LGBT Older People & COVID-19

Addressing Higher Risk, Social Isolation, and Discrimination

Issue Brief – May 2020

MAP
movement advancement project

SAGE
Advocacy & Services for LGBT Elders
“We refuse to be invisible”

Center for American Progress

There are more than 2.7 million LGBT people who are 50 years or older living across the country.¹ The current COVID-19 health crisis threatens their health, safety, and wellbeing in unique ways, including:

LGBT older people are more likely to live alone and to experience social isolation.
LGBT older people are more likely to rely on chosen family for caregiving support.
LGBT older people experience physical health disparities, often the result of discrimination, which make them more at risk for serious complications from COVID-19.
LGBT older people experience discrimination by healthcare providers, by caregivers, and in other key areas of life that make them more vulnerable during this crisis.

Many LGBT older people live in congregate care facilities such as nursing homes, long-term care facilities, or senior living communities. In addition to the higher risk these facilities may bring for contracting COVID-19, LGBT older people may be afraid to speak up or express concerns because of the discrimination they regularly experience.
LGBT older people are at increased risk for poverty and economic insecurity.

This brief summarizes what is known about LGBT older people during COVID-19 and offers tangible recommendations for ways that policymakers, advocates, and LGBT older people can remedy the many risk factors that leave them at particular risk in this current pandemic.

WHY LGBT OLDER PEOPLE ARE AT INCREASED RISK FOR COVID-19 AND ARE ESPECIALLY VULNERABLE RIGHT NOW

LGBT older people experience physical health disparities, often the result of discrimination, which make them more at risk for serious complications from COVID-19.

LGBT older people, in general, frequently report poorer physical health outcomes, which are oftentimes linked to experiences of discrimination in society as a whole and by health providers specifically.² A study by the Center for American Progress found that 65% of LGBT older people reported having pre-existing conditions, such as diabetes, asthma, heart disease, or HIV, compared to 51% of the U.S. population.³ LGBT older people also face specific disparities in physical health compared to non-LGBT older people. For example, LGBT respondents to the National Health Interview Survey were also more likely than non-LGBT respondents to be told they have cancer at 29% and 23%, respectively.⁴ A study of older LGBT older people in California found that gay and bisexual men are more likely to report hypertension, diabetes, physical disability, and poor health status than heterosexual men.⁵ The same study found that older lesbian and bisexual women report higher rates of physical disability. Recent data from the Williams Institute estimates that 32% of LGB people and 33% of transgender people in California are ages 65 and older and have fair or poor health with many others having asthma, diabetes, and heart disease, which may make them more vulnerable to serious COVID- 19-related complications.⁶

LGBT older people are more likely to live alone and experience social isolation. During this time of social distancing, this can leave them particularly vulnerable because they may have no one to count on to pick up groceries or prescriptions, to check on them, or to provide vital social connection.

Severe social isolation, which was already a tremendous challenge for older LGBT people, has increased by multiples as a result of the COVID-19 pandemic’s shelter-in- place and quarantine rules and the reality that many LGBT older people have literally nobody to reach out to for connection and support. Even before the pandemic, studies showed that LGBT older people were already twice as likely as their straight counterparts to live alone. In California, for example, the Williams Institute estimates that 39% of LGB people and 33% of transgender people over the age of 65 live alone and may be vulnerable.⁷ LGBT older people were half as likely to have life partners or significant others; half as likely to have close relatives to call for help; and four times less likely to have children to provide care. Many LGBT older people are also disconnected from families of origin. Heartbreakingly, almost a quarter of LGBT older people have no one to call in case of an emergency. And now, as COVID-19 sweeps across the country, many remain estranged from family and religiously-affiliated institutions on which others rely.

Shortly before the COVID-19 pandemic hit the U.S., the National Academies of Sciences, Engineering, and Medicine (National Academies) released a groundbreaking report entitled Social Isolation and Loneliness in Older Adults: Opportunities for the Health Care System. This report specifically spotlighted isolation among LGBT older people as deserving of particular attention. These findings are consistent with SAGE’s experience working with many thousands of LGBT older people across the country.
LGBT older people are more likely to rely on chosen family for caregiving.

LGBT older people rely on ‘chosen’ family and their communities for support. While LGBT elders’ networks of chosen family and friends may be strong and resilient, a lack of legal family ties manifests itself in three pronounced ways. First, friend networks often age simultaneously, meaning they may not be in the physical or mental condition to care for one another adequately. Second, many don’t live with families of choice, which may present challenges when governments require individuals to engage in physical distancing and avoid interacting with those who are not in our homes.

Third, many LGBT older people rely on chosen family for caretaking needs, but most of the limited existing paid leave laws do not cover chosen family. A Center for American Progress study found 42% of LGBT older people reported taking time off work to care for a friend or chosen-family member with a health-related need and, holding all other factors constant, individuals were more likely to take time off of work to care for chosen family if the individual identified as LGBT, reported having a disability, or was older.⁸ These chosen family and friend networks don’t have the legal recognition needed for people to take time away from work, share health insurance plans, or make medical decisions for one another. Especially during this health crisis, these networks may be unable to provide assistance at times of need.

LGBT older people experience discrimination by healthcare providers, by caregivers, and in other key areas of life that make them more vulnerable during this crisis.

LGBT older people are vulnerable to discrimination because of their sexual orientation, their gender identity, their age, and other factors like race. LGBT older people report experiences of discrimination across many areas of life—at work, at the doctor’s office, within residential communities and when seeking housing, and when accessing social supports like senior centers.

LGBT older people may be less likely to go to the doctor or seek assistance because they fear discrimination or have experienced discrimination. Forty percent of LGBT older respondents to SAGE’s survey in their 60s and 70s reported that their healthcare provider didn’t know about their sexual orientation.⁹ In the same survey, Hispanic LGBT older respondents were the most worried that the quality of health care they receive would decrease if they were open about their sexual orientation (34% of Hispanic respondents, compared to 23% of African American and 16% of white respondents).

Older transgender adults report high levels of negative experiences and concern about their healthcare. Two-thirds of transgender respondents felt there would be limited access to healthcare as they aged and over half feared they would be denied medical treatment because of their age.¹⁰ Older respondents were far more likely to report being current smokers, but the least likely to report nonmedical use of prescription drugs.

Many LGBT older people live in care facilities such as nursing homes, long-term care facilities, or senior living communities. In addition to the higher risk these facilities may bring for contracting COVID-19, LGBT elders may be afraid to speak up or express concerns because of the discrimination they regularly experience.

The long term impact of COVID-19 is still largely unknown. Long-term impact on people’s respiratory systems—including acute respiratory distress syndrome, paralysis, blood clots and organ failure, resulting in more long-term disabilities—would have an impact on the increased need for accommodations and supports for LGBT seniors. Given the spread of infections in nursing homes, there is an increased need to fund home and community based services and ensure that those workers have access to the equipment and supports they need to be safe.

Nearly half of LGBT people who had entered long-term care or had a loved one in long- term care experienced mistreatment in a care facility.¹¹ Nearly one-quarter (23%) of incidents that were based on a resident’s real or perceived sexual orientation and/or gender identity involved verbal or physical harassment from other residents, while 20% involved refusal to admit or re-admit, or attempted or abrupt discharge of a resident. Fourteen percent of incidents involved verbal or physical harassment by staff. While too often, these cases remain invisible, they are all too real. In 2016, for example, Marsha Wetzel sued Glen St. Andrew Living Community in Illinois because it did not protect her from other residents who harassed her based on her sexual orientation.¹² As Lambda Legal wrote in its first amended complaint, “Marsha was subjected to a pattern of discrimination and harassment because of her sex and sexual orientation, including persistent verbal harassment, threats, intimidation, and three separate assaults, at the hands of other residents. She has been called countless homophobic slurs, taunted about her relationship with [her partner] and their child, threatened with bodily harm, bullied and intimidated in all of the communal spaces in the facility, and physically injured by other residents, all because she had a committed relationship and created a family with another woman and because she is a lesbian.”¹³

Many LGBT older people live in poverty and lack economic security.

Nearly half of bisexual men (47%) and women (48%) and half of transgender older (48%) adults live at or below 200% of the federal poverty level, as do nlearly one-third of LGBT older people.¹⁴ LGBT older people are more likely to rely on federal benefits and LGBT people with disabilities report even higher rates of benefits usage. In a nationally representative survey from the Center for American Progress, 22.7% of LGBT respondents reported that they or their family received Supplemental Nutrition Assistance Program (SNAP) benefits and 41.2% of LGBT people with a disability reported using SNAP benefits.¹⁵ LGBT respondents in that same study were also more than twice as likely to report using housing assistance (6.3%) and 17.6% of LGBT respondents with disabilities reported using assistance.

During this challenging time, people with the fewest economic resources are particularly vulnerable as the safety nets that they’ve relied on are now being relied on by millions more people who have lost their jobs and need assistance.

LGBT OLDER PEOPLE ON THE FRONT LINES IN NEW YORK AND AROUND THE NATION

As social isolation reaches crisis levels, financial resources dry-up, and the safety-net is stretched-thin, many LGBT older people remain estranged from family and religiously- affiliated institutions on which others rely during crises. Consequently, we are witnessing an exponential increase in LGBT older people relying on LGBT aging organizations and others whom they trust to deliver life-saving help. And as a result, the COVID-19 pandemic is uniquely impacting not only LGBT older people, but also the organizations that serve them.

While LGBT aging organizations face budget shortfalls, LGBT older people are facing even greater challenges than older Americans in general because, as outlined above, they entered the pandemic with high levels of social isolation, thin support networks, and higher levels of financial vulnerability. Their acute social isolation and thin support networks mean that in many cases, LGBT elders have literally nobody to watch out for them—to ensure that they have essential food and medicine, to make sure they can access life-saving benefits and financial support, and to offer a modicum of social contact—other than LGBT aging organizations and members of the LGBT community. SAGE, for example, is working hard to step into this breach.

In New York City, the epicenter of the crisis, SAGE is calling thousands of elders on a regular basis to make sure that they hear from somebody and get help if needed. On the national level, SAGE launched a new program called SAGEConnect, a national emergency response initiative that links volunteers with LGBT elders who desperately need their phone to ring. We know from experience that even this kind of contact can make all the difference. One LGBT octogenarian in New York City recently expressed appreciation to SAGE for “letting people know that they’re not invisible” and said that knowing “that someone does care about [me] in the middle of this crazy crisis really makes me feel a heck of a lot better.”

Around the nation, food insecurity is emerging as a critical challenge for LGBT older adults. At SAGE of the Desert in Palm Springs, CA, staff are having to purchase food for its food bank at retail prices because its usual sources are tapped-out. It doesn’t know how long it can sustain this because funding is tight. Likewise, SAGE Cleveland is purchasing food retail and having it delivered to food insecure elders via Instacart. SAGE Rhode Island recently received a grant from an Episcopalian charity to buy and deliver food. SAGE Metro Detroit also reports that hunger and food insecurity are on the rise, hearing heartbreaking stories about people being unable to access care and resources. For example, it reported that one woman it contacted had been eating cat food. Thankfully, SAGE Metro Detroit has been able to connect these critical cases to its organizational partners.

LGBT elders are experiencing profound isolation and loneliness. And with limited or no public transportation they are unable to purchase groceries. Fear is also driving many of our seniors to stay home. Most of the LGBT seniors I work with have no family members to call on for assistance. [T]he LGBT seniors have a more profound sense of being detached and worried, because now their very limited number of contacts and supports are not available to them. Many are seeing our mainstream senior agencies stepping up and the city as well, yet the years of distrust, worry, and fear makes these offerings an overwhelming hurdle.”

— Senior Program Coordinator, SAGE Philadelphia

As much as they are stepping into the breach, LGBT organizations cannot do this work alone. It is more important than ever to empower the government and the aging network and to hold them accountable for meeting the needs of those who are most at-risk during the pandemic.

THE NEED FOR POLICY CHANGE

The challenges for LGBT older people during COVID-19 and beyond are not insurmountable. Rather, with thoughtful and speedy action, policymakers and advocates can make substantial efforts to improve the health and wellbeing of LGBT older adults. In this moment specifically, the following are key actions necessary to safeguard the health of LGBT older people.

1. Fund organizations assisting LGBT older people, who are disproportionately impacted by COVID-19. Congress, via the Administration for Community Living, should fund organizations to support the welfare of LGBT older individuals impacted by COVID-19.

2. Pass nondiscrimination protections to ensure that everyone can access the care they need. Congress should include the following language prohibiting discrimination in all COVID-19 response legislation:

No person otherwise eligible will be excluded from participation in, denied the benefits of, or subjected to discrimination in the administration of programs, services and assistance funded under this Act, under the Coronavirus Aid, Relief, and Economic Security Act, the Families First Coronavirus Response Act, or the Coronavirus Preparedness and Response Supplemental Appropriations Act based on non-merit factors such as (but not limited to) age, disability, sex (including sexual orientation and gender identity), race, color, national origin, immigration status, or religion. All recipients of funds under this Act must treat as valid all marriages that are valid under federal law.

Congress and state legislatures should also pass Long-Term Care Bills of Rights, barring discrimination on the basis of sexual orientation, gender identity, and HIV status in long-term care settings.

3. Inclusive paid family leave and family caregiving policies. Congress should include inclusive definitions of family in any new or updated paid family leave and family caregiving laws. Family must be defined to include a range of biological relatives and chosen family, as found in the PAID Leave Act (Providing Americans Insured Days of Leave Act of 2020).

4. Empower the Aging Network and hold it accountable. Congress and states should follow the lead of Illinois in designating LGBT older people and older people living with HIV as populations of “greatest social need” (target populations) under the Older Americans Act, the nation’s primary vehicle for the organization and delivery of social and nutrition programs, like Meals on Wheels. California and Massachusetts have also designated LGBT older people as a greatest social needs population.

5. Data collection of the impact of COVID-19 on LGBT people. All states and the federal government should follow the lead of Pennsylvania and include sexual orientation and gender identity in COVID-19 data collection.¹⁶

ENDNOTES

¹ Karen I. Fredriksen-Goldsen, “The Future of LGBT+ Aging: A Blueprint for Action in Services, Policies, and Research,” Generations: Journal of the American Society on Aging 40, no. 2 (2016).
² Jeff Krehely, “How to Close the LGBT Health Disparities Gap,” Center for American Progress, December 21, 2009, accessed May 17, 2020, https://www.americanprogress.org/issues/lgbt/ reports/2009/12/21/7048/how-to-close-the-lgbt-health-disparities-gap.
³ Kellan Baker, Sejal Singh, Shabab Ahmed Mirza, and Laura E. Durso, “The Senate Health Care Bill Would Be Devastating for LGBTQ
People,” Center for American Progress, July 6, 2017, https://www.americanprogress.org/issues/lgbtq-rights/news/2017/07/06/435452/senate-health- care-bill-devastating-lgbtq-people.
⁴ Centers for Medicare & Medicaid Services, Office of Minority Health, “Health Disparities Experienced among Older Sexual Minorities: National Health Interview Survey, 2013 -2014,” Data Highlight No. 5, June 2016, 2013 -2014, https://www.cms.gov/About-CMS/Agency- Information/OMH/Downloads/Data-Highlight-Health-Disparities-Among-Older-Sexual-Minorities-06-2016.pdf.
⁵ Steven P. Wallace, Susan D. Cochran, Eva M. Durazo, and Chandra L. Ford, “The Health of Aging Lesbian, Gay and Bisexual Adults in California,” UCLA Center for Health Policy Research, March 2011, https://www.ncbi.nlm.nih.gov/pubmed/21548402.
⁶ Ilan H. Meyer and Soon Kyu Choi, “Vulnerabilities to COVID-19 among Older LGBT Adults in California,” The Williams Institute, April 2020, https://williamsinstitute.law.ucla.edu/wp-content/uploads/Older-LGB-COVID-CA-Apr-2020.pdf.
⁷ Ibid.
⁸ Katherine Gallagher Robbins, Laura E. Durso, Frank J. Bewkes, and Eliza Schultz, “People Need Paid Leave Policies That Cover Chosen Family,” The Center for American Progress, October 30, 2017, https://www.americanprogress.org/issues/poverty/reports/ 2017/10/30/441392/people-need-paid-leave-policies-that-cover-chosen-family.
⁹ Robert Espinoza, “Out and Visible: The Experiences and Attitudes of Lesbian, Gay, Bisexual and Transgender Older Adults, Ages 45-75” (New York, NY: SAGE, 2014), 45 -75, https://www.sageusa.org/wp-content/uploads/2018/05/sageusa-out-visible-lgbt-market-research-full-report.pdf.
¹⁰ Sandy E. James, Jody L. Herman, Susan Rankin, Mara Keisling, Lisa Mottet, and Ma’ayan Anafi, “The Report of the 2015 U.S. Transgender Survey,” National Center for Transgender Equality, December 2016, https://www.transequality.org/sites/default/files/ docs/USTS-Full-Report-FINAL.PDF.
¹¹ The National Senior Citizens Law Center et al., “LGBT Older Adults in Long-Term Care Facilities: Stories from the Field,” accessed May 11, 2020, http://www.lgbtagingcenter.org/resources/pdfs/ NSCLC_LGBT_report.pdf.
¹² Lambda Legal, Wetzel v. Glen St. Andrew Living Community, https://www.lambdalegal.org/in-court/cases/il_wetzel-v-glen-st-andrew.
¹³ Lambda Legal, “First Amended Complaint: Wetzel v. Glen St. Andrew Living Community,” https://www.lambdalegal.org/in-court/legal- docs/wetzel_il_20181031_first_amended_complaint.
¹⁴ Charles A. Emlet, “Social Economic, and Health Disparities Among LGBT Older Adults,” Generations: Journal of the American Society on Aging 40, no. 2 (2016).
¹⁵ Caitlin Rooney, Charlie Whittington, and Laura E. Durso, “Protecting Basic Living Standards for LGBTQ People,” August 13,
2018, https://www.americanprogress.org/issues/lgbtq-rights/reports/2018/08/13/454592/protecting-basic-living-standards-lgbtq-people.

¹⁶ State of Pennsylvania, “Gov. Wolf Announces Inclusion of Gender Identity, Sexual Orientation or Expression in COVID-19 Data
Collection,” May 13, 2020, https://www.governor.pa.gov/newsroom/gov-wolf-announces-inclusion-of-gender-identity-sexual-orientation-or-expression- in-covid-19-data-collection.