Practice Management

Aging LGBTQ Patients and Barriers to Care

Aliza R. Grossberg;George T. Grossberg, MD
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Healthcare Disparities of LGBTQ Elders vs Non-LGBTQ Elders

The definition of healthcare disparities, according to the US Department of Health and Human Services, is differences in health that are a consequence of systemic economic, social, and environmental drawbacks. Many older LGBTQ individuals are concerned about healthcare access as they age. Forty percent of LGBQ adults in their 60s and 70s, as well as 43% of single, older LGBTQ individuals aged 45 to 75 years, state that their healthcare providers are not aware of their sexual orientations. Alarmingly, 65% of transgender adults aged 45 to 75 years believe “that there will be limited access to healthcare as they grow older.”15 In a different survey of LGBTQ adults aged 50 to 95 years, 21% reported not disclosing their sexual or gender identity to their physicians. This same study reported 22% of transgender adults need to see a physician but cannot afford the visit. Of the LGBTQ individuals surveyed, 15% are fearful of accessing healthcare outside of LGBTQ community. In another study of more than 2500 older LGBTQ adults, more than 10% were denied care or provided inferior care because they were LGBTQ.16 A study of administrators and care providers showed that 75% had no existing endeavors to address older LGBTQ individuals’ needs.19,20

For gay men and lesbians, there are several factors that are detrimental to their health. There are higher rates of suicidal ideation, suicide attempts, use of psychiatric medicine, and self-injurious behavior for gay men and lesbians.21-24 There are also higher rates of smoking, excessive drinking, and disability.256 Another study found that internalized stigma, obesity, lack of healthcare access, lifetime victimization, and limited physical activity were risk factors for disability, depression, and poor general health for LGB older adults.26,27

In a study of more than 2000 LGB adults aged 50 years and older, results showed that obesity, limited physical activity, lifetime victimization, and financial barriers to healthcare were each significantly and independently responsible for disability, depression, and poor general health of the participants.26 It was also found that internalized stigma was an additional predictor of disability and depression.26 Protective factors relative to poor general health, depression, and disability included increased social support and social network size.26

Mental Health Issues Faced by LGBTQ Elders

One of the reasons for increased mental health issues faced by older LGBTQ people compared with heterosexual people is continuous exposure to discrimination.20,27,28 These mental health issues faced by LGBTQ individuals may be worsened by discrimination or the expectation of discrimination by service providers.29-31 In a study of people aged 55 years and older living in Britain, older LGB individuals reported being more anxious than heterosexual individuals in the same age range. A lot of their anxiety stemmed from the belief that their sexual orientation or gender identity would affect them as they aged, and they were most specifically concerned about facing discrimination.20,31 Lesbian and bisexual women were found to be more likely to have ever had a diagnosis of depression or anxiety than heterosexual women, and it was found that 40% have a lifelong prevalence of depression and 33% have lifelong prevalence of anxiety.20,31 Bisexual and gay men were twice as likely to have ever had a diagnosis of anxiety or depression compared with heterosexual men.20,31

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Disparities Specific to Elderly Transgender Individuals

There is very limited research available on specific disparities among elder transgender and gender nonconforming populations. Research has shown that older transgender adults, relative to nontransgender older LGB adults, are at a greater risk for disability, depressive symptoms, poor physical health, and perceived stress.27,32 Relative to nontransgender adults, older transgender adults face higher risks for poor health, which has been linked to less access to healthcare, less social support, less physical activity, and increased levels of victimization, discrimination, and stress.27,32 Obstacles to obtaining care are augmented by limited services that are culturally competent.6 For transgender and gender nonconforming individuals, it is not uncommon for them to seek out care to transition from 1 gender to another in mid- or later life.33

Older transgender adults have lower levels of self-acceptance: 48% of transgender older adults face depression compared with 30% of LGB older adults and 5% of older heterosexual populations.34 More than 50% of transgender adults aged 55 years and older state they have lost close friends because of their gender identity.35 Forty percent of transgender adults aged 55 years and older state that their gender identity is the reason their children do not have contact with them.35 Moreover, 44% of transgender older adults live alone34 compared with 18% of the population.17 Transgender individuals have said that being old increases their risk of experiencing hate crimes because they have to deal with prejudice and discrimination, in addition to ageism.26

Transgender individuals are fearful that their gender identity will not be respected in long-term care and hospice facilities.36 Moreover, they are concerned that their gravestones and death certificates will not display their correct names or gender identities.17 According to 1 study of 24 countries, older transgender adults have completed few end-of-life decisions. Of transgender adults aged 51 to 60 years, 15.2% had completed a will, and of transgender adults aged 61 years and older, only 8.1% had completed a will.17 Only 8.1% of transgender adults aged 51 to 60 years and 7.4% of transgender adults aged 61 years and older had a durable power of attorney.17 There was a significant increase in those who had a will for transgender adults living with a chronic illness.

End-of-Life Issues: Hospice/Palliative Care

In general, it can be difficult for those in hospice or palliative care to focus both on disease and end-of-life care, as well as sexual health and sexuality. Sex and sexuality are connected to self-esteem, mood, pleasure, social role, and other factors that affect quality of life.37,38 Because the majority of society views significant illness, dying, and sexuality as taboo topics, it is the role of the healthcare provider to bring up these topics.38,439 Because many LGBTQ individuals face discrimination and stigmatization by society, those in palliative care may voluntarily omit information such as HIV status, sexual orientation, or other possibly stigmatizing information from their healthcare providers.38 In addition, for older LGBTQ individuals, there may be generational differences in terms of comfort in sharing information about one’s sexual orientation in healthcare settings.38,40 This is partially because of the heteronormative outlook, or the assumption that people are heterosexual, held by most of society, as well as most healthcare providers.38 Older LGBTQ adults may feel less comfortable disclosing information regarding their sexuality to healthcare providers because they may have experienced a significant amount of discrimination regarding their sexuality throughout their lives.38 Transgender individuals fear that lack of understanding or appropriate responses regarding their gender identity or expression can lead to trouble in accessing palliative care.38,41

Palliative care should include all aspects of one’s life, including sexuality, and sexuality should be a part of the “personal side of dying.”42,43 Providing palliative care for the LGBTQ population has evolved over time; the current palliative care framework for LGBTQ patients is not 1 in which HIV/AIDS is at the forefront.38 It is necessary that healthcare providers inquire about sexual identity, avoid assumptions about one’s sexual orientation (specifically that the patient is heterosexual), and ensure that partners are included in decision-making.38,44

Importance of Social Networks for LGBTQ Elders

In general, as people age, the size of their support system decreases.27,45 Social network size shrinks for older LGBTQ members as well.27 Because older LGBTQ adults are less likely to marry, partner, or have children than older heterosexual individuals, the social networks of older LGBTQ individuals may be comprised more of peers and friends than partners, spouses, or children.25,27 There is an inverse relationship between social network size and depression, disability, and poor general health among LGB elders.24,46 In addition, for LGB elders, increased social networks weaken the connection between internalized stigma and poor general health.25,46

Addressing Disparities and Barriers to Healthcare Access

To address disparities and barriers to healthcare access, it is important that healthcare providers bring up sexuality with their patients, as it is a difficult conversation for patients to initiate. Moreover, it is important to provide an “open and affirming practice style” to allow for older LGBTQ patients to feel more comfortable disclosing information regarding their sexuality.38 It is important for clinicians to guarantee privacy, confidentiality, and professionalism with each interaction.47 When approaching sexuality and end-of-life care, providers should be nonjudgmental and purposefully use language that is applicable to any sexual orientation.39,49 Clinicians should allow for patients to communicate their needs and desires to whatever extent they would like.38,48 It is imperative that providers ask for patients’ gender pronouns, which may include he, she, they, and so on. It is important to remember that one’s sexual orientation and gender identity may have changed and may continue to change with time.

Needs for Future Research

According to the Centers for Disease Control and Prevention, there is a huge need for research regarding sexual orientation and its relation to health disparities. Regarding palliative care for the LGBTQ community, a literature review noted that very few papers focused on the bisexual and transgender populations.44 In general, there is a greater need for research on caring for older bisexual and transgender populations. In addition, there is a lack of research on caring for older gender nonconforming individuals who do not identify with the gender binary, as much of the existent research focuses on transitioning from 1 binary gender to another through hormone therapy or sex confirmation surgery. Research on the most effective training and protocols for providers is also necessary to ensure LGBTQ patients feel respected by providers. There is also a need for research on the effect of the national legalization on same sex marriage by the US Supreme Court in June 2015 and its effect on healthcare provision for older LGBTQ individuals. Research is needed to understand the differences and intersectionality of older LGBTQ individuals based on race, socioeconomic status, ethnicity, and so on, and how these statuses interact with one another. Finally, further research should be conducted from the perspective of older LGBTQ individuals on how providers can best care for them.

Conclusions

Older LGBTQ individuals face significant disparities, discrimination, and stigmatization. They experience disparities in healthcare as a whole, including in mental health and palliative care. There are greater rates of depression, anxiety, obesity, smoking, disability, and poor general health among this population. Increased social networks can be helpful in minimizing some of the disparities, but healthcare providers need to play a greater role as well. Members of this population are fearful of discrimination by healthcare providers, and some will avoid care for this reason. There is a need for greater research on caring for older LGBTQ adults and how to ensure the provision of the best possible care for them.

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