Pray the Gay Away: Long-Term Care Facility Staff and Organizational Responses to Religious and Moral Exemptions for Serving LGBTQ Residents

Background and Purpose: Almost immediately after the U.S. Supreme Court mandated marriage equality, a surge in policies carved out exceptions to LGBTQ rights for religious or moral reasons. Community reports and emerging research suggests that health care providers, including long-term care workers, are increasingly invoking religious and moral legal exemptions to deny care to LGBTQ older adults. Building on street-level-bureaucracy theory (Lipsky, 2010), which focuses on how front-line workers implement policy, this study asks the following research questions: (1) How do long-term care facility workers, managers, and administrators respond when staff, visitors, or residents challenge LGBTQ rights based on religious or moral exemptions; and (2) How do processes and understandings for resolving religious and moral exemptions differ between a religious and secular-based facility?

Methods: This study employs a novel advanced multi-method qualitative design with semi-structured staff interviews (n=90) (direct care, mid-level professional, top management), content analysis of long-term care facility policies (n=75), and participant observation of two facilities for a multi-layered cross-comparative in-depth case study to inform social work research at micro and organizational levels. Given different guiding principles, missions, and emerging research on secular and religious facilities, this study uses interview data (n=80), Medicaid data, participant observation, and facility policies for in-depth case comparisons between a secular and religious-based facility. This study includes additional interviews (n=10) with top management at other facilities, given few workers at this level at any facility. Data was analyzed with three rounds of coding in Dedoose for open, focused, and thematic coding. Extensive analytical memo writing enabled conceptual development, abstraction, and data interpretation.

Results: Data analysis revealed three key themes: visibility, bodily autonomy/respect, and safety. While nearly all workers expressed universal concern for LGBTQ rights, direct care workers and managers wavered when religious or moral exemptions arose in serving transgender residents. Workers at all levels invoked facility policies regarding gender and bodily care to justify differential treatment. While religion framed organizational principles and goals at only the religious-based facility, front-line staff at both secular and religious-based facilities drew heavily on individual religious beliefs to both support inclusive care (e.g. as a Christian value) and to justify refusal of care to LGBTQ residents (e.g. justifying it as a sin). Mid-level professionals and upper-level managers at the religious facility relied more on organizational religious principles than individual religious beliefs, whereas mid-level professionals and upper-level managers rarely invoked religion at the secular facility. Instead, managers at the secular facility relied on larger, general concepts of human rights to understand and respond to these exemptions.

Conclusions and Implications: Religious and moral exemptions impact LGBTQ resident care and relationships among residents, staff, and families. Varying levels of staff employment (front-line, mid-level/upper-level management) and facility religious-affiliation shaped how workers resolve religious and moral exemptions. This research provides policymakers and practitioners with new data about how staff resolve these exemptions, which can facilitate stronger policies for LGBTQ residents, staff, and visiting families. These findings can guide social workers informing long-term care policy reform, particularly in the wake of COVID-19.