Recommendations

In this section, the recommendations made for policy and practice, based on the results and conclusions of the studies, will be summarised. A recurring theme in the studies, based on the results, is that there is a need for LGBTI competence in healthcare and social care. A key element here is that those working in healthcare, social care and other professions in which they interact with older people should have LGBTI competence and that the target group itself should not be responsible for educating the professionals they encounter. Inclusion of such knowledge in healthcare and social care study programmes and CPD initiatives is thus repeatedly highlighted as important (Egede et al., 2019; Löf & Olaison, 2018; Meggers Matthiesen, 2019; Siverskog, 2014, 2021b; Zeluf et al., 2016).

In day-to-day interactions with healthcare and social care

Knowledge about (different experiences within) the LGBTI group: The importance of there being basic knowledge among those who interact with older people through their profession about the special experiences and needs that LGBTI people may have is repeatedly highlighted. At the same time, it is important to see the LGBTI group as heterogeneous with different experiences; for example, trans people’s experiences may differ from those of gay or bisexual people, and age, gender, sexuality, health, geography, socioeconomics, ethnicity and access to relationships and social networks also create different experiences and needs. This also means that there is no ‘right way’ to respond to an LGBTI person. Instead, norm-critical knowledge about gender and sexuality and knowledge about LGBTI history and LGBTI rights are highlighted as important (Johansson Wilèn & Lundsten, 2019; Giertsen, 2017). This also includes critical self-reflection through regular dialogue that makes it possible to reflect on the assumptions you make about people’s gender, sexuality, life experiences and family status to highlight and counteract heteronormativity (Sommarö et al., 2017). In light of the paucity of knowledge about trans people, people with intersex variations and people living with HIV, this needs to be focused on in particular in competence-enhancement initiatives (Åberg, 2018; Bromseth, 2013; Egede et al., 2019; Meggers Matthiesen, 2019; Siverskog, 2014, 2021b).
Language and communication: Another factor that is frequently highlighted in the studies is the importance of being treated in a respectful, unbiased manner so that people feel safe and welcome to be open about their identity and be affirmed in who they are. Recognition and respectful language are important here. A few more concrete factors that are emphasised are the use of gender-neutral language, i.e. language that does not reflect certain assumptions. This may involve using words like ‘partner’ or ‘life partner’ instead of husband or wife, or making space for important close relationships beyond partners or family of origin by asking questions such as ‘what relationships have been important to you?’ This may also be a matter of being attentive and listening to the terms the person uses themselves and using these (Löf & Olaison, 2018:262; Meggers Matthiesen, 2019:94; Siverskog, 2021b:63 ff.). Several studies show that norm-critical, intersectional perspectives in CPD contribute to gender-neutral, inclusive healthcare interactions that provide greater scope for marginalised life experiences and needs (Sommarö et al., 2017; Johansson Wilèn & Lundsten, 2019), for which reason this is also recommended by several researchers (Tengelin et al., 2019; Lundberg, Malmqvist & Wurm, 2017).

At organisational level

The physical environment: The physical environment also influences and reproduces norms, conditions practices and may contribute to feelings of inclusion or exclusion. It can be important to see yourself represented, for example through pictures, newspapers or rainbow symbols. Gender-neutral toilets and forms that enable LGBTI identities are other examples. For those who live in nursing homes, it is important for their integrity and privacy to be respected, for example by the staff not only knocking but also waiting for a response before entering a room. These things can affect the perceived opportunities to be open and to feel safe, not least in light of how their own home has often been a haven free from heteronormativity for older LGBTI people. Another important factor is routines to deal with homophobia or transphobia if someone is abused by other residents or staff (Egede et al., 2019:97; Meggers Matthiesen, 2019; Siverskog, 2021b, 2021a).
Collaboration with LGBTI organisations: Collaboration between healthcare and social care actors, and other actors working on initiatives to, for example, create efforts to counteract mental illness and social isolation among older people, and LGBTI organisations may be a way of offering competence-enhancement initiatives and implementing social activities with an LGBTI focus. It is also important to be up to date on the resources and meeting places available for LGBTI people locally and to be able to refer people to them. LGBTI organisations and mixed-age LGBTI contexts should both work against ageism and have an awareness of age norms (Meggers Matthiesen, 2019; Siverskog, 2021b).

Person-centred care: Since the ‘equal treatment perspective’ risks being based on heteronormativity, several studies emphasise a person-centred approach instead. Life stories are often used within this approach, and these can also help understand the full context of people’s lives, and contribute to an understanding of how past life experiences also affect their experiences as an older person. Here, however, silences need to be respected and it is necessary to understand and respect that some people do not want to talk about their background. While this approach aims to shift power to the patient in the care interaction, it must not mean that the responsibility to educate and inform falls on the patient (Meggers Matthiesen, 2019; Siverskog, 2014).

At structural level

Policy: Older LGBTI people need to be represented in policy documents. This is particularly important in the area of social isolation, as interventions and initiatives are often aimed at young LGBTI people. It is important to continue effective anti-discrimination work in all areas of society to promote the health of older LGBTI people (Bränström et al., 2022:10; Public Health Agency of Sweden, 2015; Meggers Matthiesen, 2019).
Prevention work should include an older target group: The group of older LGBTI people should be addressed in prevention work against HIV, sexually transmitted diseases and suicide. The older target group living with HIV should be represented in policy and there should be knowledge about HIV in the practice of elder care. Prevention work should be carried out respectfully, avoiding stigmatisation and discrimination in light of how men who have sex with men may have experienced this earlier in life. Rehabilitation programmes after prostate cancer should be designed based on the experiences and needs of gay and bisexual men and not presuppose heterosexuality. The profession should ask patients norm-critical questions about sexuality and sexual practice to be able to provide relevant advice, for example in connection with prostate cancer (Åberg, 2018; Backer Grønningsæter & Skog Hansen, 2018; Danemalm Jägervall et al., 2019; Erlangsen et al., 2020; Qvarnström & Oscarsson,2015).
Improving trans care: Several studies highlight how trans care needs to be more accessible and designed for users to a greater extent to promote trans people’s health. There is a need for affirmative trans care, and suicide prevention and psychiatric services targeted specifically at trans people to reduce health inequalities. Trans care should also enhance its knowledge about older trans people and work to avoid ageist responses (Linander, 2018; Siverskog, 2014, 2015; Zeluf et al., 2016, 2018).

Improving working conditions in healthcare and social care: To ensure good treatment and to be able to apply a norm-critical approach in day-to-day healthcare and social care, care needs to be organised in such a way that there are reasonable working conditions, with time for CPD and for conversations in day-to-day care. As elder care has been made more efficient and market-based over several decades, this has also led to tough working conditions for the employees. There should be continuity in healthcare, with those with the greatest need having the same staff where possible, and supportive, present leadership (Siverskog, 2021b; Åberg, 2019:286 ff.).

Professional qualification study programmes and CPD

Intended learning outcomes: Implement life course perspectives on LGBTI people’s living conditions, health and ageing as intended learning outcomes in health and social sciences professional qualification study programmes. Overarching guidelines for intended learning outcomes are important instruments for monitoring how the objectives are integrated in study programmes over time (Areskoug Josefsson & Solberg, 2023). Increased knowledge about older LGBTI people’s conditions in the healthcare and social care sectors is highlighted as an important measure in several national LGBTI action plans. However, measures relating to changed intended learning outcomes and integration strategies in relation to health and social sciences professional qualification study programmes are given little focus in most Nordic countries. Intended learning outcomes (and professional ethical guidelines) send a message that teaching about a diversity of life course experiences and needs, not just norms, is considered mandatory knowledge not optional (cf. Giertsen, 2019; Lundberg et al., 2017). In addition, the implementation needs to be continuously reviewed and followed up.
Study support structures: Implement study support structures for integrating knowledge about life course perspectives on LGBTI people’s living conditions, health and ageing into professional qualification study programmes. Study support structures have been shown to facilitate the introduction of knowledge about, for example, domestic violence (Carlsson, 2020). This includes allocating resources for the establishment of systematic, long-term work to help teaching institutions translate the learning objective into integrated knowledge throughout the professional qualification study programme, from general syllabus and course syllabus to course literature, educational resources and examinations (cf. Areskoug-Josefsson & Solberg, 2023).

Study resources: A norm-critical inventory of existing study resources and of how knowledge about LGBTI perspectives, life courses, healthcare and social care is included is needed. The knowledge inventory shows that course literature in certain health and social sciences subjects continues to have a heteronormative and cisnormative basis in the representation of identities, bodies and ways of living (Giertsen, 2017; Tengelin, et al. 2019). The representation and knowledge in study resources in different professional fields needs to be investigated in more detail based on norm-critical, intersectional perspectives. If LGBTI experiences are represented, which are represented and in what way? There is generally less knowledge about older people than about younger people, and less about the living conditions of trans and intersex people than about those of gay and bisexual people. To increase the representation of older LGBTI people in course literature, it is important to know what it looks like and to ensure that particularly vulnerable groups and marginalised experiences are also included.
Course literature in Nordic languages: Resources are needed for the development of research-based course literature in the Nordic languages which includes knowledge about LGBTI perspectives, life courses, healthcare and social care. Both the articles reviewed and the interviews with higher education institution teachers on health and social sciences professional qualification study programmes highlight the importance of there being literature in their own language that can be used as course literature. This may be newly written study resources or translated literature.
Knowledge requirements in upper secondary education: Knowledge requirements must also be included in the curriculum and followed up in upper secondary healthcare and social care study programmes. The knowledge inventory shows a tendency for life course perspectives on LGBTI people’s living conditions, health and ageing among professional practitioners in healthcare and social care professions to be generally absent (Solberg, 2017; Sommarö et al., 2017; Smolle & Espevall, 2021). A large proportion of the staff working in the healthcare and social care professions have upper secondary education. This education must therefore also have learning outcomes that include LGBTI perspectives, life courses, healthcare and social care. The content of upper secondary education is outside this study, but in light of what we know about the conditions in higher education, we can assume that a similar situation exists at upper secondary level.
CPD for professionals: Knowledge about marginalised life course experiences, ageing conditions and needs need to be included as an integral part of existing CPD for professionals who interact with older people in the healthcare and social care sectors – including LGBTI perspectives. Knowledge about trans experiences and intersex experiences must be particularly highlighted and prioritised.
The role of the civil society sector in CPD: The civil society sector should be provided with long-term funding for its work to improve the living conditions of older LGBTI people through social and educational initiatives. It must be ensured that older LGBTI people do not disappear as target groups for interventions. The civil society sector should not, however, bear the ultimate responsibility and be the driver of the necessary knowledge being integrated into the social and education sectors. In light of this, CPD should be included as a more integral part of long-term municipal and regional strategic work in the healthcare and social care sectors in close dialogue and cooperation with civil society organisations.

Continued research

A number of studies also indicate what should be further explored in future research. There is a need for more quantitative and qualitative knowledge about older LGBTI people. As Bränström et al. (2022) indicate, it is important to include people of all ages in national public health studies, and to have questions about gender identity and sexuality to enable analyses of the impact of these factors. In light of the inclusion process for this report, we would like to emphasise that it is important to also present the results in such a way that all these factors are clear, so that it is possible to read something about this group. Bränström et al. (2022) also state, given how mental health is often better in older age groups than younger ones in quantitative studies with LGBTI people of all ages, that it is important to further investigate the causes of this. For example, it could be that during their lives they may have developed resilience to stress factors, but this is something that needs to be investigated further. Longitudinal studies may also facilitate analyses of causal effects and the effects of cohort and generation in relation to this (Bränström et al., 2022:10). Löf & Olaisson indicate that it is important to explore experiences of healthcare, social care and social services to a greater extent, and to translate research results into training initiatives for elder care (2018:261-262). The focus should be on how formal care and the general environment can contribute to reducing minority stress and instead strengthening mental health (Löf & Olaison, 2018; Synnes & Malterud, 2019).

In terms of quantitative knowledge, we need better data, with a larger sample of older LGBTI people, from many parts of the Nordic region. Based on the research overview, it is possible to conclude that knowledge from some countries, such as Finland and Iceland, and the Faroe Islands, Greenland and Åland is inadequate. We need more knowledge about older LGBTI people from these contexts. In view of the group’s different experiences, there is also a lack of knowledge about older intersex people, with knowledge today basically non-existent. Better quantitative data may provide greater knowledge about general patterns both in terms of the importance of gender identity and sexuality for health, well-being and ageing, to be able to point to differences within the group based on other structures/experiences, and to be able to compare differences between the different Nordic contexts. There is a need for both more systematic inclusion of gender identity and sexual orientation in population studies related to public health and quality of life, and targeted studies, which often have higher response rates than the general ones.

For example, RFSL’s targeted survey for older LGBTI people has a higher number of respondents than the Swedish Public Health Agency’s public health survey.

There are also specific knowledge needs relating to different subgroups within the group of older LGBTI people; in particular the very oldest (80+), people with trans and intersex experiences, racialised LGBTI people, LGBTI people living with HIV, and LGBTI people who are at increased risk of social isolation. Studies have previously shown how, for example, LGBTI people’s opportunities to participate in LGBTI communities depend on factors such as geography, class and health, and research needs to take these factors into account in the analysis. There is also a need to investigate how age-based arrangements and normativity structure LGBTI policies and social meeting places. Research into older LGBTI people should also aim to capture different experiences within the LGBTI community (Siverskog & Bromseth, 2019; Siverskog, 2016; Löf & Olaisson, 2018).

As can be seen from the knowledge inventory, there are large knowledge gaps in how LGBTI perspectives and ageing are included in education, professional practice and CPD. There is limited knowledge about the ways in which LGBTI people’s living conditions and life course experiences are included as mandatory elements in education and study resources (Tengelin et al., 2021; Areskoug Josefsson & Solberg, 2023), and hardly any knowledge about how older LGBTI people’s life course experiences and ageing conditions are included as mandatory elements in education and study resources. What are the knowledge and understanding requirements in intended learning outcomes, general syllabuses and course syllabuses in the Nordic countries, and how are they implemented in the form of course literature, compulsory modules and as part of the examination of the intended learning outcomes? Several studies and interviews show willingness to include knowledge, and that students seek more knowledge (Tengelin et al., 2021; Lunde et al., 2022) – but what are the reasons why this is not done by teaching staff? What are the structural changes that can support these processes? This needs to be investigated further.

Several studies have evaluated CPD initiatives such as LGBTI certification, but none of these was carried out in activities specifically aimed at older adults (Sommarö et al., 2019; Johansson Wilén & Lundsten, 2019). The studies suggest some effect of CPD in terms of norm-conscious treatment, but more inadequate knowledge about trans experiences. They also highlight the structural challenges of maintaining knowledge in organisations as a whole. Studies are needed that investigate the effects of CPD initiatives in activities that encounter older adults, including longitudinal studies that investigate the long-term effects of CPD and LGBTI certification.