Using Elder Abuse Case Studies to Develop LGBTQ+ Cultural Competency

Loree Cook-Daniels ^*

1. FORGE Transgender Aging Network, P.O. Box 1272, Milwaukee, WI, 53201, US

* Correspondence: Loree Cook-Daniels

Academic Editor: Gloria Gutman

Special Issue: Elder Abuse in the LGBT Community: A Hidden Problem

Received: July 16, 2023 | Accepted: January 08, 2024 | Published: January 15, 2024

OBM Geriatrics 2024, Volume 8, Issue 1, doi:10.21926/obm.geriatr.2401266

Recommended citation: Cook-Daniels L. Using Elder Abuse Case Studies to Develop LGBTQ+ Cultural Competency. OBM Geriatrics 2024; 8(1): 266; doi:10.21926/obm.geriatr.2401266.

© 2024 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.

1. Introduction

The use of case studies and - even more importantly - the discussion debriefing that should accompany them, are important tools in teaching professionals how to identify and intervene in elder abuse cases. That was a key finding in the 2022 systematic literature review conducted by Pratigha Ranabhat and colleagues [1]. “Effectiveness of Nurses’ Training in Identifying, Reporting, and Handling Elderly Abuse: A Systematic Literature Review,” concluded that “mixed teaching methods, such as face-to-face lectures, simulation, or case scenarios and debriefings or feedback can strengthen the learning process of nurses.” More specifically, trainees who used case studies and had debriefing reported that they were more confident in applying their knowledge of elder abuse. They also felt those training techniques had had a positive impact on their identification skills. A case scenario included in a training film helped participants better understand the theoretical knowledge they had gained through lectures. The researchers explained, “It seems that debriefing helps participants to reflect on actions taken, which can further enhance the knowledge and understanding of the best action to be taken. Additionally, having a discussion that supports participants to look and understand through another person’s point of view help[s] them to understand other options that can be used to deal with elder abuse.”

How does this training process work? Rogers and colleagues [2] describe LGBT older adults cultural competency training this way: “Participants commented on how they came to a new level of understanding about the challenges faced by older adults in this community and felt much more accepting of the community in general. This theme reflected a circular process whereby participants noticed their awareness of issues for older LGBT adults being raised, which helped them to reflect on their biases and attitudes, which, in turn, brought a deeper understanding and awareness of the issues.”

The European researchers who developed the BEING ME collaborative training on LGBT+ elders agreed. Their evaluation results found that “participants described the engagement with critical reflection, on themselves and in the learning context, as key to effective processing of good learning experiences for learners.” [3]. Case studies can also bring emotional benefits to the trainees. The researchers who presented their nursing students with a multi-part, evolving case study of an aging transgender woman and her family said: “Students also appreciated how the case study facilitated interaction between the students, bringing the whole class together.” They also noted that the case study discussion model “promotes collaborative problem-solving skills between learners and the instructor, which allows the instructor to role model how a professional nurse approaches practice.” [4].

What else besides case studies should be used in training professionals such as adult protective services workers, long-term care ombudsmen, and others who routinely come into contact with abused elders? It doesn’t appear that there’s a publicly-available curricula on the topic, but here are two tools for developing one.

Karen I. Fredriksen-Goldsen and colleagues developed a set of ten core competencies they suggested should help improve professional practice and service development for LGBTQ+ elders. Their 2014 article in Journal of Gerontological Social Work explains the core competencies in depth. We summarize it here [5].

1.1 Competency Scale

1. Critically analyze personal and professional attitudes toward sexual orientation, gender identity, and age, and understand how factors such as culture, religion, media, and health and human service systems influence attitudes and ethical decision-making.
2. Understand and articulate the ways that larger social and cultural contexts may have negatively impacted LGBT older adults as a historically disadvantaged population.
3. Distinguish similarities and differences within the subgroups of LGBT older adults, as well as their intersecting identities (such as age, gender, race, and health status) to develop tailored and responsive health strategies.
4. Apply theories of aging and social and health perspectives and the most up-to-date knowledge available to engage in culturally competent practice with LGBT older adults.
5. When conducting a comprehensive biopsychosocial assessment, attend to the ways that the larger social context and structural and environmental risks and resources may impact LGBT older adults.
6. When using empathy and sensitive interviewing skills during assessment and intervention, ensure the use of language is appropriate for working with LGBT older adults in order to establish and build rapport.
7. Understand and articulate the ways in which agency, program, and service policies do or do not marginalize and discriminate against LGBT older adults.
8. Understand and articulate the ways that local, state, and federal laws negatively and positively impact LGBT older adults, in order to advocate on their behalf.
9. Provide sensitive and appropriate outreach to LGBT older adults, their families, caregivers and other supports to identify and address service gaps, fragmentation, and barriers that impact LGBT older adults.
10. Enhance the capacity of LGBT older adults and their families, caregivers and other supports to navigate aging, social, and health services.

Perhaps more on-point is an article written to guide abuse professionals in identifying and assisting LGBT elder abuse clients. The contents included: definitions; a discussion of the larger world in which LGBT elders have lived; LGBT-specific elder abuse; new rights and protections; suggested practices in working with LGBT older adults; and conclusion [6].

2. Materials and Methods

It took a little effort, amid quite a bit of pushback, to get the U.S. elder abuse field to address the abuse of lesbian, gay, bisexual, transgender, and queer (LGBTQ+) elders¹.

The first brave advocate publicly took on the director of the (U.S.) National Center on Elder Abuse (NCEA) in 1998. The director had just announced the funding of a breakthrough national conference and book on abuse of minority elders. In front of a large audience, she loudly presumed that “of course” he would include LGBT elders. He had never intended to, but he didn’t want to spark a public argument with her, so he reluctantly agreed.

She immediately called me. I don’t know how much she knew of my background, but I had already worked in the aging field and lived within the LGBT community for more than two decades. The advocate knew me through my work at the NCEA and had recently come across an article about the gender transition of my partner. Having a trans person in her family, as well, she’d decided we were the perfect people to start the conversation. The problem was: her boss immediately said no. She didn’t want her anywhere near an LGBT workshop for political reasons. I soldiered on, recruiting speakers who studied LGBT elders, and organizing the workshop. Then my boss weighed in. He wasn’t going to stop me, but he also didn’t want me wearing a nametag with my agency’s name on it at the conference. That made it a little awkward; many conference-goes knew where I worked and were curious: had I moved on? That question was hard to answer, especially because my boss being gay himself was always swirling around my brain. But the workshop itself went well. People were excited to begin talking about the topic.

Afterwards, I turned to writing the LGBT chapter for the associated book on minority elder abuse. I followed all the guidelines and turned it in, but publication dates kept slipping, slipping, slipping until suddenly, the book was published. Without my chapter, of course.

A colleague of mine and international elder abuse expert, Dr. Rosalie Wolf, felt so badly about the whole situation that she published my paper in her Journal of Elder Abuse.

In the subsequent years I published on the topic whenever I could, especially in Victimization of the Elderly and Disabled, for which I wrote a regular column. I also trained and keynoted whenever I could (not, of course, under my employer’s sponsorship!). In 2000 when I joined FORGE, a national transgender anti-violence organization, we folded in my elder work. Opportunities expanded with the establishment of the National Resource Center on LGBT Aging in 2010. I have since consulted with and published many trainings and articles with them (some related to elder abuse, some not).

If this sounds a little haphazard, it was. It’s also how the case studies in this article were developed. Whenever I noticed my audiences were having trouble understanding something about elder abuse, intimate partner violence, trauma, or LGB or especially T people, I wrote a case study to try to address the gap. Some of these case studies were used in trainings, and some were published in various articles and books. None of them has been formally evaluated. While I am thrilled that there are now well-credentialed LGBT elder abuse researchers, books, and journals, these cases were cobbled together to meet whatever need was pressing at the time and without much of a model or structured process.

‘Cobbled together to meet whatever need was pressing at the time and without much of a model or structured process’ - sounds like the lives we LGBT elders have lived.

3. The Case Studies

For every case, if possible, recruit a skilled and sensitive observer to watch the discussion and comment at the end what and where (if at all) they identified personal or professional attitudes toward sexual orientation, gender identity, or age that might influence professionals’ attitudes and ethical decision-making. This overarching analysis should follow the case study discussion questions.

3.1 Case Study (1): Janine, Katherine, and Risa (Financial Exploitation and Physical Abuse)

Janine and Katherine have been partners for 39 years. They met and fell in love when Katherine’s daughter Risa was six years old. Katherine divorced her husband and moved in with Janine, Risa in tow. Risa had been “Daddy’s girl,” but Daddy was so devastated that Katherine was leaving him for a woman that he decided he had to protect his own emotions by walking away from his whole family, Risa included, and starting over. Risa quickly blamed Janine for the loss of her father, and her lifelong pattern of anger, obstinacy, and, later, substance abuse, began.

Janine had inherited money and had a good job, but Katherine never wanted to feel like a “kept woman,” and is very proud of the fact that she has always contributed half of the household’s budget. Even though Janine has retired, Katherine has insisted on continuing to work, to build credits for a higher Social Security benefit when she does retire.

Risa has always depended on her mother and Janine for financial assistance, but lately she has begun extorting checks for \$1,000 to \$3,000 at a time from Janine. She comes over to the house while Katherine is at work and threatens to “out” Katherine at her job - which will surely lead to Katherine being fired; the company has fired outed Gay employees in the past - if Janine doesn’t give her the money. She says Janine “owes” her, because she caused the loss of Risa’s father. The once or twice when Janine refused to sign the check, Risa punched her, and Janine gave in.

Janine hasn’t told Katherine what’s happening. She doesn’t want to see anything bad happen to Risa - Risa’s had a hard enough life as it is - and she does feel guilty that Risa’s father abandoned her. More importantly, however, she knows Katherine would be absolutely devastated if she either lost her job or if she had to confront the extent of her daughter’s problems or, even worse, both at once. So Janine keeps quiet and keeps writing the checks.

3.1.1 Janine, Katherine, and Risa Elder Abuse Discussion Questions

1. Is this elder abuse? If so, what type(s) of elder abuse are involved in this case?
2. Is this intimate partner violence? If so, what type(s) of intimate partner violence are involved?
3. Janine and Katherine have always lived in the United States and are in their 60s. Discuss what they likely learned during their lifetimes about:
   1. Being lesbian.
   2. Domestic violence.
   3. Parenting.
   4. Asking for help.
4. What economic and legal realities might be having an impact on this triad and its members’ choices?
5. How might this case come to the attention of authorities? 
6. What approaches might someone take to try to address this family’s issues?

3.1.2 Janine, Katherine, and Risa Cultural Competency Discussion Questions

1. What social/cultural contexts may be influencing Janine’s decision-making?
2. Would this case study make sense if the couple was gay male? Bisexual? Transgender? Why or why not?
3. If therapists were to be found for any or all of the family members, what particular areas of expertise would they need to have?
4. What terms and names should professionals check before using? (ex: Does the family refer to Risa as Katherine’s child or the child of both Katherine and Janine?)
5. Do any of the discussants work for an agency that has a policy that would marginalize or discriminate against any member of this family?
6. Does it matter whether Janine and Katherine are married? If so, how?
7. How might this case come to the attention of aging professionals? If the answer isn’t obvious, what kind of outreach would need to be offered from what kind of agency/ies to establish a trusting relationship with this family?
8. What resources and/or referrals might be helpful to each member of this family?

3.1.3 Developer Comments

Even though elder abuse professionals typically enter the picture at a particular, often late, point in time, it’s important to recognize that one of the hallmarks of elder abuse is that it’s often a crime involving people with long-standing relationships; the roots of a particular problem may be decades old. This case study reminds trainees of that fact, plus touches on possible roots of problems like substance abuse. Also, the inclusion of an adult child in this case study reminds trainees that even though LGBTQ elders are less likely to have children, some do.

3.2 Case Study (2): Jorge, Jesus, and Earl (Intimate Partner Violence)

Jorge is 89. He was extremely lonely when his wife died five years ago, so his only child Jesus moved him to a retirement home just a block away from Jesus’s apartment in a Latinx neighborhood of New York City. It’s a great place to live. Not only has Jorge made many friends in the retirement home, but he has become a neighborhood fixture, as well. The bank teller, the waitresses at the cafe, the grocery store clerks all know his name and enjoy shooting the breeze with him. Even better, Jesus visits almost daily, frequently accompanying his father on errands or, on sunny days, sitting with him in the park across the street, where they feed the squirrels and pigeons.

Jesus has always been single, which was the one thing that Jorge found sad about his life: no grandchildren. Lately, though, something’s been happening to Jesus. He’s grown his hair long and is wearing different, almost feminine, clothing. In fact, some of his shoes are definitely women’s shoes. He’s also begun painting his fingernails, which are very long, and it looks as though he’s wearing makeup. Jorge hasn’t wanted to bring up his observations, but his neighbor has already asked him what’s going on. For the first time in his life, he didn’t know what to say.

Meanwhile, Jesus is experiencing problems. His lover of a decade, Earl, has begun striking him during arguments. Earl says that Jesus is ruining his life by transitioning. It was one thing to have a lover who was a drag queen, but a lover who is turning into a woman is completely different. “What bars are we going to be able to go to?” “Do you really think the Gay Men’s group at SAGE is going to be comfortable with a woman sitting among them?” They’d fantasized about moving to a Gay retirement village in Florida once Jorge died - why is Jesus taking that dream away from them?

3.2.1 Jorge, Jesus, and Earl Elder Abuse Discussion Questions

1. What are the issue(s) here? Which one(s) fall under adult protective services’ scope?
2. Is this elder abuse? If so, what type(s) of elder abuse are involved in this case?
3. Is this intimate partner violence? If so, what type(s) of intimate partner violence are involved?
4. Does Jesus need to explicitly come out as transgender to Jorge?
5. Jesus and Earl are part of an organized Gay community. What does the Gay community, in general, currently tell people about:
   1. Aging?
   2. Domestic violence?
   3. Being transgender?
6. What barriers to obtaining services to help address their issues do Jesus, Earl, and Jorge each face?

3.2.2 Jorge, Jesus, and Earl Cultural Competency Discussion Questions

1. What social/cultural contexts support the use of violence in this family?
2. Would this case study make sense if Jorge and Earl were a lesbian couple? Why or why not?
3. What current political and social realities may play into this scenario?
4. What are gay men’s attitudes toward trans people?
5. What terms and names should professionals check before using? (ex: How do Jorge and Earl describe their relationship?)
6. Do any of the discussants work for an agency that has a policy that would marginalize or discriminate against any member of this family?
7. How might this case come to the attention of aging professionals? If the answer isn’t obvious, what kind of outreach would need to be offered from what kind of agency/ies to establish a trusting relationship with this family?
8. What resources and/or referrals might be helpful to each member of this family?

3.2.3 Developer Comments

Conceptualizing “power and control” as the root of intimate partner violence can complicate understanding of what occurs in a couple in which one partner is transitioning genders. Many people believe that the appropriate response to news that a person is transitioning is a hearty “congratulations,” but it’s more complicated for many intimate partners, who may be faced with the prospect of revising not only their partnership, but also their own sexual orientation and/or social network. While this fact does not, of course, condone Earl’s physical violence, a resource for those who would like to know more about the dynamics of couple negotiation of a gender transition is the 2015 Partner Abuse article, “Intimate Partner Violence in Transgender Couples: ‘Power and Control’ in a Specific Cultural Context.”

The transgender person is the abuse victim in this case study, but it is critical to understand that trans-specific power and control tactics can be used by as well as against trans people. FORGE’s Trans-Specific Power and Control Tactics publication (https://forge-forward.org/wp-content/uploads/2020/08/power-control-tactics-categories_FINAL.pdf) enumerates tactics and provides examples.

This case scenario was also developed to answer a question we frequently hear: “How in the world does someone transition without telling people?”

3.3 Case Study (3): Mr. Adams and Andrew (Institutional Sexual Abuse)

Andrew adored Mr. Adams. Not only was he lucid - it seemed like nearly all of the other nursing home residents weren’t - but he was charming. And so interesting! He had traveled so many places in the world, and had so many wonderful stories he was willing to share.

So he was absolutely devastated when Mr. Adams came to his office one day and asked if he could close the door. Something was clearly wrong. While Mr. Adams wheeled into place, Andrew came from behind his desk to draw a chair close to him. For a while, Mr. Adams wouldn’t say anything, just hanging his head down. Then, to Andrew’s horror, he saw a tear drip down his face and into his lap. Andrew took his hand and very gently said, “tell me, please.”

Slowly, haltingly, his face always turned away from Andrew, Mr. Adams did. Two of the nurse aides had begun making fun of his penis whenever they caught him alone during dressing or toileting. “They’ve noticed my…um, urine…doesn’t come out the end of my penis like, uh, most men’s,” he said. Plus they made fun of his penis’s small size. Gradually they had begun escalating their behavior, trying to make him get an erection through various means, and taunting him when nothing happened. Eventually, two days ago, they had anally raped him with something; he didn’t know what.

Andrew was appalled. He discussed his options with Mr. Adams, but he said no to everything: no reporting to authorities, no seeing a doctor, and no, he didn’t particularly want the nursing home to fire the aides, because they might come back and “hurt me.” And most emphatically, no telling his nephew, who had been appointed his guardian and was his only relative. “What do you want me to do?” Andrew asked. “I don’t know,” Mr. Adams answered. “I just felt I had to tell someone, and you are the only person I ever talk to.”

3.3.1 Mr. Adams and Andrew Elder Abuse Discussion Questions

1. Is this elder abuse? If so, what type(s) of elder abuse are involved in this case?
2. Have one or more crimes occurred here? If so, which one(s)?
3. If this took place in your state, would Andrew be a mandated reporter? Does it matter what role/profession he is in?
4. If Andrew is a mandated reporter, how should he handle Mr. Adams’s refusals to let him take action?
5. What reasons might Mr. Adams have for refusing to let Andrew take action?
6. What reasons might Mr. Adams have for needing to tell Andrew what happened?
7. If you were Andrew, what would you do next?
8. Setting aside any medical or mental health complications of the assault, does Mr. Adams’s penis need examination? Why or why not?

3.3.2 Mr. Adams and Andrew Cultural Competency Discussion Questions

1. What social/cultural contexts are likely influencing Mr. Adams? Andrew? The nurse aides?
2. What would need to change in this case study for it to fit a lesbian patient? A gay male patient? 
3. What current political and social realities may play into this scenario?
4. What are the potential risks and rewards for Mr. Adams accepting help? What would be most helpful? 
5. What terms and names should professionals check with Mr. Adams before using? 
6. What nursing home and/or legal policies might impact on this case?
7. Discuss the positives and negatives of mandatory reporting, particularly when it involves an LGBT elder.
8. How might this case come to the attention of aging professionals? If the answer isn’t obvious, what kind of outreach would need to be offered from what kind of agency/ies to establish a trusting relationship with Mr. Adams?
9. What resources and/or referrals might be helpful to Mr. Adams? To Andrew?

3.3.3 Developer Comments

Most people are unlikely to recognize from the genital description that Mr. Adams may be a transgender man who took testosterone (creating a small phallus from the clitoris) but never had surgery (to create a urethra running through the phallus). Another alternative is that Mr. Adams is a cisgender man with the condition called hypospadias² that was never corrected. There may be other rare but “perfectly normal” conditions that could be described the way Mr. Adams described himself. Their rarity is a possible distraction; many times people focus on the thing they have no context for and overlook the actual problem in the process. This case may also be an opportunity to discuss the pros and cons of mandatory reporting, particularly when it pertains to someone who has good reasons for self-protecting. Mandatory reporting is supposed to protect people, but are there cases in which it does more harm than good? Are there ways to mitigate the harm?

Many trans elders say explicitly they would rather die prematurely than enter a nursing home, fearing precisely the kind of problems Mr. Adams faced [7]. Nevertheless, there are long-term care facilities trained in providing culturally competent care to LGBTQ residents. Two places to start a search for either a trained facility or for training resources themselves are SAGECare at https://www.sageusa.org/what-we-do/sagecare/ and the Long-Term Care Equality Index at https://thelei.org/. A resource for front-line long-term care staff who will be caring for a new trans resident is “I Have a Transgender Client…Now What?” at https://www.lgbtagingcenter.org/resources/pdfs/newTransClientFactSheet.pdf. A new guide to providing person-centered, trauma-informed care of transgender older adults is available at https://www.lgbtagingcenter.org/resources/pdfs/SAGE%20Trans%20TIC%20Final.pdf.

This case study also addressed another common question: If Mr. Adams is transgender, shouldn’t all the staff in the facility know that? The answer - from both HIPAA and respect perspectives - is no.

3.4 Case Study (4): Ian, Helen, and Amy (Neglect)

Ian is clearly dying. Helen, his wife of 53 years, has honored his wishes not to call in any physicians. However, Ian is incontinent, sometimes incoherent, and obviously in agony. Helen has long lived with severe arthritis, and caring for Ian has completely exhausted her.

Their granddaughter Amy has been living with them for three and a half years. Always close to her grandparents, Amy moved in with them after she had a nervous breakdown. Gradually she has become aware of how sick Ian is, and is livid that her grandparents won’t go to the doctor. She is also angry, hurt and confused because Helen won’t let her help much with Ian. She is trying to think of who she might call to shift the family dynamic.

Helen wants Ian’s pain controlled, and she knows that if she doesn’t get some help soon, she is going to end up in a hospital, and then what would happen to Ian? She’s been wondering about hospice care, home health care, a nursing home…but is feeling extremely torn about getting help when she had promised Ian that she’d never reveal the secret only she knows: that Ian is a trans man who binds his breasts. Plus, how would she pay for the care? They are barely getting by on their income now…

3.4.1 Ian, Helen, and Amy Elder Abuse Discussion Questions

1. Is this elder abuse? If so, what type(s) of elder abuse?
2. If Helen or Amy were to get an agency like hospice or home care or adult protective services to visit, what is likely to happen? 
3. What other agency or agencies might be helpful to this family?
4. Is there any way an intervention could have a positive effect for all three family members? List what would have to happen to make that positive outcome possible.

3.4.2 Ian, Helen, and Amy Cultural Competency Discussion Questions

1. What are the likely reasons Ian made Helen promise to keep his secret and avoid doctors?
2. Would this case study make sense if Ian was a (cisgender) lesbian woman? A (cisgender) gay man? Why or why not?
3. What current political and social realities may play into this scenario?
4. What terms and names should professionals check with Ian, Helen, and Amy before using? 
5. What characteristics and/or policies might agencies need in order to appropriately and respectfully serve this family?
6. What existing local, state, and federal policies might be helpful to this family? What policies that currently do not exist would be helpful?
7. How might this case come to the attention of aging professionals? If the answer isn’t obvious, what kind of outreach would need to be offered from what kind of agency/ies to establish a trusting relationship with this family?
8. What resources and/or referrals might be helpful to Ian, Helen, and Amy?

3.4.3 Developer Comments

People often have perfectly good reasons for not doing what seems obvious to others. Amy doesn’t know why Helen won’t let her give hands-on care to Ian, and may even conclude that they perceive her as a problem, incompetent, or even, somehow, dangerous. Long-standing secrets and agreements do not necessarily get revisited when circumstances change such as Helen’s declining health or shifting social norms making it far more likely a grandchild would react positively to a relative coming out as trans. Neglect cases are typically considered “resolved” when outside care is brought into the home. But how does one ensure that care is culturally competent? And who can provide culturally competent, respectful emotional support to all three family members?

3.5 Case Study (5): Anita and Leslie (Sexual Abuse)

Anita was 63 when she lost her husband. Knowing the lopsided male/female ratio among older adults, she figured she would be spending her remaining years alone. It was not a pleasant thought, but what could one do?

She was therefore more than a little surprised when, two years later, Leslie entered the picture and swept her off her feet. In fact, there were many surprises: that she, a lifelong heterosexual, could love a woman; that her friends - despite belonging to a generation that was supposed to believe that lesbians were some strange kind of sub-human - accepted her new relationship with open arms; and that she could learn to be so, well, free. Leslie enjoyed challenging social norms, and the result was a never-ending stream of new and really wonderful experiences for Anita, who had previously led a fairly boring and predictable life.

Except for one thing: among the norms Leslie challenges are many sexual taboos. Some of these experiences were eye-opening and pleasurable, and others were…not. Yet even if Anita consented to try something once, she found that Leslie would not accept a “no.” Indeed, Leslie told her that whereas heterosexual women had to refuse their husbands as a self-protection measure, lesbians never denied their partners anything sexual. If a partner wanted it, a lesbian always enthusiastically said yes. Not only was Anita threatening her own “credentials” when she tried to say no, but saying “no” to her lover was a sign she must not really love her. Anita was appalled: of course she loved Leslie! No, of course she didn’t want to do anything to threaten the relationship. And yet…

She really wished she could ask someone for advice, but whom? Her friends were all heterosexual. As for Anita’s lesbian friends…well, how could she talk to them about something so personal when they were already straining to see her as “one of them”?

Where was the lesbian “Dear Abby” when she needed her?

3.5.1 Anita and Leslie Elder Abuse Discussion Questions

1. Is this elder abuse? If so, what type(s) of elder abuse?
2. Is this intimate partner violence? If so, what type(s)?
3. What power and control tactics, if any, is Leslie using?
4. Why doesn’t Anita recognize that Leslie is lying to her about what it means to be a lesbian? 
5. How might Anita and Leslie’s sexual practices ever become known to someone outside the couple? 
6. What might be an effective intervention for both Anita and Leslie? Do agencies exist that could be effective here?

3.5.2 Anita and Leslie Cultural Competency Discussion Questions

1. What were the social and cultural contexts that created Anita’s susceptibility to Leslie’s manipulations?
2. Can you imagine this case being about a gay man? A trans man? A trans woman? Why or why not?
3. Can you imagine this case happening if Anita were 26? Why or why not?
4. What names and terms should be checked to ensure appropriate language is used with this couple?
5. Would a domestic violence agency be useful in this case? Identify the policies/approaches that make and don’t make a domestic violence agency a good referral.
6. How might this case come to the attention of aging professionals? If the answer isn’t obvious, what kind of outreach would need to be offered from what kind of agency/ies to establish a trusting relationship with this family?
7. What resources and/or referrals might be helpful to Anita and Leslie?

3.5.3 Developer Comments

Actions have consequences. Tell people that “the other group” is different, evil, or perverted and they will readily swallow other lies about group members. Design sexuality education to avoid topics like same-sex sexuality, and you set up circumstances in which people are ripe for exploitation. Unlike some of the other case studies, here someone is clearly taking advantage and control, which then brings up the opportunity to talk about whether abusers can be rehabilitated and whether it’s possible to have an otherwise healthy relationship when part of it is clearly dysfunctional.

3.6 Case Study (6): Kathy, James, and Matthew (Abandonment)

Kathy and James have been married for 30 years. Last year James suddenly announced that he has felt like a woman all of his life and that, after experiencing a heart attack, he had decided that he can no longer live a lie. He intends to transition to female upon his retirement, in another year.

Kathy, who is 10 years younger than James, works for a big fundraising consulting firm and specializes in high-level special events - the kind that puts on gala black-tie-and-gown events. James is outgoing, handsome, has a phenomenal memory for names, has always attended her events, and is seen as a crucial part of the reason for her success.

Kathy’s natal family is large, Catholic, and close. They have a huge family reunion every year, and everyone is expected to attend. They also tend to be homophobic, intolerant of differences, and are definitely opposed to divorce.

Matthew, James and Kathy’s oldest son, has just announced that he and his wife are expecting their first child. When Kathy told Matthew about James’s intention to transition, Matthew blew up and announced that no child of his was going to have a pervert for a grandparent. After that experience, Kathy has put off saying anything to their other four children.

3.6.1 Kathy, James, and Matthew Elder Abuse Discussion Questions

1. Is this elder abuse? If so, what type(s) of elder abuse?
2. Is this intimate partner violence? If so, what type(s)?
3. What resources are there for Kathy, James, and Matthew?

3.6.2 Kathy, James, and Matthew Cultural Competency Discussion Questions

1. Identify the social and cultural contexts impacting each member of this family.
2. If James had been Janey, a woman, would the case study make sense? What would be different?
3. What are some of the social context differences between a 65-year-old trans person and a 25-year-old trans person?
4. What names and terms should be checked to ensure appropriate language is used with this family?
5. How important would it be for Kathy’s work to have a non-discrimination policy?
6. How important would it be for their state to have a non-discrimination law? A federal non-discrimination law?
7. How might this case come to the attention of aging professionals? If the answer isn’t obvious, what kind of outreach would need to be offered from what kind of agency/ies to establish a trusting relationship with this family?
8. What resources and/or referrals might be helpful to Kathy, James, Matthew and his siblings?

3.6.3 Developer Comments

Many of us would say there is no evidence fitting legal definitions of elder abuse or intimate partner violence in this case, although some may struggle with the question. It is included here because FORGE Transgender Aging Network’s research shows that trans people themselves may say there is abuse here. When we conducted a study of elder abuse among trans people, we gave standard definitions for all the terms before asking respondents who had experienced any of them to describe what happened. Consistently respondents labeled as “abandonment” family dynamics like those described above: relatives (without any caregiving responsibilities) cutting off relationships. “Abuse” cases were largely instances of discrimination and/or microaggressions. Even “self-neglect” was frequently endorsed, seemingly pointing to instances of depression or anxiety so acute that people were unable to take care of their own needs. It is likely that this mismatch of terms occurs in other settings, a reminder to professionals to cross-check the meaning of seemingly familiar terms as well as a reminder that clients may not agree with us about what are the most pressing issues in their lives. (You can read more about the study at “Sexual Violence, Elder Abuse, and Sexuality of Transgender Adults Age 60+: Results of Three Surveys”, https://forge-forward.org/wp-content/uploads/2020/09/trans-aging-3-surveys.pdf).

Although there are still not nearly enough resources for the partners and adult children of transitioning adults, there are many more resources than there used to be. Nearly all social media platforms have trans-specific forums, including, sometimes, for partners and children. Particularly noteworthy are the resources of PFLAG (https://pflag.org/) and COLAGE (https://colage.org/). Resources for James include FORGE’s ElderTG peer support listserv (http://FORGE-forward.org/aging).

4. Conclusion

It can be challenging to present enough of LGBTQ+ elder adults’ diversity to be useful without overwhelming trainees with too much material. Case studies and accompanying discussions can help bridge the gap, helping trainees to better integrate the material presented in lectures. Dividing the broad “LGBTQ+ community” into person-sized pieces via case studies can help tremendously in digesting the material, particularly if the discussion includes questions asking how the case study would be different if the primary person had a different sexual orientation and/or gender identity Discussion of case studies can also help trainees conceptualize how various social conditions (historical as well as current) may play out in people’s lives.

The Fredriksen-Goldsen LGBTQ+ core competencies set a high bar that can’t be met by case studies alone. However, this set of case studies involving nuanced and complicated relationships with an elder abuse component gives trainees practice at teasing out similarities and differences among the identities and types of abuse. They can also be referred to during lectures in order to illustrate how policies may affect elders of different identities.

Group discussions can be particularly enlightening to professionals who are used to working alone, as they may be surprised by how differently other colleagues perceive the same set of facts. Most importantly, research shows that trainees felt more confident about using what they have learned when they have worked through case studies.

Author Contributions

The author did all the research work of this study.

Competing Interests

The author has declared that no competing interests exist.

Additional Material

The following additional material is uploaded at the page of this paper.

1. Resources.