Whether it's transgender teens trying to find informed providers to help them navigate their life-changing physical transformations; lesbians who are less likely than others to get preventive breast-cancer care; or gay and bisexual men who had to push an indifferent health care system to respond to the early AIDS epidemic, LGBT individuals have faced many challenges in the health space. As researchers look for ways to improve LGBT health, one issue hasn't received much attention with respect to this population, although it is an equal-opportunity process: aging. Now, groundbreaking research is taking a closer look at the unique ways middle-age and older LGBT adults experience getting older, revealing some key obstacles and disparities.
The National Institutes of Health-funded study tracking more than 2,400 LGBT U.S. adults shows gaps in their physical and emotional health, as well as widespread concerns about safe options for accessing high-quality health care and long-term care.
An estimated 2.4 percent of the older population self-identifies as LGBT, with many more who haven't yet "come out," according to Karen Fredriksen-Goldsen, principal investigator of the multifaceted study, "Aging With Pride: National Health, Aging and Sexuality/Gender." “We need to develop interventions to reduce disparities, promote health in these communities, and ensure we have services for these older adults that are culturally competent,” she says.
On the brighter side, her research team also discovered the health-promoting power of resilience among LGBT seniors who are leveraging communities of mutual support. That support, she found, can provide a buffer, of sorts, against some of the disparities identified.
More than two-thirds of participants had experienced victimization, such as physical and verbal assaults, and discrimination more than three times in their lives, says Fredriksen-Goldsen, who is also a professor of social work and director of the Healthy Generations Hartford Center of Excellence at the University of Washington.
"LGBT seniors are more likely to have poor general health, more chronic conditions, higher rates of disability and more psychological distress," she says. Discrimination and victimization are the strongest predictors of poor aging, she adds. In particular, gay and bisexual older men are more likely than heterosexual men to have poor general health and to live alone.
Lesbian and bisexual older women have higher rates of cardiovascular disease, and are more likely than heterosexual women to have multiple chronic conditions. "In our study, about 47 percent have a disability," Fredriksen-Goldsen says. “And disability starts at younger ages, likely due to higher rates of chronic conditions and other stressors."
Among LGBT people, transgender and bisexual older adults are at even greater risk for victimization and discrimination, and bisexual and transgender adults are more likely to live in poverty, which heightens their risk for health care disparities and poor health.
Within the LGBT population, greater health disparities exist for older adults in racial and ethnic minority groups, Fredriksen-Goldsen says. However, she adds, “religious and spiritual activities are also greater in those communities, which tends to offset some of the risks."
Social support matters. "We do find that even though there are many disparities, most LGBT older adults are aging well and have good health," she says. "Linked to that, we keep finding consistent predictors are greater levels of social support, less victimization and discrimination, more community engagement and a sense of community connectedness and belonging."
While she wasn't part of the study, 72-year-old Rita Smith – who came out as a lesbian in the 1970s – embodies that sense of connectivity and social engagement. A retired community education director for recycling and waste prevention in Seattle, Smith now throws herself into activities from serving on the board of the nonprofit Generations Aging With Pride to pruning fruit trees in Seattleites' yards and teaching them to prune via workshops – a carryover from her "idyllic" childhood among apple orchards. "It's a way to be out with there and celebrate the fact that I'm relatively fit and capable," she says. And her health is fine. "It could be better if I were more diligent with my exercise but I feel quite healthy," Smith says.
Unfortunately, Smith's situation is not the case for everyone. Past and present social biases affect the quality of care LGBT people receive – a 2009 national survey, for example, found that some LGBT patients were being refused needed care and that some health professionals were refusing to touch them – as does their attitude toward the health care system on which they become more dependent with age.
Unhealthy habits that people maintain as young adults – such as smoking, overeating, being sedentary and heavy drinking – catch up to most people with age. But health consequences may be more likely in LGBT seniors, says Dr. Jesse Joad, president of GLMA: Health Professionals Advancing LGBT Equality, a U.S.-based association whose members include LGBT physicians, nurses, physician assistants, researchers and other health professionals in several countries. One example is that lesbians and other sexual-minority women tend to be more obese, she notes. The result, she says, is higher risk for heart disease, arthritis, stroke and Type 2 diabetes.
LGBT people tend to smoke more than others, Joad says, raising their risk of chronic pulmonary obstructive disease, or COPD, and lung cancer. Added to all this is a reluctance in some LGBT people to seek out preventive health care, including screening exams like mammograms, and medical treatment for existing health problems, due to concerns about health care biases.
Evidence shows transgender people, in particular, are more resistant to seeing health providers. "Either they have been treated poorly in the past, or they're just aware of what has happened to other people," Joad says.
Stigma is at the root not only of health care disparities but many unhealthy behaviors in the LGBT community, Joad adds. For instance, she says, higher rates of substance abuse, smoking and problem drinking "are thought to be the ways LGBT people have coped with the stigma they face all the time."
For Smith, substances were never an issue. "I had not been inclined to be a drinker or smoker," she says. But others were. "Part of the reason the [Seattle-based] Lesbian Resource Center existed back in the 60s [was] it had been founded by people who were recognizing that the only place lesbians were getting together were bars," she recalls. "So the LRC was intentionally alcohol-free." While alcohol can act as a social lubricant, it can also provide a dicey refuge for isolated people who don't feel accepted.
Coming out as LGBT is considered empowering and emotionally healthy. However, staying out can be tricky for older people who need assistance from in-home caregivers or residential facilities, especially if they fear potential victimization and discrimination.
"Many of the LGBT seniors, especially if they have increased needs, and don't have the support around them, say that they feel that they have to go back into the closet when they're most vulnerable," Fredriksen-Goldsen explains. "If they're going to go live in a long-term care facility, certainly it can create isolation for them."
LGBT study participants shared fears that some facility residents might be biased, and some reported feeling bullied by other residents. “Facilities need to consider how they’ve provided a welcoming environment," Fredriksen-Goldsen says.
Smith and her friends are at a stage where they visit others in their social circle who now live in residential facilities, and also consider their own future options. As a rule, they don't feel particularly drawn to any of the sites. "It's not necessarily so much that we think it would be a horrific kind of setting, but just an uncomfortable place where we feel that we don't necessarily belong," she says. "Where we can't be our whole selves."
However, she adds: "For me – bless the women's movement – I'm more inclined to say, 'They'll just have to get over themselves.' And I do tend to be pretty bold in terms of standing up for myself.”