Two of the biggest cultural challenges in Western society remain age and sexuality. Despite significant developments in recent times, including important protective legislation for both groups, older people and LGBT (lesbian, gay, bisexual and transgender) people remain social groups that often attract ambivalent attention. As with other areas of cultural tension, such as racism, both ageism and homophobia can be seen as attitudes that contain powerful fears beneath the surface hatred. For individuals and society as a whole, such feelings can also be seen as expressions of what we fear or resist within ourselves.

Freud long ago suggested that we are all essentially bisexual, and thus promoted a sense of the potential within us for sexual desire, if not activity, of a diverse nature, rather than having a single fixed sexual standpoint or object choice.¹ However, while the majority remain attached to one gender choice for both sexual activity and relationship, the situation in regard to ageing is more confrontational, as sooner or later we have to face the biological fact of getting older and we thus have to move through different stages of life and experience as time passes. This, I suggest, is a significant developmental challenge, and one that we tend to struggle with.

It is, for example, one of the reasons why counselling and psychotherapy with older adults has tended to remain in the shadows. Even Freud was less amenable to the challenges of ageing than of sexuality, as illustrated in his famous comment that once one has reached 50 one is really too old for analysis² – written at the age of 49! Ageing remains a powerful process for us, and therapeutic work with older adults can still be a difficult task for even experienced therapists to take on, confronting us, as it does, with our own ageing and mortality.^{3, 4} Putting age and LGBT together can have an even more powerful impact, and in this article I want to put forward some thoughts about the particular challenges of working therapeutically with older LGBT men and women, for both gay, lesbian and heterosexual practitioners.

Ageing and LGBT
The challenges of ageing that we all face may be significantly exacerbated if we are gay or lesbian (I shall concentrate on gay men and lesbians, while acknowledging that bisexuals and particularly transgender people face both similar and different challenges). They are, for example, twice as likely to be single and to live alone than their heterosexual peers, and four times as likely to have no children (often a significant element of comfort, care and dependency in later life for older parents).⁵ Equally, they are much less likely to access health and social care services for fear of discrimination, and may feel a need to hide their sexual orientation.⁶

The loss of full health and mobility and consequent diminishing of independence can be painful processes to encounter as we age, together with the many psychological losses that are an inevitable part of growing older (such as bereavements, loss of professional roles, and so on). The isolation and invisibility that can be a part of the experience of ageing for LGBT people can serve to make these experiences more painful, while also leaving the individual without the practical and emotional support that could serve to soften the blow. However, experience of homophobic discrimination in the past may not only lead to fears now as an older person, but may actually be repeated through unchallenged attitudes on the part of workers who are uncomfortable with looking after gay men or lesbians.6

We need to understand the histories of older LGBT people in order to offer appropriately developed and sensitive services, based on a fundamental principle: the avoidance of the assumption of heterosexuality. This assumption is, I would suggest, largely practised throughout health and social care systems, as it tends to be in society at large, and indeed, in terms of older people, may be practised by younger gay and lesbian people themselves; it is endemic in our cultural thinking and can be exceedingly difficult to grow out of.

History
Gay men and lesbians alive today at age 65 and over have lived through significant and often troubling times, not least – especially for men – the earlier illegal nature of their sexual life before the Wolfenden Report of 1967 legalised male homosexuality in the private sphere. This and subsequent socio-cultural developments, while clearly progressive, can seem a mixed blessing to some older gay and lesbian people: the loss of a closed society may actually be difficult, the loss of secrecy and even of risk, and the increasingly open arena characterised by equality legislation and particularly civil partnerships can seem irrelevant to those who have grown up in a very different world and forged selves and relationships in their own way without public approval or even knowledge. The youth-oriented tendencies of society generally, and equally of the gay and lesbian communities, can leave older LGBT people feeling ignored or even denigrated, subject potentially to the double discrimination of both homophobia and ageism. Relational challenges may be in terms of a long established partnership, an intergenerational partnership with a significant age difference, or the experience of ageing alone; and if professional care is needed, there are the many questions raised by this relational context, as touched on above.

It is also important to remember that this generation lived through the intense early years of HIV and AIDS in the UK – with all the losses those years brought with them. These losses, and equally the experience of living on for those with HIV who have responded well to newer treatments, are further intrinsic elements of this generational experience. As older people are not generally seen as sexual, or even necessarily permitted to be so by society, and as gay and lesbian people tend to be defined by their sexuality, the older gay or lesbian person can become doubly invisible. Thus, how do they make sense of their sexual selves as they age? Because, whether sexually active or not, there remains an internal sexual self and desire as we grow older, and this is just as much an essential part of our psychic functioning as when we are younger.⁷

Therapeutic work and relationships
If there is a significant age difference in the therapeutic relationship, what might this mean to either client or therapist? Further, in terms of sexuality and sexual orientation, how does this manifest itself for both parties: what is disclosed, what is left unspoken and how is this experienced in the therapeutic process? As therapists, our own associations to age and ageing, including how we feel about our chronological age and equally what we see ahead of us, are internally present and significant as we start to work with an older client. Our own experiences of older people (grandparents, for example, or older neighbours when we were children) can hold powerful internal associations for us; and equally as adults ourselves, the presence of ageing parents who may be becoming more dependent on us can also serve to stimulate powerful feelings.³

Different feelings will be evoked if we are working with someone closer to us in age, sharing a generational identity but possibly experiencing it differently and holding different fears or aspirations. Either way, powerful transferential and countertransferential feelings can be stimulated, and will need to be thoughtfully worked with for therapy to be effective. I would like to offer two contrasting case studies to illustrate some of these themes and dynamics, drawing on psychodynamic theory.

Case study one
The first case is a man I worked with myself over 10 years ago, a case that was instrumental in my own earlier development of work with older adults, which has stayed with me as a powerful example of relational dynamics around age and sexuality. As a gay man, I was particularly interested in working with an older gay client, and I will include some of my thinking and processing of the material from this time, as well as later reflections, drawing particularly on Kleinian concepts.

Damian, as I shall call him, was 90 years old when I met him, following referral by his GP for a lingering depressive mood brought on by serious physical health concerns and fear, guilt and psychological exhaustion. His relationship of over 60 years was both a fundamental element in his life (and his partner was his chief carer) and also a source of guilt and discomfort, as Damian feared he had damaged him by persistent sexual promiscuity over many years. Damian also feared a persecutory afterlife, which I saw as both a reflection of his internal ‘bad objects’ and also a projection of internalised homophobia and ageism.

In terms of the former, he had grown up in a world where there was little to encourage or validate his sexuality, and he had developed his gay self essentially through his partnership and through seeking endless intense sexual experiences. In terms of ageing, he described having always hated and mocked older people, and he said he hated himself for growing old. We worked together for just four months, brought to a close by his death following a major stroke. I was in my early 40s at this time, almost 50 years Damian’s junior, and my own age and stage of life I see as significant in terms of how I experienced and understood the material and dynamics of the work at the time.

I felt that Damian oscillated between a chaotic return to a paranoid-schizoid state (wherein he felt he had lost whatever had been good in his life and was consumed with fear at the thought of being reunited with others who would judge him) and a depressive concern for his partner, feeling guilt about past actions and wishing to make reparation before death. His relationship with his mother, who had died when he was in his 30s, had been painful and neglectful: he had been brought up largely by a nanny, his mother fretful and in poor health, forever retiring to her bed to smoke, where he would be brought to say goodnight. The prospect of death seemed rather like an ultimate trip to her smoky bedroom from which he would never escape.

If his mother remained an internal ‘bad object’, the ‘good object’ of his partner sometimes seemed fragile and potentially harmed, both by Damian’s bad behaviour in the past and equally the demands of the present, as he felt he was a burden to him by being ill and dependent. I wondered if he held onto a belief in an afterlife essentially as an opportunity to make the reparation he feared he would not make before death. My own relationship with him reflected much of this internal difficulty. While he seemed able to feel some degree of reassuring contact with me, it was impossible to maintain this, and as with his partner, the containment I might provide came in and out of focus, likewise contaminated by the shadow of his mother’s neglect.

Faced with death, which Damian knew was near and which he sometimes wished for, he could not achieve a satisfactory integration and seemed often on the brink of disintegration. I was often left feeling hopeless and inadequate: both my own process, and also a reflection of his internal state projectively identified with me. There was certainly much feeling transferred to me by Damian from his relationship with his partner, perhaps as a way of protecting the latter from the extremes of fragility and ambivalence. I felt a fusion of parent and lover/carer (the mother also being an unavailable lover in the infant Damian’s Oedipal world). I feel now that there was something seductive in the gratitude he occasionally expressed to me for my help; and perhaps my struggle with the extremes of his internal world also expressed a resistance to and fear of his seductive overtures. I feel from this distance that they contain a marrying of themes of sex and death; mixed, I imagine, with the ambiguity of age in my eyes of the time and the need, I suspect I felt, to hold onto my comparative youthfulness and vitality; my own wish to survive.

I feel, revisiting this scenario, that it tellingly illustrates both significant themes described earlier in this article and also something of my own younger concerns and preoccupations. The second case I wish to describe is one I supervised several years later, which vividly shows intergenerational dynamics in action, including a developmentally important role reversal in midlife.

Case study two
This client presented, at age 55, with a major relational and developmental crisis. His partner of 30 years, 25 years his senior, was increasingly exhibiting signs of dementia and it was becoming almost impossible to care for him at home. The client, whom I shall call Nick, was becoming unable to manage both the practical care and patience needed, but equally the psychological stability to understand and accept the shifting relational meanings of what was happening. One significant element of the relational dynamic was Nick’s very poor relationship with his father as he grew up, and the degree to which the partner had both provided care and containment for the young Nick but also exhibited authority and even dominance that Nick had embraced and valued.

Now Nick was faced with a potentially painful role reversal. Although he had worked as a social worker, he did not feel equal initially to the demands of this new role, and was angry and distressed at the loss of the father figure he had looked to for both love and authoritative containment. Over a year of therapeutic counselling, he was able to face not only the loss of the role his partner had so ably filled, but also, increasingly over time, his own wish and ability to grow up and start to become more independent, to care for himself. His own ageing, addressed with a gay counsellor of a similar age, became more meaningful to him and could be experienced as a process not so much of sad inevitability but one of creative and progressive liveliness. The loss of his partner, who moved into a care home, was of course very sad and needed to be mourned, but also came to be seen as a process of potential liberation. The counsellor described his own sense of how Nick was able to move forward, including a vital relation to the counsellor as symbolic mentor. A somewhat eroticised transference, but still with the counsellor as a senior/carer kind of figure as the partner had been, developed over time into an appreciative and, as it were, more mature relationship. The work ended with Nick more settled and able to cope with the ongoing caring role towards his partner, but also more energised and hopeful about the future and his individual potential.

As older people
These two studies show different aspects of therapeutic work with this client group, and highlight important themes, such as the past difficulty for gay men and lesbians to feel sufficiently validated in their sexual orientation as younger adults, and how this might play out as they age. One particularly significant factor in both stories is the role of parents: the absent or neglectful mother or father, whose inability to provide good enough care leads to unmet need, which must of psychological necessity be looked for in adult relationships. This is, of course, not exclusive to LGBT development, but the sexual orientation of the individual does raise further needs and complexities.

I have described some of the themes I see as central to working with older LGBT people, and offered some clinical illustration of these from therapeutic and supervisory work. As much as anything, I would emphasise the personal as well as interpersonal experience of the therapist that is valuably reflected on when working with this client group: we cannot meaningfully offer therapy in this context without being confronted with our own ageing and our own personally identified sexual orientation. There is great challenge but also potentially great interest in this work, whatever our chronological age and sexual identity: we are confronted with the meaning of our own ageing, and offered the stimulus of working intergenerationally and learning from the extensive life and psychic experience of the client. If gay or lesbian ourselves, we can also engage more deeply with the history of our own community, and thus also help to prepare ourselves for our own future.

As LGBT people age within a society that is increasingly living longer and also, at least externally, acknowledging the existence of alternative sexualities and their rights, we are all faced with the psychological reality of diversity and its relational dynamics. These dynamics are powerfully represented in the interpersonal experience of therapy.

David Richards is a BPC and UKCP registered and BACP senior accredited psychodynamic psychotherapist and supervisor. He has worked extensively with older adults and with gay men and lesbians in both community settings and private practice, and has been involved in the development of services for older LGBT people. Please email david.richards56@ntlworld.com

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