Abstract
Purpose:
Sexual minority (SM) older adults report poorer mental health than their heterosexual peers. While all older adults can experience age discrimination and other aging concerns (e.g., functional decline), SM older adults also experience sexual orientation-related discrimination and aging concerns (e.g., that they will have to be less open about their sexual orientation to get support as they age). The goals of this study were to examine the roles of (1) sexual orientation and age discrimination and (2) sexual orientation-specific and general aging concerns in depression and anxiety among SM older adults.
Methods:
As part of a larger study, 477 SM older adults (aged ≥50 years) completed an online survey in September 2021. The majority were gay/lesbian (83%), cisgender men (40%) or cisgender women (34%), and non-Latinx White (39%) or Latinx (34%). Analyses controlled for age, sexual orientation, gender identity, and race/ethnicity.
Results:
Sexual orientation discrimination and age discrimination were positively associated with depression and anxiety. A significant interaction indicated that sexual orientation discrimination was positively associated with anxiety at low, moderate, and high levels of age discrimination, but the association was strongest at the low level. Sexual orientation-specific and general aging concerns were also positively associated with depression and anxiety. Significant interactions indicated that sexual orientation-specific aging concerns were associated with higher depression and anxiety at low and moderate, but not high, levels of general aging concerns.
Conclusions:
A range of factors contribute to mental health among SM older adults and there are complex relationships between general and sexual orientation-specific factors.
Keywords: aging concerns, discrimination, mental health, older adults, sexual minority
Introduction
The health disparities affecting sexual minority (SM) populations are well documented among youth and adults,1–4 but older adults remain underrepresented in health disparities research. Of note, the age at which older adulthood begins varies across studies. For example, prior studies have operationalized older adulthood as beginning at age 45,5,6 age 50,7,8 and age 65.9 Regardless, the available evidence indicates that SM older adults remain at elevated risk for adverse mental health outcomes (e.g., poor mental health, mood and anxiety disorders) compared with their heterosexual peers.6,7,10–12
These disparities are likely related to the unique challenges that SM older adults face (e.g., discrimination), which are rooted in living in a heterosexist and ageist society. However, few studies have examined both sexual orientation- and age-related factors that contribute to adverse mental health outcomes among SM older adults. To address this gap, the goals of the current study were to examine the roles of discrimination and aging concerns in the mental health of SM older adults.
According to the Minority Stress Model,3,13 SM people experience unique stressors related to stigmatization of their sexual orientation (e.g., discrimination), which can have a detrimental impact on their mental health. The Health Equity Promotion Model highlights the importance of attending to intersecting social positions, including sexual orientation and age, to understand the health of SM people across the life course.14
Although relatively few studies have focused on the mental health of SM older adults, the available evidence indicates that similar to SM youth and adults, sexual orientation-related discrimination is a risk factor for adverse mental health outcomes among SM older adults.5,8,15 For example, prior studies have found that experiencing more sexual orientation-related victimization and discrimination in one's lifetime is associated with a greater likelihood of meeting a cutoff for depression16 as well as worse mental health-related quality of life8 among SM older adults.
Even fewer studies have examined age-related discrimination in relation to mental health among SM older adults. As an exception, one study found that greater age-related discrimination and sexual orientation-related discrimination were each associated with greater depression and that depression and anxiety were highest for those who experienced higher levels of both types of discrimination.5
SM older adults have also described unique experiences of discrimination at the intersection of their sexual orientation and age. For example, they have described concerns about being rejected or neglected by care staff and residents at long-term care facilities and potentially having to conceal their sexual orientation to avoid mistreatment,17,18 invisibility in cultural representations,19 and ageism in some SM communities,19,20 especially communities of SM men who tend to place high value on youthfulness and attractiveness.19,21
Older adults report a number of concerns related to aging other than discrimination, such as social isolation, declines in physical health and functioning, financial concerns related to retirement, changes in housing, and loss of one's partner.22 Although people of all sexual orientations can experience these concerns, they are more common among SM older adults compared with heterosexual older adults. For example, one study found that gay and lesbian older adults reported more general aging concerns (e.g., becoming socially isolated and lonely, having no one to care for them) compared with heterosexual older adults.5 In addition, compared with heterosexual older adults, SM older adults are more likely to have a disability, be childfree, and have less intensive contact with their families.10,16 As a result, SM older adults are more likely to experience loneliness compared with heterosexual older adults.10
Prior research has also found that SM older adults experience unique sexual orientation-specific aging concerns, such as concerns that their family will not care for them when they are older because of their sexual orientation and that they will have to be less open about their sexual orientation to get support as they age.5
In general, prior research on older adults' mental health has found that more negative attitudes toward aging are associated with poorer mental health23,24 and that lower quality of life (inclusive of aging concerns, such as concerns about capacity for work, financial resources, and mobility) is associated with greater likelihood of meeting criteria for generalized anxiety disorder and agoraphobia.9 However, to our knowledge, no prior studies have examined whether general and sexual orientation-specific aging concerns interact to predict greater depression and anxiety.
The available evidence indicates that SM older adults experience a range of stressors at the intersection of sexual orientation and age, but little is known about the roles of these stressors in their mental health. Therefore, the goals of the current study were to examine the main and interaction (i.e., moderation) effects of (1) sexual orientation and age discrimination and (2) sexual orientation-specific and general aging concerns on depression and anxiety.
We hypothesized that (1) greater sexual orientation and age discrimination would be associated with greater depression and anxiety, (2) the associations between sexual orientation discrimination and depression and anxiety would be stronger for participants who reported greater age discrimination, (3) greater sexual orientation-specific and general aging concerns would be associated with greater depression and anxiety, and (4) the associations between sexual orientation-specific aging concerns and depression and anxiety would be stronger for participants who reported greater general aging concerns.
Methods
Participants and procedures
Data for this study come from the Columbus Healthy Aging Project (CHAP), a cross-sectional survey of risk factors for adverse health outcomes among older adults (age ≥50) in Columbus, Ohio. Data were collected in September 2021. Recruitment occurred through Facebook and Instagram. Inclusion criteria included (1) age ≥50 years; (2) residence in Columbus, Ohio, or surrounding suburbs; (3) internet access to complete the online survey; and (4) a valid e-mail address.
Participants were compensated with a $20 Amazon gift card. All procedures were approved by the Institutional Review Board at The Ohio State University, all participants provided informed consent, and the research was completed in accordance with the Declaration of Helsinki as revised in 2013.
The full sample included 794 participants. Given the focus of the current analyses on sexual orientation-related experiences, 317 heterosexual participants were excluded from the analytic sample. The analytic sample included 477 SM older adults (aged 50–88 years, mean [M] = 58.2, standard deviation [SD] = 6.1).
The majority identified as gay or lesbian (82.6%) and participants included cisgender men (39.8%), cisgender women (34%), transgender/nonbinary individuals (22.6%), and a small number of individuals who did not report their sex assigned at birth or reported it as intersex (3.6%). The largest proportion of participants was non-Latinx White (39.2%), followed by Latinx (34%), non-Latinx Black (22.6%), and non-Latinx different race (4.2%).
Measures
Sexual orientation discrimination
An adapted version of the Everyday Discrimination Scale was used to measure sexual orientation discrimination.25 The original measure asks, “In your day-to-day life, how often do any of the following things happen to you?” The instructions were adapted to focus on sexual orientation (“Thinking about how your sexual orientation impacts your day-to-day life…”). Then, participants are presented with nine items (e.g., “You are treated with less respect than other people are,” “You are called names or insulted”). Items are rated on a 6-point scale (ranging from 1 = never to 6 = every day/daily) and responses are averaged (α = 0.95).
Age discrimination
The same adapted version of the Everyday Discrimination Scale was used to measure age discrimination,25 but the instructions focused on age (“Thinking about how your age impacts your day-to-day life…”). The measure demonstrated excellent internal consistency (α = 0.95).
Sexual orientation-specific aging concerns
Participants were asked to rate the extent to which they agreed or disagreed with four statements from a prior study5: (1) Because of my sexual orientation, I worry that my family will not care for me when I am older; (2) Because of my sexual orientation, I worry that I will not receive government aid when I am older; (3) I am concerned that getting the support I need as I age will influence my openness about my sexual orientation; and (4) I am concerned that doctors, nurses, or other care providers will make assumptions about my health (e.g., HIV status) based on my sexual orientation. Each item was rated on a 5-point scale (ranging from 1 = strongly disagree to 5 = strongly agree) and responses were averaged (α = 0.78).
General aging concerns
Participants were asked eight questions about general aging concerns from a prior study5: (1) In general, how concerned are you about growing older? (2) How concerned are you about becoming socially isolated and lonely? (3) How concerned are you that there will be no one to care for you in your old age? (4) How concerned are you about the possibility of needing services from a long-term care facility? (5) How concerned are you that you will have enough money to support yourself after retirement? (6) How concerned are you that a person close to you (e.g., partner/spouse, family, friends) will be given visitation rights if you are sick in the hospital? (7) How concerned are you that a person close to you (e.g., partner/spouse, family, friends) will be given inheritance rights after you pass? (8) How concerned are you that you will be treated with respect by health care professionals? Each item was rated on a 6-point scale (ranging from 1 = not at all concerned to 6 = extremely concerned) and responses were averaged (α = 0.90).
Depression
The Patient Health Questionnaire–8 was used to assess depression symptoms (e.g., “Little pleasure or interest in doing things”) over the past 2 weeks.26 Each item was rated on a 4-point scale (ranging from 1 = not at all to 4 = nearly every day) and responses were summed (α = 0.93).
Anxiety
The Generalized Anxiety Disorder–7 scale was used to assess anxiety symptoms (e.g., “Being so restless that it is hard to sit still”) over the past 2 weeks.27 Each item was rated on a 4-point scale (ranging from 1 = not at all to 4 = nearly every day) and responses were summed (α = 0.93).
Data analyses
A series of regression analyses were conducted using the PROCESS macro (version 4.0)28 in SPSS, version 28. Bootstrapping with 5000 iterations and 95% confidence intervals (CI95s) was applied to examine the main and interaction (i.e., moderation) effects of (1) sexual orientation and age discrimination and (2) sexual orientation-specific and general aging concerns on depression and anxiety. Analyses controlled for age, sexual orientation, gender identity, and race/ethnicity. Less than 1% of data were missing.
Results
Demographics are presented in Table 1, bivariate correlations, means, and standard deviations are presented in Table 2, and standardized regression coefficients are presented in the text and in Tables 3 and 4.
Table 1.
Demographic Characteristics of Study Participants (N = 477)
| Demographic characteristics | N (%) |
|---|---|
| Sexual orientationa | |
| Gay | 214 (44.9%) |
| Lesbian | 180 (37.7%) |
| Bisexual | 52 (10.9%) |
| Queer | 11 (2.3%) |
| Pansexual | 7 (1.5%) |
| Asexual | 12 (2.5%) |
| A different identity | 1 (0.2%) |
| Sex assigned at birthb | |
| Female | 229 (48.0%) |
| Male | 227 (47.6%) |
| Intersex | 11 (2.3%) |
| Did not report | 10 (2.1%) |
| Gender identityb | |
| Woman | 169 (35.4%) |
| Man | 205 (43.0%) |
| Transgender woman | 25 (5.2%) |
| Transgender man | 26 (5.5%) |
| Genderqueer | 51 (10.7%) |
| Gender nonconforming | 1 (0.2%) |
| Race/ethnicity | |
| Non-Latinx White | 187 (39.2%) |
| Non-Latinx Black | 108 (22.6%) |
| Latinx | 162 (34.0%) |
| Non-Latinx different race | 20 (4.2%) |
Sexual orientation was recoded into two groups for analyses: gay/lesbian (N = 394) and all other sexual minorities (N = 83).
Sex assigned at birth and gender identity were recoded into three groups for analyses: cisgender men (N = 190), cisgender women (N = 162), and gender minorities (N = 108). Participants who did not report their sex assigned at birth (N = 10) or who reported it as intersex and did not specifically identify as transgender, genderqueer, or gender nonconforming (N = 7) were not included in our three groups for analyses.
Table 2.
Intercorrelations Among Study Variables
| Variables | 1. | 2. | 3. | 4. | 5. | 6. | M (SD) |
|---|---|---|---|---|---|---|---|
| 1. Sexual orientation discrimination | — | 3.11 (1.29) | |||||
| 2. Age discrimination | 0.89*** | — | 3.16 (1.31) | ||||
| 3. Sexual orientation-specific aging concerns | 0.46*** | 0.48*** | — | 3.09 (0.97) | |||
| 4. General aging concerns | 0.47*** | 0.45*** | 0.37*** | — | 4.09 (1.07) | ||
| 5. Depression | 0.69*** | 0.71*** | 0.33*** | 0.38*** | — | 11.56 (6.51) | |
| 6. Anxiety | 0.67*** | 0.69*** | 0.33*** | 0.40*** | 0.85*** | — | 10.57 (5.80) |
M, mean; SD, standard deviation; ***p ≤ 0.001.
Table 3.
Main and Interaction Effects of Sexual Orientation- and Age-Related Discrimination Predicting Depression and Anxiety
| Depression |
Anxiety |
|||
|---|---|---|---|---|
| β | CI95 | β | CI95 | |
| Sexual orientation discrimination | 0.29 | 0.15–0.42 | 0.31 | 0.17–0.45 |
| Age discrimination | 0.41 | 0.28–0.55 | 0.37 | 0.23–0.51 |
| Interaction | −0.04 | −0.11 to 0.03 | −0.09 | −0.16 to −0.02 |
| Age | −0.09 | −0.15 to −0.02 | −0.08 | −0.15 to −0.01 |
| Cisgender men | Ref. | Ref. | Ref. | Ref. |
| Cisgender women | 0.05 | −0.09 to 0.20 | 0.08 | −0.07 to 0.23 |
| Gender minorities | 0.002 | −0.17 to 0.17 | 0.10 | −0.10 to 0.26 |
| Non-Latinx White | Ref. | Ref. | Ref. | Ref. |
| Non-Latinx Black | 0.22 | 0.05–0.38 | 0.35 | 0.17–0.52 |
| Latinx | 0.44 | 0.29–0.59 | 0.37 | 0.21–0.53 |
| Non-Latinx different race | 0.09 | −0.23 to 0.41 | 0.15 | −0.18 to 0.48 |
| Gay/lesbian | Ref. | Ref. | Ref. | Ref. |
| Different sexual orientation | −0.10 | −0.27 to 0.08 | −0.15 | −0.34 to 0.03 |
Analyses controlled for age, race/ethnicity, sexual orientation, and gender identity. Bold font indicates statistical significance (p < 0.05). CI95, 95% confidence interval.
Table 4.
Main and Interaction Effects of Sexual Orientation-Specific and General Aging Concerns Predicting Depression and Anxiety
| Depression |
Anxiety |
|||
|---|---|---|---|---|
| β | CI95 | β | CI95 | |
| Sexual orientation-specific aging concerns | 0.23 | 0.14–0.32 | 0.21 | 0.12–0.30 |
| General aging concerns | 0.25 | 0.15–0.36 | 0.29 | 0.19–0.40 |
| Interaction | −0.16 | −0.24 to −0.07 | −0.15 | −0.24 to −0.06 |
| Age | −0.10 | −0.18 to −0.01 | −0.09 | −0.17 to −0.002 |
| Cisgender men | Ref. | Ref. | Ref. | Ref. |
| Cisgender women | −0.04 | −0.22 to 0.14 | −0.01 | −0.19 to 0.18 |
| Gender minorities | 0.10 | −0.11 to 0.32 | 0.16 | −0.05 to 0.38 |
| Non-Latinx White | Ref. | Ref. | Ref. | Ref. |
| Non-Latinx Black | 0.42 | 0.21–0.62 | 0.55 | 0.34–0.76 |
| Latinx | 0.65 | 0.47–0.84 | 0.60 | 0.42–0.79 |
| Non-Latinx different race | 0.23 | −0.18 to 0.65 | 0.29 | −0.13 to 0.71 |
| Gay/lesbian | Ref. | Ref. | Ref. | Ref. |
| Different sexual orientation | −0.03 | −0.25 to 0.20 | −0.07 | −0.30 to 0.15 |
Analyses controlled for age, race/ethnicity, sexual orientation, and gender identity. Bold font indicates statistical significance (p < 0.05). CI95, 95% confidence interval.
Sexual orientation and age discrimination
Main and interaction effects are presented in Table 3. Greater sexual orientation and age discrimination levels were significantly associated with greater depression and anxiety. The interaction between sexual orientation and age discrimination was significant in the model predicting anxiety. Simple slopes demonstrated that greater sexual orientation discrimination was significantly associated with greater anxiety at low (conditional effect = 0.40, standard error [SE] = 0.08, CI95 = 0.24–0.56), moderate (conditional effect = 0.31, SE = 0.07, CI95 = 0.17–0.45), and high (conditional effect = 0.22, SE = 0.08, CI95 = 0.07–0.38) levels of age discrimination (Fig. 1). Contrary to expectations, the association between sexual orientation discrimination and anxiety was stronger at lower levels of age discrimination. The interaction between sexual orientation and age discrimination was nonsignificant in the model predicting depression.
FIG. 1.
Interaction between sexual orientation- and age-related discrimination predicting anxiety. Simple slopes of sexual orientation discrimination predicting anxiety at low (−1 standard deviation), moderate (mean), and high (+1 standard deviation) levels of age discrimination. Figures reflect adjusted results, which control for age, race/ethnicity, sexual orientation, and gender identity. The y-axis includes positive and negative values because the outcome was standardized.
Sexual orientation-specific and general aging concerns
Main and interaction effects are presented in Table 4. Greater sexual orientation-specific and general aging concerns were associated with greater depression and anxiety. The interaction between sexual orientation-specific and general aging concerns was significant in the model predicting depression. Simple slopes demonstrated that greater sexual orientation-specific aging concerns were significantly associated with greater depression at low (conditional effect = 0.37, SE = 0.07, CI95 = 0.24–0.50) and moderate (conditional effect = 0.23, SE = 0.05, CI95 = 0.14–0.32), but not high (conditional effect = 0.09, SE = 0.05, CI95 = −0.004 to 0.19), levels of general aging concerns (Fig. 2).
FIG. 2.
Interaction between sexual orientation-specific and general aging concerns predicting depression. Simple slopes of sexual orientation-specific aging concerns predicting depression at low (−1 standard deviation), moderate (mean), and high (+1 standard deviation) levels of general aging concerns. Figures reflect adjusted results, which control for age, race/ethnicity, sexual orientation, and gender identity. The y-axis includes positive and negative values because the outcome was standardized.
The interaction between sexual orientation-specific and general aging concerns was also significant in the model predicting anxiety. Simple slopes demonstrated that greater sexual orientation-specific aging concerns were significantly associated with greater anxiety at low (conditional effect = 0.33, SE = 0.07, CI95 = 0.20–0.46) and moderate (conditional effect = 0.21, SE = 0.05, CI95 = 0.12–0.30), but not high (conditional effect = 0.08, SE = 0.05, CI95 = −0.02 to 0.18), levels of general aging concerns (Fig. 3). Again, contrary to expectations, the associations between sexual orientation-specific aging concerns and depression and anxiety were stronger at lower levels of general aging concerns.
FIG. 3.
Interaction between sexual orientation-specific and general aging concerns predicting anxiety. Simple slopes of sexual orientation-specific aging concerns predicting anxiety at low (−1 standard deviation), moderate (mean), and high (+1 standard deviation) levels of general aging concerns. Figures reflect adjusted results, which control for age, race/ethnicity, sexual orientation, and gender identity. The y-axis includes positive and negative values because the outcome was standardized.
Discussion
Consistent with the Minority Stress Model,3,13 we replicated and extended prior findings5,15,16 by demonstrating that participants who experienced more sexual orientation- and age-related discrimination reported greater depression and anxiety. One study also found that the associations between age discrimination and depression and anxiety were strongest at high levels of sexual orientation discrimination and that depression and anxiety were highest for those who experienced high levels of both types of discrimination.5 Based on an examination of our simple slope plots, we also found that anxiety was highest for those who experienced high levels of both types of discrimination. However, we found that the association between sexual orientation discrimination and anxiety was weaker at higher levels of age discrimination. Given that SM older adults may have experienced sexual orientation discrimination throughout their lives, age discrimination may be a more recent and therefore more salient stressor. This could explain why sexual orientation discrimination was less strongly associated with anxiety at higher levels of age discrimination and why those who experienced high levels of age discrimination experienced the highest levels of anxiety regardless of the extent to which they experienced sexual orientation discrimination.
Despite evidence that older adults report aging concerns other than discrimination,22 very few studies have examined these concerns in relation to SM older adults' mental health. We found that participants who reported more sexual orientation-specific and general aging concerns also reported more severe depression and anxiety. Furthermore, we found that greater sexual orientation-specific aging concerns were associated with greater depression and anxiety at low and moderate levels of general aging concerns, but not at high levels of general aging concerns.
One possible explanation for these findings is that our measure of general aging concerns captured a wider range of concerns (e.g., becoming socially isolated and lonely, needing services from a long-term care facility, not having enough money to support oneself after retirement) compared with our measure of sexual orientation-specific aging concerns, and, on average, our participants reported higher levels of general aging concerns compared with sexual orientation-specific aging concerns.
Therefore, it is possible that the breadth of general aging concerns reflected in the measure contributed to general aging concerns having a stronger influence on mental health compared with sexual orientation-specific aging concerns. In addition, it is likely that the extent to which sexual orientation-specific aging concerns influence mental health depends on a person's openness about their sexual orientation and the level of acceptance they experience. If a person is open about their sexual orientation and accepted by their family, then sexual orientation-related aging concerns may be less likely to influence their mental health.
Finally, SM older adults may have experienced some of the sexual orientation-specific aging concerns throughout their lives (e.g., concern that providers will make assumptions about their health based on their sexual orientation), whereas general aging concerns reflect a newer threat to one's sense of self and safety. This “novelty” may have also contributed to general aging concerns having a stronger influence on mental health compared with sexual orientation-specific aging concerns.
Limitations
Our study should be considered in light of several limitations. First, our data were cross-sectional and longitudinal data are needed to examine the extent to which discrimination and aging concerns are associated with increases in depression and anxiety over time. Second, our participants lived in or near Columbus, Ohio, and it is unknown if our findings generalize to the broader population of SM older adults. Third, we adapted the Everyday Discrimination Scale to focus on sexual orientation and age. Although prior studies have also adapted it to focus on specific demographics, participants may have been unable to determine why they were discriminated against at times. We encourage researchers to use measures designed to assess specific experiences of heterosexism and ageism in future studies and to consider other forms of oppression (e.g., racism, cissexism) and intersectional discrimination. Furthermore, the associations tested in this study may differ as a function of demographic characteristics (e.g., race, ethnicity, gender identity), which could be tested in future studies. Finally, although our measures of aging concerns have been used in a prior study,5 there is a need for greater attention to measurement of these constructs and the development of measures that comprehensively assess the range of aging concerns experienced by SM older adults.
Conclusions
The available evidence indicates that SM older adults remain at elevated risk for adverse mental health outcomes compared with their heterosexual peers.6,7,10–12 Our findings highlight the range of factors that contribute to SM older adults' mental health, including sexual orientation- and age-related discrimination as well as sexual orientation-specific and general aging concerns. In addition, our findings demonstrate that general and sexual orientation-specific factors interact in complex ways to influence mental health in this population.
A systematic review identified a number of promising mental health interventions for older adults as well as characteristics that were associated with better intervention outcomes (e.g., whether the intervention accommodated individual preferences, needs, and levels of functioning).29 To our knowledge, no prior studies have specifically developed a mental health intervention for SM older adults. Based on our findings, such an intervention should attend to discrimination at the intersection of sexual orientation and age as well as other concerns related to aging, including sexual orientation-specific concerns. Clinicians can draw on resources for adapting evidence-based interventions to address minority stress to inform their work with SM older adults.30 Finally, structural interventions are also needed to reduce sexual orientation- and age-related discrimination at their sources.
Authors' Contributions
B.A.F. was involved in conceptualization (lead); supervision (lead); writing—original draft (lead); and methodology (supporting). B.W.K. was involved in formal analysis (lead); visualization (lead); and writing—original draft (supporting). I.B. and T.M. were involved in writing—original draft (supporting). C.D. was involved in formal analysis (supporting); visualization (supporting); methodology (supporting); and writing—review and editing (equal). E.M. was involved in investigation (lead); methodology (lead); project administration (lead); and writing—review and editing (equal).
Disclaimer
The content is solely the responsibility of the authors and does not necessarily represent the official views of the funding agency.
Author Disclosure Statement
No conflicts of interest exist.
Funding Information
B.A.F. and C.D. were supported by grants from the National Institute on Drug Abuse (K08DA045575, PI: B.A.F.; and K01DA046716, PI: C.D.).
References
- 1. King M, Semlyen J, Tai SS, et al. A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people. BMC Psychiatry 2008;8(1):70; doi: 10.1186/1471-244X-8-70 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 2. Marshal MP, Dietz LJ, Friedman MS, et al. Suicidality and depression disparities between sexual minority and heterosexual youth: A meta-analytic review. J Adolesc Health 2011;49(2):115–123; doi: 10.1016/j.jadohealth.2011.02.005 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3. Meyer IH. Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: Conceptual issues and research evidence. Psychol Bull 2003;129(5):674–697; doi: 10.1037/0033-2909.129.5.674 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4. Semlyen J, King M, Varney J, et al. Sexual orientation and symptoms of common mental disorder or low wellbeing: Combined meta-analysis of 12 UK population health surveys. BMC Psychiatry 2016;16(1):67; doi: 10.1186/s12888-016-0767-z [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5. Lytle A, Apriceno M, Dyar C, et al. Sexual orientation and gender differences in aging perceptions and concerns among older adults. Innov Aging 2018;2(3):igy036; doi: 10.1093/geroni/igy036 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6. Stinchcombe A, Wilson K, Kortes-Miller K, et al. Physical and mental health inequalities among aging lesbian, gay, and bisexual Canadians: Cross-sectional results from the Canadian Longitudinal Study on Aging (CLSA). Can J Public Health 2018;109(5–6):833–844; doi: 10.17269/s41997-018-0100-3 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 7. Fredriksen-Goldsen KI, Kim HJ, Barkan SE, et al. 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 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8. Fredriksen-Goldsen KI, Kim HJ, Shiu C, et al. Successful aging among LGBT older adults: Physical and mental health-related quality of life by age group. Gerontologist 2015;55(1):154–168; doi: 10.1093/geront/gnu081 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9. Canuto A, Weber K, Baertschi M, et al. Anxiety disorders in old age: Psychiatric comorbidities, quality of life, and prevalence according to age, gender, and country. Am J Geriatr Psychiatry 2018;26(2):174–185; doi: 10.1016/j.jagp.2017.08.015 [DOI] [PubMed] [Google Scholar]
- 10. Fokkema T, Kuyper L. The relation between social embeddedness and loneliness among older lesbian, gay, and bisexual adults in the Netherlands. Arch Sex Behav 2009;38(2):264–275; doi: 10.1007/s10508-007-9252-6 [DOI] [PubMed] [Google Scholar]
- 11. Sivakumaran G, Margolis R. Self-rated health by sexual orientation among middle-aged and older adults in Canada. J Gerontol B Psychol Sci Soc Sci 2020;75(8):1747–1757; doi: 10.1093/geronb/gbz067 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12. Valanis BG, Bowen DJ, Bassford T, et al. Sexual orientation and health: Comparisons in the women's health initiative sample. Arch Fam Med 2000;9(9):843–853; doi: 10.1001/archfami.9.9.843 [DOI] [PubMed] [Google Scholar]
- 13. Brooks VR. Minority Stress and Lesbian Women. Lexington Books: Lexington, MA, USA; 1981. [Google Scholar]
- 14. Fredriksen-Goldsen KI, Simoni JM, Kim HJ, et al. The health equity promotion model: Reconceptualization of lesbian, gay, bisexual, and transgender (LGBT) health disparities. Am J Orthopsychiatry 2014;84(6):653–663; doi: 10.1037/ort0000030 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 15. Brown AL, Matthews DD, Meanley S, et al. The effect of discrimination and resilience on depressive symptoms among middle-aged and older men who have sex with men. Stigma Health 2022;7(1):113–121; doi: 10.1037/sah0000327 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16. Fredriksen-Goldsen KI, Emlet CA, Kim HJ, et al. The physical and mental health of lesbian, gay male, and bisexual (LGB) older adults: The role of key health indicators and risk and protective factors. Gerontologist 2013;53(4):664–675; doi: 10.1093/geront/gns123 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 17. Johnson MJ, Jackson NC, Arnette JK, et al. Gay and lesbian perceptions of discrimination in retirement care facilities. J Homosex 2005;49(2):83–102; doi: 10.1300/J082v49n02_05 [DOI] [PubMed] [Google Scholar]
- 18. Stein GL, Beckerman NL, Sherman PA. Lesbian and gay elders and long-term care: Identifying the unique psychosocial perspectives and challenges. J Gerontol Soc Work 2010;53(5):421–435; doi: 10.1080/01634372.2010.496478 [DOI] [PubMed] [Google Scholar]
- 19. Suen Y. Lesbian, Gay, Bisexual and Transgender Ageing. In: Routledge Handbook of Cultural Gerontology. (Twigg J, Martin W. eds.) Routledge: New York, NY, USA; 2015. [Google Scholar]
- 20. Brennan-Ing M, Seidel L, Larson B, et al. Social care networks and older LGBT adults: Challenges for the future. J Homosex 2014;61(1):21–52; doi: 10.1080/00918369.2013.835235 [DOI] [PubMed] [Google Scholar]
- 21. Schope RD. Who's afraid of growing old? J Gerontol Soc Work 2005;45(4):23–39; doi: 10.1300/J083v45n04_03 [DOI] [PubMed] [Google Scholar]
- 22. Airth L, Oelke ND. How neoliberalism, ageism and stigma drive the lack of policy for older adults' mental health. J Psychiatr Ment Health Nurs 2020;27(6):838–843; doi: 10.1111/jpm.12618 [DOI] [PubMed] [Google Scholar]
- 23. Bryant C, Bei B, Gilson K, et al. The relationship between attitudes to aging and physical and mental health in older adults. Int Psychogeriatr 2012;24(10):1674–1683; doi: 10.1017/S1041610212000774 [DOI] [PubMed] [Google Scholar]
- 24. Chachamovich E, Fleck M, Laidlaw K, et al. Impact of major depression and subsyndromal symptoms on quality of life and attitudes toward aging in an international sample of older adults. Gerontologist 2008;48(5):593–602; doi: 10.1093/geront/48.5.593 [DOI] [PubMed] [Google Scholar]
- 25. Krieger N, Smith K, Naishadham D, et al. Experiences of discrimination: Validity and reliability of a self-report measure for population health research on racism and health. Soc Sci Med 2005;61(7):1576–1596; doi: 10.1016/j.socscimed.2005.03.006 [DOI] [PubMed] [Google Scholar]
- 26. Kroenke K, Strine TW, Spitzer RL, et al. The PHQ-8 as a measure of current depression in the general population. J Affect Disord 2009;114(1–3):163–173; doi: 10.1016/j.jad.2008.06.026 [DOI] [PubMed] [Google Scholar]
- 27. Spitzer RL, Kroenke K, Williams JBW, et al. A brief measure for assessing generalized anxiety disorder: The GAD-7. Arch Intern Med 2006;166(10):1092–1097; doi: 10.1001/archinte.166.10.1092 [DOI] [PubMed] [Google Scholar]
- 28. Hayes AF. Partial, conditional, and moderated mediation: Quantification, inference, and interpretation. Commun Monogr 2018;85(1):4–40; doi: 10.1080/03637751.2017.1352100 [DOI] [Google Scholar]
- 29. Niclasen J, Lund L, Obel C, et al. Mental health interventions among older adults: A systematic review. Scand J Public Health 2019;47(2):240–250; doi: 10.1177/1403494818773530 [DOI] [PubMed] [Google Scholar]
- 30. Pachankis JE, Soulliard ZA, Morris F, et al. A model for adapting evidence-based interventions to be LGBQ-affirmative: Putting minority stress principles and case conceptualization into clinical research and practice. Cogn Behav Pract 2022; doi: 10.1016/j.cbpra.2021.11.005 [DOI] [Google Scholar]