A few years ago, Rabbi Sara Paasche-Orlow was spending time with, and comforting, a friend who was dying of cancer. Along with all of the usual difficulties and complexities of end-of-life care, there was an additional concern for the friend. Despite being married to her lesbian partner, she didn’t feel like she could be open about it with the hospice worker.

“When hospice came in, I couldn’t stay next to her in the bed,” the friend told Paasche-Orlow, “I had to separate myself. I had to pretend I was something I wasn’t.”

Although Paasche-Orlow never learned the exact reason for the discomfort, her friend’s reluctance to reveal her sexual identity is widespread among non-heterosexual senior citizens in long-term care. A recent national survey of this population by the National Resource Center on LGBT Aging—which provides support and services to lesbian, gay, bisexual, and transgender elders—found that the respondents were frequently mistreated by care-center staff, including cases of verbal and physical harassment, as well as refusal of basic services. Some respondents reported being prayed for and warned they might “go to hell” for their sexual orientation or gender identity.

In Paasche-Orlow’s case, her friend’s statement haunted her so much that she launched a series of programs to help long-term-care residents and staff members deal with the barriers to care for LGBT seniors—and the health disparities that may result. Her aim is to guard these seniors from being forced back into the closet as they age.

“I couldn’t go back and change it for my friend, but we could start thinking much more proactively about this,” Paasche-Orlow said.

With gay marriage legal nationwide and organizations such as The LGBT Aging Project, a nonprofit that advocates for equal access to life-prolonging services, in operation for more than a decade, Americans should theoretically be living in a golden age for LGBT seniors. Yet the LGBT Aging Center’s survey found that only 22 percent of respondents felt they could be open about their sexual identities with health-care staff. Almost 90 percent predicted that staff members would discriminate based on their sexual orientations or gender identities. And 43 percent reported instances of mistreatment. Meanwhile, few elder-care providers have services directly targeted at helping them.

To deal with this problem, Paasche-Orlow decided to integrate LGBT-focused programs into her work as the director of Religious and Chaplaincy Services at Hebrew SeniorLife, a Harvard-affiliated organization that provides health care to more than 3,000 Boston-area elders. Paasche-Orlow’s programs range from sensitivity training to bringing in LGBT youth from local high schools to spend time with residents.

Although the residents are grateful for the programs, community members such as Mimi Katz acknowledge there’s still a long way to go. Katz, who came out as a lesbian in 1968, lives in a Hebrew SeniorLife facility in Brookline, Massachusetts. She says that one of the major problems today’s elders must contend with is unspoken homophobia. “In the more liberal Brookline kind of setting, nobody is going to be overtly homophobic,” she said. “It’s the same thing as racism. Nobody wants to think of themselves as a racist, but then somebody will say, of one of the black aides, ‘Oh, she’s so well-spoken.’ That kind of thing. Or somebody will say to me, about a woman whose child is gay, ‘Oh, the heartache she goes through.’”

Katz can’t help but be exasperated when these moments occur. “It’s like, ‘Hello!’” she said.

In terms of concrete activities offered by Hebrew SeniorLife, Katz was especially appreciative of her community’s screening of the 2010 documentary Gen Silent, which follows the stories of six LGBT senior citizens who must navigate the intricacies of a long-term care system that is unsupportive of LGBT individuals. But Katz believes what will ultimately benefit LGBT elders the most is staff training. “The only way to deal with it is by example,” Katz said.

According to Paasche-Orlow, most care providers and staff members would never knowingly discriminate against someone because of their sexual identity. But that doesn’t mean LGBT seniors feel like they can be themselves. There’s a difference, Paasche-Orlow acknowledged, between wanting to provide a safe environment and actually providing one. “What we know about the whole field of cultural competency is that, unless I really understand the person I’m serving, I’m going to provide them with what I personally would like, or what I think they need.”

For example, a well-meaning staff member might accidentally make an LGBT elder uncomfortable by asking certain questions—about spouses, children, or grandchildren—that assume the resident is heterosexual. “Instead, we encourage people to ask, ‘Who are the important people in your life?’” Paasche-Orlow said.

Paasche-Orlow’s work does seem to be influencing the Hebrew SeniorLife staff. “The series of LGBT trainings that we went through opened my eyes to the experiences and needs of the transgender community,” said Marie Albert Parent Daniel, a nurse at Boston’s Hebrew Rehabilitation Center who now considers herself an LGBT advocate. “The trainings also gave me language and terminology to help support and educate staff members who may be struggling with how to best care for LGBT residents. … It hurts my heart to see that there are elderly people who are afraid to share their stories and live openly.”

Although an increasing number of long-term care facilities throughout the country are doing more to reach out to LGBT seniors, significant progress is needed before this becomes a widespread practice, said Tari Hanneman, director of the Health Equality Project at the HRC Foundation. “Unfortunately, because so many LGBTQ elders are not comfortable being out, aging service providers often do not realize that they are serving this population and do not recognize that they may need to change their policies and practices to become more LGBTQ-inclusive.”