Lenses for Inclusive Practice

This chapter discusses lenses to enhance your work with older adults who have experienced abuse or neglect. We outline the following briefly and provide links for further learning:

1. Trauma-Informed Practice
2. Cultural Humility and Safety
3. Age, Disability, and Dementia-Friendly Practice
4. Gender Lens
5. Sexual Orientation and Gender Identity Lens

1. Trauma-Informed Practice

What is Trauma?

Traumatic experiences are diverse. What unites them is that they overwhelm a person or community’s ability to cope.^[1] Trauma can result of experiences of violence, loss, injury, fear, neglect, or mistreatment. A traumatic event might be a uniquely personal event, such as a sexual assault, or a more collectively experienced natural disaster or war. Trauma can also be intergenerational and historical, such as Indigenous people’s experience of survival of residential schools. People can be traumatized by witnessing harm to others. Vicarious trauma, which is common among people who assist survivors of trauma, can occur as a result of hearing about other people’s traumatic experiences.

Trauma can have significant consequences on a person’s well-being, and can impact a person throughout the rest of their life. Trauma can cause changes to a person’s brain, and have longstanding physical, psychological, and emotional impacts.^[2] Post-traumatic stress disorder is one of the most commonly discussed health conditions that can result of trauma. However, trauma can also express itself in the body as, for example, compromised immune systems, chronic pain, and gastrointestinal problems.^[3] Ultimately, everyone’s response to trauma, and the events that can give rise to trauma, is unique, and circumstances surrounding the event, particularly access to emotional support, impact well-being following a trauma. As one toolkit explains:

• It is not the event that determines whether something is traumatic to someone, but the individual’s experience of the event and the meaning they make of it. Those who feel supported after the event (through family, friends, spiritual connections, etc.) and who had a chance to talk about and process the traumatic event are often able to integrate the experience into their lives, like any other experience.^[4]

Elder abuse and neglect can cause trauma. Survivors of elder abuse and neglect may have experienced other forms of trauma earlier in their lives. These earlier experiences will likely  impact their needs for support and assistance. Consequently, it is useful to bring a trauma-informed lens to elder abuse work.

What is Trauma-Informed Practice?

Trauma-Informed Practice (TIP) is a relational approach to the way a person does their work or provides services. TIP differs from trauma-specific services, which help people deal with the impacts of trauma, such as medical services or counselling.^[5] Any service—even if they are not directly helping with the impacts of trauma—can be provided in a trauma-informed manner.

TIP does not require the disclosure of a traumatic experience. To provide services in a trauma-informed manner, a person needs to:

• Understand what trauma is;
• Recognize the potential for trauma and triggers when they present;
• Acknowledge the impacts a traumatic experience has had on a person’s life; and
• Deliver services in a way that avoids doing further harm.

TIP benefits everyone, including the service provider—even those who have not experienced trauma.^[6]

It is important to be sensitive to how trauma can be experienced differently by people who are immigrants, living with disabilities, Indigenous, youth, 2SLGBTQ+, among others. The effects of historical and intergenerational trauma can be triggered by any additional traumas, including elder abuse.^[7] This aspect of practice is discussed in more detail in the section on cultural safety.

Principles of Trauma-Informed Practice

There are four key principles to trauma informed practice.^[8]

1. Have Trauma Awareness

To have a trauma-informed practice, you need to understand how common trauma is, and how trauma impacts a person, physically, mentally, and emotionally. An important part of TIP is to make sure your practice does not re-traumatize the individual, especially when your practice is dealing more directly with the trauma the person has experienced.^[9] Know all people will experience trauma in different ways and be impacted by trauma in unique ways. Every person will need different support.^[10]

2. Nurture an Environment of Safety and Trust

You must create a service environment where the person feels safe. Create a physical environment which feels safe and gives as much privacy as is possible. Create a social environment where the person feels safe to express their thoughts and feelings without fear of judgment.^[11]

You must support the client to have clear expectations of what services you can provide and what you cannot. You should explain the purpose of each meeting. This is especially important when you are giving legal or medical services and there are limits on your time. If you are not able to address all the person’s needs, refer the person to other services. Only refer to another agency if you have confidence in their ability to help. Creating predictable expectations fosters a sense of trust and safety.^[12]

Being a lawyer, doctor or other professional inherently comes with perceptions of power. Apply strategies to reduce this power dynamic, for example:

• Sit next to your client, not across from a table—but only if that arrangement feels safe to them;
• Dress in more casual attire; and
• Avoid bringing power-laden objects such as briefcases into the meeting space.^[13]

Limit the number of questions you ask in a row and try to pose more open-ended questions.^[14] Ensure your demeanor is as relaxed and informal as possible and offer a bit of yourself to the client in exchange for the information they are offering you.^[15]

3. Support Opportunities to Express Choice and Collaborate

A person who has gone through trauma often experiences a lack of control or powerlessness. When an older person is being abused, this feeling of powerlessness may be acute. TIP cultivates an environment where a survivor of abuse is given the ability to gain back their control, be included in making decisions about what they want to do, and regain a sense of dignity. The older person should be allowed to express what they want to do without fear of judgment.^[16]

The older person who has survived abuse or neglect should be choosing what happens next. If the person does not want to take an action you are suggesting, their autonomy must be respected—except in situations where they cannot make a decision for themselves due to a lack of mental capacity to make that decision. However, even if the person does not understand enough information to make decisions independently, for reasons such as serious disability, they should be included in decisions and their wishes should be respected. Further, often we can adapt the way we communicate, or provide other support that enables a person to understand enough information to make their own decisions. It is crucial that survivors of abuse be supported to feel control of the situation, as this helps them to feel hope.^[17]

4. Create Opportunities to Build Strength and Skills

In addition to inviting the person to have opportunities to regain a sense of control and dignity, an aspect of TIP is to support the person identify what strengths they have and develop new skills to help them cope with the trauma and gain resiliency skills.^[18]

Incorporating TIP into your Work

To develop a truly trauma-informed practice, the whole organization should embrace TIP principles, including organizational level policies and workplace culture. Each staff person and volunteer should understand trauma, and apply the principles of safety, trustworthiness, and empowering choice in all their interactions.^[19]

People who work directly with survivors of trauma should have self-awareness and watch for signs of vicarious trauma in themselves and others. When dealing with other people’s trauma on a regular basis, a person can feel burnout, fatigue, and other psychological and physical symptoms. Vicarious trauma is more than burnout; it involves feeling trauma themselves, including preoccupation with the experiences of their client. A practitioner should be attentive to their own well-being, alert for triggers and poor coping strategies, and make self-care plans.^[20] Organizational policies should support such self-care.

Resources

Trauma-Informed Practice Guide

This guide was written for professionals working with people living with mental health illnesses and substance use. This guide outlines what trauma is, what trauma-informed practice is, and how to implement it.

• bccewh.bc.ca/wp-content/uploads/2012/05/2013_TIP-Guide.pdf

Healing Families, Helping Systems: A Trauma-Informed Practice Guide for Working with Children, Youth, and Families

This guide was written for people working with children, youth, and families. It outlines the general principles of trauma-informed practice, and how it can be implemented in working with families, and within an organization.

• www2.gov.bc.ca/assets/gov/health/child-teen-mental-health/trauma-informed_practice_guide.pdf

A toolkit for navigating section 276 and 278 Criminal Code matters as complaint counsel in criminal proceedings

This publication is intended to help lawyers representing complainants in sexual assault criminal proceedings. This guide discusses trauma-informed practice and how to apply it to your practice as a lawyer. The principles can be applied to any legal practice.

• www.westcoastleaf.org/our-publications/complainant-counsel-toolkit/

The Trauma-Informed Lawyer Podcast

Hosted by Myrna McCallum, available on Spotify, Apple Podcasts or by visiting: https://traumainformedlegal.ca/

Golden Eagle Rising Society, Trauma-Informed Legal Practice Toolkit

This toolkit was created for lawyers, law students, law professors and others in the legal sector.

• www.goldeneaglerising.org/photos/trauma-informed-legal-practice-toolkit

2. Cultural Humility and Safety

Defining Terms

Elder abuse work should be approached with consideration of cultural humility and safety. In this section we briefly discuss the concepts of cultural humility, cultural safety, and cultural competency, including why some writers prefer some of these terms over others. The shared values underlying these concepts recognize the impact of racism and colonialism on access to services and supports, as was articulated in the 2020 In Plain Sight Report^[21] and Truth and Reconciliation Commission (TRC) calls to action.^[22] This approach to work also aligns with the rights espoused in the United Nations Declaration on the Rights of Indigenous People.^[23]

Cultural Humility

The First Nations Health Authority (FNHA) prefers the expression “cultural humility”, which they define as follows:

Cultural humility is a process of self-reflection to understand personal and systemic conditioned biases, and to develop and maintain respectful processes and relationships based on mutual trust. Cultural humility involves humbly acknowledging oneself as a life-long learner when it comes to understanding another’s experience.^[24]

Another source characterizes cultural humility as “a lifelong commitment to self-evaluation and critique, to redressing power imbalances . . . and to developing mutually beneficial and non-paternalistic partnerships with communities on behalf of individuals and defined populations.”^[25] Definitions of cultural humility emphasize not only life-long learning about other cultures and communities, and their histories and practices, but also self-reflection and self-critique. As Myrna McCallum and Gloria Ng explain in the WCL toolkit, “[c]ultural humility will encourage you to critically examine common unconscious biases which feed myths and stereotypes, question your sources of knowledge, and open your mind to new perspectives.”^[26]

Cultural Safety

Definitions of cultural safety and cultural humility are similar. A recent report by West Coast LEAF describes cultural safety in the context working with Indigenous people as follows:

Putting cultural safety into practice means recognizing that historical, economic, and social contexts, coupled with structural and interpersonal power imbalances, shape people’s outcomes and experiences with systems like the child welfare system. […] For Indigenous peoples, this means naming and recognizing the past and present role of colonialism.

Cultural safety also requires the people who hold positions of power in these systems to actively re­flect and challenge the “largely unconscious and unspoken, assumptions of power held” […] in their roles, including the policies and culture of their institutions and systems.^[27]

FNHA speaks of going beyond cultural awareness and sensitivity to create “an environment free of racism and discrimination.”^[28] As one writer explains, “[t]he outcome of the culturally safe practice is a two-way relationship built on respect and a bicultural exchange which aims for equality and shared responsibility.”^[29] Cultural safety can be used to describe systems, policies, practices, and power structures, as well as relationships.

What is considered safe care or services must be defined by the person or community accessing supports, not the practitioner.^[30] Some writers question the capacity to ensure another’s safety.

Previously, the term cultural competency was used to discuss the learning required to work ethically in intercultural setting characterized by power imbalances.^[31] Most writers now consider this terminology outdated. The FNHA stopped using the term “cultural competency” because it implies that a person can become competent in the cultures of other people through basic training.^[32]

Regardless of the varied terminology, the underlying themes that support best practice are:

• Committing to life-long learning regarding cultural difference;
• Engaging in self-reflection regarding identity, bias, and power;
• Identifying and challenging systemic and structural discrimination, colonization, and oppression; and
• Striving for relationships characterized by trust, respect, equity, and collaboration.

Applying a Cultural Safety Lens to Abuse and Violence

Applying a cultural safety lens to elder abuse means recognizing colonialism as a key determinant of health for older Indigenous peoples, and valuing Indigenous views of kinship structures. These kinship structures differ from colonial views of family and are important to wellness and self-determination for Indigenous people.^[33] Solutions should be local and come from the community, not be imposed by the state, which has been an agency of oppression.^[34]

The National Collaborating Centre for Aboriginal Health points out that discussions of family violence in Indigenous communities often place the blame within families and focus on gendered colonial stereotypes of men and women, and the heterosexual nuclear family unit. Such approaches do not account for the intersecting forms of violence experienced by Indigenous peoples, including colonialism, residential schools, and child apprehensions,^[35] or recognize resilience linked to cultural identity and community.

Access to Health Care and Dementia Services

Indigenous people face significant barriers in accessing health care and dementia services. The Report of the TRC describes how Indigenous people continue to experience racism in all aspects of health care.^[36] The barriers Indigenous peoples face accessing health and other services are largely a result of colonialism. Barriers include: ^[37]

• Racism, discrimination, and sexism;
• Cultural differences;
• Language and literacy issues;
• The reticence of western medicine practitioners to embrace traditional Indigenous healing practices;
• Poverty;
• Lack of health care system attention to spiritual well-being;
• Lack of services in rural areas, including clean tap water, internet, and long-term care facilities; and
• Jurisdictional barriers linked to the division of power and responsibility between the federal and provincial government in relation to health care for Indigenous peoples living off and on reserves.

As we point out in our 2019 report Conversations about Care, “[c]olonization, and the residential school system in particular, have both damaged people’s sense of autonomy, and generated trauma and fear, resulting sometimes in a lack of ability to engage with the system, and other times in a culture of assent.”^[38]

Responses to elder abuse must align with Indigenous perspectives on health and wellness, including Indigenous healing practices, and cultural understandings of dementia. Aging well might include a preference for informal care, shared caregiving, and aging within the community. Additionally, health and social services must combat the ongoing effects of colonialism, including power imbalances, and a lack of trust and respect in health care professionals and the government. An older person’s wishes and values must be respected, and care and services must be culturally safe.^[39]

Resources

National Collaboration Centre for Indigenous Health

This organization provides information, resources, and tools for improving the health of Indigenous peoples in Canada. They have many publications on cultural safety in health care.

• www.nccih.ca/en/

Provincial Health Services Authority in BC: San’yas Indigenous Cultural Safety Training

These courses, provided by the PHSA, cover cultural safety training for anyone working with Indigenous peoples. There are specific modules for people working in health care, mental health, and child welfare.

• www.sanyas.ca/

Communicating Effectively with Indigenous Clients by Lorna Fadden^[40]

This guide explains how Aboriginal English differs from Standard English, and how Aboriginal English can be misinterpreted by police and the legal system. It describes the biases and prejudices that are associated with speaking Aboriginal English. The guide provides practice suggestions on how lawyers can work with the legal system and their client to reduce prejudice and better represent their clients.

• www.aboriginallegal.ca/assets/als-communicating-w-indigenous-clients.pdf

First Nations Health Authority, “Our History, Our Health”

Provides information on the history of Indigenous peoples and colonialization.

• www.fnha.ca/wellness/our-history-our-health

3. Age, Disability, and Dementia-Friendly Practice

Applying an age, disability, and dementia-friendly approach to your work will help your clients to feel more comfortable and safe. These strategies will also support them to describe their experiences and communicate their needs and wishes. However, strategies of inclusion enhance accessibility for everyone.

Age, disability, and dementia-friendly practices cover a range of considerations and strategies, including:

1. Rejecting ageism and challenging stereotypes
2. Supporting the knowledge and expertise of staff and volunteers;
3. Modifying the built and designed environment;
4. Communicating for accessibility; and
5. Applying best practices when developing  written material.

In this section we talk about disability generally and also identify some practices that can be particularly helpful to people living with dementia. Ultimately, every person’s experience of disability is unique, and you will often need to get better acquainted with a person in order to appreciate how to provide meaningful support. Once older people sense a genuine interest in accommodating their needs and supporting their capacity, they may identify additional helpful strategies. Disclosure of needs related to disability requires a degree of trust.

Ageism and Stereotypes

There is significant stigma linked to aging, dementia, and disability. We must reject stereotypes and challenge negative assumptions about aging, disability, and dementia. Remember that older people contribute meaningfully to their communities, and have a wide range of abilities, roles, and interests. ^[41]

It is important to avoid ageist and ableist language. Words can have a harmful impact on people and contribute to stigma. The language around dementia is often very negative, focusing on loss of memory, identity, and ability. We should acknowledge loss without assuming that everyone living with dementia is “suffering from dementia”.

People living with dementia are often reduced to labels. Language should be people-first. Choose expressions such as “person living with dementia”.^[42] Being alert to the terms you are using as they can help to promote the dignity and autonomy of the older adults and reduce stigma.

When interacting with people who are living with dementia, keep in mind that the term “dementia” is not culturally universal. You many need to learn what term is appropriate for the cultural group you are interacting with to make sure you are using the respectful and appropriate language.[43]

Knowledge and Training

The opposite of stereotype is accurate information. Training is critical to helping staff and volunteers to understand the physical and mental changes associated with aging and living with a disability. Training topics could include:

• What is dementia?
• How does disability impact decision-making rights?
• How do ageism and ableism impact older people?
• How can we better serve older people and people living with disabilities.^[44]

The Built and Designed Environment

The built and designed environment must be accessible to your older client. This goes beyond physical accessibility for people with mobility issues, such as people using a wheelchair or walker. For a physical environment to be truly accessible, it must consider the wide array of abilities. Medical conditions and disabilities can impact mobility, vision, hearing, cognition, perception, and memory.^[45]

The building you work in should be constructed or adapted to be accessible for all people. For building accessibility, most people only think of accessibility for mobility challenges, such as having elevators, ramps, and doors. If you are involved in making a building accessible, you should also consider door handles instead of doorknobs and having parking close to the building entrance. The floors should be smooth and be made of a non-slippery material, and the building should be well-maintained.^[46] The World Health Organization’s Global Age-friendly Cities: A Guide contains many suggestions, including a short age-friendly outdoor spaces and buildings checklist.^[47]

The design of an office space is just as important as building design. Design should reflect the accessibility needs of people with disabilities that impact mobility as well as other issues such as cognitive changes. In designing an office space, you should:

• Follow a floor plan which is easily navigable;
• Ensure there is adequate space between pieces of furniture for a walker or wheelchair;
• Make sure rooms are well illuminated;
• Choose firm furniture with arms to make it easier for people to get in and out;
• Choose electronics with buttons that are sufficiently large for people with difficulty using their hands;
• Ensure both waiting rooms and meeting rooms address a variety of accessibility needs; and
• Include a quiet environment for waiting that suits people living with sensory or cognitive disabilities.^[48]

For people with cognitive impairments, the ability to way find through the building is important. You should consider how you can make your space easier to navigate. There are several things you could consider:

• Ensure your office is designed and furnished in a way that makes it easy to move through.
• Use signage which is readable from farther away (for example, use a large font).
• Post clear signage written in plain language.
• Place signs in locations which are readable from all heights, including when using a wheelchair.
• Ensure signs are well illuminated.^[49]

Meeting In-Person

Most older adults prefer to meet in person.

Choose a time of day which works best for your client. Many people living with dementia are better at understanding information at certain times of day. This is often earlier in the day, but depends on the person. If possible, schedule extra time for the meeting so you can give the client more time to process information and ask questions, and allow for breaks. Meet in a room which is calm, quiet, and has few distractions.^[50]

The following strategies can support communication and decision-making:

• Sit close enough that it is easy to hear you, subject to their comfort;
• Allow extra time to explain their story, process information, ask questions, and make decisions;
• Let your client have breaks, particularly if they seem tired;
• Provide plain language written material summarizing the main points you discussed;
• Break down the information into small, meaningful chunks;
• Be flexible and patient—rushing can create stress, which can undermine people’s ability to understand information; and
• Allow opportunities for follow-up questions.^[51]

Some people find it helpful to bring a trusted family or friend to support them with communication and decision-making. However, this requires vigilance for abusive or controlling inter-personal dynamics.^[52]

When speaking to a client (or writing), some strategies that can support comprehension are:

• Use plain language, including avoiding jargon, abbreviations and slang;
• Avoid sarcasm;
• Summarize what the client has told you and allow them to correct errors;
• Try different words if a person does not understand the information.
• Maintain eye contact;
• Allow the older person to see your mouth, in case they use lip-reading to support their hearing;
• Pay attention to non-verbal cues—gestures, body language, and actions can express feelings, priorities, and needs^[53]

If leaving voice-mail or talking on the phone, give the information slowly and in plain language. Always repeat numbers. Inquire whether a follow up email or letter would be helpful. Consider inviting the older person to repeat the information to check for understanding.

Don’t assume literacy in English or any other language. Summarize any written material you provide. Watch out for practices that assume literacy and provide a respectful way for older people to let you know if they require further explanations of material. Few people want to admit that they cannot read in English.

Print and Online Written Material

The following strategies will help you to develop written materials that are accessible and easy to understand:

• Write in plain language;
• Minimize technical or professional language, abbreviations, and jargon;
• Limit the number of key points you are making in each document;
• Use active voice;
• Put your key points first;
• Use short words, sentences, and paragraphs;
• Use real life examples, but use them sparingly;
• If you are drafting instructions, write them simply and clearly, and number the steps; and
• Use language that is dementia friendly and person centered.^[54]

When you are designing a document, thoughtful design can help make it more readable and understandable.

• Use a larger font, at least 12 point;
• Avoid italics, capitalizing full words, and underlining as much as possible;
• Use headings to break down the material into smaller sections;
• Include white space rather than trying to squish a lot of material into each page;
• Make paragraphs flush to the left and ragged on the right; and
• Use visuals to illustrate your points, but smartly and sparingly. Make these visuals simple and in plain language.^[55]

Your website should also be designed so that it is accessible for all. In addition to following the writing and design guidelines above, here are additional tips for making your website more accessible.

• Make the text easy to enlarge;
• Use high contrast colors;
• Make the information available in multiple formats, including text, audio, and visual;
• Choose colours that will produce a high contrast experience for people who are colour-blind; and
• Leave a lot of space around clickable targets.^[56]

Some people have disabilities that are immediately recognizable; others have disabilities that can be invisible. It is important not only to accommodate older people’s needs and abilities, but also to ask respectful questions about the kinds of support each unique person needs. An attitude of compassionate curiosity can open the door for a disclosure that helps you to better understand an older person’s needs.

Resources

World Health Organization

“Global Age-friendly Cities: A Guide” (2007)

• www.who.int/ageing/publications/Global_age_friendly_cities_Guide_English.pdf

Alzheimer Society of Canada

Meaningful Engagement of People with Dementia: A Resource Guide

• alzheimer.ca/sites/default/files/files/national/meaningful-engagement/meaningful-engagement-of-people-with-dementia.pdf

 Person-Centred Language Guidelines

• alzheimer.ca/sites/default/files/files/national/culture-change/person-centred-language-guidelines.pdf

4. Gender Lens

What is a Gender Lens?

When working with older people it is important to bring a gender lens to your work. Gender has a significant impact on life experiences which continues into later life. ^[57] Women face many barriers that impact health and vulnerability to abuse, and their experience of gender-related barriers is impacted by other aspects of identity and oppression. As we noted in our 2017 report on older women:

Older women are as diverse as the general population, and they described inequality, unmet needs and disadvantage related to their experience of aging in minority communities. Honouring older women’s experiences means applying to our work an intersectional lens that considers barriers uniquely experienced by some older women.^[58]

Bringing a gender lens to practice is not just about awareness of differential impacts; it means adopting a transformative approach that “addresses the causes of gender-based health inequalities and works to transform harmful gender roles, norms, and relations”.^[59] This means addressing a woman’s unique experiences while recognizing and working to challenge systemic factors.

Barriers to Health and Well-Being

Women experience many barriers throughout life that can impact health and well-being and can lead to increased vulnerability in later life, such as:

1. Reduced income and savings: Women make less money than men on average. Reasons for this lack of pay equity include women being more likely to work in part-time employment, precarious employment, non-unionized work, and female-dominated occupations which are undervalued such as child care. These jobs typically have fewer benefits and are less likely to have pensions. Additionally, women take on the majority of the caregiving and household tasks, which impacts their income-earning potential. These factors mean women are more likely to be living in poverty in later life, making them more vulnerable to abuse. Women may have more difficulty leaving an abusive relationship because they are more likely to be living in poverty, relying on a spouse for income or pension, or have precarious ties to employment throughout their lives.^[60]
2. Intersecting forms of discrimination: Sexism, racism, and ableism cause harm and limit access to services. Intersectionality is when a person experiences multiple forms of discrimination which, together, create unique barriers to accessing support and assistance. For example, an older immigrant woman may face sexism, ageism, and racism, and the woman faces a unique discrimination due to the intersecting types of discrimination. A woman’s experiences cannot be separated into discrete forms of discrimination; they combine in unique ways and create unique experiences for each person which cannot be truly disentangled. In considering a gender lens, you must also consider the impact of being older, disabled, indigenous, an immigrant, a minority, LBGTQ, among others, and how this intersectionality has impacted a woman’s experiences and the barriers she faces.^[61]

Abuse and Violence

Women are more vulnerable to abuse and violence. Age and frailty compound vulnerability. A woman who is older may be less physically able to respond to abuse and living with multiple chronic health conditions. Older women often receive or provide care, which can impact their ability to leave an abusive situation. Atira Women’s Resource Society identifies 13 challenges experienced by older women survivors of violence.^[62] They include:

• Leaving an abusive situation poses a risk of loss of the ability to live independently forever;
• Speaking out regarding abuse raises fears of loss of decision-making autonomy;
• Breaking ties with an abuser can give rise to increasing financial insecurity, particular if a woman is financially dependent on abusive partner or financial decision-making (attorney under a power of attorney; property guardian);
• Resisting abusive family dynamics can put at risk important relationships, such as contact with children and grand-children;
• Seeking help risks consequences for the people they love, particularly when a dependent adult child is breaking the law; and
• Moving to a transition house raises questions about how their health needs will be addressed in a new environment or community.

Some groups of women have greater vulnerability to abuse, for example:

1. Indigenous women live with historical trauma and the past and current effects of colonialism, including residential schools, foster care and family separation, and the ongoing stories of missing and murdered women from their communities.
2. Immigrant women may face barriers due to their immigration status, language, literacy, and isolation.^[63]

Caregiving Relationships

Caregiving has a significant impact on the lives of most older women, and so responses to abuse of women who are older must be attentive to caregiving responsibilities and valued relationships. A woman may not be comfortable with an intervention that she perceives as harming a relationship or person who matters to her. She may value the relationship over her own physical or emotional well-being. Some women may fear upsetting the family network or losing contact with a grandchild. Immigrant women may believe they are reliant on a sponsoring relative for their continuing residency status in Canada. She may fear bringing shame to her family.

Isolation is linked to poor quality of life in old age and a risk factor for earlier mortality, so maintaining family connections and relationships can be a source of well-being and healing.^[64] Elder abuse responses must respect a woman’s right to make her own relationship decisions while offering safety planning options.

Access to Justice

Older women face barriers to accessing justice when they would like a legal remedy for the abuse.^[65] Research has shown many women do not know their legal rights and options. Many older women cannot afford to pay a lawyer to take legal action and are unaware of what pro-bono legal and advocacy services are available. There is a lack of language interpretation for legal services, creating a further barrier for immigrant older women. If an older woman wishes to leave an abusive situation, there are few transition houses specifically for older women.^[66]

Resources

Status of Women Canada

Gender-Based Analysis Plus course

• cfc-swc.gc.ca/gba-acs/course-cours-en.html

Atira

Promising Practices Across Canada For Housing Women Who Are Older And Fleeing Abuse (2015)

• atira.bc.ca/wp-content/uploads/Promising-Practices-for-Housing-Women-who-are-Older.pdf

L Greaves et al.

Integrating Sex and Gender Informed Evidence into Your Practices: Ten Key Questions on Sex, Gender & Substance Use

• bccewh.bc.ca/featured-projects/integrating-and-measuring-the-effect-of-sex-gender-and-gender-transformative-approaches-to-substance-use

5. Sexual Orientation & Gender Identity Lens

The lifetime of barriers faced by 2SLGBTQ+ peoples do not disappear when that person reaches older age, and the discrimination they face can be compounded or intersect with the discrimination and barriers related to aging. Your practice should consider the needs of 2SLGBTQ+ older adults, and work to counteract the stigma, discrimination, and barriers.^[67]

Barriers to Health and Well-Being

Older 2SLGBTQ+ adults face stigma and discrimination. They are particularly vulnerable to having mental and physical health challenges as a lifetime of stigma and discrimination can lead to chronic stress and barriers to medical care. 2SLGBTQ+ adults face barriers in health care, employment, housing, and other areas, and are more likely to experience social isolation. They are less likely to be married or have children, so they rely more on chosen family and friends for support. This means that in later life, they are less likely to have family members available as informal caregivers and supporters. There are not many services available for seniors which are affirming of gender identity or sexual orientation. Transgender older adults face the greatest stigma, discrimination, and barriers, and experience a great deal of abuse, including within the health care system.^[68]

Barriers in Health Care and Long-Term Care

2SLGBTQ+ older adults face numerous barriers in receiving respectful and high-quality health care throughout life. These barriers are significant in long-term care, where there is a lack of privacy, and most care homes are heteronormative and not accepting of the needs of a diverse range of residents. 2SLGBTQ+ residents experience discrimination, abuse, and neglect from residents, staff, and health care professionals. Transgender older adults are often not allowed to wear the clothing that matches their gender identity, use the correct washrooms, or be identified by the pronouns or names they use. If the person in long-term care is not capable of making health care or personal decisions, their decision-maker may not respect their gender identity.^[69]

Applying a Lens to your Practice

To bring an inclusive lens to your practice, you should consider the needs of 2SLGBTQ+ older adults. This includes educating yourself and your staff on the barriers faced by 2SLGBTQ+ older adults and how you can better assist them, including using the proper pronouns and using gender inclusive language and imagery. Your policies should go beyond being neutral to gender identity and sexual orientation. Your policies should directly seek to combat stigma, discrimination, and lack of knowledge.^[70]

Here are some basic practices that can support trans inclusion in particular:

• Ask what pronoun they use to refer to themselves, and use them.
• Do your best to get the pronouns right. If you make a mistake—apologize, work toward doing better, and move on. 
• Don’t assume pronouns tell a person’s full story.
• Respect people’s boundaries about disclosure of gender identity and sexual orientation. Take your lead from them, and avoid outing anyone.
• Use chosen names. If people have changed their names to reflect their gender identity, do not use their deadname.
• Apply trauma-informed practice. Many trans people experience violence and abuse long before they experience elder abuse or neglect.

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Endnotes

[1] Myrna McCallum & Gloria Ng, “A toolkit for navigating section 276 and 278 Criminal Code matters as complainant counsel in criminal proceedings” West Coast LEAF (April 2020) at 6, online: <www.westcoastleaf.org/our-publications/complainant-counsel-toolkit/> [WCL Toolkit]; Emily Arthus et al, Trauma-Informed Practice Guide (May 2013) at 6, online: BC Provincial Mental Health and Substance Use Planning Council bccewh.bc.ca/wp-content/uploads/2012/05/2013_TIP-Guide.pdf [Trauma-Informed Practice Guide].

[2] Nancy Poole, Christina Talbot, & Tasnim Nathoo, “Healing Families, Helping Systems: A Trauma-Informed Practice Guide for Working with Children, Youth and Families” BC Ministry of Children and Family Development (January 2017) at 4, online: <www2.gov.bc.ca/assets/gov/health/child-teen-mental-health/trauma-informed_practice_guide.pdf> [BC Ministry of Children TIP Guide]; “SAMHSA’s Concept of Trauma and Guidance for a Trauma-Informed Approach” Substance Abuse and Mental Health Services Administration (2014), online: <store.samhsa.gov/product/SAMHSA-s-Concept-of-Trauma-and-Guidance-for-a-Trauma-Informed-Approach/SMA14-4884> [SAMHSA TIP].

[3] Trauma-Informed Practice Guide, supra note 1, at 7;

[4] Klinic Community Health Centre, “Trauma-informed: The Trauma Toolkit” (2013) at 9, online: https://trauma-informed.ca/wp-content/uploads/2013/10/Trauma-informed_Toolkit.pdf.

[5] Trauma-Informed Practice Guide, supra note 1 at 13.

[6] Trauma-Informed Practice Guide, ibid; Elba Bendo et al, “Pathways In A Forest: Indigenous Guidance on Prevention-Based Child Welfare” West Coast LEAF (September 2019), online: <www.westcoastleaf.org/our-publications/pathways-in-a-forest/> [WCL Pathways]; SAMHSA TIP, supra note 2.

[7] Trauma-Informed Practice Guide, ibid; WCL Toolkit, supra note 1.

[8] Adapted from Trauma-Informed Practice Guide, ibid, at 13-14.

[9] Trauma-Informed Practice Guide, ibid, at 12; BC Ministry of Children TIP, supra note 2, at 9.

[10] Trauma-Informed Practice Guide, ibid; WCL Toolkit, supra note 1.

[11] Trauma-Informed Practice Guide, ibid; WCL Toolkit, ibid; BC Ministry of Children TIP Guide, supra note 2; WCL Pathways, supra note 6; SAMHA TIP, supra note 2.

[12] Ibid.

[13] These and other suggestions can be found in WCL Toolkit, ibid.

[14] WCL Toolkit, ibid at 18.

[15] Trauma-Informed Practice Guide, supra note 1; WCL Toolkit, ibid.

[16] Trauma-Informed Practice Guide, ibid; WCL Toolkit, ibid; BC Ministry of Children TIP Guide, supra note 2; WCL Pathways, supra note 1; SAMHSA TIP, supra note 2.

[17] Ibid.

[18] Trauma-Informed Practice Guide, ibid; WCL Pathways, ibid; BC Ministry of Children TIP Guide, ibid.

[19] Trauma-Informed Practice Guide, ibid; BC Ministry of Children TIP Guide, ibid; SAMHSA TIP, supra note 2.

[20] Trauma-Informed Practice Guide, ibid; WCL Toolkit, supra note 1.

[21] Mary Ellen Turpel-Lafond, In Plain Sight: Addressing Indigenous-Specific Racism and Discrimination in B.C. Health Care (2020), online: <www.engage.gov.bc.ca/addressingracism/>.

[22] Truth and Reconciliation Commission of Canada, Call to Action (Winnipeg: Truth and Reconciliation Commission of Canada) [TRC].

[23] Convention on the Rights of Indigenous Peoples, UNAG online: NEEDS PROPER CITATIONwww.un.org/development/desa/indigenouspeoples/declaration-on-the-rights-of-indigenous-peoples.html.

[24] First Nations Health Authority, #itstartswithme: FNHA Policy Statement of Cultural Safety and Cultural Humility, at 11, online: www.fnha.ca/documents/fnha-policy-statement-cultural-safety-and-humility.pdf [#itstartswithme].

[25] Ella Green-Moton and Meredith Minkler, “Cultural competence or Cultural Humility? Moving Beyond the Debate” (2020) 12:1 Health Promotion Practice 142.

[26] Supra note 1.

[27] WCL Pathways, supra note 6 at 16-17, relying on the work of: Cheryl Ward, Chelsey Branch & Alycia Fridkin, “What is Indigenous Cultural Safety — and Why Should I Care About It?” (2016) 11:4 Visions Journal 29; Elaine Papps & Irihapeti Ramsden, “Cultural safety in nursing: The New Zealand experience” (1996) International Journal for Quality in Health Care, 8, 491; Irihapeti Ramsden, “ Kawa Whakaruruhau: Cultural safety in nursing education in Aotearoa” (1993), Wellington; Vicki Smye & Annette J. Brown, ‘Cultural safety’ and the analysis of health policy affecting aboriginal people (2002) Nurse Researcher, 9:3, 42 as cited in Alison J Gerlach, “A Critical Re­action on the Concept of Cultural Safety” (2012) 79:3 Can J Occup Ther 151 at 152.

[28]  #itstartswithme, supra note 25 at 10.

[29] Simon Brascoupé, “Cultural Safety: Exploring the Applicability of the Concept of Cultural Safety to Aboriginal Health and Community Wellness,” (Nov 2009) Journal de la santé autochtone 6 at 15.

[30] WCL Pathways, supra note 6; Aboriginal Nurses Association of Canada cited in Lauren Baba, Cultural safety in First Nations, Inuit and Metis public health: Environmental scan of cultural competency and safety in education, training and health services (Prince George, BC: National Collaborating Centre for Aboriginal Health, 2013), online: <www.nccih.ca/495/Cultural_Safety_in_First_Nations,_Inuit_and_M%C3%A9tis_Public_Health.nccih?id=88> [NCCAH, Cultural Safety].

[31] See for example, Moton and Minkler, supra note 26 at 142; Hieu Van Ngo, Cultural Competence: A Guide to Organizational Change. Prepared for Citizenship and Immigration Canada (2010), online: Government of Alberta albertahumanrights.ab.ca/Documents/CulturalCompetencyGuide.pdf; NCCAH, Cultural Safety, ibid; National Centre for Cultural Competence, “What is cultural competence?” online: www.sydney.edu.au/nccc/about-us/what-is-cultural-competence.html (last accessed 8 June 2020).

[32] #itstartswithme, supra note 25, at 11.

[33] NCCAH Family Violence, ibid.

[34] Cindy Holmes & Sarah Hunt, Indigenous communities and family violence: Changing the conversation (Prince George, BC: National Collaborating Centre for Aboriginal Health, 2017), online: <www.nccih.ca/495/Indigenous_Communities_and_Family_Violence__Changing_the_conversation.nccih?id=202> [NCCAH Family Violence]. Ibid.

[35] Ibid.

[36] TRC, supra note 23 at 23-24.

[37] Regine Halseth, Overcoming barriers to culturally safe and appropriate dementia care services and supports for Indigenous peoples in Canada (Prince George, BC: National Collaborating Centre for Aboriginal Health, 2018), online: <www.nccih.ca/495/Overcoming_barriers_to_culturally_safe_and_appropriate_dementia_care_services_aan_supports_for_Indigenous_peoples_in_Canada.nccih?id=243> [NCCAH Dementia Care].

[38] CCEL, Conversations about Care: The Law and Practice of Health Care Consent for People living with Dementia, CCEL Report 10 (2019) at 229.

[39] NCCAH Dementia Care, supra note 38.

[40] Lorna Fadden, Communicating Effectively with Indigenous Clients (Toronto: Aboriginal Legal Services), online: <www.aboriginallegal.ca/assets/als-communicating-w-indigenous-clients.pdf>.

[41] Public Health Agency of Canada, Age-Friendly Communication – Facts, Tips and Ideas, Catalogue No HP 25-11/2010E-PDF (Ottawa: Public Health Agency of Canada, 2010), online: <www.canada.ca/en/public-health/services/health-promotion/aging-seniors/publications/publications-general-public/friendly-communication-facts-tips-ideas.html> [PHAC].

[42] Alzheimer Society of Canada, “Person-Centred Language Guidelines” (2017), online: <alzheimer.ca/sites/default/files/files/national/culture-change/person-centred-language-guidelines.pdf> [AS Language].

[43] AS Language, ibid.

[44] Kevin Smith, “Elder Law Toolkit” (Paper delivered at the Canadian Elder law Conference, Vancouver, 15 November 2019) [unpublished].

[45] Smith, ibid.

[46] Smith, ibid; World Health Organization, “Global Age-friendly Cities: A Guide” (2007), online: <www.who.int/ageing/publications/Global_age_friendly_cities_Guide_English.pdf > [WHO Age-Friendly]

[47] WHO Age-Friendly, ibid.

[48] Smith, ibid; WHO Age-Friendly, ibid; PHAC, supra note 42.

[49] Ibid.

[50] WHO Age-Friendly, ibid; PHAC, supra note 42; Alzheimer Society of Canada, “First Responder Handbook” (2015), online: <alzheimer.ca/sites/default/files/files/national/first-responders/first_responder_handbook_e.pdf> [AS Handbook];

[51] Ibid.

[52] See for example, BCLI, Undue Influence Recognition/ Prevention: A Reference Aid, online: http://www.bcli.org/wordpress/wp-content/uploads/2015/10/undue-influence_guide_tool.pdf.

[53] WHO Age-Friendly, ibid; PHAC, ibid; AS Handbook, supra note 51; AS Language, supra note 43.

[54] WHO Age-Friendly, ibid; PHAC, ibid; AS Language, ibid; Smith, supra note 45; Alzheimer Society of Canada, “Meaningful Engagement of People with Dementia: A Resource Guide” (2015), online: <alzheimer.ca/sites/default/files/files/national/meaningful-engagement/meaningful-engagement-of-people-with-dementia.pdf> [AS Engagement].

[55] WHO Age-Friendly, ibid; PHAC, ibid; AS Engagement, ibid; Smith, ibid.

[56] Smith, ibid.

[57] Canadian Centre for Elder Law, We are Not all the Same: Key Law, Policy and Practice Strategies for Improving the Lives of Older Women in the Lower Mainland, Report 8 (Vancouver: BC Law Institute, 2017), online: <www.bcli.org/publication/we-are-not-all-the-same> [CCEL Dialogue Project].

[58] Ibid, from Executive Summary.

[59] L Greaves et al., Integrating Sex and Gender Informed Evidence into Your Practices: Ten Key Questions on Sex, Gender & Substance Use (Vancouver: Centre of Excellence for Women’s Health, 2020) at 15, online: <bccewh.bc.ca/featured-projects/integrating-and-measuring-the-effect-of-sex-gender-and-gender-transformative-approaches-to-substance-use/>.

[60] CCEL Dialogue Project, supra note 58.

[61] Ibid.

[62] Atira Women’s Resource Society, “Promising Practices Across Canada For Housing Women Who Are Older And Fleeing Abuse” (2015), online: <atira.bc.ca/wp-content/uploads/Promising-Practices-for-Housing-Women-who-are-Older.pdf> {Atira].

[63] CCEL Dialogue Project, supra note 58.

[64] British Columbia, “Understanding and Responding to Elder Abuse” (Vancouver: November 2014) at 6, online: <www2.gov.bc.ca/assets/gov/law-crime-and-justice/criminal-justice/victims-of-crime/vs-info-for-professionals/info-resources/elder-abuse.pdf> [BC, Understanding Elder Abuse]; Canada, National Seniors Council, Report on the Social Isolation of Seniors, Catalogue No Em12-6/2014E-PDF (Ottawa: National Seniors Council, October 2014) at 7-8, online: <www.canada.ca/en/national-seniors-council/programs/publications-reports/2014/social-isolation-seniors/page01.html>.

[65] CCEL Dialogue Project, supra note 58.

[66] CCEL Dialogue Project, ibid; Atira, supra note 63.

[67] Alisa Grigorovich, “Older LGBTQ adults and inclusive research and design of services and technologies” (Webinar delivered for AGE WELL NCE, 7 May 2020) [unpublished]; A.J. Lowik, “Contextualizing Abuse and Neglect Among Transgender Older Adults” (Webinar delivered for BC Association of Community Response Networks, 18 February 2020), online: <bccrns.ca/provincial-learning-event/> [unpublished].

[68] Ibid.

[69] Ibid.

[70] Ibid.