Journal of Gerontological Nursing

Feature Article 

The Invisible Elderly: Lesbian, Gay, Bisexual, and Transgender Older Adults

Rita A. Jablonski, PhD, CRNP; David E. Vance, PhD, MGS; Elizabeth Beattie, PhD, RN, FGSA

Abstract

More than 2 million older adults identify as lesbian, gay, bisexual, or transgender (LGBT). The purpose of this article is to present an overview of the physical and mental health needs of LGBT older adults to sensitize nurses to the specific needs of this group. Nurses are in a prominent position to create health care environments that will meet the needs of this invisible, and often misunderstood, group of people. [Journal of Gerontological Nursing, 39(11), 46–52.]

Dr. Jablonski is Associate Professor, School of Nursing, and Dr. Vance is Associate Director, Center for Nursing Research, and PhD Coordinator, The University of Alabama at Birmingham, Birmingham, Alabama; and Dr. Beattie is Director, Dementia Collaborative Research Centre, School of Nursing, Queensland University of Technology, Brisbane, Australia.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Rita A. Jablonski, PhD, CRNP, Associate Professor, School of Nursing, The University of Alabama at Birmingham, NB 520, 1720 2nd Avenue South, Birmingham, AL 35294-1210; e-mail: rajablon@uab.edu.

Received: July 24, 2013
Accepted: August 15, 2013
Posted Online: September 24, 2013

Abstract

More than 2 million older adults identify as lesbian, gay, bisexual, or transgender (LGBT). The purpose of this article is to present an overview of the physical and mental health needs of LGBT older adults to sensitize nurses to the specific needs of this group. Nurses are in a prominent position to create health care environments that will meet the needs of this invisible, and often misunderstood, group of people. [Journal of Gerontological Nursing, 39(11), 46–52.]

Dr. Jablonski is Associate Professor, School of Nursing, and Dr. Vance is Associate Director, Center for Nursing Research, and PhD Coordinator, The University of Alabama at Birmingham, Birmingham, Alabama; and Dr. Beattie is Director, Dementia Collaborative Research Centre, School of Nursing, Queensland University of Technology, Brisbane, Australia.

The authors have disclosed no potential conflicts of interest, financial or otherwise.

Address correspondence to Rita A. Jablonski, PhD, CRNP, Associate Professor, School of Nursing, The University of Alabama at Birmingham, NB 520, 1720 2nd Avenue South, Birmingham, AL 35294-1210; e-mail: rajablon@uab.edu.

Received: July 24, 2013
Accepted: August 15, 2013
Posted Online: September 24, 2013

Approximately 2 million older adults identify as lesbian, gay, or bisexual (Fredriksen-Goldsen et al., 2011); however, this may be an underestimation given the reticence many have about disclosing their status. This estimation is further complicated by some who practice same-sex behaviors, but by and large, identify themselves as heterosexual. Likewise, the numbers of individuals who identify as transgender are somewhat more difficult to measure also due to ambivalence about disclosing; regardless, such estimates range from 0.3% to 0.5% (Fredriksen-Goldsen, Cook-Daniels, et al., 2013).

When asked if they provided services tailored to the needs of lesbian, gay, bisexual, or transgender (LGBT) older adults, only 15% of the Area Agencies on Aging replied in the affirmative (Knochel, Croghan, Moone, & Quam, 2012). The remaining agencies did not offer tailored services to LGBT individuals because they never received a request for such services; in fact, some respondents believed that all older adults require the same services, regardless of sexual orientation. LGBT older adults may also contribute to their invisibility by deciding not to disclose to health professionals and agencies. Many LGBT older adults have lived lives filled with discrimination and, as a result of negative experiences with health care agencies and personnel, are at greater risk for poorer health than their “straight” counterparts (Fredriksen-Goldsen et al., 2011, Fredriksen-Goldsen, Cook-Daniels, et al. 2013; Fredriksen-Goldsen, Emlet, et al., 2013).

In the first federally funded national survey of LGBT older adults and their caregivers, researchers found that the majority of respondents identify as gay men (61%), followed by lesbians (33%), trans-gender (7%), bisexual men (3%), bisexual women (2%), and “queer” (a term used with few but a pejorative comment to many [Haber, 2009]) or “other” (1%) (Fredriksen-Goldsen et al., 2011). The majority of individuals who identified as transgender were male-to-female (60%). Twenty-six percent of individuals identified as female-to-male, whereas the remaining either chose “other” or declined to answer (Fredriksen-Goldsen et al., 2011). The numbers of transgender individuals may be higher because of how these older adults classify themselves. After completing the transition process, which includes sexual reassignment surgery, some older adults no longer identify as transgender; they instead identify as either male or female (Fredriksen-Goldsen, Cook-Daniels, et al., 2013). For the sake of simplicity and clarity, the abbreviation LGBT will be used in this article to denote the lesbian, gay, bisexual, and transgender community.

The purpose of this article is to present an overview of the physical and mental health needs of LGBT older adults to sensitize nurses to the specific needs of this group. We conclude with specific suggestions as to how nurses can create health care environments that will meet the needs of this invisible, and often misunderstood, group of people within our care.

Health Disparities of LGBT Older Adults

The LGBT community is as heterogeneous as any other group of older adults who come from different racial/ethnic, religious/spiritual, educational, and socioeconomic backgrounds. For most of these older adults, it is fair to say they grew up in a family and a society that was unaware or misinformed about what being LGBT was or how people became “that way.” Sadly, the current cohort of LGBT older adults may have experienced a lifetime of discrimination: being shunned by family, friends, religious organizations, and the medical community; ridiculed or physically attacked; or labeled as criminals, perverts, or sinners (Haber, 2009). In fact, it was not until 1973 that homosexuality was removed as a mental disorder from the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association (Institute of Medicine, 2011). Yet, despite this unprecedented and bold stand, the lack of information and misrepresentation in the media of what it meant to be LGBT undoubtedly contributed to continued discrimination and prejudice, which was often expressed in victimization such as threats or attacks to one’s body, job, or property. In fact, in one survey, 82% of LGBT older adults reported having been victimized at least once, whereas 64% reported having been victimized three or more times in their lifetime (Fredriksen-Goldsen et al., 2011). Approximately 25% have experienced discrimination at work, either through denial of a position or a promotion, or simply being fired once their sexual orientation or gender identity become known (Fredriksen-Goldsen et al., 2011). Thirteen percent reported either receiving inferior care or being denied care because of their sexual orientation or gender identity (Fredriksen-Goldsen et al., 2011). Given the cumulative effect of such negative experiences, it is surprising that as many as 80% disclose their sexual or gender identity to a health care provider (Fredriksen-Goldsen et al., 2011; Fredriksen-Goldsen, Cook-Daniels, et al., 2013); however, those who were treated worse may not identify as gay at all anymore out of fear of such victimization.

Fortunately, given the slowly changing political climate for social justice for LGBT issues over the past few decades since the Stonewall Riots when the LGBT civil rights movement began in New York City, some age-related differences among the current LGBT cohort must be considered. Older adults ages 50 to 64 are more likely to disclose their sexual orientation or gender identity than those 65 or older (Fredriksen-Goldsen et al., 2011). To understand this inclination between these two groups, it is important to consider whether such individuals realized they were LGBT; for those who “came out” to themselves before the Stonewall Riots, they did not have any political clout; these individuals would be 65 and older now. For those who “came out” after the Stonewall Riots, they were in the midst of growing self-identity as a “proud” community in a changing political landscape; these older adults would be ages 50 to 64 now.

In addition to such historical differences that influence perceptions among LGBT older adults, differences among lesbians, gay men, bisexual men and women, and transgender older adults themselves obviously exist. Lesbians, for example, report a “triple threat” of insignificance due to combined marginalization from heterosexism, sexism, and ageism (Averett, Yoon, & Jenkins, 2011, p. 216); and this could be a quadruple threat of social insignificance if one is a person of color or has other “unfavorable” societal attributes (e.g., mental illness, physically disabled, poor).

LGBT older adults face significant health disparities, even after controlling for income, educational level, and age. Almost half of LGBT older adults have a disability, defined as the need for specialized equipment or physical activity limitations. Nearly two thirds of transgender older adults experience disability compared to half of lesbians and bisexual men and women (Fredriksen-Goldsen et al., 2011). Gay men had the lowest rates of disability at 41% (Fredriksen-Goldsen et al., 2011). Obesity is a significant problem for many LGBT older adults as well. Forty percent of transgender older adults are obese (Fredriksen-Goldsen, Cook-Daniels, et al., 2013). Lesbians and bisexual women have the same rates of obesity, 34%. The obesity rates for gay men and bisexual men are also similar, 19% and 18%, respectively (Fredriksen-Goldsen et al., 2011).

Living arrangements are another distinction to be considered among LGBT older adults. In the heterosexual population, older women are more likely to live alone than men. In the LGBT population, this is reversed: Gay and bisexual men are more likely to live alone compared to lesbians and bisexual women (Fredriksen-Goldsen et al., 2011). Thus, gay and bisexual older adults may require more social support to age in place. Also, it is important to consider that not all families are accepting of one’s partners. Families may be uncomfortable including their uncle’s “roommate” in family events; and as such, couples may not be integrated into other families of orientation. Thus, this may be an important area for special attention at senior centers and other venues so that the “roommate” is not left home isolated from the rest of the community.

Mental health problems are another health disparity that should be considered in LGBT older adults. In particular, transgender individuals experience more mental health problems than lesbian, gay, and bisexual older adults. Forty-eight percent of transgender older adults report depression, compared to the overall depression rates for LGB older adults at 31% (Fredriksen-Goldsen, Cook-Daniels, et al., 2013). When examined individually, lesbians and gay men have lower depression rates (27% and 29%, respectively) whereas bisexual men and women have similar depression rates (35% and 36%, respectively) (Fredriksen-Goldsen, Emlet et al., 2013). In regard to anxiety, 39% of transgender older adults have this diagnosis, compared to 22% of gay and lesbian older adults. Bisexual older men and women fare differently: Bisexual older men have similar anxiety rates as gay men (24%), whereas 34% of bisexual older women experience anxiety (Fredriksen-Goldsen et al., 2011). Serious thoughts of suicide followed similar patterns: 71% of transgender older adults considered suicide at some point in their lives compared to 35% of lesbians, 37% of gay men, 39% of bisexual men, and 40% of bisexual women (Fredriksen-Goldsen et al., 2011). Fortunately, not all of the news is bad. The majority of LGBT older adults (89%) feel positive about belonging to the LGBT community (Fredriksen-Goldsen et al., 2011). Also, there is some literature that suggests that once someone has dealt successfully with a difficult life challenge, such as coming out to oneself and others, this produces crisis competence (i.e., hardiness, resilience); as such, this life skill can help one with successful aging as well (Vance, Struzick, & Masten, 2008).

Long-Term Care and LGBT Older Adults

Although older adults rarely relish the thought of requiring long-term care, LGBT older adults have additional unique concerns. Many older adults who have “come out of the closet” grapple with whether to make their LGBT status known to nursing home staff for fear of facing discrimination during a period of increased vulnerability (National Resource Center on LGBT Aging, 2012b; Stein, Beckerman, & Sherman, 2010). They also fear being ostracized and maltreated by other nursing home residents, especially roommates (Stein et al., 2010). LGBT older individuals may constantly self-censor to appear “straight.” Although non-LGBT nursing home residents are free to reminisce about their lives and families, LGBT older adults worry about offending others by talking about their lives as gay individuals (Stein et al., 2010).

Transgender individuals also expressed concerns about long-term care. After experiencing a lifetime of harassment and violence, the thought of being vulnerable and frail and requiring care from others is frightening. Although some may have completely changed their physical appearance via sexual reassignment surgery, many older adults have not (Fredriksen-Goldsen, Cook-Daniels, et al., 2013; Kaufman, 2010). Individuals who wish to appear female may use prosthetic breasts, whereas individuals wishing to appear male may use compression vests to minimize existing breasts (Kaufman, 2010). Nursing home staff and fellow residents may respond to the discovery that “Paula” is biologically “Paul” with a range of reactions, including astonishment, shock, anger, and confusion (Kaufman, 2010). Transgender older adults may find themselves being addressed by the non-preferred pronoun and the wrong name, while being assigned to a room based on their biological gender instead of their identified gender.

Aging with HIV

Another particular area of concern in the LGBT older adult community is aging with HIV. Nine percent of LGBT older adults have HIV. Most of these infections are in gay or bisexual men; in fact, 14% of gay or bisexual men are HIV positive (Fredriksen-Goldsen et al., 2011). Fortunately, lesbians experience a lower rate of infection compared to the larger “straight” community; this is probably due to the type of biological risk associated with the different modes and amount of fluid exchange during sexual interaction between gay/bisexual men, heterosexuals, and lesbians. Regardless, aging with HIV can affect several areas that affect successful aging including physical, cognitive, social, and spiritual health in both LGBT and heterosexual individuals (Vance, Bayless, Kempf, Keltner, & Fazeli, 2011; Vance, Brennan, Enha, Smith, & Kaur, 2011).

Fortunately, data are reflecting that those who respond well to combination antiretroviral therapy (cART) for HIV and avoid any detrimental health issues (e.g., intravenous drug use) tend to have survival rates similar to those without HIV (Rodger et al., 2013). This news is encouraging; clearly, cART has been shown to help protect and reconstitute the immune system and prevent AIDS progression. Yet, despite such encouragement, HIV is associated with increased systemic inflammation and cART is associated with increased metabolic syndromes that can promote hypertension, hypercholesterolemia, heart disease, diabetes, liver disease, renal disease, and certain carcinomas (Vance, Mugavero, Willig, Raper, & Saag, 2011). As such, there is concern that these conditions will accelerate the aging process in those living with HIV. Therefore, aggressive preventive techniques such adequate physical exercise, good nutrition, proper sleep hygiene, and sufficient medication management of HIV and comorbid conditions is strongly considered as a way to counteract some of these negative physical affects (Vance, Eagerton, Harnish, McKie, & Fazeli, 2011; Vance, Fazeli, Moneyham, Keltner, & Raper, 2013).

Addressing these preventive techniques may also be a way to help with successful cognitive aging in those with HIV. Several studies have shown that older adults with HIV may be more vulnerable of developing cognitive deficits, perhaps due to the systemic inflammation that also promotes neuroinflammation (Vance, Fazeli, et al., 2013). For example, in a sample of 162 younger and older adults with and without HIV, Vance, Fazeli, and Gakumo (2013) found that in a battery of nine neuropsychological and everyday functioning measures, older adults with HIV performed the worst compared to the other three groups. Thus, as people age with HIV, the development of such cognitive deficits may result in poorer everyday functioning, inability to meet work-related demands, poorer financial management, and decreased driving ability, all of which can affect social functioning as well (Vance, Bayless et al., 2011).

Decreased social functioning has been shown to be a risk factor of unsuccessful aging in healthy adults and those aging with HIV. In a sample of 160 older adults (50 or older) with HIV living in New York City, Shippy and Karpiak (2005) found that 71% lived alone, 47% were not in a committed intimate relationship, and 57% indicated that their emotional needs were unmet. For LGBT older adults who may not have traditional and convenient sources of social support, these findings may be especially problematic. In fact, in addition to homophobia and ageism, HIV-related stigma may further impact social functioning and quality of life in those aging with HIV. In a sample of 60 older gay men with HIV, Slater et al. (2013) examined the predictors of quality of life; these researchers found that in addition to more medical comorbidities, more HIV-related stigma and emotional-focused coping and less perceived emotional/information social support was associated with poorer quality of life. Likewise, in a related study of 50 adults with HIV, more negative affect was reported in those who were older, experienced more HIV stigma, and were more lonely (Vance, 2006a). These findings are of concern given that studies have shown that lack of meaningful social contact as well as social withdrawal and isolation, which are common with a diagnosis of HIV, can predispose one to less social stimulation and poorer cognitive health (Vance, 2010; Wilson et al., 2007). Thus, there is a concern that all adults with HIV, including LGBT older adults, must be proactive in seeking out and maintaining social supports, which can affect physical and cognitive health, and even perhaps spiritual health.

The spiritual resources of those aging with HIV can also help facilitate whether one is aging successfully (Vance, Brennan, et al., 2011). In a sample of 50 aging adults with HIV, Vance (2006b) found that 72% indicated their spirituality changed after being diagnosed. On further questioning, 44% indicated they considered their HIV to be a blessing. Many participants commented that they realized once they were HIV positive, that this was a “wake up call” for them to live life better in every way (i.e., physically, socially, spiritually). As a result, many used their HIV diagnosis to improve their lives by reducing/ceasing substance use, going back to school, or seeking a deeper relationship with God. As a result, it was not surprising to see that those who considered HIV to be a blessing and those whose spirituality changed as a result of being diagnosed indicated that that they were aging more successfully than those who did not see HIV as a blessing. For those who are LGBT, this change in spirituality may be more pronounced, as many have to break away from the beliefs of their family concerning their sexual orientation, HIV diagnosis, or both. In fact, Cotton et al. (2006) remarked in their study that as many as 25% of those with HIV felt alienated from their place of worship due to HIV-related stigma and 10% switched their place of worship. Furthermore, Brennan, Strauss, and Karpiak (2010) found that in older adults with HIV, less than 50% reveal their serostatus to those in their congregation and 15% report attending religious services less. Given the social and personal benefits of engaging in one’s faith as well as the effect of HIV in the LGBT community, these biopsychosocial and spiritual trends in older adults with HIV deserve consideration in the topic of LGBT aging.

Specific Transgender Concerns

Transgender older adults have the greatest difficulty with accessing health care. They are most likely to experience financial barriers, receive inferior care, and be denied health care (Fredriksen-Goldsen, Cook-Daniels, et al., 2013). In one study, 11% of LGB older adults stated that they have either received inferior care or have been denied health care because of their sexual orientation compared to 40% of transgender older adults (Fredriksen-Goldsen et al., 2011). The issue of poor health care is further exacerbated by lack of knowledge on the part of clinicians. As Kaufman (2010) noted, few clinicians have had content regarding the health needs of trans-gender individuals. Clinicians may not realize that physical examinations or intimate care are sources of extreme anxiety to transgender older adults. Sex-reassignment surgery may have not been an option for older transgender adults; others may have undergone surgery when techniques were less refined, resulting in scarring and genitalia that may appear abnormal to the clinician (Feldman, 2010). As noted in more detail below, it is important for clinicians to understand that physical examinations and screening tests are predicated on the organs actually present instead of the appearance of the person (Kaufman, 2010). Many transgender older adults use, or have used, exogenous hormones. These hormones raise the risk of breast, ovarian, uterine, and prostate cancers. For example, a male-to-female older adult who used exogenous female hormones will require mammograms to screen for breast cancer (Feldman, 2010).

Implications for Nurses

Content about the specific care needs of LGBT individuals, especially older adults, is virtually nonexistent in nursing textbooks (Eliason, Dibble, & DeJoseph, 2010). Only eight of 5,000 nursing journal articles concentrated on LGBT health issues (Eliason et al., 2010). Without this information, nurses cannot provide culturally competent care. The first step nurses can take to care for LGBT older adults is to realize that they already have LGBT patients or residents. Given lifetime experiences of negativity at best and violence at worst, LGBT older adults may not always openly share their identity with health care providers. Furthermore, LGBT older adults may have prior life experiences, such as having been married or having children, that cause nurses to assume heterosexuality (National Resource Center on LGBT Aging, 2012b).

Nurses can also change the way they ask for information, both verbally and in writing. Questions about sexual orientation and gender identity should be routinely asked of all patients or residents. Given the discrimination faced by LGBT older adults, the nurse must preface this information with why the questions are being asked: “To provide the best and most sensitive care for all of our patients, we ask questions that may seem different.” Also, questions about sexual orientation and gender identity need to be asked separately, as they are unrelated. On forms, a blank line can be included after the “male” and “female” choices, to allow older adults to label their own gender (National Resource Center on LGBT Aging, 2012b). Another option is to ask “What is your gender?” and leave a blank to allow for an individual to complete the question as he or she believes appropriate (National Resource Center on LGBT Aging, 2012a). Questions such as marital status may need to be amended; one possibility is to offer the choice “married/partnered.” The Table includes helpful resources for nurses and other health care providers. Additionally, the nurse should inquire about social support and the size of the older adult’s social network. A recent study found that higher levels of social support and larger social networks acted as protective factors for gay, lesbian, and bisexual older adults (Fredriksen-Goldsen, Cook-Daniels, et al., 2013). These protective factors reduced the odds that the older adult would suffer from depression and overall poor health (Fredriksen-Goldsen, Cook-Daniels, et al., 2013).

Helpful Lesbian, Gay, Bisexual, and Transgender (LGBT) Caregiver Resources

Table:

Helpful Lesbian, Gay, Bisexual, and Transgender (LGBT) Caregiver Resources

If an older adult identifies as trans-gender, the nurse must ask how the client wishes to be addressed. Also, the nurse must inquire as to how the older adult prefers his or her information recorded on permanent medical records (National Resource Center on LGBT Aging, 2012a). The nurse must also ask what surgeries have been completed. For male-to-female sexual reassignment surgery, a vagina may have been created using the glans penis; the prostate is not routinely removed. In this case, the older adult would need both a prostate surface antigen test or digital rectal examination and a Pap smear (Feldman, 2010). The nurse should query about medications, especially hormones such as estrogen and testosterone. For services that are segregated according to gender, such as room assignments and restrooms, the decision should be based on the older adult’s gender identity, not biological gender (National Resource Center on LGBT Aging, 2012a,b).

Conclusion

The current cohort of LGBT older adults has encountered a lifetime of discrimination, violence, and even persecution. These experiences have left many suspicious of health care providers and systems. Nurses first need to acknowledge that they are already providing care to LGBT older adults in a variety of settings that are heterocentric. The next step is to change how nurses obtain information regarding gender, identity, and significant others. In the case of trans-gender older adults, nurses require tact and sensitivity when obtaining medical and surgical histories, as well as during physical examinations and intimate procedures. By adopting inclusive language and practices, nurses are in the best position to provide thoughtful and culturally appropriate care to these older adults.

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  • Wilson, R.S., Krueger, K.R., Arnold, S.E., Schneider, J.A., Kelly, J.F., Barnes, L.L. & Bennett, D.A. (2007). Loneliness and risk of Alzheimer disease. Archives of General Psychiatry, 64, 234–240. doi:10.1001/archpsyc.64.2.234 [CrossRef]

Helpful Lesbian, Gay, Bisexual, and Transgender (LGBT) Caregiver Resources

Name Site Description
Services and Advocacy for Gay, Lesbian, Bisexual, and Transgender Elders (SAGE) http://www.sageusa.org This group was begun in the late 1970s and started out as “Senior Action in a Gay Environment.” The purpose of the group is to provide LGBT older adults with the unique resources they need to age successfully. The site is very comprehensive, with information for consumers and clinicians alike.
National Resource Center on LGBT Aging http://www.lgbtagingcenter.org This is a project operated by SAGE. The site contains excellent and free information for LGBT older adults, aging organizations, and clinicians. Content includes webinars, documents, and links to other resources.
Lavender Health http://www.lavenderhealth.org This site was developed, and is currently maintained, by a team of nurses who “have experience in LGBTQ communities, both as members of the communities and as providers, researchers, and educators.” Of special interest are the two PowerPoint presentations free for downloading: “Introduction to LGBTQ Healthcare Issues” and “Culture is More than Ethnicity: Best Practices for LGBTQI Communities.” The presentations can be accessed directly at http://www.lavenderhealth.org/educationFiles/mediaEd.html.
National Gay and Lesbian Task Force http://www.thetaskforce.org The Task Force works to identify and correct discriminatory practices against LGBT individuals. Free downloadable research reports and resources specific to aging are available.

Keypoints

Jablonski, R.A., Vance, D.E. & Beattie, E. ( 2013). The Invisible Elderly: Lesbian, Gay, Bisexual, and Transgender Older Adults. Journal of Gerontological Nursing, 39( 11), 46– 52.

  1. Older adults ages 50 to 64 are more likely to disclose their sexual orientation or gender identity than those 65 or older.

  2. As people age with HIV, the development of cognitive deficits may result in poorer everyday functioning, inability to meet work-related demands, poorer financial management, and decreased driving ability, all of which can impact social functioning as well.

  3. When caring for transgender older adults, clinicians need to understand that physical examinations and screening tests are predicated on the organs actually present instead of the appearance of the person.

  4. Questions about sexual orientation and gender identity should be routinely asked of all patients or residents.

10.3928/00989134-20130916-02

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