LGBT seniors came of age in a culture hostile to gay people. While the days of considering homosexuality a disease and a crime may be over for good, homophobia still affects the health of older gay people.

The three biggest issues affecting the health of LGBT seniors are isolation, a lack of traditional family structures and economic insecurity, issues that are often intertwined, advocates say.

Past discrimination can have a real affect on the lives of today’s seniors, said Jan Couvillion, former outreach to elders activities manager at New Leaf, a San Francisco healthcare center for LGBT people that closed in 2009 after 35 years of operation.

Overall, LGBT elders are half as likely as their straight peers to have a close relative to rely on for help, and elderly lesbian couples are twice as likely as heterosexual couples to live below the poverty line, according to a report by SAGE, an advocacy group for LGBT seniors, “Improving the Lives of LGBT Older Adults.” These are significant risk factors for poor health outcomes, the report noted.

“Most lesbians, at least the ones I know, spent their lives walking the fence,” said Couvillion, who is 70 years old and a member of the activist group Older Lesbians Organizing for Change.

Peers who came out at work were often discriminated against and lost their jobs, Couvillion said. The jobs they took to replace their positions often were at much lower pay, she added, which had a long lasting effect on their economic security and on their wellbeing. “There is the stress and the loss of dignity,” Couvillion said.

The traditional family structures that people rely on for care in old age are often broken for elderly LGBT people too, creating an isolation Couvillion sees today in her work as a senior peer advocate for the Tenderloin Self-Help Center. She described an 84-year-old lesbian client who lives in an SRO alone and manages her own incontinence by sleeping on a plastic sheet with no blankets. Coming out often meant severing family bonds for this generation of seniors, and lesbians who didn’t have children are often left to fend for themselves, Couvillion said.

Healthcare providers’ lack of knowledge about the needs of LGBT patients, combined with a lack of resources, make these issues all the more difficult to address, said Dan Ashbrook, the director of Lavender Seniors of the East Bay, an organization devoted to improving the lives of LGBT senior citizens. In addition to organizing lunches and visits to cut down on the isolation of LGBT seniors, Lavender Seniors conducts trainings to help nursing home staff offer better care to older gay people.

“Only three percent of healthcare workers have human sexuality training,” Ashbrook said. A lack of statistics and other data on LGBT seniors only compounds the challenges of determining how to get this population the services that they need, he added.

“Usually LGBT specific organizations do this kind of work,” Ashbrook said of training nursing home staff about human sexuality and the challenges faced by gay seniors. “We just don’t have the resources to do it,” he added.

The additional education is needed, according to the Center for Elders Independence in Berkeley, one of the two nursing homes where Lavender Seniors is training staff with a grant from Alameda County. Though the center has a diverse population, and has other types of cultural sensitivity training, Lavender Seniors was providing them with their first training about LGBT issues.

“The staff aren’t always comfortable, and older participants don’t always approve of LGBT staff,” said Elinor Davis, communications specialist for the center.

The challenges for LGBT staff were highlighted at the training. Staff members recalled an openly gay nurse who was harassed by participants. Patients demanded that the nurse wear gloves when he touched their food trays, the staff said, because they feared that he was infected with HIV and could pass it onto them through causal contact. The nurse left the center after one day of work there.

Changing the institutional culture could prevent such incidents, which create a challenging atmosphere for LGBT seniors as well as the staff, Ashbrook said. Ashbrook began by the training by reviewing the history of discrimination against LGBTs. He showed clips from the documentary “On These Shoulders We Stand,” where interviewees recalled the institutional harassment from police that was an accepted part of life for gay people before the 1970s.

LGBT seniors remember this history all too well. “Attitudes were very negative,” Couvillion recalled of her childhood in Texas in the 1940s and 50s. “They used the word ‘faggot’ or ‘fairy.’ I didn’t hear the word lesbian until I was much older.”

Frank Howell, 73, said his parents “called in an whole army of psychologists” when they discovered he was gay in his teenage years in the 1950s. Howell’s parents went so far as to take him to the state mental hospital, but balked at having him committed. “We just said to hell with it and we went home and buried it” after the state hospital suggested a 30-day confinement, recalled Howell, who is active in Lavender Seniors.

Such a history is why institutions should make LGBT people feel explicitly welcome, Ashbrook said. “When our policies are don’t ask don’t tell, we are creating a stigmatized population,” Ashbrook said, “creating one big problem – seniors don’t get care.”

LGBT adults are more likely to delay seeking medical care, to seek medical care in emergency rooms, and to delay or not get needed prescription medicine, according to the SAGE report. They are more likely to have their emotional problems treated with medication, more likely to smoke, to have cancer and to have abused drugs or alcohol when they were younger, the report also noted.

Making LGBT people feel welcomed means making them feel visible in materials like brochures and intake forms, Ashbrook said. He also encouraged staff to actively seek out information about the family lives of center participants because LGBT seniors might be reluctant to volunteer information about their same-sex partners. Knowing about anti-discrimination laws and policy and making other seniors aware of these policies is also an essential step in creating a welcoming environment, Ashbrook said.

The world is changing at a rapid pace for LGBT people, Ashbrook said. When Lavender Seniors started 16 years ago, few organizations existed to advocate for older LGBT people. Now, he said, care providers are starting to expect LGBT clients. Ashbrook sees that kind of change as a sign of the increasing acceptance of LGBT people.

Couvillion, however, is more cautious. Discrimination still exists, even in places like San Francisco thought of as gay meccas, Couvillion said. LGBT seniors came to places like New Leaf, the center that closed in 2009, because they didn’t feel welcome in other senior centers, she said.

“LGBT organizations are being pushed to mainstream,” she said. “I’m not sure that it’s good to put gay seniors in mainstream care.”

Ashbrook thinks LGBT organizations will be increasingly called on to provide training, rather than direct assistance. The movements of the last 10-20 years have been successful, he said, in creating a new climate for LGBT seniors.