LGBT+ concerns of ageing and accessing aged care services in Australia: A cross‐sectional study

Abstract

Objective

People older than 65 years are anticipated to comprise a steadily increasing proportion of the Australian population. This older adult population is also made up of other sub‐populations that may experience similar, different or additional needs to the ‘average’ older adult, such as LGBT+ people. Given the well‐documented history of oppression, stigma and discrimination, research is critically needed to understand how to best support the concerns and needs of populations such as LGBT+ people.

Method

The present cross‐sectional study aimed to explore the concerns of ageing and accessing aged care services among 171 LGBT+ people in Australia.

Results

The results revealed that LGBT+ people were most concerned about their health and physical functioning, including feelings of isolation, loneliness and abandonment as they age. The results also indicated a range of specific concerns for accessing aged care services, including feeling respected and service quality and discrimination, particularly from religiously run organisations.

Conclusions

Despite a relatively small and homogenous sample, this study was able to identify important beliefs and experiences held by this cohort to help shape advocacy, policy, procedures and education.

Policy impact.

This study reveals ageing and aged care concerns among LGBT, Sistergirl and Brotherboy Australians, including ongoing fear of stigmatisation and a desire for respectful, inclusive care. These findings highlight a need for ongoing improvements in education and workforce policy to ensure safe and affirming services.

1. INTRODUCTION

Ageing entails biological, psychological and sociological changes that increase the need for aged care and community services (e.g. health‐care, housing and community access). While there is an increased likelihood of the need to access these services for all older people, diverse priority sub‐populations of older people need to access these services in different ways (e.g. older people with a disability may need more variety and intensity of services) and have unique experiences of these same services. ¹ , ² Lesbian, gay, bisexual, trans, (hereon LGBT+) communities have documented experiences of oppression, stigma, discrimination, criminalisation and pathologisation potentially finding aged care services retraumatising or problematic, particularly those run by some religious organisations. ³ , ⁴ , ⁵ Despite societal shifts, older LGBT+ Australians face unique barriers to service access and may delay help seeking due to past negative experiences and trauma or fear of rejection and discrimination. ⁶ , ⁷ Given these experiences, this study sought to explore: (1) LGBT+ Australian's concerns about ageing; and (2) the concerns of LGBT+ Australian about accessing aged care services.

1.1. LGBT+ and ageing

In Australia, approximately 16% of the population (4.2 million people) is older than 65 years and this is projected to rise to 22% by 2050. ⁸ , ⁹ Much of the existing literature treats older people as a homogenous group, overlooking minority experiences. This invisibility may stem from researcher biases and systemic issues, such as a lack of nuanced questions about sexual orientation and gender identity in the Australian Census. ¹⁰ , ¹¹ This ageing population will likely increase demand for a variety of services, including aged care services. Older LGBT+ people experience many of the same and more pronounced effects of ageing as their cis‐heterosexual counterparts, and also face additional and unique challenges, including stigma, inequitable treatment and lack of acceptance and support. ¹² , ¹³ Recognising these unique needs, older LGBT+ Australians have been formally identified as a group requiring specific consideration in national health, mental health and alcohol and other drug strategies. ¹⁴ , ¹⁵ , ¹⁶ Despite socio‐cultural progress in Australia, LGBT+ people remain more likely to experience inequitable treatment and discrimination, leading to distrust in health‐care, legal and justice systems. ¹⁷ , ¹⁸ This distrust can result in reluctance to disclose identity or seek help, despite this community experiencing poorer mental and physical health outcomes. ¹⁹ , ²⁰ , ²¹ , ²²

1.2. Ageing concerns

Ageing concerns can include finances, health and grief/loss. LGBT+ people share many of these concerns, but also experience specific ones, such as discrimination, stigma and racism as well as lack of family and peer support, and unequitable treatment from health‐care providers. ¹³ , ²³ , ²⁴ , ²⁵ For example, Czaja et al. (2016) found that gay men's concerns centred around discrimination, lack of social support, fear of ‘coming out’, isolation, legal and financial issues, and limited community resources. Lesbian concerns were similar, with added worries about loss of loved ones and health‐care providers' lack of knowledge about their community. Furthermore, Willis et al (2020), found that older trans people held a high degree of ambivalence towards their expectations for inclusive social care services.

1.3. Aged care service access concerns

Findings from the Australian Government Royal Commission into Aged Care Quality and Safety suggest many older Australians had difficulties accessing inclusive, respectful and person‐centred care. ²⁶ This has reinforced what others have found with respect to adverse experiences, particularly among LGBT+ related discrimination and prejudice. ²⁷ , ²⁸ In Australia, eligibility for aged care services is typically from 65 years of age; however, for Aboriginal and Torres Strait Islander peoples, eligibility begins at 50 years due to well‐documented health inequities, lower life expectancy and earlier onset of chronic conditions compared to the non‐Indigenous population. These factors highlight the importance of considering culturally appropriate and accessible aged care services for First Nations peoples. Houghton (2018) found that LGBT people of colour worried that both their race and LGBT+ identity would lead to poor care, and reduced access to health services. Trans and gender‐diverse individuals are also more likely to express concerns that their intersecting identities may impact the quality of care they receive than cisgender individuals. ²⁹ , ³⁰ Concerns exist about disclosing LGBT+ identity to providers, how this might affect service quality, and whether services might be denied. ³¹ , ³² , ³³ Further concerns include providers' lack of knowledge about LGBT+ people, inadequate care, lack of compassion and ignorance, ²⁷ , ³⁴ as well as worries about residential care and potential mistreatment from other residents. ³⁵ , ³⁶

Previous Australian research has indicated most LGBT+ people were concerned about service quality being affected by their sexual identity. ³⁷ Key concerns regarding service access included recognition and inclusion of same‐sex relationships and partners, service awareness and inclusion of LGBT+ people and their issues, and potential prejudice and discrimination from providers. ³⁰ , ³⁷ , ³⁸ , ³⁹ , ⁴⁰ Older individuals were more likely than younger individuals to have concerns about access to LGBT+ specific services and discrimination. ⁶ , ³⁸ , ⁴¹

1.4. Rationale

With an ageing population, exploring the unique needs of specific sub‐populations is essential to ensure the current and future workforce is prepared to deliver culturally appropriate and sensitive care, including those with intersecting identities. ²⁴ , ⁴² While some research has explored LGBT+ Australians' concerns about ageing and aged care access, understanding contemporary beliefs is crucial. Broadly, research on the ageing concerns of LGBT+ people remains limited. Understanding these concerns can help government and non‐government organisations provide enhanced inclusive and affirming services. Organisations can use this research to develop policies, procedures, programs and services that provide quality care, respecting the rights, dignity and diversity of each LGBT+ person. Thus, this study explores LGBT+ people's concerns about ageing and accessing aged care services in Australia.

2. METHOD

2.1. Research design

Data for this exploratory cross‐sectional study were extracted from a larger data set collected using the Building a better picture of LGBT, Sistergirl and Brotherboy ageing and caring in Queensland, Australia online survey ¹⁹ co‐developed in consultation with a Community Advisory Group (CAG) of sexually and gender‐diverse people and those with innate variations of sex characteristics (hereon IVSC; also known as intersex variations/traits) with intersecting identities, including those with lived experiences of ageing and living with HIV. Importantly, the authors of this study are of diverse sexualities and genders, including intersecting identities such as ageing, First Nations background, living with HIV, culturally and linguistically diverse, disability and living in a regional, remote or rural setting. The study utilised a descriptive, quantitative design with all variables measured at one time point. This manuscript was prepared in accordance with the Checklist for Reporting of Survey Studies (CROSS) guideline (see Appendix S2).

2.2. Materials

The survey for the current study was adapted from a similar prior survey conducted by the LGBT Ageing Action Group in 2007/2008 in consultation with the CAG and a number of co‐authors from the original survey team. Details regarding the working group, survey development and quantitative results have been published elsewhere. ³⁸ The research was granted ethics approval by the University of Southern Queensland Human Research Ethics Committee (approval no.: H21REA098). All the project activities were performed in accordance with the ethical standards of the University of Southern Queensland Human Research Ethics Committee, and with the 1964 Declaration of Helsinki and its later amendments, including the Australian National Statement on Ethical Conduct in Human Research (2007)—Updated 2018.

2.3. Survey questions

The survey included a range of demographic variables including age, gender identity, if their gender was different from that assigned at birth, sexual/romantic orientation, intersex variations, First Nations background, country of birth, location of living and HIV status.

2.4. Ageing concerns

Three questions were asked in relation to ageing concerns. The first asked participants to identify all relevant concerns of ageing that applied to them from a selection of 15 options (e.g. ‘being alone’, ‘not having my health or personal needs understood’, ‘lack of respect for my identity’), including an open‐ended ‘other’ option. A second question asked participants to identify their top three health concerns that related to ageing from an array of 20 options (e.g. ‘general decline in health’, ‘loss of mobility’ or ‘a mental illness’). Last, participants were asked about their current financial situation including whether they believed they would struggle financially as they age. Please refer to Appendix S1 for a list of the survey question items.

2.5. Aged care service access concerns

Concerns of accessing aged care services were explored with three questions. The survey first asked participants to identify whether they held concerns about their sexual or gender identity affecting the quality of the aged care services provided to them on a three‐point scale (i.e. options included ‘yes’, ‘no’ and ‘not sure’). Participants were then asked to identify their main concerns of accessing aged care services from an array of 19 options (e.g. ‘services may not be aware or inclusive or me’, ‘staff are not trained in sexuality issues’ or ‘services not recognising my cultural identity’), including an open‐ended ‘other’ option. Last, participants were asked to identify the main ways they were concerned that their sexual or gender identity may affect the quality of aged care services from a collection of 15 options (e.g. ‘I am not concerned’, ‘not receiving sensitive service provision’ or ‘not having my same sex relational or partner/s recognised’), including an open‐ended ‘other’ option. Participants were able to select as many options as relevant to them. Please refer to Appendix S1 for a list of the survey question items.

2.6. Participants and recruitment

Eligibility to participate in the study included being a minimum of 18 years of age; living in Queensland, Australia; and identifying as a sexually and/or gender‐diverse person and/or born with an innate variation of sex characteristics (IVSC). Data were collected from 1 July 2021 to 1 August 2022. One hundred seventy‐one people completed the full survey. Demographic information for the sample is presented in Table 1. While the survey was intended to be inclusive of persons born with IVSC, no participants reported being born with IVSC. Similarly, while almost 5% of the participants identified as First Nations, only one participant each identified as either Sistergirl or Brotherboy. In consultation with a Queensland IVSC community representative (also a CAG member) and the broader steering committee, and to avoid misleading readers or misrepresenting the experiences of people born with IVSC and Sistergirl and Brotherboy people, the results and discussion will refer to LGBT+ peoples here on.

TABLE 1.

Demographic frequencies of participants (N = 171).

Variables	Count	%
Age
Younger than 50 years	76	44.4
Older than 50 years	95	55.6
Gender
Male (cis)	67	39.2
Female (cis)	69	40.4
Transgender man	6	3.5
Brotherboy	1	0.6
Sistergirl	1	0.6
Non‐binary	17	9.9
Gender diverse	2	1.2
Other—not specified	3	1.8
Prefer not to say	1	0.6
Sexual/romantic orientation
Lesbian	58	33.9
Gay	60	35.1
Straight/heterosexual	7	4.1
Bisexual	14	8.2
Pansexual	12	7.0
Queer	15	8.8
Asexual/aromantic	3	1.8
Other—not specified	2	1.2
First Nations status
Yes, Aboriginal	7	4.1
Yes, Aboriginal and Torres Strait Islander	1	0.6
No	160	93.6
Prefer not to say	3	1.8
Country of birth
Australia	135	78.9
Other (e.g. New Zealand, UK, United States and Netherlands)	36	21.1
Living with HIV
Yes	16	9.4
No	153	89.5
Not specified/prefer not to say	2	1.2

Multiple purposive sampling approaches were used. Participants were recruited via flyers that were either paper or electronic with a QR code and survey link and were distributed to various LGBTQIA+ and health‐related organisations, including government and not‐for‐profit, between 1 July 2021 and 1 August 2022. Participants were able to complete the survey via a paper copy (by request) or online; there was the inclusion of a participants information sheet and a consent form included, which was completed by all participants before completing the survey. While the full survey participants completed was estimated to take between 30 and 60 min, the current study focuses on three of the survey questions pertaining to concerns of ageing and accessing aged care services, estimated to take significantly <30–60 min.

2.7. Data analysis

The data were visually inspected using bar charts and histograms to determine any inconsistencies or anomalies in the data. The questions related to ageing were merged given their similarities and then separated into thematically coherent categories. The options for the main concerns of accessing aged care services were distilled into nine thematic categories while the options relating to quality of care was distilled into five thematic categories. Frequency of endorsement of the themes was then recorded and summed.

3. RESULTS

3.1. Participants

The current study included 171 participants, primarily consisting of cis‐female (40.4%), cis‐male (39.2%), non‐binary (9/9%) people and trans (3.5%) people. Participants identified with a variety of sexual and romantic orientations, including gay (35.1%), lesbian (33.9%), queer (8.8%), bisexual (8.2%) and pansexual (7.0%). Participants identified as primarily being born in Australia (78.9) and being older than 50 years (55.6%). Further demographic information can be found in Table 1.

3.2. Ageing concerns

The three most common ageing concerns were as follows: General Health and Physical Function (167 responses; e.g. general decline in health, loss of physical function), Interpersonal (144 responses; e.g. maintaining social networks and friends, losing contact with my culture) and Intrapersonal (125 responses; e.g. self‐esteem). The least common concern was the following: Financial (8 responses; e.g. struggling with lack of finances). All categories and response counts are presented in Table 2.

TABLE 2.

Frequencies of ageing concerns.

Concerns of ageing	Total count	% of total population (N = 171) (%)
General health and physical function concerns	167	97.66
Interpersonal concerns	144	84.21
Intrapersonal concerns	125	73.10
Relevance	110	64.33
Respect	93	54.39
Stigma/discrimination	92	53.80
Being misunderstood and disempowered	62	36.26
Practical concerns around managing chronic illness, medications and disability	51	29.82
Financial	8	4.68

3.3. Aged care service access concerns

The three most common aged care service access concerns (Table 3) were as follows: Concerns about receiving respect and recognition (128 responses), Concerns around quality of services (e.g. inadequate staff training, limited inclusiveness) (107 responses) and Concerns that services are often religious‐based organisation (106 responses). Excluding the ‘other – not specified’ response, the least endorsed option included having ‘no concerns’ (17 responses).

TABLE 3.

Frequencies of service access concerns.

Concern of access to service	Total count	% of total population (N = 171)
Concerns about receiving respect and recognition	128	74.85
Concerns around quality of services (i.e. inadequate staff training and limited inclusiveness)	107	62.57
Concerns that services are often religious‐based organisation	106	61.99
Concerns around discrimination and safety	102	59.65
Services may not be aware or inclusive of me	100	58.48
Concerns about affording services	78	45.61
Relevance	67	39.18
I don't have any concerns	17	9.94
Other—not specified	5	2.92

4. DISCUSSION

This study explored LGBT+ concerns about ageing and their beliefs and expectations regarding aged care services in Australia. With a growing ageing population, it is crucial to understand the unique needs of priority populations, including lesbian, gay, bisexual, transgender, queer, Sistergirl and Brotherboy people. Given their history of stigma and discrimination, this group has specific concerns about ageing and accessing aged care services. Furthermore, there is an identified gap in the training and competencies of aged care facility staff in supporting this group. There are also recent political attacks on societal and scientific endeavours to understand and support policies and research that affect a range of priority populations that are traditionally covered in Diversity, Equity and Inclusion programs. ⁴³ The recent changes to policies in countries like the United States that seek to ignore known systemic issues in LGBT+ people demonstrate the critical need for the current research. In understanding the types of concerns LGBT+ people have, it will support future attempts to create evidence‐based training opportunities.

4.1. Concerns about ageing

The most common concern about ageing was general health and physical function (n = 167; 97.66%). Participants endorsed concerns such as general health decline, loss of independence, mobility and physical function, ageing as a gender‐diverse and cognitive decline. While health and physical function are likely concerns for most older people, this study highlights the prominence of these factors for ageing LGBT+ individuals. Given the disproportionate burden of ill health and disability experienced by LGBT+ people (e.g. living with HIV, mental illness, disability, Sistergirls and Brotherboys), ³⁰ , ⁴⁴ , ⁴⁵ , ⁴⁶ community members from this key priority group may require aged care services earlier or more intensively than their non‐LGBTQ+ counterparts.

Interpersonal concerns, such as maintaining social networks or losing cultural connections, were endorsed by 84.21% of participants (n = 144). Intrapersonal concerns, such as feeling unloved, abandoned or having poor self‐esteem, were reported by 73.10% (n = 125). A recent meta‐analysis found higher rates of loneliness among individuals from sexual minority groups compared to heterosexual individuals, ⁴⁷ with social barriers and discrimination being key determinants of loneliness and social isolation. ⁴⁸ These interconnected concerns likely reflect the recognition that many LGBT+ peoples have experienced rejection and fear its recurrence.

Overall, this study highlights the unique ageing concerns of LGBT+ Australians. The most prevalent concerns relate to physical, mental and social well‐being, mirroring ongoing challenges faced by many LGBT+ people before reaching older age. ³⁸ Specifically, a disproportionate percentage of LGBT+ people report experiencing physical and mental health challenges and higher rates of social isolation and loneliness compared to their cis‐heterosexual peers, ⁴⁷ , ⁴⁹ which are reflected in their ageing concerns.

4.2. Concerns about accessing aged care services

A significant proportion of participants (n = 128; 74.85%) expressed concerns about receiving respect and recognition, such as services not recognising same‐sex partners or diverse gender experiences. This echoes previous research and highlights ongoing concerns and experiences of prejudice among LGBT+ people. ³⁶ , ⁵⁰ Despite legal advances in Australia (e.g. marriage equality), these concerns may reflect the lived/living experience of discrimination and bias within parts of the community. ⁵¹

Nearly two‐thirds (62.57%) of respondents (n = 107) were concerned about the quality, awareness and inclusion of LGBT+ identities/experiences in diverse services. This centred on the belief that aged care staff might lack training in working with LGBT+ people or that few services cater to this diverse community. Government and other organisational initiatives like the ‘Rainbow Tick’ ‘Yellow Tick’, ‘Safe Space Alliance’ and ‘Silver Rainbow’ program aim to address this lack of cultural sensitivity. ⁵² , ⁵³ , ⁵⁴ Other research has also identified ongoing issues with low training standards, which competency standards hope to address. ⁵⁵ , ⁵⁶ Over half (61.99%) (n = 106) of participants expressed concern about stigmatisation or discrimination by religious organisations. In Australia, many not‐for‐profit and community sector aged care service providers and organisations are religiously affiliated. This concern likely reflects historical and contemporary experiences of systemic stigma and discrimination justified by oppressive religious values. ³ , ⁵⁰ , ⁵⁷

4.3. Limitations, implications and future research

Despite pertinent findings arising from this novel exploratory cross‐sectional study, it is not without limitations. The relatively small sample size limited the diversity of ethnic, cultural and linguistic backgrounds represented; however, the sample size was appropriate for the research questions. Similarly, participants needed English language and health literacy proficiency, which likely limits the representativeness of underserved communities. Another limitation of this study relates to the data being obtained from a sample of LGBT+ people in Queensland. As such, the generalisability of the findings beyond this geographical footprint is limited. The study may also be subject to self‐reporting bias. More specifically, the recruitment strategies used may have disproportionately attracted individuals with a stronger interest in the study topics and/or those with greater affiliation with the LGBT+ communities.

The results primarily reflect cisgender white people identifying as sexually diverse. Notably, there were no participants who were born with IVSC. As reported in the literature, people with IVSC often face medically unnecessary surgeries and treatment without consent, pathologisation, secrecy, stigma, discrimination and shame, which reinforces endosexism, cisgenderism and heteronormative conformity, ⁵⁸ leading to poorer mental and physical health. ⁵⁹ They also report negative experiences with disclosure in social, ⁵⁸ educational ⁶⁰ , ⁶¹ and health‐care ⁶² contexts. The prospect of exposure due to dependence on aged care services may be particularly distressing. ⁶² Similarly, we were only able to recruit two people who identified as either Sistergirl or Brotherboy. Future research must represent the diversity of gender identity and expression, including within First Nation communities. Further co‐designed and peer‐led research is needed to understand the nuanced needs, concerns and preferences of this diverse population and in relation to promoting affirming aged care and reducing stigma among health professionals and wider society, including supporting community members with further intersecting identities. ⁶³ , ⁶⁴ , ⁶⁵ , ⁶⁶ , ⁶⁷

Future research should focus on specific sub‐populations within the LGBT+ communities, including trans and gender‐diverse people, those with IVSC, Sistergirls, Brotherboys, First Nations peoples, culturally and linguistically diverse people, and those living in regional, rural and remote communities. This more comprehensive approach can reveal the breadth and nuances of experiences within the LGBT+ community. ⁶⁸ , ⁶⁹ It can also clarify beliefs to inform public health interventions and targeted training for the aged care sector. Research exploring current experiences of LGBT+ people accessing aged care services and the needs of aged care staff is also needed. Finally, future research should use diverse methodologies, such as semi‐structured interviews and yarning methodologies, ⁷⁰ , ⁷¹ to further elucidate the unique experiences and stories of this diverse vulnerable and key priority population.

5. CONCLUSION

This study explored the concerns of older LGBT+ Australians regarding ageing and accessing aged care services. Concerns typically centred around general health, safety and discrimination, service quality, respect and recognition. Identifying these concerns provides important insights into the beliefs and experiences of LGBT+ Australians that can help shape future advocacy, policy, procedures, training and further research. Given the modest and homogenous sample, future research should use qualitative methodologies to explore other portions and broader/more representative samples of the LGBT+ population.

FUNDING INFORMATION

This work was supported by the University of Southern Queensland. The authors also acknowledge the financial support provided by Queensland Positive People and Queensland Council for LGBTI Health.

CONFLICT OF INTEREST STATEMENT

No conflicts of interest declared.

Supporting information

Appendices S1–S2

Scott K, Brown DJ, Brömdal A, et al. LGBT+ concerns of ageing and accessing aged care services in Australia: A cross‐sectional study. Australas J Ageing. 2025;44:e70084. doi: 10.1111/ajag.70084

DATA AVAILABILITY STATEMENT

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.