Tip Sheet

Sexual Orientation and Gender Identity


Person-centered care involves recognizing the whole person we care for and appreciating that each person has multiple identities and is multidimensional. Sexual orientation and gender identity are core aspects of a person. They affect individuals in many ways throughout one’s life span. For instance, sexual orientation and gender identity influence a person’s sense of self, social connections, interests, health and well-being.

This tip sheet introduces a version of the Preferences for Everyday Living Inventory (PELI) that your organization can adopt to address, and raise awareness of, the unmet needs of Lesbian, Gay, Bisexual, and Transgender (LGBT) older adults residing in nursing homes. By including specific questions and response options in the Rainbow PELI that pertains to sexual orientation and gender identity we:

  • Raise awareness and educate our staff about LGBT inclusion and cultural sensitivity.
  • Convey that the care team/provider recognizes and affirms the existence of LGBT individuals and families.
  • Provide opportunities for individuals to self-disclose their sexual orientation and/or gender identity.
  • Increase our ability to provide competent care and appropriate support to meet the needs of and promote the wellbeing of LGBT individuals and families.

Asking questions that are inclusive helps to heal the history of discrimination that the LGBT community has faced from the medical world. Even if none of the questions are answered or lead to disclosure, asking them sends the message that the LGBT community is recognized and welcomed.


  • Sexual orientation = Describes who one is attracted to emotionally, romantically and/or sexually. It encompasses attraction, behavior and identity.
  • Gender identity = A person’s innermost concept of being a boy, man, girl, woman, or another gender. One’s gender identity may not correspond with one’s physical anatomy, or gender assigned at birth. Gender identity does not determine sexual orientation.

The LGBT community uses a variety of acronyms, such as LGBTQIA (Lesbian, Gay, Bisexual, Queer or Questioning, Transgender, Intersex, Asexual). We use the term LGBT in its most inclusive sense to include all non-heterosexual sexual orientations and/or multiple gender identities. Note that labels and terms change over time and resonate differently for people. Be sensitive and open to the language and labels individuals use (and do not use) for themselves. Pay attention, and use the terms individuals use to self-identify.

“Coming Out” – What You Need to Know

The expression “coming out” refers to the act of disclosing or revealing one’s own sexual orientation or gender identity (this includes self-discovery, coming out to one’s self). This is an ongoing process. People are unique, and each person has a different coming out experience. Important aspects of this process to consider are:

  • Be open to learning about each person as a unique individual with a unique life journey.
  • Some people come out only to a few individuals in their lifetime. Respect this confidentiality.
  • Not everyone self-identifies with a label or wants to be put into a category. Do not make assumptions about what term or label a person uses to describe their identity.
  • During an individual’s lifetime, their sexual orientation and/or gender identity may change. 
  • Listen carefully to the words individuals use, as people may talk in code or drop clues to disclose or “test the waters” to see if it is safe to come out to a certain person or within a certain situation. For instance, someone might say that they are “part of the family,” “a friend of Dorothy,” “on the down low,” or “have a roommate.”
  • “Outing” is when someone reveals another person’s sexual orientation or gender identity without permission. Each person has the right to decide whether and how to discuss and reveal their sexual orientation and gender identity. Respect this decision.

No one should be forced to disclose their sexual orientation and/or gender identity. It is a privilege to have someone feel comfortable and safe enough to come out to you. But they may not want that information shared with others. Only document on the medical record or disclose to the care team what an individual has consented for you to share.

Follow-Up Questions for those who Choose to Disclose

  • Individuals may talk in “code”. Don’t be afraid to ask them what a “code” word means. For example, say: “I want to make sure I understand you fully, what did you mean by ____?”
  • Someone may disclose to you, but not want the information shared with others. If someone discloses, follow up with: “Thank you for sharing. Are you comfortable with my sharing this information with the rest of the care team?”
  • Honor the person’s request for disclosure. If a person does not wish to share this information with anyone else on the care team, do not document the information in the medical record. Explain that if they change their mind at any point, the information will be used only to ensure the best possible care and support.

Implementation Suggestions for Providers

  • Offer cultural sensitivity training for LGBT older adults as in-service training for staff – at all levels of the organization.
  • Provide LGBT resources for individuals receiving care and their loved ones.
  • Have an LGBT champion within the organization who can support other staff and individuals receiving care. 
  • Consider creating a Task Force or Employee Workgroup to inspire culture change and educational efforts.
  • Consider participating in the Healthcare Equality Index (HEI): http://www.hrc.org/hei
  • Display a rainbow flag, poster, brochure, sticker or sign from LGBT organizations, such as Human Rights Campaign, National Resource Center on LGBT Aging, SAGE, PFLAG, Fenway Institute, GLMA, GLAAD, or the National Coalition for LGBT Health. Environmental cues can communicate visually to individuals that the LGBT community is welcomed, recognized, and embraced.
  • Build a trusting relationship with the interviewee prior to the Rainbow PELI interview.
  • Conduct Rainbow PELI interviews in a safe space (in a private space).
  • Be mindful that this may be the first time the individual is asked about their sexual orientation and/or gender identity, and they may feel uncomfortable. To ease concerns, explain that we ask everyone these questions because we don’t want to make assumptions about who each person is. We want to assist everyone to thrive and flourish.
  • Remind people that they can ask staff not to document information they share in the interview. The information can always be kept confidential, if that is what they prefer.

Where You will Find Changes to the PELI

The Rainbow PELI adds options to follow-up questions in the PELI-NH Full version. For example, if someone says being a member of a club is very important, we added LGBT club and PFLAG as options. Follow-up questions and response options also provide opportunities for an individual to disclose their gender identity and expression. This includes providing a wider range of options for preferred pronouns for each person. We do not want to assume we know someone else’s sexual orientation and gender identity. 

Do not assume.  Let people tell you who they are.

New sexual orientation and gender identity follow-up questions and response options included in the Rainbow PELI are: Q01, Q07, Q20, Q30, Q32, Q34, Q45, Q47, Q48, Q49, Q53, Q54, Q60, Q67, Q68

About the Series

This is one in a series of Tip Sheets on using the Preferences for Everyday Living Inventory (PELI) to improve person-centered care. Topics include: How to Get Started, Interview Tips, Working with Proxies, Helping Staff Engage, Integrating Preferences into Care Plans and more. View our full series of Tip Sheets.

Have questions or comments? Please e-mail us at PELI-Can@miamioh.edu or call our helpline at 513-529-3605.

Rabbi Erica Steelman, MPP & Victoria Crumbie, MS, CTRS, The Madlyn and Leonard Abramson Center for Jewish Life This work is licensed under the Creative Commons Attribution-NoDerivatives 4.0 International License. Based on a work at https://preferencebasedliving.com/. To view a copy of this license, visit http://creativecommons.org/licenses/by-nd/4.0/.