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Study on Long-Term Care Service Awareness, Needs, and Usage Intention of Elderly Male Homosexuals in Taiwan and Their Ideal Long-Term Care Service Model

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25 November 2023

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29 November 2023

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Abstract
The present study examines the long-term care service awareness, needs, and usage intention of elderly male homosexuals in Taiwan and their ideal long-term care service model. This study of five elderly male homosexual subjects aged 66 to 73 years was intended as a preliminary exploration. Interviews were used to collect data. The study determined that the five subjects had high awareness of long-term care services, as they had actual experience of long-term care services or even participated in care service staff training to obtain certificates. Some even had experience in applying for home care services and experienced problems during use. The subjects perceived that they were very likely to require long-term care services in the future and tended to use home care services if they required long-term care services. Due to their personal experiences, the subjects had negative awareness of long-term care services and worried that long-term care service staff had poor attitudes toward homosexuals. The subjects considered the most important aspects of long-term care to be basic medical care and lifestyle care. However, they worried that long-term care staff would delay or refuse to provide such services due to the subjects’ sexual orientation or stereotypes, and they were concerned above all about the “friendly attitude” of long-term care staff. They hoped that long-term care staff were friendly toward homosexuals and did not discriminate against them, and they felt that it would be more appropriate for homosexual long-term care staff to provide assistance. In terms of vision, while preferring organizations with homosexual employees, the subjects worried that they would be stigmatized and discriminated against . With regard to ideal long-term care services, while considering institutions with homosexual staff to be ideal, the subjects also worried that these would be labeled as institutions that were dedicated to homosexuals, potentially resulting in discrimination. Therefore, they hoped that the sexuality sensitivity of long-term care staff could be improved and that they would undergo professional continuing education to learn about homosexuals, the situation and care needs of homosexuals, and care techniques for homosexuals.
Keywords: 
Subject: Social Sciences  -   Gender and Sexuality Studies

1. Introduction

Taiwan holds the distinction of being the first country in Asia to legalize same-sex marriage. This landmark decision significantly boosted the visibility of the lesbian, gay, bisexual, transgender, and queer (LGBTQ+) community nationally. With this increased recognition, all sectors in Taiwan, including long-term care, must address relevant LGBTQ+ issues. This necessitates modifying services to accommodate the distinct needs and ensure adequate support for LGBTQ+ individuals (Hong, 2022).
Taiwan is also among the countries experiencing the fastest population aging globally (Taiwan’s Ministry of the Interior, 2018). To tackle the challenges of an aging population and a declining birth rate, the Taiwanese government has included long-term care as an essential issue on the policy agenda, actively addressing the emerging needs and issues related to an aging society. Nevertheless, the government's focus on long-term care services for the LGBTQ+ community remains relatively limited. The presence and specific needs of LGBTQ+ individuals in the realm of long-term care have largely been overlooked and rendered invisible (Hong, 2019). Mark et al. (2014) noted that research on the needs of older adults rarely addresses the unique circumstances of the LGBTQ+ population. Older LGBTQ+ individuals often lack confidence in the friendliness and acceptance of service providers, leading to lower utilization of care and medical services. Cahill et al. (2000) suggested that compared to their heterosexual counterparts, older LGBTQ+ individuals have a greater need for care. Their frequent concealment of identity, driven by fears of discrimination, ridicule, or harassment, can seriously harm their mental and physical health. This concealment and its consequent health impacts significantly increase their chances of requiring long-term care (Bridget & Lisa, 2013). Many older LGBTQ+ individuals feel fearful when considering entering long-term care facilities (Brotman et al., 2003). Such fears can lead to psychological distress, including suicidal thoughts (Putney et al., 2018). Older LGBTQ+ individuals worry about being subjected to institutional control, prejudice, and discrimination.
Consequently, they often do not disclose their sexual orientation and gender identity, making them virtually invisible in long-term care settings (Barrett et al., 2009). Their invisibility also means they are overlooked in gerontology, policy-making, and law (Harrison, 2006). Therefore, a general lack of awareness about LGBTQ+ needs in long-term care often leads long-term care workers to presume heterosexuality in all their clients (Hong, 2017). Barrett (2008) pointed out that the assumption of heterosexuality can make LGBTQ+ individuals feel that their identity is misunderstood and that their partners and friends are neglected in the care planning and decision-making processes. In seeking services, older LGBTQ+ individuals and their caregivers may confront extra stress, burdened with concerns about acceptance, the necessity to conceal their identities, respect, and safety (Moone et al., 2016). Due to fears of discrimination or culturally incompetent care, LGBTQ+ individuals often avoid using formal care services (Gabrielson, 2011; Goldberg et al., 2005). A total of 92% of older LGBTQ+ individuals have indicated that acceptance is a crucial factor in choosing care services (Gardner et al., 2014). Katherine et al. (2018) explored the hopes and fears of older LGBTQ+ individuals contemplating long-term care at the end of their lives, identifying prevalent worries. These include social isolation, reduced autonomy, heightened vulnerability to internalized homophobia, and risks of being in unsafe environments. According to demographic studies, older LGBTQ+ individuals tend to have inferior physical and mental health compared to their heterosexual peers (Fredriksen et al., 2014).
The signing of the LGBTQI+ Senior Bill of Rights in 2021 by Governor Murphy of New Jersey, USA, was a response to the unequal treatment encountered by older LGBTQ+ community members in long-term care. This legislation safeguards older LGBTQ+ individuals and those living with HIV in long-term care facilities, ensuring they receive fair and equitable care. Governor Murphy stated that the government’s role is to protect these individuals from discrimination in long-term care settings because “No one should ever feel ashamed for who they are, and everyone should be able to live with the dignity and equality that they deserve.” The LGBTQI+ Senior Bill of Rights prohibits any discriminatory or unfavorable treatments in long-term care facilities based on an individual’s sexual orientation, gender identity, gender expression, intersex status, or HIV status (Official site of the State of New Jersey, 2021).
This study began exploring long-term care issues for the LGBTQ+ community in Taiwan starting in 2015. Initially focusing on older LGBTQ+ individuals, the study found no participants from this group in the field. Wang (2010) noted in his research on older gay and bisexual men (GBM) that Taiwanese older LGBTQ+ individuals tend to be reticent due to heteronormative cultural pressures, making it a significant challenge to encourage them to share their life experiences openly. The minority stress model (Meyer, 2003) suggests that the unique stressors associated with LGBTQ+ identity include direct discrimination, fear of discrimination, internalized homophobia, and concealing one’s identity. Despite these challenges, the study did not cease and shifted focus to middle-aged GBM to understand their attitudes towards long-term care (Hong, 2018a). In the same year, to bring public attention to LGBTQ+ long-term care in Taiwan, the study surveyed 202 LGBTQ+ participants during the Taiwan Pride Parade 2017. This was to understand the perspectives on long-term care across different age groups within the Taiwanese LGBTQ+ community (Hong, 2018b).
In advocating for LGBTQ+ long-term care in Taiwan and preventing delays in seeking medical help due to hiding their identity, the study planned the “Taiwan LGBTQ+ Long-Term Care Exhibition” in 2021. During this time, the researchers met two GBM working as home care aides, gaining preliminary insights into their working conditions and stressors. During the interviews, the partner of one of the aides, an older GBM, expressed a deep interest in the research topic. Consequently, the research team invited him for an interview to understand the attitudes of older GBM toward long-term care. He gladly accepted the invitation and introduced three other older GBM to participate in the study. Meanwhile, another aide providing home care for an older GBM helped facilitate the older GBM's willingness to participate in the research.
As outlined above, this study aims to gain insight into the perceptions, needs, and willingness of five older GBM to use long-term care services and understand their ideal vision for such services.

2. Methods

2.1. Research Methods

This study aims to gain insight into the perceptions, needs, and willingness of older GBM to use long-term care services and understand their ideal vision for such services. In-depth interviews were chosen as the research method to achieve this. This approach was selected, particularly because the study is exploratory. Creswell (2007) posits that qualitative research can offer preliminary direction and theoretical framework for topics that have not been extensively explored. Given the lack of related research in Taiwan and Asia addressing the stated objectives of this study, qualitative in-depth interviews were utilized for exploration.

2.2. Participants

This study involved five older LGBTQ+ individuals as participants. In terms of background information, all participants were male, ranging in age from 66 to 73 years, with three being retired and two still employed.
Table 1. Basic Information of Study Participants.
Table 1. Basic Information of Study Participants.
Participant Age Education Marital Status Relationship Status Coming out Status Belief
A 71 College Married but separated from opposite-sex partner In a same-sex relationship Out to friends, not to family Buddhism
B 73 Junior high school Never married Single Out to family and friends None
C 69 College Never married In a same-sex relationship Out to friends, not to family Taoism
D 67 Master’s Never married Single Out to friends, not to family None
E 66 Senior high school Divorced In a same-sex relationship Out to family and friends Taoism

2.3. Research Tools

The study employed a semi-structured interview outline developed by the researchers in 2018 to guide the interview process. Interviews were the primary method of data collection. Participants were asked for their consent before setting a date for the interviews, and confirmation calls were made on the day of the interview to finalize the location and time. Digital recording devices were used throughout to capture the content of the interviews.

2.4. Data Analysis

Thematic analysis was adopted for analyzing the study data. The interview transcripts were coded, and through this coding process, categories and themes relevant to the research objectives were progressively extracted from the interview data.

2.5. Research Ethics

In line with respecting and protecting the rights and privacy of the participants, consent forms detailing the study's purpose, process, and ethics were prepared. Participants were asked to read these forms thoroughly. This was to enable them to understand the purpose of the study, its procedures, and time commitment. Further, it allowed them to understand their right to participate or withdraw at any point voluntarily and the principle of confidentiality. All these ethical considerations were aimed to minimize any risks. Interviews were conducted only after reaching a consensus with the participants. The identities of the five study participants were anonymized using codes to protect their privacy.

3. Results

The analysis of the study results is divided into four subsections. The first subsection describes the understanding of long-term care services among older GBM in Taiwan; the second summarizes their needs regarding these services; the third presents their willingness to utilize long-term care services; and the fourth discusses the ideal long-term care services from the perspective of older GBM in Taiwan.

3.1. Understanding of Long-Term Care Services Among Older Gay Bisexual Men in Taiwan

The study indicates a high level of awareness about long-term care services among older GBM, primarily due to their prior experiences with the services. They are well-informed about the contents of long-term care services.
My mother was bedridden for a long time after a fall. Back then, our financial situation allowed us to hire a caregiver. After spending significantly over the years, my brother, who was opposed to this, insisted on moving her to a nursing home. I disagreed and chose early retirement to care for my mother myself. This experience made me familiar with various long-term care services and what’s available. (PD)
I enrolled in a healthcare aide training course to better understand the fine details needed in elderly care and learn about taking care of my health as I age. It also helped me appreciate the hard work of healthcare aides so that I would not be unreasonable and demanding when I am under care. I was delighted to receive my healthcare aide certificate. Initially, I wanted to work as a healthcare aide, but my relatives and friends opposed it, citing my age and the after-effects of a car accident. My partner works in home care; thus, we discuss current care services, and I am clear about the subsidies available for long-term care services. (PA)
I was hospitalized for prostate cancer surgery and applied for home care afterward. My understanding of care services improved thanks to a friend who works in home care and has been a great help... He helped set up an accessible space in my house and found a gay home care aide. I cannot go to work now and work from home, with a gay home care aide assisting me with daily tasks. (PC)
I have experience with it since my family members and relatives have applied for home care or hired foreign caregivers. I understand that poor health can lead to many inconveniences; even bathing and eating require help. Therefore, I try my best to stay healthy and exercise as much as possible. I go to the gym to keep my body in good shape. (PE)
If there is a need for long-term care services, older GBM, due to their personal experiences, often hope for long-term care workers who are themselves members of the LGBTQ+ community.
Diagnosed with this cancer, I initially felt hopeless. During a previous hospital stay, a lady was caring for me, which was awkward and made me feel very sad. Fortunately, a friend understood my mental strain and reminded me that death is an inevitable part of life, encountered at any age. He advised me to face it positively and to undergo active treatment as long as my physical condition allowed. He then helped me find a gay home care aide. I find that care from a gay person is less embarrassing. We can talk about topics like gay senior living and emotional life. (PC)
If the care provider is also gay, there is a better understanding. Specifically, we do not need to hide anything. We are all gay; there are no awkward barriers. (PB)
Previously, my partner, a home care aide, took care of me. Thus, I believe care services from a gay are better. I have seen many home care aides who are older women, chatty and nosy. If they discovered something about me, the gossip would be endless. (PA)
Regarding the types and functions of long-term care services, five older GBM are clear about these due to their deep engagement. For instance, PC, who has applied for home care, knows precisely which services he can use, and PA, having taken a healthcare aide course, is very familiar with long-term care. The other participants are acquainted with these services because their parents have used them.
I took a healthcare aide course. Therefore, I understood it well and encouraged my partner to enroll. He now has more stable work because of it. (PA)
My mother stayed in a care facility, so I understand institutional care. My father attended daycare services; thus, I am also familiar with that. (PE)
All five older GBM showed similar levels of awareness and understanding towards long-term care workers but harbored negative perceptions, worrying about their attitudes towards LGBTQ+ clients. Their concerns stem from personal experiences.
In the healthcare aide course I attended, many students were older adult women who do not necessarily accept gay individuals. When my partner attended a continuing education class where homosexuality was mentioned, the women showed no interest, and he also avoided coming out at work, fearing discrimination. (PA)
From my observation, long-term care workers are not very gay-friendly… In that environment, even older clients are not treated with much respect. Some heads of long-term care facilities are arrogant, making it evident that coming out is not an option. (PC)
I have always encountered unfriendly attitudes toward gays, and it is still the case. The older they are, the less they understand gays, and it is the same with long-term care workers now; they hardly know any gay individuals. (PD)
All five older GBM expressed a wish for long-term care workers to be LGBTQ+-friendly and non-discriminatory, suggesting that care from LGBTQ+ long-term care workers would be more fitting and comfortable.

3.2. Need for Long-term Care Services Among Older Gay Bisexual Men in Taiwan

When questioned about the likelihood of requiring long-term care services, all five older GBM indicated a high probability, as they all have had prior experiences with such services.
Even if I had no prior experience, I would still feel the need. Everyone, at some point, requires care. In our family, some relatives live in facilities, and foreign domestic workers take care of others, so the need is universal. (PD)
The need is inevitable, and early learning of caregiving knowledge and skills is crucial. At any age, as long as one is physically able, I encourage everyone to attend healthcare aide courses. Working as a healthcare aide is not mandatory, but at the very least, it helps increase medical knowledge and self-care skills, which can be handy when family members need care. In the event of an accident or disability, I would need long-term care services. Home or institutional care depends on government policies, regulations, and financial capability. (PA)
Of course, I would need long-term care services if I become bedridden or develop dementia without hope of recovery. I fear that the government’s eligibility criteria for applying for these services are so stringent that they are practically inaccessible and merely a tool for political campaigns. (PD)
I do need it, but I try my best to maintain my health to avoid being bedridden and dependent on others. (PB)
All five older GBM believe that support from friends and partners in caregiving is critical. They are less likely to receive care from family members due to systemic societal discrimination and a lack of a public care system. Consequently, LGBTQ+ individuals typically prefer to seek assistance from friends and partners rather than from their biological families or the health and welfare system (Shippy, Cantor, & Brennan, 2004; Bell & Weinberg, 1981). Some LGBTQ+ individuals also refrain from seeking help from their families due to not having come out to them.
In my understanding, caregiving responsibility naturally falls to the family. Friends and partners are not obliged to care; they only provide moral support. Without family, one has to rely on friends, which depends on how close these friendships are. It is all relative—you get back what you put in, depending on the people you interact with. In seeking help, I would turn to my partner, as he has a healthcare aide certificate. Of course, he should be paid for his services. Further, some long-term care workers or facilities worry about the sexual needs of gay clients. In reality, most gays who require long-term care no longer have sexual needs; rather, the concern should be about protection from sexual harassment. In our times, gays could only seek relationships and live their lives in the shadows; thus, our thoughts tend to be more pessimistic, and hoping for a peaceful end is a blessing. (PA)
Friends often provide more care, especially for older gay men who lack a partner, their own housing, or savings. They need a facility that offers shelter and three meals a day. A model similar to some charitable organizations could be considered, where those still capable of manual dexterity can engage in simple manufacturing within the facility to help supplement their income. (PD)
Additionally, the most crucial requirement is equal care. All five older GBM believe that the most essential needs in long-term care are primary medical and daily life care. However, there is apprehension whether long-term care workers might delay or refuse services due to sexual orientation or stereotypical misconceptions. The “friendly attitude” of the long-term care workers is their primary concern.
I once hired a lady who made it very awkward for me. She would ask why I, at my age and with my earning capacity, lived alone and was not married. I had to brush off her questions casually. She did not know I was gay. So, there were no serious issues, but it was tiring to dodge these questions in care. I find it easier to chat with gay home care aides; there is less judgment and more common ground in conversations. (PC)
It would be even better if male gay healthcare aides who are careful and skillful, especially in physically demanding services, were available. They tend to be more competent and comfortable with female care recipients, avoiding awkwardness. Similarly, male recipients have better psychological comfort and less discomfort. (PA)
If they could empathize with the social circumstances of gays, that would be preferable. However, currently, there is a lack of education that allows long-term care providers to understand and recognize gays. (PD)
As I just mentioned, there is little awareness about gays in long-term care. If they could learn to interact with gays in a friendly and affirmative manner, perhaps many would not be as worried. Many gay individuals I know are concerned about being bullied or having to lie about their preferred gender if they end up in a nursing home. (PE)

3.3. Willingness to Use Long-Term Care Services Among Older Gay Bisexual Men in Taiwan

When queried about the perceived likelihood of using long-term care services, all five older GBM indicated a high probability, primarily due to their experiences with such services. Notably, they all expressed a preference for home-based care. Hong’s (2018a) study on middle-aged GBM similarly found a tendency toward utilizing home-based care services.
We predominantly favor home-based care. In my case, I have already applied for home care services. Financially, I am pretty sound and can manage costs over 30,000 NT$ monthly. Nonetheless, my primary concern is that my current illness might not quickly subside. (PC)
I prefer getting care at home. In the future, I am considering the option of hiring foreign caregivers. (PE)
I had a disheartening experience when I applied for a veterans’ home. As soon as they found out about my sexual orientation, they immediately rejected me. That incident made me quite angry. I believe it is better to stay physically fit and go for home care instead of residing in an institutional setting. (PB)
My choice is home care, mainly because my partner can care for me, contributing to his income. (PA)
I tend to visit local community care centers when my health allows. Otherwise, I will have to rely on home care services. (PD)
The group noted that the average cost for self-funded long-term care services was over 40,000 NT$.
Economically, I am in a position where I can afford a bit over 40,000 NT$ each month for these services. (PC)
Considering the care expenses it is generally about 40,000 NT$ or more. Since many gay men are unmarried and without family support, it is crucial to evaluate their capacity to shoulder such financial burdens. Generally, those requiring long-term care cannot work, leading to minimal or no income. (PE)
The decision to apply for long-term care depends on one’s health situation and financial means. My retirement pension is just over 30,000 NT$. I can only afford up to 1,000 NT$ daily for care services. When factoring in medical costs, it appears that I have no alternative but to await death at home. The expenses for caring for my mother amounted to over 60,000 NT$ monthly, nearing a million annually. Over the seven years we employed a foreign caregiver until her passing, the total expenditure was approximately seven million NT$. (PA)

3.4. Ideal Long-Term Care Services from the Perspective of Older Gay Bisexual Men in Taiwan

Older LGBTQ+ individuals agree on the concept of constructing LGBTQ+-specific long-term care facilities. This idea mirrors the vision shared in Hong’s (2018a) interviews with middle-aged LGBTQ+ people, highlighting the desire for such dedicated institutions. However, there is also a fear of being labeled.
I dream of an environment akin to a villa with a garden, accessible facilities, meals, hygiene care, and all at an affordable cost. Ideally, these should be gay-specific systems designed by and for gays, whether male or female. If heterosexual norms dictate the standards, they are simply outdated. (PD)
A gay-specific institution would be preferable, but its regulations must be determined privately, not widely broadcast. If everyone knows it is a gay long-term care center, residents might face pointing fingers whenever they step outside. (PE)
The best would be an institution for gays, but it might get stigmatized as “exclusively for gays,” inviting different treatment... Government regulations stipulate specific requirements for establishing long-term care facilities in terms of equipment and zones. Therefore, we should check whether these government regulations align with the realities of society and urge the government to make improvements. My preference for a specific type of environment is not the main issue. I once aspired to create a gay-friendly daycare service. I bought a ground-floor shop, considering its accessibility for older adults with mobility issues and easier evacuation in emergencies. When I inquired about its establishment, my application was rejected because commercial areas are not permissible locations, dousing my plans in cold water. The permissible areas are upstairs in residential zones or independent houses with bathrooms, layouts, and corridors that must all be equipped with accessible facilities and space. (PA)
I am aware of a gay-friendly elder care association managed by a gay. It remains to be seen whether they will evolve into a gay-specific long-term care facility. However, if they do, I would be willing to move in. Being surrounded by fellow gay individuals would undoubtedly offer a sense of reassurance. We could also learn from Japan’s gay-friendly senior housing. These places are staffed by managers who assist with shopping, medical appointments, and other basic life needs. Particularly appealing are the low rents communal dining areas that encourage interaction among residents, thus preventing isolation. Forming friendships here and mutually aiding each other can enhance independent living. Many single elders face difficulties renting homes because landlords fear what might happen if something goes wrong. Older gays are likely to encounter these issues as well. (PB)
The unanimous opinion among the five older GBM interviewed is that an increase in gender sensitivity among long-term care workers is imperative in addition to LGBTQ+-specific long-term care facilities.
Our biggest concern is the perspective of the long-term care workers towards us. If they exhibit homophobia, whether they live in a facility or use home care services, it would be a source of immense distress. Therefore, care providers must be knowledgeable about gay individuals and understand the social predicaments faced by the gay community and the specific care challenges we encounter. They must be able to see things from our perspective and comprehend our needs. (PD)
There is a definite need to enhance the understanding of gay issues. My partner mentioned that continuous education on gender sensitivity for long-term care workers rarely addresses gay topics. They cover other gender issues instead. How can care providers comprehend our problems without being educated about them? How can we dare to come out of the closet? Unless care providers first understand what being gay means and the concerns gays have regarding long-term care, we are too frightened to reveal our true selves. We have to remain hidden because our generation has been hurt too much in the past. In our times, gays could only seek affection while hiding in the shadows. No wonder our outlook is rather bleak and pessimistic. To die well is a fortune we hope for at the end. (PA)
Most of the older gays I know are retired and in relatively good health, but we still contemplate future care for one another. As friends age, who will take care of whom? That is why we discuss the importance of having long-term care providers who understand and do not discriminate against gays. If they are knowledgeable and nonjudgmental, we will consider living in care facilities and utilizing daycare and home care services. (PB)
Living to this age, one starts to consider life in old age. We have insurance to assist us, but human care is unpredictable. The news shows only a fraction of the mistreatment that happens. Much remains unseen. I have heard from social workers in long-term care facilities that older adults are not always treated kindly, and as gays, that scares us even more. (PE)
I have asked my home care aide, who said they must take courses on gender sensitivity. Nevertheless, these courses seldom cover the care of gay individuals. It is disappointing because if instructors do not address the reality of being gay, the care providers’ understanding of gays will be based solely on what they see on TV. They will not realize that there are many types of gay individuals, not just the stereotypes portrayed on television. Therefore, it is vital to elevate the gender sensitivity of care providers and equally important to educate them on the care of the gay population. (PC)

4. Discussion

The analysis presented herein reveals that the five older GBM possess a considerable awareness of long-term care services. This awareness is rooted in their actual experiences, both in directly utilizing these services and dealing with the attendant issues. They all acknowledge a high probability of future dependence on long-term care services. Should the need arise, they display a preference for home care services. They are also conscious of the looming issue of long-term care, confronted by a scarcity of personnel, and some have participated in caregiver courses and wish to engage in gay-friendly custodial services. Cahill and South (2000) noted that, in contrast to heterosexuals, GBM bear more significant concerns stemming from social safety nets, pension schemes, and issues related to health and long-term care as they enter old age.
Consequently, older GBM have a heightened awareness of care services, informed by their own experiences and those of their close friends and family who have utilized such services. However, Mark et al. (2014) established that studies on the needs of older adults rarely address the unique circumstances of the LGBTQ+ population, leading to a lack of confidence in service providers among older LGBTQ+ individuals and a consequent decrease in the utilization of care and medical services. The five older GBM harbor a predominantly negative perception of long-term care workers, and their apprehension stems from personal experiences regarding the attitude of caregivers toward LGBTQ+ individuals. Shauna (2019) has identified that older LGBTQ+ individuals often face discrimination and bias in long-term care and are frequently compelled to confront their sexual orientation during the aging process. Hence, these men believe that when entering long-term care beyond basic medical and life care, their primary concern is whether caregivers might refuse or delay services due to sexual orientation or stereotypical misconceptions. Long-term care workers’ “friendly attitude” is paramount to them. Bridget and Lisa (2013) suggest that the risk of needing long-term care for older LGBTQ+ individuals is higher than for heterosexual elders. Many older LGBTQ+ individuals feel fear at the prospect of entering long-term care facilities (Brotman et al., 2003). Research in Taiwan by Wang (2011) indicates that older GBM face dual social exclusion: invisible in a heterosexual society and unwelcome within the LGBTQ+ community due to their aging bodies. Gofyy (2011) voices the experience of Taiwan’s older GBM who have lived through the stigma of homosexuality being deemed “dirty, dark, and shameful,” a stain many still struggle to erase. Having experienced such stigma, the five older GBM hope for long-term care workers who are gay-friendly and non-discriminatory, suggesting that care providers who are themselves members of the LGBTQ+ community might offer more pertinent support. While they see the value in dedicated LGBTQ+ facilities, they worry about being stigmatized or viewed differently, aligning with the desires and concerns expressed by Hong (2018a) for exclusive LGBTQ+ long-term care facilities without the fear of labeling.
Furthermore, these men advocate for improved gender sensitivity among long-term care workers and call for continuing education that addresses the recognition of LGBTQ+ people, their situations, and their specific care needs. Choi & Meyer (2016) found that many studies show older LGBTQ+ individuals avoid or delay medical services due to discrimination by long-term care, with many possibly living single or in solitude. Supportive housing in later life is a critical concern for older LGBTQ+ individuals, yet most long-term care providers are not adequately prepared to meet their needs (Elizabeth et al., 2020).
Older GBM bear significant pressures and experience a heightened sense of repression compared to their younger counterparts. Some are still shackled by the stigma of their past, leading to a perpetual self-scrutiny marked by negative perceptions such as “I am not accepted” or “The other person dislikes me.” For older members of the LGBTQ+ community, various social conditions often present disadvantages that adversely affect their health. According to a 2018 AARP survey, over 60% of LGBTQ+ individuals aged 45 and above harbor concerns about potential neglect, abuse, harassment, or restricted services in long-term care facilities; alarmingly, 54% of gender-diverse respondents feared that concealing their identity was a prerequisite for accessing suitable care centers (Houghton, 2018). Additionally, research by SAGE & the Equal Rights Center has indicated that up to 48% of older LGBTQ+ individuals have faced discrimination when seeking long-term care services.
Although same-sex marriage has been legalized in Taiwan, heterosexual norms persist within its culture, implying an inherent societal expectation of heterosexuality and rendering other gender diversities as unnatural, thereby perpetuating a culture of heteronormativity. Whether long-term care in Taiwan can respect and accommodate the needs of the LGBTQ+ community remains a concern for older LGBTQ+ individuals. The Taiwanese society’s insufficient support system for older LGBTQ+ persons compels them to confront more severe care challenges. Therefore, it is crucial for long-term care workers and facilities to cultivate an understanding and recognition of the unique social and psychological experiences of LGBTQ+ individuals. Through education tailored to LGBTQ+ issues, both can enhance their empathy and comprehension of the LGBTQ+ plight, fostering an environment where values of inclusivity and attitudes of friendliness prevail. This would enable the delivery of diverse professional services to be more effective in collaboration and specialization.

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