Resilience and Disparities among Lesbian, Gay, Bisexual, and Transgender Older Adults

Introduction

Increasing diversity is a defining feature of the growing older adult population across the globe. The expanding multicultural older adult population presents both opportunities and challenges in healthcare and gerontological research and public policy. Despite tremendous advancements in health, minority and historically disadvantaged communities bear higher levels of illness, disability, and premature death. A primary commitment of the National Institutes of Health (2010) is to reduce and eliminate health disparities, which are defined as differences in health impacting communities that have, as a result of social, economic, and environmental disadvantage, systematically encountered obstacles to good health (Department of Health and Human Services, 2010). Yet, the unique health and aging needs of lesbian, gay, bisexual, and transgender older adults are rarely addressed in research or policy.

The Centers for Disease Control and Prevention (2011) identifies research on sexual orientation as one of the most pronounced gaps in health disparities research. A recent report by the Institute of Medicine (2011) ascertains that lesbian, gay, bisexual, and transgender older adults are one of the least understood groups in terms of their health and aging-related needs. In a 25-year review of the literature, Fredriksen-Goldsen and Muraco (2010) conclude that health research is glaringly absent in studies about lesbian, gay, bisexual, and transgender aging. It is important to recognize and understand the prevalence of health disparities by sexual orientation among older adults and the unique factors that characterize the experiences and needs of lesbian, gay, bisexual, and transgender adults as they age. In addition, there are implications of such disparities in aging-related public policy, services, and research. Understanding aging across these historically disadvantaged groups expands our knowledge of the diverse experiences and needs of the older adult population.

In the first study funded by the National Institutes of Health and the National Institute on Aging to address the aging and health of lesbian, gay, bisexual, and transgender adults 50 years of age and older, important new findings provide a portrait of the health disparities and strengths in these communities (Fredriksen-Goldsen et al., 2011). Collectively, data from a state-level population based study and data from a national survey of lesbian, gay, bisexual, and transgender older adults reveal essential knowledge about the prevalence of health disparities and resilience in these communities.

Health Disparities: What Do We Know?

Utilizing state-level population based data, we found that contrary to the myth that older adults will not reveal their sexual orientation in public health surveys, approximately two percent of adults age 50 and older self-identify as lesbian, gay, or bisexual. Based on the number of adults age 50 and older currently living in the U.S., these findings indicate that more than two million older adults self-identify as lesbian, gay, or bisexual. Given the tremendous surge in the aging of the population in the next few decades, the number of older lesbians, gay men, bisexual women, and bisexual men will continue to rise exponentially. The population of lesbian, gay, bisexual, and transgender older adults is expected to double between 2000 and 2030.

Lesbian, gay, bisexual, and transgender older adults are a resilient yet at-risk population experiencing significant health disparities. The prevalence of many common health problems is elevated among these groups, even when taking into account differences in age distribution, income, and education. Compared to their heterosexual counterparts, lesbian, gay, and bisexual older adults are at an elevated risk of disability and mental distress. Forty-one percent of lesbian, gay, and bisexual adults age 50 and older have a disability; surprisingly, among sexual minority adults 18 years of age and older, women are more likely to have a disability than are men (Fredriksen-Goldsen, Kim, & Barkan, in press). Important differences in health behaviors are also evident, with lesbian, gay, and bisexual older adults more likely to smoke and engage in heavy drinking than their heterosexual counterparts.

Important differences between sexual minority women and heterosexual women are also evident. For example, older lesbians and bisexual women report heightened risks of cardiovascular disease and obesity and a lower likelihood of having a mammogram as compared to older heterosexual women. When comparing sexual minority men to heterosexual men, older gay and bisexual men are more likely to experience poor physical health compared to heterosexual men of similar age. While information on HIV status is not available in the population-based data, this disparity is likely related to the prevalence of HIV among gay and bisexual men. Given the effectiveness of anti-retroviral therapies, more adults are living into old age with HIV disease. It is also important to note that differences emerge between sexual minority groups. For example, older lesbians are significantly more likely to engage in heavy drinking as compared to older bisexual women. Furthermore, diabetes is significantly more common among older bisexual men than among older gay men, and older bisexual men are less likely to have obtained an HIV than gay men.

The study also illustrates important sociodemographic differences by sexual orientation and age. Despite higher levels of education for older lesbians, gay men, and bisexuals, and the higher likelihood of employment for older lesbians and bisexual women compared to older heterosexual women, this does not result in higher incomes. All of the older sexual minorities groups are less likely to be partnered or married, which likely reflects limited access to marriage and may result in less support as they age. Older gay and bisexual men, compared to older heterosexual men, have significantly fewer children in the household and are significantly more likely to live alone. In the general population, older women are more likely to live alone than older men, however in these populations, the trend is reversed and gay and bisexual older men are at an elevated risk for living alone. Older adults who live alone in the general population are at risk of social isolation, which is linked to poor mental and physical health, cognitive impairment, and premature morbidity and mortality.

Important health strengths are also evident among older lesbians, gay men, and bisexual women and men. For example, older gay and bisexual men show lower likelihood of obesity and a higher likelihood of receiving a flu shot and an HIV test as compared to older heterosexual men. In addition, older lesbians and bisexual women are more likely to receive an HIV test than their heterosexual counterparts. Furthermore, while much of the research on aging in these communities is based on an assumption of differences by sexual orientation, there are some important similarities in health. For example, there are no differences found by sexual orientation in terms of having health insurance, engaging in physical exercise, or having high blood pressure or high cholesterol.

“LGBT older adults are a resilient yet at-risk population experiencing significant health disparities.”

Risk and Protective Factors Impacting the Health of LGBT Older Adults

Since disparities in health exist among lesbian, gay, and bisexual older adults, we collaborated with 11 agencies across the nation that serve lesbian, gay, bisexual, and transgender older adults to conduct the first national study on lesbian, gay, bisexual, and transgender aging and health (Fredriksen-Goldsen et al., 2011). By conducting a census of socio-demographically diverse participants connected to these agencies, we assessed risk and protective factors associated with health among 2,560 lesbian, gay, bisexual, and transgender older adults. Although most previous studies of aging in these communities have relied on responses from adults in mid-life, this study represents a much broader age spectrum, ranging in age from 50 to 95, with 10 percent age 80 and older, 25 percent age 70-to-79, 41 percent age 60-to-69, and 24 percent age 50-to-59. This component of the study is also unique because it includes transgender older adults (seven percent).

The findings from this national study confirm the higher rates of disability found in the state-level population based study, with almost half of the lesbian, gay, bisexual, and transgender older adults having a disability. The elevated risk of mental distress found in the population based study is also substantiated; an alarming one-third (31 percent) of lesbian, gay, bisexual, and transgender older adults report depression. Transgender older adults are at heightened risk of both disability and depression. More than half (53 percent) of the lesbian, gay, bisexual, and transgender older adults experience loneliness and more than one-quarter (27 percent) have experienced the death of a partner.

There are also positive signs of health and resilience in these communities. For example, most of the lesbian, gay, bisexual, and transgender older adults (91 percent) engage at least weekly in leisure and wellness activities and 82 percent engage in moderate physical activities. Eighty-nine percent feel good about belonging to their communities. More than one-third (38 percent) attend spiritual or religious services or activities at least once a month.

Social and Historical Context of Aging

The social and historical context of aging influences disparities in health. The lived experiences of lesbian, gay, bisexual, and transgender older adults range from coming of age in the shadow of the Great Depression to being part of the baby boom generation. In order to understand the lives of these older adults, particularly the oldest, we must understand the historical context of their lives. Many of these older adults came of age during an era when homosexuality and gender variance were severely stigmatized and criminalized, and as a result, invisibility reigned. The impact of the civil rights movements in the 1960s and the Stonewall riots in 1969 sparked the gay liberation movement and younger lesbians, gay men, bisexual, and transgender adults began to emerge from the margins of society.

Many lesbian, gay, bisexual, and transgender older adults have spent the majority of their lives masking their sexual orientation and gender identity, with their life stories largely silenced.

Unlike some minority groups, most lesbian, gay, bisexual, and transgender older adults are not readily identifiable and they must constantly manage the disclosure of their sexual orientation or gender identity fearing discrimination and victimization.

Discrimination and Victimization

Over their lifetime, most lesbian, gay, bisexual, and transgender older adults have faced serious adversity. Discrimination creates several significant risk factors for lesbian, gay, bisexual, and transgender older adults and their communities (Fredriksen-Goldsen, Kim, Muraco & Mincer, 2009). Both historical and contemporary experiences of victimization create obstacles to accessing and utilizing necessary health and social support services. Due to the perception of being lesbian, gay, bisexual, or transgender, 82 percent of these older adults have been victimized at least once in their lives, and nearly two-thirds (64 percent) at least three times. More than two-thirds (68 percent) have experienced verbal insults and 42 percent have been threatened with physical violence. Other types of victimization they have experienced include being hassled by police (27 percent), threatened to be outed as lesbian, gay, bisexual, or transgender (23 percent), not hired for a job (22 percent), or had property damaged (20 percent). Transgender older adults experience higher levels of victimization and discrimination than non-transgender older adults.

Obstacles to Healthcare

Lesbian, gay, bisexual, and transgender older adults encounter obstacles in accessing quality healthcare services which can have extensive consequences. The American Medical Association (2009) states that if physicians do not recognize patients’ sexual orientation and patients do not disclose, it can result in serious medical problems. However, 21 percent of lesbian, gay, bisexual, and transgender older adults have not revealed their sexual orientation to their primary physician, with bisexual women and men less likely to disclose than lesbians and gay men. This prevents discussions about sexual health, hormone therapy, risk of breast cancer, hepatitis and HIV risk, or other potential risk factors. Thirteen percent of lesbian, gay, bisexual, and transgender older adults have been denied or provided inferior healthcare and almost one-quarter (22 percent) of transgender older adults need to see a doctor but can’t because of cost. In addition, 15 percent fear accessing healthcare outside the lesbian, gay, bisexual, and transgender community and eight percent fear accessing healthcare inside the community.

Distinct Networks of Support

While biological family members play a primary role in the support of older adults in the general population, most lesbian, gay, bisexual, and transgender older adults care for one another. They rely most heavily on partners and friends, many of a similar age, to provide assistance and help as they age. More than one-quarter (27 percent) assist someone close to them who has a health issue or other needs. Of the caregivers, 35 percent provide care to a partner or spouse, 32 percent to a friend, and 16 percent to a parent or parent-in-law. Seventeen percent currently receive care: 54 percent from their partner or spouse and 24 percent from a friend. While in the general caregiving literature women provide the majority of care, in the lesbian, gay, bisexual, and transgender communities, men are as likely to provide care as women (Fredriksen-Goldsen, 2007; MetLife Mature Market Institute, 2010). The importance of friends in the lives of lesbian, gay, bisexual, and transgender older adults is well documented, yet recent research has found that friends often recognize limits in their ability to provide care over the long-term, especially when decision making is required for the older adult receiving care (Muraco & Fredriksen-Goldsen, in press). Despite the fact that their support systems differ and they often lack legal protection for their loved ones, an alarming 30 percent do not have a will and 36 percent do not have a durable power of attorney for healthcare.

Implications for Moving Forward

Addressing the unique circumstances of lesbian, gay, bisexual, and transgender older adults requires a comprehensive approach to transform existing public policies, aging services, and research. There are recent advances in policies addressing the needs of lesbian, gay, bisexual, and transgender older adults; for example, effective January 2011, new federal regulations were enacted to prohibit discrimination in visitation based on sexual orientation and gender identity by hospitals participating in Medicare and Medicaid programs. Yet many existing public policies that are intended to support older adults in times of need are often inaccessible to lesbian, gay, bisexual, and transgender older adults and their loved ones. For example, same-sex partners do not have access to federal family leave benefits, equivalent Medicaid spend-downs, Social Security benefits, bereavement leave, or automatic inheritance of jointly owned real estate and personal property.

The unique health risks faced by these older adults require changes in legislation that are often considered beyond the scope of aging-related policy. For example, policy and programmatic interventions are needed to combat existing discrimination, victimization, and stigma. Protection from discrimination based on sexual orientation and gender identity in employment as well as housing and public accommodations at federal, state, and local levels are needed to insure the economic security and safety of these older adults and their families. Given the high levels of victimization experienced by lesbian, gay, bisexual, and transgender older adults, it is imperative that hate crimes based on sexual orientation, gender identity, and age be fully prosecuted. As we move forward, it is essential that services and demonstration projects funded by the Older Americans Act (OAA) target social and health services and programs that address the needs of lesbian, gay, bisexual, and transgender older adults and their caregivers.

Services and Intervention Developments

Many lesbian, gay, bisexual, and transgender older adults are living alone without adequate services or supports. Creating comprehensive health and aging services for lesbian, gay, bisexual, and transgender older adults by fostering partnerships between aging and general services in the lesbian, gay, bisexual, and transgender community, as well as with federal, state, and local mainstream providers of health and aging services is desperately needed.

Cultural competency training is necessary for healthcare and human service professionals addressing lesbian, gay, bisexual, and transgender older adults and caregivers, incorporating diversity in age, gender, ethnicity, race, education, income, geographic location, and ability. It is important to define the competencies necessary for effective healthcare practice with lesbian, gay, bisexual, and transgender older adults and their families and advocate for the integration of these competencies as part of the degree requirements in educational programs including medicine, nursing, social work, and other educational programs.

To respond effectively to health disparities and consequent needs, interventions are needed that are tailored to meet the distinctive health and aging needs of lesbian, gay, bisexual, and transgender older adults, recognizing that bisexual and transgender older adults are critically underserved. The early detection and identification of such at-risk groups will enable public health initiatives to expand the reach of strategies and interventions to promote healthy communities, especially aimed at prevention and reduction of obesity, heavy drinking, and smoking. The expansion of HIV prevention, education, and treatment programs to include older adults will be an important step forward.

Research

In order to address these critical health and aging needs, it is imperative that sexual orientation and gender identity measures be included in aging-related research, including in public health surveys. Better data collection documenting sexual orientation and gender identity is needed to determine the risk of health disparities, as well as elevated morbidity and mortality among older sexual minorities. While there are ambiguities in measurement, important advancements are being made in the development and utilization of measures of sexual orientation, sexual identity, gender identity, and sexual behavior.

While previous research has generally collapsed lesbian, gay, bisexual, and transgender older adults into a single sexual minority group, the findings reported here document important differences, and the heterogeneity of subgroups should not be overlooked (Fredriksen-Goldsen, Kim, Barkan, Balsam, & Mincer, 2010; Kim & Fredriksen-Goldsen, in press). Research is desperately needed to better understand the impact of risk and protective factors on the health of lesbian, gay, bisexual, and transgender older adults, including the increased likelihood of living alone, not having children, and relying on peers to provide assistance.

We need to better understand the life course trajectories of those reaching old age in these communities. Given the existing peer-based support structures within these communities, those living to very old age may be at high risk for institutionalization. Future research is needed to explore the decision-making processes guiding lesbian, gay, bisexual, and transgender older adults and their caregivers and the relationships between health and key life events and the utilization of informal and formal supports.

Conclusion

Given the increasing diversity in our aging society, it is imperative that we begin to address the health and aging needs of lesbian, gay, bisexual, and transgender older adults. Examining the health and well-being of older adults from historically disadvantaged populations sheds new light on diversity as well as cumulative risks in aging. Understanding aging across these communities requires a perspective cutting across the life course as it intersects with individual, cultural, and societal effects. The insights gleaned through this work exemplify aging as a multidimensional process embedded with inequalities and opportunities in an increasingly heterogeneous society.