Skip to main content
Journal of General Internal Medicine logoLink to Journal of General Internal Medicine
editorial
. 2023 Feb 10;38(6):1538–1540. doi: 10.1007/s11606-023-08064-z

Caring for LGBTQ+ Older Adults at Home

Mariah L Robertson 1,2,, Jennifer L Carnahan 3, Carl G Streed Jr 4,5
PMCID: PMC10160310  PMID: 36763203

A PATIENT STORY

It was clear when I (MLR) entered his home something was missing. The walls were adorned with beautiful artwork but no hint of family or community. I approached with curiosity. “How long have you lived in this area?” and “Have you always lived alone?” and “From whom do you derive support?” The answers were guarded. He had been living in the area for years. Most of his friends had moved or died. No family to speak of. A few friends in the building but none who would miss him if they were to lose contact. At a later visit when, with permission, I went to his desk to look at glucose logs and saw a small picture hidden in a nook. Two men, embracing, smiling brightly at the camera. Complete. No missing pieces.

With time I learned more. The loss of his partner. His isolation from family who didn’t approve of his relationship. No children between the two of them. The friends they shared as a couple disappeared when his partner died. He expressed fear of becoming further isolated if he shared his past relationship—it had happened before with his family—why wouldn’t it happen again? I wondered how often I was missing important pieces of my patients’ personhood.

LGBTQ + OLDER ADULTS AND HOME-BASED CARE

There are at least 3 million lesbian, gay, bisexual, transgender, and queer (LGBTQ +) adults over the age of 50 in the United States and this number is projected to increase to more than 7 million by 2030.1 As LGBTQ + populations age, past and present inequities must be acknowledged and addressed as they pose serious risks for poorer health outcomes. Recent research has found an overwhelming majority (82%) of LGBTQ + older adults have experienced at least one instance of victimization or discrimination in their lifetime.2 The 2015 US Trans Survey revealed that 23% of transgender older adults report avoiding physicians for fear of mistreatment.1 When seeking senior housing, almost half (48%) of same-sex couples have experienced adverse treatment.1 While some states have been working to uphold anti-discrimination laws for LGBTQ + long-term care residents, as of submission, 29 states lack explicit inclusion of sexual orientation or gender identity in housing protections.3

Being single, financially impoverished, and socially isolated are risk factors for being homebound4 and disproportionately more common among LGBTQ + older populations. LGBTQ + older adults are twice as likely to be single and to live alone and four times less likely to have adult children compared to their straight, cisgender peers.5 We also see higher rates of poverty and isolation: over half (59%) of LGBTQ + older adults lack companionship and 53% feel isolated from others. Many LGBTQ + older adults may both need long-term care and be reluctant to enter it for fear of discrimination and lack of housing protection.6 Because of these important factors, it is essential to have adequate and equitable care for homebound LGBTQ + older adults.

To our knowledge, there exists no published data evaluating the health outcomes for homebound LGBTQ + older adults broadly or specifically those with multiple intersecting marginalized identities (e.g., LGBTQ + racial and ethnic marginalized communities). Given the fact that LGBTQ + older adults have higher risks for more medical comorbidities and social isolation, owing largely to discrimination, we recognize that we are likely missing many LGBTQ + older adults who we are caring for in our work.

While meeting people where they are is a crucial part of improving access to healthcare among isolated older adults, it also is important to consider the implications of entering someone’s home. Just as older adults are concerned about “returning to the closet” if they require nursing home care, they may feel a similar need to protect themselves with home care.6 With the rapid expansion of programs like hospital-at-home and home-based primary care, more providers are entering the home environment including physicians across specialties (e.g., family and internal medicine, geriatric medicine, hospice, and palliative care), advanced practice providers, nurses, physical and occupational therapists, social workers, community health workers, and home health aides. As such, home care organizations and hospital systems must adapt to and understand the diversity of patients and families receiving home-based services.

STRATEGIES AND RECOMMENDATIONS

Having strangers enter the home, including clinicians, can be potentially traumatizing for LGBTQ + older adults. Universal funding to train the existing home care workforce as well as building a more diverse and representative workforce is critical to providing equitable and affirming care to LGBTQ + older adults. While all tenets of trauma-informed care apply in this setting, being intentional about key principles when caring for LGBTQ + older adults in the home setting is especially important (Table 1).

Table 1.

Applying Trauma-Informed Care (TIC) Principles to Care of Homebound LGBTQ + older adults

TIC principle* Application
Safety Create an environment of psychological safety with intention toward physical and interpersonal environments that facilitate feeling safe in your “safe space”
Peer support Create connections to peers including local SAGE** chapters and other community resources to assist in combating social isolation and improve community connectedness
Empowerment, voice, and choice Understand existing power differentials and the ways LGBTQ + persons have historically been diminished in voice and choice and recipients of coercive treatment
Cultural, historical, and gender issues Move past stereotypes and biases to offer access to gender-affirming care. Leverage the healing value of traditional cultural connections and incorporate policies, protocols, and processes that recognize and address historical trauma, especially as it relates to sexual orientation and gender identities

*Adapted from Substance Abuse and Mental Health Services Administration (SAMHSA) Principles, **Services & Advocacy for LGBT Elders 

A comprehensive solution also involves starting upstream with universal training regarding healthy aging for LGBTQ + persons across disciplines in medicine who care for older adults.7 These trainings must explicitly include how to talk with patients about sexual practices, gender identity, and sexuality; explore the role of gender-affirming care across the lifespan; and signal clinicians and systems are competent and compassionate to earn patient’s trust.

At a home care organization and health systems level, this means understanding the unique needs of LGBTQ + older adults and employing expertise from existing organizations such as Services & Advocacy for LGBT Elders (SAGE) who can assist in data acquisition, knowledge, resources, and trainings. Utilizing these existing resources created by LGBTQ + communities is a comprehensive approach that both acknowledges important resources developed over decades and includes these communities in future efforts. Local and national policy changes must also incorporate these educational and training efforts. This includes having the Centers for Medicare and Medicaid Services require training on LGBTQ + topics for providers delivering home-based medical services.

SUMMARY

We present here the beginning of a discussion on how to enhance recognition of the unique factors impacting the care of LGBTQ + older adults broadly and more specifically in the home setting. We hope that home care providers and health systems will begin to understand how historical and structural factors may impact the trust an LGBTQ + older adult might have in the providers coming into their homes. Home-based care delivery is important to equitable care of older adults and as we continue to expand the care options in the home, we must be aware of the factors that might make a home visit traumatizing for our LGBTQ + patients. By taking a trauma-informed approach to care and thinking about the ways we can leverage the work put in by the LGBTQ + community, we can help ensure that care to the growing homebound LGBTQ + population is safe and affirming.

Acknowledgements

Dr. Carnahan was supported by the National Institute On Aging division of the National Institutes of Health [Grant K23AG062797].

Dr. Streed was supported by National Heart, Lung, and Blood Institute career development grant (NHLBI 1K01HL151902-01A1), an American Heart Association career development grant (AHA 20CDA35320148), Doris Duke Charitable Foundation (Grant #2022061), and the Boston University School of Medicine Department of Medicine Career Investment Award.

Conflict of Interest

The authors declare no competing interests.

Footnotes

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

References


Articles from Journal of General Internal Medicine are provided here courtesy of Society of General Internal Medicine

RESOURCES