholics and Alanon 12-step groups support system for older lesbian adults during the later years of her marriage What do geriatric care who are newly dealing with their due to family-of-origin issues with managers and other sexuality and alcoholism that this could alcoholism. She left the marriage after practitioners need to make a positive impact in the overall she began to get in touch with her feel- quality of life. ings and get sober. While in individual know? therapy, she was suicidal at times in When asked about the vital points Practice Implications her thinking while trying to control her that practitioners need to know, Dot This first participant in current use of codeine and alcohol to numb stated the importance of a compas- research illustrated some of the points feelings. Eventually, she reached a sionate listener especially with older made regarding the need to more fully point wherein she was confronted in lesbian adults who may be coming out understand the lived experiences of therapy that she needed to address her later in life while simultaneously deal- older lesbian adults with alcoholism. alcoholism. She described a pivotal ing with having alcoholism. Dot em- Dot was able to obtain sobriety with relationship with this therapist as vital phasized that, “compassion is needed a pivotal and strong, safe therapeutic to her entering an outpatient therapy for older women who are coming out.” connection with her individual therapist group that was focused on dealing Due to her struggles of realizing about along with other support from group with alcoholism. The one-on-one her sexual orientation after she had therapy focused on alcoholism in safe therapeutic connection that she been married to a man for many years addition to involvement in several described with this licensed clinical and having a family, she stressed the 12-step recovery support groups. Her social worker that she reportedly had importance for social workers “with willingness to seek professional help been seeing for about two years was the ability to listen ‘cause sometimes and to attend community support

PAGE 22 of Spring 2012 Geriatric Care Management groups aided her transformation. research to address services available adults (DHHS Publication No. SMA98- Practitioners dealing with older and the practice strategies that may 3179, Treatment Improvement Protocol work best for older adults with Series 26). Rockville, MD: Substance lesbian adults need to be aware of Abuse and Mental Health Services the community support available in problems with alcohol and other drugs Administration, Office of Applied Studies. their respective areas such as lesbian who are lesbian (Satre, 2006). Center for Substance Abuse Treatment. and gay specific community centers Recent research has noted a need (1998). Substance abuse among older which may provide socialization to focus more study on behalf of the adults (Treatment Improvement Protocol and community event opportunities, LGBT aging population. For example, Series, No. 26, CSAT Publication No. SMA 12-step group contact information, 98-3179). Rockville, MD: U.S. Department Fredrickson-Goldsen and Muraco such as national official websites of Health and Human Services, Public (2010) in the comprehensive review (Alcoholics Anonymous http://www. Health Service, and Substance Abuse and of the literature, note that LGBT older Mental Health Administration. aa.org and Alanon http://www.al- anon.alateen.org/) and the website for adults are particularly in need specific Center for Substance Abuse Treatment. the national Sage Organization that to a lack of available community (2001). A provider’s introduction to substance abuse treatment for lesbian, reaches out to older lesbian and gay resources and community support. Fredrickson-Goldsen and Muraco gay, bisexual, and transgender individuals. people (http://www.sageusa.org). Rockville, MD: U.S. Department of Health (2010) as well as the most recent Many communities do not have and Human Services. Substance Abuse and Institute of Medicine health report welcoming service centers for older Mental Health Services Administration. (2011) have demonstrated that the lesbian women and it may well be a Cochran, B. N. & Cauce, A. M. (2006). LGBT aging population is a hidden geriatric care manager’s specific work Characteristics of lesbian, gay, bisexual, to help to create social and community and marginalized group in society that and transgender individuals entering opportunities within their home areas. is in need of community outreach to substance abuse treatment. Journal of address issues of health and behavioral Substance Abuse Treatment, 30(2), 135- The national Sage Organization is one 146. organization that can provide initial health. Research is currently underway ideas and programming for training with a phenomenological approach to The DASIS Report. (2005). Older adults in substance abuse treatment: Update. to improve cultural sensitivity and understand how older lesbian women treatment for older lesbian consumers have recovered from alcoholism. Gaps Eliason, M. J. & Hughes, T. (2004). of services. As previously stated, there in understanding are being inquired Treatment counselors’ attitudes about lesbian, gay, bisexual and transgendered are few resources available for this about related to specific challenges clients: Urban vs. rural settings. Substance older lesbian population with alcohol- and strengths related to how older Use & Misuse, 39(4), 625-644. ism due largely from stigma and lack lesbians experience alcoholism, Farkas, K. J. (2008). Aging and substance of focused empirical research. access to formal alcoholism treatment, use, misuse, and abuse.Aging Times.4(2). and how they attained and sustain Conclusion Finfgeld-Connett, D. L. (2004). Treatment sobriety. Results of this work will of substance misuse in older women using Older lesbian women remain be forthcoming in future research a brief Intervention model. Journal of virtually invisible even with estimates presentations and articles. Gerontological Nursing, 30-37. that there are between one and three Fingerhood, M. (2000). Substance abuse million older lesbian and gay adults References in older people. Journal of the American age 65 and older in America today and Geriatric Society, 48, 985-995. are predicted to increase to between Anderson, S. (2009). Substance use Fredrickson-Goldsen, K. I. & Muraco, A. two and seven million by 2030 disorders in lesbian, gay, bisexual, & transgender clients. New York: Columbia (2010) Aging and sexual orientation: A 25 (Shankle, et al., 2003). As previously University Press. year review of the literature. Research on stated, the multiple challenges facing Aging, 32(3), 372-413. Axner, S. (2008). Substance use and abuse this particular subset of older adults among older adults: Reflections from an Finnegan, D. G., & McNally, E. B. (2002). presents an urgency to address the MSWstudent. Aging Times.4(2). Counseling lesbian, gay, bisexual, and health and mental health needs of transgender substance abusers: Dual Benshoff, J. J., & Harrawood, L. K. identities. New York: Haworth. this population in research to inform (2003). Substance abuse and the elderly: practice and policy (Butler, 2004; Unique issues and concerns. Journal of Finnegan, D. G. & McNally, E. B. (2000). Zodikoff, 2006). The Substance Rehabilitation, 69(2), 43 -48. Making up for lost time: Chemically dependent lesbians in later life. Journal of Abuse and Mental Health Service Butler, S. S. (2004). Gay, lesbian, Gay and Lesbian Social Services, 11(2/3), bisexual, and transgender (GLBT) elders: Administration, Center for Substance 105-118. Abuse Treatment (2001) has noted The challenges and resilience of this several areas in which further research marginalized group. Journal of Human Gabbay S. G.,& Wahler J. J. (2002). Behavior in the Social Environment, 9(4), Lesbian aging: Review of a growing is needed which includes the effects of 25-44. literature. Journal of Gay andLesbian aging, sexual identity, discrimination, Social Services, 14 (3), 1-21. Blow, F. C. (2000). Substance abuse and substance use and abuse with among older adults: An invisible epidemic. Gfroerer, J., Han, B., Colliver, J., & Penne, the older lesbian population. Much In F. C. Blow (Ed. Consensus Panel M. (2008). Substance use disorder among importance has been placed on future Chair), Substance abuse among older continued on page 24

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Older Lesbian Adults and McFarland, P. L. & Sanders, S. (2003). A Shibusawa, T. (2006). Older adults with Alcoholism: A Case Study pilot study about the needs of older gays substance/alcohol abuse problems. In B. for Practitioners and lesbians: What social workers need Berkman (Ed.), Handbook of social work to know. Journal of Gerontological Social continued from page 23 in health and aging (pp. 141-148). New Work, 40 (3), 67-80. York: Oxford University Press. Trunzo, aging baby boomers in 2020. Paper McKirnan, D. J., & Peterson, P. L. (1989). D., & Henderson, L. (2008). Older adults presented at Gerontological Society of Alcohol and drug use among homosexual in substance abuse treatment: Trends America Conference. National Harbour, men and women: Epidemiology and and characteristics. Paper presented MD. population characteristics. Addictive at Gerontological Society of America Gfroerer, J., Penne, M., Pemberton, M., Behaviors, 14, 545-553. Conference, National Harbour, MD. Folsom, R. (2002). Substance abuse Menninger, J. A. (2002). Assessment and Valanis, B. G., Bowen, D. J., Bassford, T., treatment need among older adults in treatment of alcoholism and substance- Whitlock, P., Charney, P., & Carter, R. A. 2020: the impact of the aging baby-boom related disorders in the elderly. Bulletin of (2000). cohort. Drug and Alcohol Dependence, 69, the Menninger Clinic, 66(2), 166-183. 127-135. Sexual orientation and health: Mercer, C. H., Bailey, J. V., Johnson, A. Comparisons in the women’s health Hall, J. M. (1996). Lesbians’ participation M., Erens, B., Wellings, K., Fenton, K. initiative sample. Archives of Family in Alcoholics Anonymous: Experiences A., Copas, A. (2007). Women who report Medicine, 9(9), 843-853. of social, personal, and political tensions. having sex with women: British national Contemporary Drug Problems, 23(1), probability data on prevalence, sexual Watts, M. (2007).Incidences of excess 113-138. behaviors, and health outcomes. American alcohol consumption in the older person. Nursing Older People, 18(12), 27-30. He, W., Sengupta, M., Velkoff, V. A., Journal of Public Health, 97 (6), 1126- & DeBarros, K. A. (2005).U. S. Census 1133. Wilsnack, S. C., Hughes, T. L., Johnson, Bureau current population reports: National Gay and Lesbian Task Force T., Bostwick, W. B., Szalacha, L. A., 65+ in the United States (pp. 23-209). (2005). LBT female elders fact sheet. Benson, P., Aranda, F., Kinnison, K. E. Washington, D C: U. S. Government Retrieved May 15, 2010 from http:// (2008). Drinking and drinking-related Printing Office. www.thetaskforce.org/downloads/misc/ problems among heterosexual and sexual minority women. Journal of Studies on Hughes, T. L., & Wilsnack, S. C. (1997). LBTFemaleEldersFactSheet.pdf Alcohol & Drugs, 69 (1), 129-139. Use of alcohol among lesbians: Research National Gay and Lesbian Task Force and clinical implications. American (2010). Outing Age 2010: Public Policy Zodikoff, B.D. (2006). Services for Journal of Orthopsychiatry, 67(1), 20-36. Issues Affecting Lesbian, Gay, Bisexual lesbian, gay, bisexual, and transgender Hooyman, N. R., & Kiyak, H. A. (2008). and Transgender (LGBT) Elders. Retrieved older adults. In B. Berkman (Ed.), Social gerontology: A multidisciplinary May 15, 2010 from www.thetaskforce.org/ Handbook of Social Work in Health and perspective. Boston: Pearson. reports_and_research/outing_age Aging (pp. 569-575). New York, NY: Oxford University Press. Institute of Medicine of the National Ratner, E. (1988). A model for the Academies (2011). The health of LGBT treatment of lesbian and gay alcohol abusers.Alcoholism Treatment Quarterly, People: Building a foundation for better Dr. Noell Rowan is Assistant understanding. Retrieved April 14, 2011, 5(1/2), 25-46. Professor and Director, BSW from www.iom.edu/Reports/2011/The- Roberts, S. J. (2006). Health care Health-of-Lesbian-Gay-Bisexual-and- recommendations for lesbian women. Program, Kent School of Social Transgender-People.aspx. Journal of Obstetric, Gynecologic, & Work, University of Louisville. Neonatal Nursing, 35(5), 583-591. Her research efforts focus on the Jenkins, D. J., Rowan, N. L., & Parks, C. (2008). Recovery and resiliency Rowan, N. L. & Faul, A. C. (2007). overarching areas of gerontology, in older gay addicts. Paper presented Substance abuse. In J. A. Blackburn LGBT population and alcohol and at Gerontological Society of America & C. M. Dulmus (Eds.), Handbook of other drug addictions, spirituality, Conference. National Harbour, MD. gerontology: Evidence-based approaches and the impact on social work to theory, practice, and policy (pp. 309- education and practice. She is Jones, B. E. (2001). Is having the luck of 332). growing old in the gay, lesbian, bisexual. interested in cultural sensitivity, transgender community good or bad Satre, D. D. (2006). Use and misuse of resiliency and quality of life and luck? Journal of Gay and Lesbian Social alcohol and drugs. In D. Kimmel, T. Rose, health and mental health in social Services, 13(4), 13-14. & S. David (Eds.), Lesbian, gay, bisexual, work education and practice. and transgender aging: Research and Korper, S. P. & Raskin, I. R. (2003). clinical perspectives (pp. 131-151). New She is a Hartford Geriatric The impact of substance use and abuse York: Columbia University Press. Social Work Faculty Scholar by the elderly: The next 20 to 30 years. in Cohort XI and is currently In Substance Abuse and Mental Health Seidman, I. E. (2006). Interviewing as Services Administration, Office of qualitative research. New York: Teachers’ conducting her research on Applied Studies. Substance Use by Older College Press. resiliency and quality of life Adults: Estimates of Future Impact on the of older lesbian adults with Shankle, M. D., Maxwell, C. A., Kutzman, Treatment System. E. S., & Landers, S. (2003). An invisible alcoholism. In 2009, she was Matthews, C. R., Lorah, P., & Fenton population: Older lesbians, gay, bisexual honored for the Best Research in J. (2005).Toward a grounded theory of and transgender individuals. Clinical LGBT at the Diversity Symposium lesbians’ recovery from addictions.Journal Research and Regulatory Affairs, 20, held at Ball State University. of Lesbian Studies, 9(3), 57-68. 159-182.

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American Social Health Association P.O. Box 13827 Research Triangle Park, NC 27709 Aging, Relationships, Phone: 919-361-8400 STI Resource Hotline: 919-361-8488 & Sexuality: Tools and Website: www.ashastd.org ASHA is recognized for developing Resources for Geriatric and delivering accurate, medically reliable information about sexually Care Managers transmitted infections. This is where you will find the facts, support, Jennifer A. Crittenden, MSW and resources, questions and answers, and thorough information on sexually Lindsay Day, LSW transmitted diseases.

This resource article is designed to provide key professional resources, American Society on Aging LGBT information, consumer resources, and training materials on love, relationships, Aging Website and sexuality in older age. The authors of this article do not endorse any of the 71 Stevenson Street, Suite 1450 organizations listed but rather are providing them as a general starting point for San Francisco, CA 94105-2938 Phone: 1-800-537-9728 considering, discussing, and exploring issues of older adult relationships and sexuality. The resources provided are listed in alphabetical order and available Website: www.asaging.org/education/5 training curricula are noted in resource descriptions as appropriate. The American Society on Aging (ASA) offers professional education, publications and online information Website: www.healthinaging.org/ and training resources that are nation- AARP Love & Sex Website agingintheknow/ ally recognized. This website provides This is a website set up by AARP a wealth of information on an array of This website was created by the to provide information about topics related to LGBT and aging. American Geriatrics Society Founda- relationships, love and sex after tion for Health in Aging (FHA). Aging 50. AARP provides a wealth of in the Know offers up-to-date infor- resources that are both engaging to Hartford Institute for Geriatric mation for consumers on health and read and easy to understand. Nursing Sexuality and Aging Website aging, including a section devoted to This website features nursing standard Website: www.aarp.org/relationships/love-sex/ sexuality and sexual concerns. practice protocols on issues of sexuality and aging. The information AARP Report on Sexuality at presented on the website is evidence- Midlife and Beyond American Psychological Association’s Aging and Human based content and includes an This report details a 2004 survey Sexuality Resource Guide assessment of sexual health in older study conducted by AARP adults for professionals to utilize. 750 First Street NE examining the role that sexuality Washington D.C. 20002-4242 Website: http://consultgerirn.org/topics/ plays in quality-of-life issues for Phone: 1-800-374-2721 sexuality_issues_in_aging/want_to_know_more midlife and older adults. The 2004 study also delves into attitudes Website: www.apa.org/pi/aging/resources/ toward sexuality among older guides/sexuality.aspx LGBT Aging Issues Network minorities. This is a website developed by the 71 Stevenson Street, Suite 1450 Website: http://assets.aarp.org/rgcenter/ American Psychological Association San Francisco, general/2004_sexuality.pdf to educate professionals about aging CA 94105-2938 and sexuality. It contains a plethora Phone: 1-800-537-9728 Aging in the Know of citations for empirical evidence Website: www.asaging.org/lain on aging and sexuality, summary 40 Fulton Street, 18th Floor chapters, case presentations, and As an affiliate of the American New York, New York 10038 resources to use for education in Society on Aging, the LGBT Aging Phone: 212-755-6810 teaching settings or with clients. continued on page 26

PAGE 25 of Geriatric Care Management Spring 2012

Aging, Relationships, & Sex- and well-being of the lesbian, gay, transgender (LGBT) older adults. uality: Tools and Resources bisexual, and transgender community Established in 2010, the center is for Geriatric Care Managers by providing advocacy that supports led by Services & Advocacy for continued from page 25 research, policy, education, and GLBT Elders (SAGE) in partnership Issues Network (LAIN) works to training on this topic. The website with 10 other organizations from foster professional development, features a compilation of resources for around the country. In an effort to multidisciplinary research and wide- consumers and providers including improve the quality of services and ranging dialogue on LGBT issues information on sexual health. supports for LGBT Older Adults, in the field of aging. They carry out the National Resource Center offers this mission through publications, National Gay and Lesbian a training curriculum on LGBT conferences, and cosponsored events. Task Force cultural competency to service providers free-of-charge. Providers 1325 Massachusetts Ave. NW, Ste 600 can request this free training on the LGBT Aging Project Washington, DC 20005 website. 555 Amory Street Phone: 202-393-5177 E-mail: [email protected] Jamaica Plain, MA 02130 National Sexuality Resource Center Phone: 617-522-1292 Website: www.thetaskforce.org 835 Market Street, Suite 517 Website: www.lgbtagingproject.org NGLTF is a national organization San Francisco, CA 94103 The LGBT Aging Project is a non- dedicated to ending discrimination Phone: 415-817-4512 profit organization that was founded against gay, lesbian, bisexual, and E-mail: [email protected] transgender people at the local, in 2001 by a group of advocates from Website: http://nsrc.sfsu.edu/issues/sex-and- state, and national level. Their both the aging service network and the aging LGBT community. The Aging Project aging initiative is in place to raise collaborates with community partners awareness of the needs of the aging The National Sexuality Resource to conduct research among LGBT GLBT population through research, Center is committed to promoting elders and providers and has provided networking, and training. healthy sexuality, dispelling training to more than 2,000 people. common myths about sexuality, and The LGBT and Aging Project works National Institute on Aging encouraging sexual literacy. NSRC’s to increase public awareness of LGBT Sexuality in Later Life AgePage website features a section which elders and caregivers and the issues provides a plethora of information This consumer resource discusses that impact their lives. specifically related to sex and aging. common problems and conditions that may interfere with sexuality Our Bodies Ourselves National Association on HIV Over 50 and sexual expression as one ages in language that is easy to understand. 5 Upland Road #3 23 Miner Street, Ground Level Visit the website for a PDF version of Cambridge, MA 02140 Boston, MA 02212-3319 this brochure, or to order hard copies Phone: 617-245-0200 Website: www.hivoverfifty.org of this consumer education resource. E-mail: [email protected] The National Association on Website: www.nia.nih.gov/HealthInformation/ Website: www.ourbodiesourselves.org HIV Over 50 is a volunteer based Publications/sexuality.htm Our Bodies Ourselves (OBOS), organization which promotes also known as the Boston Women’s education, training, and advocacy National Resource Center Health Book Collective (BWHBC), to those over 50 with a diagnosis of on LGBT Aging is a nonprofit, public interest wom- HIV. Their website provides research, en’s health education, advocacy, education, and communication around c/o Services & Advocacy for GLBT Elders (SAGE) and consulting organization. Their the interplay between HIV and aging. 305 Seventh Avenue • 6th Floor New York, NY 10001 mission is to “provide accessible, Phone: 212-741-2247 research-based information about National Coalition for LGBT Health E-mail: [email protected] women’s health and sexuality.” 1325 Massachusetts Avenue NW, Suite 705, Website: www.lgbtagingcenter.org Washington, DC 20005 The National Resource Center Project Visibility Phone: 202-558-6828 on LGBT Aging is the country’s Boulder Aging Services Division E-mail: [email protected] first and only technical assistance P.O. Box 471 Website: www.lgbthealth.net resource center working to improve Boulder, CO 80306 The National Coalition for LGBT the quality of services and supports Phone: 303-441-3570 Health works to improve the health offered to lesbian, gay, bisexual, and E-mail: [email protected]

PAGE 26 of Spring 2012 Geriatric Care Management

: www.bouldercounty.org/help/adults/ Website Sexuality and Aging Today Blog pages/projvis.aspx Jennifer A. Crittenden is the Hyatt Hall, One University Place Fiscal & Administrative Officer Project Visibility is a training Chester, PA 19013-5792 at the University of Maine Center program developed in 2004 by Phone: 610-388-5062 on Aging. Nearly all research Boulder County Aging Services, after E-mail: [email protected] projects and grant-funded the agency conducted extensive focus programs under her management groups with area LGBT elders. The Website: www.sexualityandaging.com entail the translation of academic goal of Project Visibility is “to co- This website is part of an educational research into professional and create an aging services community outreach initiative of the Widener public education programs, events, and dissemination that is informed, sensitive to, and University Graduate Program in Human activities. Jennifer has developed supportive of Lesbian, Gay, Bisexual, Sexuality. The mission of this initia- educational workshops, trainings, and Transgender elders.” The training tive is to “enhance the sexual health, conferences, and other activities is designed for administrators and knowledge, and well-being of people in for a wide range of audiences, staff of nursing homes, assisted living mid and later life by providing qual- including older adults, caregivers, residences, home care agencies, and ity sexuality education to individuals, healthcare professionals, social other senior service providers, as well couples and to professionals who serve service professionals, and as the friends and families of LGBT them.” The website features a compila- administrators. Jennifer currently elders. tion of resources for professionals and develops online educational consumers alike with regards to the topic offerings for professionals and of sexuality and aging. caregivers throughout the country Senior Sex: Tips for Older Men via the Center’s cutting-edge research, evaluation, and training The Senior Sex webpage was Training to Serve projects. Jennifer received her developed by the Mayo Clinic to 2365 N. McKnight Road, Ste 3 Bachelor’s degree in Psychology provide tips for maintaining a healthy from the University of Maine and St. Paul, MN 55109 and satisfying sex life as you get holds a Master’s degree in Social Phone: 651-251-5774 older. Work also from the University of E-mail: [email protected] Website: www.mayoclinic.com/health/senior- Maine. sex/MC00057 Website: www.trainingtoserve.org Training to Serve (TTS) is a train- ing curriculum that was developed by Lindsay Day holds a BSW Services & Advocacy for GLBT representatives from the Metropolitan from the University of Maine Elders (SAGE) Area Agency on Aging (MAAA), GLBT and is a Master in Social Work 305 Seventh Avenue, 15th Floor Generations, University of Minnesota, candidate at the University of New York, NY 1001 and MN Department of Human Services. Maine, working as an intern at Phone: 212-741-2247 Training to Serve is now recognized as the University of Maine Center E-mail: [email protected] an independent organization dedicated to on Aging. She is involved in a number of projects at the Center Website: www.sageusa.org providing training and education about the unique needs of LGBT older adults. on Aging including a rural SAGE is best known as the country’s Providers can request the TTS training Maine older adult impaired largest and oldest organization dedi- curriculum through the contact informa- driving project and coordination cated to improving the lives of les- tion provided on the TTS website. of the Seventh Annual Maine bian, gay, bisexual, and transgender Geriatrics Colloquium. Lindsay (LGBT) older adults. SAGE focuses is interested in issues impacting its work on providing programs and Aging Sexuality and Intimacy kinship caregivers as well as services for the LGBT older adult, Tipsheet, University of Cincinnati LGBT aging issues. She recently completed an independent providing technical assistance and Center for Aging with Dignity Aging research study that examined training as well as advocating for This consumer tipsheet developed by quality-of-life indicators and LGBT and aging issues nationally. the University of Cincinnati Center means for addressing quality- In partnership with the Brookdale for Aging with Dignity provides some of-life issues for transgendered Center on Aging of Hunter College, basic information about aging and individuals. She is also affiliated SAGE offers “No Need to Fear, No sexuality and some factors that may with the Hartford Partnership Need to Hide,” a training program impact sexuality as one ages. Program for Aging Education at about inclusion and understanding Website: http://nursing.uc.edu/centers/aging_ the University of Maine and is of lesbian, gay, bisexual, and trans- with_dignity/exploring_aging/aging_education.html pursuing a certificate in Rural gender elders for long-term care and Gerontological Social Work. assisted living facilities. Click on “Part 5 Sexuality & Intimacy”

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