Aging LGBTQ Patients and Barriers to Care
There are approximately 1 to 3 million LGBTQ individuals aged 65 years and older living in the United States.
Introduction and Definitions
When working with patients, it is important to consider their sexual orientation and gender identity to ask the right questions and provide the best care possible. There is not substantial research on caring for the elderly LGBTQ (lesbian, gay, bisexual, transgender, and queer) population. This article attempts to explain the need for informed providers in caring for the elderly LGBTQ community.
It is necessary to understand key definitions when working with LGBTQ communities. Some of these definitions include, but are not limited to:
- Sex: "Sex refers to a person's biological status and is typically categorized as male, female, or intersex (i.e., atypical combinations of features that usually distinguish male from female). There are a number of indicators of biological sex, including sex chromosomes, gonads, internal reproductive organs, and external genitalia."1 In the United States, one's natal sex is assigned at birth.
- Gender: Gender, according to the World Health Organization, "refers to the socially constructed characteristics of women and men -- such as norms, roles and relationships of and between groups of women and men. It varies from society to society and can be changed."2 Gender, according to the online Merriam-Webster Dictionary, is described as "the behavioral, cultural, or psychological traits typically associated with one sex."3 However, this definition is harmful because one may identify as a particular gender that is not male or female. Gender must be viewed as fluid, and we therefore must be accepting and understanding that one's gender may not fit into the boxes that read "male" or "female."
- Gender identity: Gender identity refers to the gender with which an individual identifies. According to the American Psychological Association, it is "one's sense of oneself as male, female, or transgender."1 However, as stated earlier, gender does not just refer to male, female, or transgender.
- Transgender: Transgender is used to describe those with "gender identities, expressions, or behaviors not traditionally associated with their birth sex."4 Transgender males are males who were assigned the female sex at birth, and transgender females are females who were assigned the male sex at birth. It is important to note that individuals are not referred to as transgendered but, rather, as transgender. Being transgender is an identity and not a disorder. In addition, they may be attracted to any gender or genders.
- Nonbinary and gender nonconforming: These individuals do not identify within the constraints of the gender binary of male and female. They may identify as both genders or neither gender.4,5 This is important to consider when discussing one's gender identity, in that a person's gender identity may not be male, female, or transgender. Similar to transgender individuals, those with this identity do not have a disorder, and they may be attracted to any gender or genders.
- Gender dysphoria: Gender dysphoria "refers to the distress that some [transgender and gender nonconforming individuals] may experience at some point in their lives as a result of incongruence between their gender identity and birth sex." It is included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and "improves with gender-affirming treatment."6
- Cisgender/cisgendered: According to the Oxford English Dictionary, cisgender describes "a person whose sense of personal identity and gender corresponds with their birth sex."7
- Sexual orientation: Sexual orientation is used to describe one's preference of sexual or romantic partner. This may include lesbian, gay, bisexual, asexual, and more. However, one's sexual orientation does not always fit in distinct groupings. In addition, one's sexual orientation may change over time.
- Lesbian: Lesbians are women attracted to other women.
- Gay: Gay men are attracted to other men.
- Bisexual: Bisexual individuals are those attracted to both men and women.
- Queer: Queer can encompass multiple definitions. It can be used to describe those who identify as being nonheterosexual or as an umbrella term for the LGBTQ community. It can also be used by those who are attracted to more than 1 gender or by those who do not identify with cultural norms surrounding sexuality. It is important to note that the term "queer" may be used by individuals who themselves identify as queer, but it may be otherwise viewed as discriminatory, depending on the individual, community, geographic location, and so on.
It is important to note that the LGBTQ community is not homogenous, and that groups within the acronym are not homogenous either.
As the US population ages, it becomes more diverse.8,9 It is difficult to assess the size of the LGBT population, but there are estimates that 3.5% of adults in the United States are LGB, approximately 0.3% of whom are transgender.10-12 The National Gay and Lesbian Task Force Policy Institute approximates that there are 1 to 3 million LGBT Americans who are aged 65 years and older. As the number of older people in the United States increases and will continue to increase for the next decades, it is estimated that the number of LGB adults will surpass 6 million by 2030.9,13,14
Needs and Concerns of Older LGBTQ Adults
A survey of 2376 LGBTQ adults aged 45 to 75 years found that older LGBTQ adults have many concerns, some of which are unique to being both elderly and LGBTQ. For example, 51% of older LGBTQ individuals (those aged 45 to 75 years) are "very or extremely concerned about 'having enough money to live on,' as compared to 36% of non-LGBT people."15 In addition, 32% of the older LGBT population is concerned about "being lonely and growing old alone," relative to 19% of the non-LGBT population.15 Older LGBTQ adults are concerned about opportunities available to them if others know about their sexual orientation or gender identity. For example, 27% of them believe that if others know about their sexual orientation, work or volunteer positions will not be available to them.15 Thirty-three percent of transgender adults feel these positions will not be available to them if others know about their gender identity.15 When seeking out housing, 13% of LGBTQ adults and 25% of transgender older adults say they have been discriminated against because of their sexual orientations or gender identities.15
In another study that surveyed 2560 LGBTQ adults aged 50 to 95 years across the United States, responses showed that 68% had faced verbal harassment at some point in their lives, and 43% were threatened with violence. In terms of mental health, 53% report feeling lonely, and 31% have depression. Of the gay and bisexual male participants in the survey, 14% were living with HIV.16 This study identified the 5 services most needed by the LGBTQ community as social events, transportation, support groups, legal services, and senior housing. In another study, 54% of LGBT adults said that their gender identity makes aging more difficult.17,18