Adequacy of Care for the 2SLGBTQIA+ Aging Population in Long-term Care Facilities in Ontario

Hi everyone! I am Chloe Schotanus, a third-year social work student at Thompson Rivers University in Kamloops, BC. Before I begin my podcast, I would like to acknowledge that I have the privilege to study, learn, and live on the traditional and unceded territory of the Tk’emlúps te Secwépemc, who are part of the Secwépemc Nation. As we engage in meaningful conversations today, let us reflect on our shared responsibilities to these lands and the peoples whose histories, cultures, and contributions continue to shape them. I also want to offer a quick disclaimer: I may occasionally forget to verbally state all my references, as there’s so much to cover. However, I’ll be providing a script with proper citations and a reference page, so you can follow along with the sources I’m using! Statistics Canada states that Ontario is Canada’s most populated region with over 3 million older adults (Statistics Canada, 2019). And it is estimated that at least 155,000 older LGBTQ adults over the age of 60 years live in Ontario (Statistics Canada, 2019). Today's podcast will address the crucial and overlooked issue of the adequacy of care provided to 2SLGBTQIA+ aging populations living in long-term care homes, specifically in Ontario. These facilities are meant to be safe, supportive spaces for some of our most vulnerable citizens and yet the policies governing them often fail to address the unique needs of certain groups, specifically the queer community. More specifically, today's focus will center on the Long-Term Care Homes Act of 2007. This act was not only designed to regulate the long-term care homes in Ontario but also to ensure that the residents receive high-quality care in a safe and supportive environment, and we will speak on how this act has failed to meet the needs of 2SLGBTQIA+ individuals and exploring how the act has since been revoked as of 2021 and has now been updated and replaced with a new act called the Fixing Long-Term Care Act (2021). we’ll explore whether these updated policies offer better support—or if, like the many other social policies in Canada, this act reveals significant gaps that highlight systemic disparities. When we talk about systemic disparities, it’s important to understand what it means to belong to a marginalized group. Marginalized groups, like the 2SLGBTQIA+ community, are populations that have historically been excluded from full participation in society due to systemic barriers such as discrimination, stigma, and unequal access to resources. For aging adults in this community, these barriers are often compounded in long-term care settings, where policies rarely reflect their lived experiences or address their specific needs. From a social work perspective, these policies will be critically analyzed using the Canadian Association of Social Workers (CASW) Code of Ethics. Focusing on values like respecting the inherent worth and dignity of all individuals and providing competent, inclusive care has highlighted key shortcomings. These include the lack of mandated gender-affirming care and insufficient inclusive training for staff. Inclusive training is crucial for providing staff with the tools to understand and respect diverse identities, like those of 2SLGBTQIA+ residents (Boulé et al., 2020, p. 252). It includes practices such as using correct pronouns, understanding the impacts of historical discrimination, and creating and nurturing affirming environments. Without this training, the risk of harm whether intentional or not remains high. Lets start by unpacking what it means when we talk about “Adaquecy or quality of Care”. The WHO (World Class Health Organization) states “the adequacy of care is the degree to which health services for individuals and populations increase the likelihood of desired health outcomes.” and that Quality health care can be defined in many ways but there is growing acknowledgement that quality health services should 1 be Effective – by providing evidence-based healthcare services to those who need them; 2 be Safe – avoiding harm to people for whom the care is intended for; and 3 be Person-centred – by providing care that responds to individual preferences, needs and values. (World Health Organization, n.d.). For the 2SLGBTQIA+ community which is an acronym that stands for Two-Spirit, Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual, and other diverse gender and sexual identities. adequate care isn’t just about the basic services it must also address the unique challenges tied to their lived experiences, including a history of discrimination and invisibility in healthcare systems. When we talk about quality of care for aging adults, it's essential to recognize that this goes beyond just physical health. In fact, sexuality is a key component of well-being throughout life, yet conversations about sexual health tend to focus mainly on younger individuals. As Le, Bennich, and Strandberg (2024) discuss, this is largely shaped by our society's youth-focused mindset, which often overlooks the sexual health needs of older adults. Aging is frequently associated with inevitable physical and cognitive decline, leading to a widespread assumption that older adults’ sexual needs and desires are less important, particularly in the context long-term care settings, which is untrue. For 2SLGBTQIA+ individuals, this assumption is even more pronounced, as their sexual and gender identities have often been marginalized. This brings us to another key term that is central to our discussion and that is understanding what culturally sensitive care is. This approach involves providing care that acknowledges and respects the cultural, social, and personal identities of individuals, recognizing that each subgroup of the 2SLGBTQIA+ community has distinct experiences and challenges."(Boulé et al., 2020, p. 235). For 2SLGBTQIA+ seniors, culturally sensitive care should focus on intersectionality, such as recognizing the trauma many faced from historical discrimination in healthcare. Which we will be discussing historical discrimination more in-depth as we move into the historical context portion of the podcast. To understand the challenges faced by 2SLGBTQIA+ seniors in long-term care homes, we need to take a step back in history. It’s important to remember that the generation of 2SLGBTQIA+ seniors we’re talking about grew up in a time when being queer wasn’t just frowned upon it was criminalized. According to Alberta Health Services until 1969 in Canada, homosexuality was considered a crime. And it wasn’t until 1973 that the American Psychological Association finally removed "homosexuality" from its list of mental disorders. For many in this generation, simply existing as their true selves was an act of defiance. To survive, they had to hide their identities sometimes even from their closest friends and family because revealing themselves could mean facing discrimination, violence, or worse (2019). This wasn’t just a personal struggle but rather was part of a much larger social battle. For decades, 2SLGBTQIA+ individuals had to live in secrecy, feeling as though their love and identities didn’t belong in the world around them. And this sense of invisibility wasn’t just limited to the streets or social spaces; it also extended into healthcare settings, particularly long-term care homes. Even after 1969 when the Criminal Law Amendment Act was introduced, and homosexuality was decriminalized in Canada this change didn’t reflect into healthcare spaces where 2SLGBTQIA+ individuals could be themselves. In fact, the healthcare system remained behind the times, offering little support to those who were seeking both dignity and care in their later years and even though strides have been made the healthcare system is still worryingly behind. To put it into perspective growing up with the message that your very identity was wrong. Has been the lived experience of so many aging 2SLGBTQIA+ Canadians, as for they had to endure a world that marginalized and, for much of their lives, outright rejected them. While Bill C-33 in 1996 finally added "sexual orientation" as a protected ground of discrimination under the Canadian Human Rights Act (Canada, Bill C-33, 1996). the healthcare system wasn’t quick to catch up. It has been shown through research and diving into the specificities of the long term care home act of 2007 that Long-term care homes still arent equipped to recognize or support the sexual and gender diversity of their residents. In fact, for many years, the healthcare system has been blind to the specific needs of 2SLGBTQIA+ seniors. Making individuals fearful of living in them. fast forwarding to 2007 when Ontario passed the Long-Term Care Homes Act and as discussed earlier in the podcast this was an attempt to regulate care facilities and ensure that residents receive high-quality, respectful care. On paper, this was a good step. But here’s the catch: this legislation did very little for 2SLGBTQIA+ residents. The policy didn’t specifically address the unique experiences of sexual and gender minorities, leaving them vulnerable to discrimination, isolation, and neglect and having no protection against the potential abuse. Around the same time, advocacy organizations like Rainbow Health Ontario (founded in 2008) and Egale Canada (founded in 1986) began to challenge these gaps in care. These groups pushed for systemic change, calling for long-term care homes to adopt inclusive, culturally competent care practices. Rainbow Health Ontario, for example, fought for gender-affirming care and inclusive staff training, which would equip caregivers with the skills to respect the gender and sexual identities of 2SLGBTQIA+ residents (Rainbow Health Ontario, n.d.). This push for inclusion was crucial because, without these changes, the risk of harm, even if unintentional, remained high. Now that we’ve looked into the history of discrimination and marginalization of 2SLGBTQIA+ individuals in canada, let’s shift to understand just how these past experiences continue to impact seniors in Ontario today. The fear and trauma that so many lived through in the past aren’t just abstract concepts; they’re still very much present in the lives of aging 2SLGBTQIA+ individuals. And this is especially true when it comes to navigating healthcare systems, which have long been unprepared or unwilling to address their unique needs. let me share an example from a study held by Boulé and colleagues in 2022. In this study, one participant, a trans person, described their ongoing health needs, and the deep fears they have about receiving care as they age. They said: 'As a trans person specifically, there are certain things I have to do on a more ongoing basis. I have to dilate my vagina, and every four months, I have to take estrogen at intervals. I still have a certain small amount of facial hair, and I’m sort of wondering, if I was incapacitated in some way or another, how would this stuff happen? My partner will say, "Oh well I’ll do it," but yeah, what if you’re not around?' This is just one of the many powerful statements that have been recorded in these studies that highlights the specific, personal health needs that many 2SLGBTQIA+ seniors face. The fear of being incapacitated, not having someone to advocate for them, and of their needs being ignored or misunderstood in a healthcare setting these are all real concerns for aging members of the community. It’s not just about providing physical care; it’s about understanding the person as a whole, which includes gender identity, sexual orientation, and the unique medical needs that may come with that. And this is where the gaps in policies like the Long-Term Care Homes Act of 2007 and even the newer Fixing Long-Term Care Act (2021) become painfully clear. These acts, while offering some regulatory frameworks for care, still leave 2SLGBTQIA+ seniors vulnerable to neglect, and discrimination within care home facilities. Without the proper enforcement of mandatory gender-affirming care training for all staff the fears shared by participants are not just theoretical. And its something that many seniors are grappling with every day. And until healthcare policies specifically address these issues, these concerns will continue to shape the lived experiences of aging 2SLGBTQIA+ Canadians. Let’s take a moment and look at the big picture. The introduction of the Fixing Long-Term Care Act in 2021, replacing the outdated Long-Term Care Homes Act of 2007, was a move to modernize care and address glaring gaps in the system. But it brings up a big question: has this new legislation actually addressed the unique needs of 2SLGBTQIA+ seniors? And if so, how? Compared to the historical past of the queer community, there has been prominent progress. In fact, organizations like the Rekai (RAKAI) Centres in Toronto the first of its kind are leading the way with innovative, inclusive practices. Rekai has publicized its mission to create long-term care units specifically designed for 2SLGBTQIA+ residents which was a groundbreaking move in a sector that has historically ignored sexual and gender diversity. Here’s what Rekai is doing differently -They’re hiring culturally competent staff, trained to understand and respect the needs of 2SLGBTQIA+ individuals. -They’ve identified staff members who are either part of the community or strong allies, ensuring representation and empathy in care. -They’re curating programming tailored to the unique experiences and interests of queer residents. -And they’re transforming their environments with inclusive artwork and décor, sending a clear message: this is a safe space. They are steps that are creating a home where residents can feel seen, respected, and, most importantly, safe. But while these strides are encouraging, it shouldnt be sugarcoated: because these efforts are the exception, not the rule. The Fixing Long-Term Care Act still doesn’t explicitly address the needs of 2SLGBTQIA+ seniors. yes, it talks about person-centered care, and quality of life, and increasing training but without specific guidelines on cultural competency or gender-affirming care, the door remains open for discrimination and neglect. So, has the current perspective changed from the original approach to long-term care? The answer is complicated. On paper, yes the shift to a more resident-focused framework and the rise of inclusive facilities like Rekai show that there’s been progress. But in practice, many care homes remain unequipped to meet the needs of 2SLGBTQIA+ residents. Why? Because Policies like the Fixing Long-Term Care Act fail to explicitly mandate inclusivity training or standards for culturally competent care. While the act states that all residents have the right to be treated with dignity and respect, regardless of their identity or background, it doesn’t explain how these rights will be enforced. Without accountability measures, many homes continue to rely on a one-size-fits-all approach, leaving queer seniors isolated and unsafe. As discussed earlier the Fixing Long-Term Care Act claims to promote Value 1 of the CASW code of ethics which is the dignity, equity, and quality of life for residents and emphasizes person-centered care, yet it falls short of explicitly recognizing the unique needs of marginalized populations. While the act attempts to regulate care quality, it doesn’t go far enough in addressing the structural barriers faced by queer seniors. For instance, without specific protections against homophobia, transphobia, or culturally insensitive practices, residents remain at risk of discrimination or neglect. Considering how the Fixing Long-Term Care Act aligns with the TRC Calls to Action. The Act primarily focuses on operational standards for long-term care, yet it makes no explicit mention of reconciliation or the need to address the systemic harms experienced by Indigenous communities, including those who identify as 2SLGBTQIA+. For example, TRC Call to Action #22 urges governments to ensure that Canadian health-care system to recognize the value of Aboriginal healing practices and use them in the treatment of Aboriginal patients. Yet, the Act doesn’t incorporate these principles into its framework. Leaving a significant gap in how the act addresses intersectional identities and systemic oppression. (British Columbia, 2015) But change is possible. Organizations like Rainbow Health Ontario and Egale Canada are pushing for better policies and practices, and trailblazers like Rekai are proving that inclusive care isn’t just a dream it’s actually achievable. The Rekai Centre is a shining example of how care homes can meet these needs of inclusivity, but it’s still just one facility. The work is far from over. The challenge now is to scale these efforts across Ontario and hold the government accountable. Because everyone deserves a home where they can be themselves, no matter their age, gender, or who they love. The work is far from over. The challenge now is to scale these efforts across Ontario and hold the government accountable because everyone deserves a home where they can be themselves no matter their age, gender, or religion.