Disparities in Aging: The LGBTQ+ Population

#### **Purpose:**

When discussing disparities in healthcare, the aging LGBTQ+ population often gets overlooked and is generally poorly understood. The purpose of this page is to overview some of the disparities facing this population of older adults and discuss relevant issues pertinent to clinical patient care.

**Topics of Discussion and Learning Objectives:**

1. Understand disparities this population is vulnerable to, including social isolation and mental health

2. Understand what kinds of discrimination this population is likely to face

3. Understand in which clinical setting this population is most likely to face discrimination

4. Understand some steps that can be taken by clinicians to ameliorate these disparities
5. Become aware of some reseources for further reference on this topic

**Discussion:**

Social Isolation and Mental Health

LGBTQ adults experience higher rates of mental health issues including suicide attempts, anxiety, depression, and substance abuse, which has been attributed to increased levels of marginalization as a minority group.1

The older LGBTQ population is:2,3

* Is 40% more likely than the average older adult to age without a partner
* Is 70% more likely to than the average older adult to have no children
* Is about 40% more likely to live alone than the average older adult

Discrimination

Discriminatory legislative and health practices in America include historical classification of homosexuality as a mental disorder, forced institutionalizations, conversion therapy, dishonorable discharges in the military over sexual orientation, and the mismanagement of the AIDS crisis. For many of these reasons, the aging LGBTQ population is less likely to trust mainstream institutions. More than 20% of this population chooses not to disclose their sexual orientation or gender to their primary physician. It is important to remember that while mainstream culture today is much more accepting of a diverse range of sexual and gender identities, this acceptance is relatively new, and many older adults may not feel comfortable being "out" or discussing these topics openly.

* Transgender people have a higher incidence of:4,5
	+ HIV/STDs
	+ Mental health issues
	+ Suicide
* LGBT older adults:1,2
	+ 13% have been denied or received inferior healthcare
	+ Almost 50% have a disability
	+ Over 30% report depression
	+ Men have higher rated of HIV than general population
	+ Women have higher rates of cardiovascular disease and obesity
	+ Women are less likely to get mammograms
	+ Are more likely to face housing and caregiver discrimination
* Long Term Care Facilities: over 70% of adults age 65+ receive LTC during their lifetime, but this setting is particularly prone to abuse, especially with minority populations.6,7
	+ Only 20% pf LGBTQ seniors in LTC report they are comfortable being open about their sexual orientation
	+ 23% in LTC experience verbal or physical harassment by other residents
	+ 26% in LTC experience verbal or physical harassment by staff

Recommendations for Clinicians

To increase inclusiveness, address disparities, and improve the clinical experience8

1. Include same-sex couples in marketing images
2. Use non-judgmental and inclusive language on intake forms
	1. include more options than male/female for gender
	2. have options for biological sex AND gender expression
	3. have options for preferred pronouns
3. Use terminology and pronouns that patients prefer
4. Understand that while many older LGBTQ adults may not have biological families or traditional family structure, many have close friends or friend groups that fulfill this role
	1. include these members into plan of care and treatment consideration just like you would any other family member
5. Don’t assume sexual orientation or gender identity based on appearances, whether someone is married, or whether they have children
6. Provide opportunities for staff to develop cultural competence in this area
7. Educate yourself as a healthcare provider on terminology and best practice, don't rely on patients in minority groups to educate you

#### **Additional Resources:**

20 Common Nursing Home Problems—and How to Resolve Them: http://www.nsclc.org/

Improving the Lives of LGBT Older Adults: http://www.lgbtmap.org/improving-the-lives-oflgbt-older-adults.html.

SAGE (Services and Advocacy for LGBT Elders): http://www.lgbtagingcenter.org/

The National Center for Transgender Equality: http://transequality.org/

Inclusive Services for LGBT Older Adults: https://www.sageusa.org/wp-content/uploads/2018/05/sageusa-welcoming-agency-guide-inclusive-services-for-lgbt-older-adults.pdf

Caring for the Older LGBT Adult: http://lgbthealtheducation.org/wp-content/uploads/Module-6-Caring-for-Older-LGBT-Adults.pdf

References:

1. Cannon SM, Shukla V, Vanderbilt AA. Addressing the healthcare needs of older Lesbian, Gay, Bisexual, and Transgender patients in medical school curricula: a call to action. *Med Educ Online*. 2017;22(1):1320933. doi:10.1080/10872981.2017.1320933.

2. Fredriksen-Goldsen KI, Kim H-J, Barkan SE, Muraco A, Hoy-Ellis CP. Health disparities among lesbian, gay, and bisexual older adults: results from a population-based study. *Am J Public Health*. 2013;103(10):1802-1809. doi:10.2105/AJPH.2012.301110.

3. Wallace SP, Cochran SD, Durazo EM, Ford CL. The health of aging lesbian, gay and bisexual adults in California. *Policy Brief UCLA Cent Health Policy Res*. 2011;(PB2011-2):1-8. http://www.ncbi.nlm.nih.gov/pubmed/21548402. Accessed July 16, 2018.

4. Safer JD, Coleman E, Feldman J, et al. Barriers to healthcare for transgender individuals. *Curr Opin Endocrinol Diabetes Obes*. 2016;23(2):168-171.

5. Fredriksen-Goldsen KI, Cook-Daniels L, Kim HJ, et al. Physical and mental health of transgender older adults: An at-risk and underserved population. *Gerontologist*. 2014;54(3):488-500. doi:10.1093/geront/gnt021.

6. Johnson MJ, Jackson NC, Arnette JK, Koffman SD. Gay and Lesbian Perceptions of Discrimination in Retirement Care Facilities. *J Homosex*. 2005;49(2):83-102. doi:10.1300/J082v49n02\_05.

7. White JT, Gendron TL. LGBT elders in nursing homes, long-term care facilities, and residential communities. In: *Handbook of LGBT Elders: An Interdisciplinary Approach to Principles, Practices, and Policies*. Cham: Springer International Publishing; 2016:417-437. doi:10.1007/978-3-319-03623-6\_21.

8. American Geriatrics Society Ethics Committee. American Geriatrics Society Care of Lesbian, Gay, Bisexual, and Transgender Older Adults Position Statement. *J Am Geriatr Soc*. 2015;63(3):423-426. doi:10.1111/jgs.13297.

-Britt Lademann