Sexual and gender minority older adults (those who are age ≥50 and identify as lesbian, gay, bisexual, transgender, and/or queer [LGBTQ]) are described as a generation of people who are “aging in silence” because they have historically been left out of aging services, policies, and research (Choi & Meyer, 2016; Fredriksen-Goldsen, 2016, 2017; Fredriksen-Goldsen & Espinoza, 2014). Today's 2.4 million LGBTQ older adults are without adequate aging services and resources designed to address their unique strengths and challenges. Five million LGBTQ older adults are expected to live in the United States by 2030, and this estimate doubles to 10 million when considering older adults who may not identify as LGBTQ but engage in same-sex behavior and romantic relationships (Fredriksen-Goldsen, 2018; Fredriksen-Goldsen et al., 2015; Fredriksen-Goldsen & Kim, 2017; Gates, 2017). In this editorial, we draw from the Health Equity Promotion Model (Fredriksen-Goldsen et al., 2014) to discuss social strengths of the LGBTQ community. We suggest health care providers gather information about families of choice and community connections to better understand and integrate sources of support into the care of LGBTQ older adults.
Health Equity Approaches
Health initiatives that exist for LGBTQ older adults often highlight the need to eliminate sexual and gender minority-based discrimination and health disparities. More than a decade of published research indicates that LGBTQ older adults consistently report more mental and physical health problems compared to their non-LGBTQ counterparts, including greater rates of depression, isolation, cardiovascular disease, and chronic pain (D'Augelli & Grossman, 2001; Fredriksen-Goldsen et al., 2012; Fredriksen-Goldsen, Kim, et al., 2013; Fredriksen-Goldsen et al., 2017; Meyer, 1995, 2003; Wallace et al., 2011). Minority stress theory, one of the most prominent theoretical frameworks used to explain LGBTQ health, proposes that disparate health outcomes among LGBTQ adults are a result of increased exposure to prejudice, discrimination, and social stress (Frost et al., 2015; Meyer, 1995, 2003). However, although minority stress theory advances our understanding of the connection between stigma and health outcomes among LGBTQ individuals, this framework is mostly focused on the negative experiences of LGBTQ adults (e.g., poor health, discrimination, victimization) and neglects an in-depth consideration of the positive aspects and strengths associated with belonging to the LGBTQ community.
Expanding on minority stress theory, Fredriksen-Goldsen et al. (2014) proposed the Health Equity Promotion Model, which considers resilience factors that influence LGBTQ individuals' health and well-being over time. Indeed, many LGBTQ older adults are happy and healthy despite the pervasiveness of prejudice and discrimination (Fredriksen-Goldsen, Emlet, et al., 2013; Riggle et al., 2008; Van Wagenen et al., 2013). Social and communal processes, such as social support and community integration, are incorporated into the Health Equity Promotion Model as factors that may buffer LGBTQ older adults from the negative health impacts of discrimination and social marginalization. Two social components of LGBTQ life that health care providers can address and encourage in their work with LGBTQ older adults are briefly reviewed.
Families of Choice
Many LGBTQ older adults have created “families of choice” to establish non-biological networks of social and familial support. Current LGBTQ older adults often receive care and support from friends, neighbors, ex-partners, and other community members, for instance, because family rejection and laws that prohibited same-sex marriage have left them with limited biological or legal family ties (Barker et al., 2006; Grossman et al., 2000; Himes & Reidy, 2000). However, relationships among families of choice may go unacknowledged when general intake forms are overly simplistic about relationship networks or questions about quality of support and care are not sufficiently expansive.
In health care settings, it is important to recognize how LGBTQ older patients may have a broader definition of family support than is traditionally understood (e.g., in biologically rooted definitions of kin and family). Several steps can be taken to ensure providers understand the complexity—and significance—of families of choice. At the most basic level, providers can gather information from LGBTQ older adults about who they identify as a support system. As common as asking about marriage or children, asking questions such as, “Who is important to you in your life?” can provide more knowledge of the care and support of LGBTQ older adults (Table 1; adapted questions drawing from the National Resource Center on LGBT Aging). This type of information can signal who may be playing a physical or emotional caretaking role in someone's life; moreover, knowing the strength and intensity of patients' relationships with others may be particularly useful for understanding the psychological impact if such relationships dissolve for any reason (e.g., in cases of declining health, death, geographic separation). In sum, redefining the notion of “family” has provided some LGBTQ people with a great deal of social support, security, and comfort. Recognition of this aspect of life can enhance one's understanding of LGBTQ older adults and who they draw upon for love and support.
Questions for Health Care Providers to Inquire About LGBTQ Older Adults' Families of Choice and/or Social Networks
Related to families of choice, another source of strength among LGBTQ people stems from community connectedness (e.g., a sense of connection to or emotional affiliation with other LGBTQ people; Frost & Meyer, 2012; Kertzner et al., 2009). The degree to which people feel connected to other LGBTQ people varies across individuals. A sense of belonging to one's community may involve thinking of community at a specific level (e.g., locally or virtually through online networks) and in the abstract (e.g., as a broad sense of connection to other LGBTQ people in the world). Having pride in one's identity and connection to one's community is associated with positive outcomes for LGBTQ older adults, such as higher quality of life and lower internalized homophobia (Fredriksen-Goldsen et al., 2015; Masini & Barrett, 2008; Meyer, 2003); thus, health care providers and services for older adults (e.g., independent living, assisted living, adult day care, long-term care) may encourage or facilitate activities that may connect LGBTQ people with one another. For example, this might involve helping to advertise or coordinate local or virtual events that are specific to LGBTQ issues that may be of interest to LGBTQ individuals, such as local pride celebrations or movie nights that promote LGBTQ–inclusive themes. The National Resource Center on LGBT Aging (2015, 2018) has created a step-by-step toolkit for aging services to offer LGBTQ–themed movie viewings and discussions for older adults (access https://www.sageusa.org/wp-content/uploads/2018/05/sageusa-step-by-step-guide-for-lgbt-elder-programming.pdf) as well as a practical guide for aging services to partner with local LGBTQ groups to promote events (access https://www.sageusa.org/wp-content/uploads/2018/05/sageusaage-friendly-inclusive-services-guide-for-lgbt-organizations.pdf).
Further, learning the extent to which patients are immersed with LGBTQ communities would be an important construct to assess as part of LGBTQ individuals' overall health and well-being. Asking LGBTQ patients about the extent of their connection to and contact with other LGBTQ people would be an important first step to understanding the important role that community may play in the lives and health of LGBTQ older adults. Drawing from Frost and Meyer's (2012) community connectedness scale, questions health care providers may use to assess LGBTQ older adults' engagement with their community and their desire to be involved with LGBTQ–specific activities and events are suggested in Table 2.
Questions Health Care Providers Can Ask LGBTQ Older Adults About Engagement and Connectedness to the LGBTQ Community
Taken together, given the growing number of older adults who identity as LGBTQ, it is important for health care providers to not only understand the risk and stress associated with LGBTQ health disparities but also to learn more about how LGBTQ people live, socialize, and build relationships with others. Asking questions that allow LGBTQ older adults to convey this information can give providers greater insight into their social strengths. Increased awareness of families of choice and community connectedness will enhance providers' understanding of LGBTQ people and the care they provide and, in turn, may strengthen LGBTQ patients' trust in health care providers.
Britney M. Wardecker, PhD
Assistant Professor, College of Nursing
The Pennsylvania State University University
Jes L. Matsick, PhD
Assistant Professor, Psychology and
Women's, Gender, & Sexuality Studies
The Pennsylvania State University University
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Questions for Health Care Providers to Inquire About LGBTQ Older Adults' Families of Choice and/or Social Networksa,b
|Who is important to you in your life?|
|Who might you call first for support and assistance?|
|Who do you consider to be closest to you?|
|Is there anyone you can rely on for help if needed? If so, who are they to you?|
Questions Health Care Providers Can Ask LGBTQ Older Adults About Engagement and Connectedness to the LGBTQ Community
|Do you feel connected to other LGBTQ people?|
|Do you have contact with other people who identify as LGBTQ? For example, do you have any friends who are LGBTQ? Or are you involved with any groups tha t might be LGBTQ–related?|
|How satisfied are you with the amount of contact and connection you have with other LGBTQ people?|
|Would you be interested in connecting with other LGBTQ people through activities and events?|