Unequal Policymaking on the Ground: Discrimination Toward LGBTQ+ Nursing Home Residents

Background and Purpose: Nursing homes (NHs) provide care to diverse older adults with disabilities and complex needs. Residents rely heavily on staff to help with critical daily activities, including eating, bathing, grooming, dressing, and socializing with other residents. While sparse research exists about services for LGBTQ+ older adults in NHs, existing research has documented numerous instances of discrimination and concerns about discrimination from current and prospective LGBTQ+ residents. Building on street-level bureaucracy theory, which focuses on how front-line workers implement policy, this study examines the following research question: how do NH staff understand and respond to discrimination toward LGBTQ+ residents?

Methods: This study employs a multi-method qualitative design with semi-structured staff interviews (n=90) (direct care/mid-management/upper-management), content analysis of facility policies on residents’ rights and discrimination, and participant observation of two facilities that had received the highest level of national certification for LGBTQ+ culturally responsive services (n=8 months) for a multi-layered cross-comparative in-depth case study. Data were 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—which highlight the complexity and messiness of staff understandings and responses to LGBTQ+ discrimination. While nearly all workers expressed universal concern for LGBTQ+ rights broadly and nondiscrimination protections for LGB residents specifically, direct care workers (e.g., certified nursing assistants, licensed practical nurses) and mid-managers (nurse managers) more readily accepted discrimination against transgender residents. Staff at all levels invoked facility policies regarding gender and bodily care to justify differential treatment, especially for transgender residents. While research in other contexts has found that visibly gender nonconforming persons experience heightened discrimination, here, staff justified discrimination against transgender residents when they were not visibly gender nonconforming as potentially violating other residents’ rights. Direct care workers and mid-managers framed their concerns around “trauma” that other residents with disabilities (especially residents with cognitive disabilities like dementia) may experience and concerns for their safety if/when learning that another resident’s gender was different from what they expected. Upper-level managers relied heavily on written policies, liability concerns, and facility reputation to support bodily autonomy/respect of transgender residents but also to justify exceptions based on trans visibility and perceptions of the gendered body.

Conclusions and Implications: Varying levels of organizational positioning (front-line/mid-level/upper-level management) shaped how workers understood and responded to discrimination toward LGBTQ+ residents in complex ways. Widespread staff justification of discrimination toward transgender residents presents a significant problem for NH facilities, their staff, and residents that must be addressed, particularly given recently growing attacks on transgender rights. Direct care staff and mid-managers also invoked concerns about cisgender residents’ disabilities to erase the need for anti-discrimination protections for transgender residents with disabilities. These findings present empirical data that researchers, practitioners, and policymakers can invoke in this heightened era of NH reform and equitable service delivery to identify sources for staff resistance to serving transgender NH residents and to develop policy and practice interventions.