When Paula Pilecki approached 26 assisted living facilities in Marin County about making their facilities more receptive to all sexual orientations, she was shocked at the response.

“Almost all of them said ‘There are no gay people in our facilities so we don’t have to do that,” sighs Pilecki, executive director of Spectrum LGBT Center, a San Rafael-based advocacy group.

For a generation of LGBT pioneers demanding equality to encourage a bold exit from the closet, the aging process has forced them into a startling new strategy.

Go back inside.

Or in the words of the 2011 documentary Gen Silent, “The generation that fought hardest to come out is going back in the closet.”

The challenges of aging are plentiful, yet the health effects on older LGBT adults can often be worse. Because these seniors tend to be single and childless – sometimes even being ostracized by their own families – they face more extreme social isolation, higher rates of depression, and may even suffer “resident on resident” abuse in long-term care facilities.

“There’s just so much fear,” said Cathy Koger, LGBT program coordinator for Peninsula Family Service headquartered in San Mateo.

In many ways, the generation that fought its way outside the closet has been victimized by simple demographics. While more than half of Americans support marriage equality, this largely reflects the voices of younger Americans and plummets for people over 65.

Because of the pervasive fear LGBT elders face as they grow older, aging professionals say helping them can be problematic.

“The biggest challenge is finding the hidden LGBT seniors,” said Koger.

In 2011, the National Senior Citizens Law Center reported that nearly 90% of polled LGBT adults predicted that staff at a long-term care facility would discriminate against an “out” LGBT elder. More than half predicted staff would abuse or neglect them.

The report is rife with tales of fear.

A San Francisco man reported that for 16 days staffers at a skilled nursing facility refused to shower his partner until he insisted on proper care; eventually, the man took his partner home where he showered and shaved him free of staff discrimination.

Vera and Zayda, partners for 58 years, never publicly revealed their relationship and so became “sisters” when Vera moved into assisted living. After she died, Zayda herself moved into a facility, but she was too fearful to publicly display pictures of her former lover.

Pilecki says that changing the culture of healthcare depends on the cooperation of healthcare professionals.

“It’s critically important that you are paving the way for your peers,” Pilecki said at a recent conference on the topic in Santa Clara. “You serve as role models for the rest of the country.”

She outlines the “best practices” needed for long-term care facilities – or any organization – to safely include LGBT seniors:

– Staff training on an annual basis to “elevate” the dialogue
– Forms that include a partner or RDP (registered domestic partner)
– A nondiscrimination statement that includes sexual orientation and gender
– Clear inclusion of LGBT members in activities and resources in both printed material and websites
– Programs, workshops and activities targeting the LGBT community
– Annual reports with photos of the LGBT community
– Posters with statements welcoming diversity

Well-known attorney, writer and LGBT activist Daniel Redman takes a more aggressive stance.

“The message you send as a higher up, as someone in charge of your facility is really important,” said Redman. He suggested this simple rule for long-term care managers: “If there’s any discrimination in this facility, you’re out.”

Michelle Alcedo describes one important success story. At a Bay Area long-term care facility, the LGBT seniors first held a clandestine meeting that four years later became completely public and accepted.

Alcedo, director of programs for Openhouse – which advocates for LGBT seniors in San Francisco – said having a staff member who is openly gay speeds the acceptance process.

Pilecki cited Kaiser Permanente in northern California as especially progressive in its acceptance of both LGBT employees and patients. Several years ago, her agency Spectrum also approached Marin General Hospital asking it to take a leadership role in the area.

Today, Marin General and Kaiser’s 36 facilities are both highlighted as leaders in the “LGBT Healthcare Equality” list, published by the Human Rights Campaign, along with 15 other California organizations, that also includes Scripps Health’s 27 San Diego facilities.

By striking down the Defense of Marriage Act in June, the U.S. Supreme Court confirmed the shifting mood of the country and increasing support for benefits like Social Security and Med-Cal (California’s version of Medicaid) to same sex married couples and RDPs.

“Everyone deserves to be safe,” said Redman.

“Defend them,” summarized Pilecki. “Protect them. Don’t set them up for failure. Set them up for success.”