Supporting older LGBTQ+ people in social care
Written by Dr Grace Krause and edited by Dr Kat Deerfield
June 2025
In this evidence summary, we highlight relevant and up-to-date research about the experiences and needs of older LGBTQ+ people and what good care for this group looks like.
Every person in Wales deserves to get person-centred and dignified support as they grow older. This means making sure that everyone gets care and support that values who they are.
Introduction
In the last Wales Census in 2021, 77,000 people (three per cent) described themselves as gay, lesbian, bisexual, or selected the ‘other sexual orientation’ option. And over 10,000 people (0.4 per cent) reported being transgender (Welsh Government, 2023). People of all ages can be LGBTQ+, but often public perception around LGBTQ+ identities is associated with younger people. As a result, the needs of LGBTQ+ people from older generations (aged 60 or over) aren’t always as visible as they should be. In this evidence summary, we share some research findings on how to make social care better for older LGBTQ+ people. We look at evidence on what worries older LGBTQ+ people and why they may sometimes find it hard to engage with care and support. We also look at the consequences of not recognising LGBTQ+ people’s identities in care settings. And we explore transphobia and homophobia, and how healthier conversations can be supported. We look at how family and other social connections may be different for LGBTQ+ people and how social care can support these connections. Finally, we give some practical advice on how to make social care settings more inclusive.
In 2023, a United Nations independent report on protections for LGBTQ+ people in the UK raised concerns about the role of misinformation in public discussions about LGBTQ+ rights, especially transgender people’s rights (Madrigal-Borloz, 2023). It can be hard to know what good information is. In this evidence summary, we provide an overview of research evidence on LGBTQ+ older people and social care. Our focus is how to support access to good care and support for LGBTQ+ older people. We’ve prioritised research that centres the voices of older LGBTQ+ people as well as social care staff working with older people. We’ve drawn out lessons that support person-centred care to enable all people who access support services in Wales to live a good life at any age.
There’s not a lot of research available on some topics related to LGBTQ+ people. In a review of research on health inequalities for LGBTQ+ people, McDermott et al. (2021) identified a lack of available research. This was the case even though the research they did find showed significant health inequalities. They argued that the assumptions people make about LGBTQ+ inequalities impact on what research is available. Researchers and funders may think that these inequalities are a thing of the past, so they don’t produce research about them (McDermott et al., 2021).
There are some limitations to this evidence summary. Because there’s not much research available, we don’t include an in-depth discussion of the needs of non-binary, intersex, or asexual people. We also understand that LGBTQ+ people are a diverse group and that their experiences will vary depending on other characteristics. For example, socioeconomic status, race, and other intersecting factors will mean that individual LGBTQ+ people have different experiences.
Key concepts
LGBTQ+ stands for lesbian, gay, bisexual (bi), transgender (trans), and queer or questioning. The + symbol acknowledges other identities that are included in this term, such as intersex, asexual, and aromantic. The identities under the LGBTQ+ umbrella divide roughly into two types: sexual identity (who we are attracted to) and gender identity (how we experience our own gender).
You can find more information about the different language people use from Stonewall’s list of LGBTQ+ terms (Stonewall, 2022). The LGBTQ+ Action Plan for Wales also has a glossary and links to additional resources about terminology (Welsh Government, 2023). Our definitions in this section are based on these sources.
The LGBTQ+ acronym includes all sexual orientations except heterosexuality. People who identify as gay or lesbian are attracted to people of their own gender. People who identify as bi are attracted to people of more than one gender. People who identify as asexual usually aren’t sexually attracted to people of any gender, and people who identify as aromantic usually don’t experience romantic attraction.
The identities under the LGBTQ+ umbrella divide roughly into two types: sexual identity (who we are attracted to) and gender identity (how we experience our own gender)
Someone’s gender identity is how they experience their own gender. People whose gender identity matches the sex that was registered when they were born are cisgender. People whose gender identity is different from the sex registered when they were born are transgender. Transgender is an umbrella term that covers different ways that people relate to their gender identity. This includes men who were assigned female at birth (transgender men), women who were assigned male at birth (transgender women), and non-binary people. People who are non-binary don’t identify as men or women, or they experience their gender as outside of the male/female binary.
Some people are intersex, which means they naturally have biological characteristics that differ from what society expects for male or female bodies. Some intersex people’s gender identity matches the sex that was registered when they were born, but this is not the case for many. For example, one study found that only 23 per cent of intersex people who were assigned male at birth identify as men later in life (Henningham and Jones, 2021).
Queer is sometimes used as an umbrella term for the LGBTQ+ community as a whole and includes multiple identities. Also, some people identify as queer, rather than using a more specific label. While queer is widely used by many members of the LGBTQ+ community, it’s important to keep in mind that some LGBTQ+ people find the term hurtful. For this reason, we avoid using the term as an umbrella term to describe LGBTQ+ people in this evidence summary, even though some of the research we include uses this term.
There are other ways that people talk about their sexual orientation and gender identity, and people sometimes change the labels they use to describe themselves as they find out more about themselves.
A report from the Equality and Human Rights Commission (EHRC) found that LGBTQ+ people in Wales are at risk of bullying and discrimination. The report found that older transgender people in particular are concerned that they may not have their identity respected when accessing social care (EHRC, 2023). Discrimination and violence against LGBTQ+ people can take many obvious forms, like physical violence or unequal access to medical care. But there are also more subtle ways that LGBTQ+ people can have worse experiences in care settings than other people. The research we explore in this summary shows how this can happen when LGBTQ+ people’s specific needs are not recognised.
To understand why many LGBTQ+ people experience, or worry they might experience, difficulties with social care, it’s important to explore the concepts of heteronormativity and cisnormativity (see Willis et al., 2023). Heteronormativity is the idea that people are generally assumed to be heterosexual. Cisnormativity means that people are assumed to be cisgender. Both terms suggest that ideas of what’s “normal” can exclude people whose gender or sexuality sits outside of these assumptions. This can make it difficult for LGBTQ+ people to have their needs and preferences met.
Older LGBTQ+ people in legislation and guidance
LGBTQ+ Action Plan for Wales (2023)
The LGBTQ+ Action Plan for Wales acts as a framework to bring together LGBTQ+ policy within Wales. It sets out the concrete steps Welsh Government will take “to tackle the existing inequalities experienced by LGBTQ+ communities, to challenge discrimination, and to create a society where LGBTQ+ people feel safe to live and love authentically, openly, and freely as themselves”. This includes removing barriers to accessing health and social care for LGBTQ+ people.
Equality Act 2010
The Equality Act 2010 is a piece of UK legislation that protects the rights of people with specific characteristics. These “protected characteristics” include age, disability, gender reassignment, marriage and civil partnership, pregnancy and maternity, race, religion or belief, sex, and sexual orientation. The Public Sector Equality Duty requires that public bodies consider how their decisions and policies will impact all groups protected under the Equality Act.
Age friendly Wales (2021)
Age friendly Wales: our strategy for an ageing society lays out Welsh Government policy for better supporting people as they age. The goals of the plan are to enhance well-being, improve local services and environments, build and retain people’s own capability, and tackle age-related poverty.
Visibility of LGBTQ+ older people in care settings
It can be hard to talk about gender identity and sexual orientation in care settings (Willis et al., 2016). People may be worried about starting conversations in case they upset someone. Heteronormative and cisnormative assumptions in social care can mean that LGBTQ+ people become invisible in these settings (Willis et al., 2023). One way to address this is to increase awareness of the fact that some older people are LGBTQ+ and help social care staff be more open to talking about those identities.
In Willis et al.’s (2016) focus group with social care staff and managers, participants described how hard it could be to have conversations about sexual identity (see also Hafford-Letchfield, 2017). They described an absence of discussion around lesbian, gay, and bisexual identities. The authors also noted that the staff sometimes struggled to even use the words lesbian, gay, or bisexual. Willis et al. (2016) suggest that one reason that staff may be hesitant to bring up LGBTQ+ issues is that they may see sexual orientation as separate from and irrelevant to a person’s care needs. They found that some participants believed discrimination based on sexual orientation was a thing of the past and therefore not something that impacted care now.
These views were also noted by Knocker and Smith (2021) in their work for Age UK. They argue that LGBTQ+ people become invisible in care settings because of the idea that older people’s sexuality isn’t important, and that care staff shouldn’t discuss this. Willis (2017) also notes that sometimes care providers express their commitment to equality by saying things like “We would treat everyone the same anyway”.
To make sure that everyone has equal access to good care, the different needs and wants of individuals need to be taken into account
While wanting to treat everyone the same may be well intentioned, it becomes a problem when people’s needs and past experiences aren’t considered. To make sure that everyone has equal access to good care, the different needs and wants of individuals need to be taken into account.
In a study on making residential care more inclusive for lesbian, gay and bisexual people in Wales, Willis (2017) interviewed people from older people’s human rights groups and from independent housing organisations. Participants suggested that spaces could become more inclusive with simple changes to the environment. They gave examples like displaying pictures of same-sex couples in public areas or using rainbow stickers to mark areas as inclusive (Willis et al. 2016).
The risks of increased visibility
However, it’s important to be aware of what Westwood (2015) describes as “risky visibility”. This means that people known to be LGBTQ+ may face hostility or isolation because of their identity. It’s therefore important to recognise that increased visibility of LGBTQ+ people isn’t the same thing as addressing homophobia or transphobia.
Jeyasingham (2008), writing about social work education, warns that more awareness does not automatically translate into better treatment of LGBTQ+ people. The author argues that awareness will only lead to more acceptance if it’s focused on changing beliefs about what’s normal and good. For example, when portrayals of LGBTQ+ people are overly stereotypical or too simplistic, this can lead to problematic awareness (see also Richardson, 2000; Willis, 2017).
If discussions of LGBTQ+ issues are insensitive or discriminatory, there’s also the danger of causing distress to LGBTQ+ people accessing support. As many older LGBTQ+ people will have experienced violence and discrimination in the past, they may have significant anxieties even about things that are intended to be positive. In residential care, LGBTQ+ people – both staff and older people accessing care – may worry about the unintended consequences of things that are meant to be supportive. For example, they may worry that holding a Pride event may lead to increased discrimination, if other residents and staff hold homophobic or transphobic beliefs. LGBTQ+ staff or residents may also worry that they’ll be put in a position where they must engage in emotionally challenging or distressing conversations (Willis, 2017).
This doesn’t mean we should avoid raising awareness of LGBTQ+ people. But it’s important that increasing awareness of LGBTQ+ older people includes challenging homophobia and transphobia when it arises.
Past experiences of discrimination
Older LGBTQ+ people may worry about engaging with health and social care providers because they’ve had bad experiences in the past. In research on older LGBTQ+ people, one strong theme that emerges is that they worry about experiencing transphobia or homophobia from care providers (Stinchcombe et al., 2017). Willis et al. (2016) interviewed older lesbian, gay and bisexual people in Wales and found that they were strongly influenced by past experiences of discrimination. This included experiences of physical violence and having their identities classified as psychiatric disorders.
Older LGBTQ+ people will have lived through times when their identities were not just less socially accepted but actually criminalised. In England and Wales, sex between men was a crime until 1967, and the age of consent was higher for sex between men until 2000 (see the Sexual Offences Act 1967 and the Sexual Offences (Amendment) Act 2000). Section 28 of the Local Government Act 1988 (UK) prevented “promoting homosexuality” in schools or local government publications. Section 28 was in effect until 2003. Willis (2017) argues that it’s important to remember these historical facts to understand why some older people may not feel that it is safe for them to be “out” as LGBTQ+.
A US study that surveyed 2,281 gay and bisexual men found a strong connection between how much discrimination the respondents felt there was in their communities and their access to medical care. The more discrimination they felt there was, the less likely they were to have access to regular medical care. However, this effect was mitigated for men who were strongly connected to the LGBTQ+ community (Anderson-Carpenter et al., 2018). We discuss the importance of recognising LGBTQ+ older people’s community connections later in this evidence summary.
One factor identified in research on older LGBTQ+ people is the significance of having lived through the HIV/AIDS epidemic. Much of the treatment of gay and bisexual men, specifically in the 1980s and 1990s, was characterised by medical neglect and stigma. Research shows that this has had a lasting impact on how some older LGBTQ+ people engage with services.
Older LGBTQ+ people will have lived through times when their identities were not just less socially accepted but actually criminalised
A Canadian study that looked at the experiences of older gay men showed that navigating the HIV/AIDS epidemic shaped all participants’ relationships to the healthcare system, regardless of whether they were HIV positive themselves. Kia et al. (2018) argue that these experiences of marginalisation have an impact both on older gay men’s access to healthcare and on the outcomes of that healthcare. They argue that the history of discrimination against gay men leads them to see healthcare as a “site of subjugation”. This means that they’ve had such negative experiences over time that they feel as though they’ve lost their freedom and their rights within these spaces. While this study looks specifically at healthcare, the lessons from it are also important to social care. This may impact how gay men and other LGBTQ+ people interact with any institutions offering care and support.
Participants in Kia et al.’s (2018) study described both homophobia and stigma about HIV/AIDS as something they had experienced in the past as well as something they deal with today. Some interviewees who were HIV positive described feeling as if health professionals were making assumptions about their character. And one interviewee who was HIV negative reported being regularly referred for testing despite being in a decades-long monogamous relationship.
Transgender people are also likely to have a complicated relationship to health services and anxieties about accessing care that meets their needs. Research shows that some transgender people avoid examinations or treatment because they’re worried about experiencing discrimination. This can lead to transgender people experiencing worse health (Safer et al., 2016). These worries can also manifest in relation to social care, especially where it relates to support with daily activities and things like getting dressed or personal hygiene. In a study of older transgender people, Jones and Willis (2016) found that some people were worried about being confronted with discriminatory attitudes if care staff were uncomfortable working with someone who is transgender. They were particularly concerned about this because they felt they may not be able to challenge discrimination from a care worker. Jones and Willis (2016) further emphasise the need for social care staff to understand how previous experiences may lead transgender people to be mistrustful of social care services and be particularly uncomfortable with staff changes.
Diverse families and communities
People can have quite specific views about what family means and generally speaking they’re based on Western and heteronormative ideas. Willis et al. (2024) note that older LGBTQ+ people can feel excluded in social care settings that are built on heteronormative and cisnormative assumptions. We’ve looked at why it’s important to question our underlying assumptions of what “good” families look like in our evidence summary on supporting marginalised families. Heteronormative, previously discussed in in the key concepts section, means that we assume that heterosexuality is the default or best way of experiencing attraction. Research suggests that LGBTQ+ people may experience their family or kinship relationships in different and wider ways than cisgender straight people do (Knocker and Smith, 2021; Peel and McDaid, 2015). The term “kinship” is used in relation to LGBTQ+ family forms to emphasise the fact that they often make sense of their family histories and connections through more than biological connection (Garwood, 2022). This is sometimes referred to as “chosen family, family of choice or Lavender families” (Stinchcombe et al., 2017).
Research shows that LGBTQ+ people’s life satisfaction, access to care, and general well-being are strongly linked to having a sense of community and belonging (Orel, 2004; Jones and Willis, 2016; Kneale et al. 2021, Willis et al. 2023). LGBTQ+ people often have extended networks of people, such as friends or partners, who aren’t given the same status as biological family. Jones and Willis (2016) emphasise the need to support these relationships as well as supporting older LGBTQ+ people to engage in their wider communities. It’s also important to be able to manage conflict, should it arise, between someone’s chosen family and their biological family. In Peel and McDaid (2015), LGBTQ+ people talked about their worries about losing access to their chosen family if they became too frail to advocate for themselves.
In Willis et al. (2016), older lesbian, gay, and bisexual people in Wales said it was very important to them for their relationships to be treated as just as important as heterosexual couples. For people working in social care, this means not making assumptions about the nature of people’s relationships based on assumptions about gender. Recognising the relationships that matter to people also means acknowledging and valuing the wider chosen families that older LGBTQ+ people may have built. This includes making sure that these wider networks are involved in care decisions (Stinchcombe et al., 2017). This can also make care more inclusive for aromantic people, who may not have romantic relationships at all, and polyamorous people, who may have more than one romantic relationship at the same time.
Dementia and LGBTQ+ people
McGovern (2014) suggests that LGBTQ+ people with dementia may be “triply marginalised” because of their age, their cognitive impairment, and their sexual orientation and/or gender identity. It’s important for those providing care and support to be aware of the particular vulnerabilities of this group.
There are many ways that dementia may uniquely affect LGBTQ+ people. People who have never disclosed their LGBTQ+ identity may unintentionally “out” themselves because of dementia symptoms (Peel and McDaid, 2015). Respondents in a study on LGBTQ+ people with dementia emphasised the importance of valuing people’s identity, especially as they had more difficulty holding on to it themselves. For them, like LGBTQ+ people in other studies, the idea of having to deny or hide their identity later in life was a major cause of distress (Peel and McDaid, 2015).
Transgender people with dementia may also experience specific struggles. If they’ve never shared their gender identity, they may reveal it when they develop dementia symptoms. They may also forget things that they’ve changed as part of affirming their gender identity. This may include things like their name, the pronouns they use, the way they dress, or that they’ve undergone gender affirming medical treatment. Peel and McDaid (2015) emphasise the need for care providers to support transgender people with their gender identity in an accepting and open way. One participant in their study stressed the need to carefully manage reminiscence therapy with older transgender people. Reminiscence therapy aims to improve people’s well-being by discussing memories and past experiences in order to stimulate mental activity. This may be a more complicated experience for people who may struggle with memories being from a time when they lived their life as someone of a different gender. Another respondent noted that it was important to support the identity of transgender people with dementia, especially when biological family members were uncomfortable with their identity and tried to pressure them into “being someone they didn’t want to be” (Peel and McDaid, 2015).
Some practical tips
Research says there are some practical things social care workers can do to make care more LGBTQ+ friendly. These tips are adapted from Keemink (2024) and Knocker and Smith (2021).
- Don’t assume that everyone you work with is heterosexual and cisgender, just because they have not said otherwise. This means being conscious about the language you use as well as the support needs someone might have. It also means not making assumptions about how people want to dress or be treated by others.
- Value the relationships that people have. This means valuing people’s partners no matter what gender they are. It also means asking the person accessing care and support who the most important people for them are and supporting these relationships.
- Enable and support older LGBTQ+ people to take part in the local LGBTQ+ community, if that’s something they want.
- Build connections to LGBTQ+ organisations to take guidance from LGBTQ+ people.
- Proactively support staff to improve their knowledge of LGBTQ+ issues and counteract misinformation and prejudices.
- Remember that LGBTQ+ people all relate to their identity and the world around them differently. Be ready to be led by individuals about how important they feel their LGBTQ+ identity is to their sense of self.
- Celebrate LGBTQ+ identities, relationships, and inclusion. Things like rainbow flags or having LGBTQ+ representation in pictures displayed can do a lot to make people feel more comfortable.
- Speak up about homophobia and transphobia at work. Make sure that discriminatory language isn’t normalised within care settings and that people are comfortable coming forward with concerns.
Conclusion
Everyone in Wales deserves to age with dignity and have access to care and support that meets their needs. Research on older LGBTQ+ people tells us that they often worry that they won’t get support that values who they are. This evidence summary can help social care staff feel more confident in providing support in a way that celebrates diversity and meets the needs of LGBTQ+ people.
Additional reading
Here is a list of the five most relevant resources to supporting older LGBTQ+ people in social care that are either open access or freely available on the NHS Wales e-Library.
- Hafford-Letchfield, T., Almack, K., Simpson, P. and Willis, P. (2017) ‘Developing inclusive residential care for older lesbian, gay, bisexual and trans (LGBT) people: an evaluation of the Care Home Challenge action research project’. Health and Social Care in the Community, 26 (2), pp. e312-e320, doi:10.1111/hsc.12521, available at https://doi.org/10.1111/hsc.12521.
- Keemink, J. (2024) Creating inclusive residential care for LGBTQ+ elders (CIRCLE), University of Kent, available at https://research.kent.ac.uk/chss/research-projects/creating-inclusive-residential-care-for-lgbtq-elders-circle/ (accessed: 1 April 2025).
- Peel, E. and McDaid, S. (2015) ‘Over the rainbow’: lesbian, gay, bisexual and trans people and dementia project summary report, University of Worcester, available at https://dementiavoices.org.uk/wp-content/uploads/2015/03/Over-the-Rainbow-LGBTDementia-Report.pdf (accessed: 24 February 2025).
- Westwood, S. (2015) ‘“We see it as being heterosexualised, being put into a care home”: Gender, sexuality and housing/care preferences among older LGB individuals in the UK’, Health and Social Care in the Community, doi:10.1111/hsc.12265, available at https://doi.org/10.1111/hsc.12265.
- Willis, P., Beach, B., Powell, J., Vickery, A., Cameron, A. and Smith, R. (2023) ‘“There isn’t anybody else like me around here”: the insider-outsider status of LGBT residents in housing with care schemes for older people’, Frontiers in Sociology, 8, 1128120, doi:10.3389/fsoc.2023.1128120, available at https://doi.org/10.3389/fsoc.2023.1128120.
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