The voice of lesbian, gay, bi-sexual, transgender, queer (LGBTQ) society has been historically latent and muffled. Inadequate data collection on LGBTQ demographics has remained a limitation for researchers and statisticians and has limited the impact of this minority population on legislative agendas. Without the input of key stakeholders, policies and mandates considered status quo can be altered with the stroke of a pen.
According to a National Academies of Science, Engineering, and Medicine (NASEM; 2017) report, health equity occurs when all burdens and benefits of disease processes become equally distributed among its community members. By creating a domain where health care is accessible, vulnerable populations have greater opportunities to experience the benefits of a vibrant community. Although NASEM (2017) recognizes many health care outcomes are based on behaviors and poor choices, social determinants of health including neighborhood conditions, lack of transportation, violence, unemployment, and lack of education weigh heavily on health care outcomes. Healthy People 2020 (U.S. Department of Health and Human Services [USDHHS], 2019a,b,c) also asserts that social determinants play a critical role in the prevalence of unequal and avoidable health care disparities among populations in conjunction with accessibility to health care.
Estimation of prevalence data for the LGBTQ older population is challenging. Yarns et al. (2016) estimated there are 1 million LGBTQ adults 65 and older residing in the United States. Fredriksen-Goldsen et al. (2011) estimated approximately 2 million adults 50 and older self-identified as lesbian, gay, or bisexual. Projected populations of LGBTQ adults 65 and older are estimated to reach 4 to 8 million by 2030 (Fredriksen-Goldsen et al., 2015). Estimates were based on an extensive 25-year literature review as well as data obtained from the USDHHS. Statistics showed that limited research on LGBTQ demographics prior to 2000 created bias when evaluating health care trends and analyses of LGBTQ health (Gates, 2014). LGBTQ older adults born prior to 1945 witnessed an era where social climates denounced same sex encounters as culturally and ethically unacceptable with participation lending itself to legal ramifications and volatile retribution. In 1973, medical coding and descriptors used by the American Psychiatric Association classified homosexuality as a mental health disorder identified specifically as a sociopathic personality disorder (Institute of Medicine [IOM], 2011b). Transgender identities were coded as gender identity disorders or gender dysphoria. The failure of the health care community to acknowledge homosexuality as a sexual preference further contributed to skepticism and suspicions of health care providers. In fear of physical or psychological retribution, LGBTQ older adults were forced to suppress sexual identity and stay in the closet.
Despite recent estimates on the number of gender and sexual minorities living in the United States, there is sufficient evidence in the literature that this number may be underrepresented. Until the di-annual census survey completed in 2010, same sex couples were not addressed in the questionnaire. The 2010 questionnaire did not ask specific questions about sexual orientation, but extrapolated data by identifying couples of the same sex who indicated their relationship status was married or living with a partner and unmarried (Deschamps & Singer, 2016). People who identified as gender neutral and transgender were widely underrep-resented, and few surveys even exist to analyze transgender populations. Gates (2011) affirmed that acknowledging and understanding accurate population tallies of the LGBTQ population is a “critical first step to informing a host of public policies and research topics” (p. 1).
Health disparities in the LGBTQ community recently came into focus at the national level. The IOM (2011b) dissected the conceptual perspectives of LGBTQ health issues with stigmatization at the origin of continued prejudice and discrimination. The USDHHS Healthy People 2020 initiative recognized the importance of improving health outcomes for LGBTQ individuals. Globally, members of the LGBTQ community exhibit a number of health disparities related to physical health and wellness, sexually transmitted diseases, mental health, substance use, victimization, bullying, and housing insecurity (Centers for Disease Control and Prevention [CDC], 2016; Ward et al., 2015). Older adults identifying as LGBTQ are susceptible to many health disparities. Age has a direct impact on experiences and quality of life over the life span (IOM, 2011a), with many LGBTQ older adults reporting a lifetime of victimization, racism, discrimination, health inequalities, and shame during a time when expression of LGBTQ identity was suppressed due to legal ramifications (Kim & Fredriksen-Goldsen, 2017).
A variety of social determinants further health disparities for LGBTQ older adults, with the influence of demographic factors on mental and physical well-being (IOM, 2011b). Education in sexual and gender minority communities may or may not have an association with accessibility to health care. Rural communities tend to have less support systems for the LGBTQ community, whereas larger cities tend to have greater opportunities for support systems and accessibility to health care services.
Although the overall body of knowledge related to LGBTQ health disparities is growing, research highlighting health disparities in aging gender sexual minorities (GSM) continues to lag. The National Health Interview Survey (NHIS) has been in existence since 1957 and is the nation's primary source of data related to the nation's health. Data obtained from the NHIS guide governmental agencies in creating national initiatives for health and tracking health outcomes (CDC, 2014). In 2013, for the first time in the NHIS's history, inclusive excellence was promoted by including a question on sexual orientation (Gonzales et al., 2016). Results from the NHIS provided a framework for future research to examine health disparities experienced by LGBTQ individuals in comparison to their heterosexual counterparts.
Fredriksen-Goldsen et al. (2017) examined health disparities in adults 50 and older using information from the 2013 and 2014 NHIS. Results from the study suggested similarities to global health disparities experienced by all LGBTQ individuals. Those individuals 50 and older experienced higher rates of chronic conditions, poorer health outcomes, and higher incidence of mental health conditions and disability (Fredriksen-Goldsen et al., 2017).
An aging population combined with significant health disparities positions LGBTQ older adults to seek health care from a system that has supported health inequalities for many years. Despite national health policies that promote non-discrimination, LGBTQ older adults continue to experience provider bias and negative reactions from health care providers (Deschamps & Singer, 2016).
Climate by State
Despite the awareness of LGBTQ inequalities and national initiatives to improve the lives of LGBTQ individuals, many states' laws continue to uphold inequalities and provide less protection for GSM's human rights. Hasenbush et al. (2014) in conjunction with the Williams Institute published The LGBT Divide: A Data Portrait of LGBT People in the Midwestern, Mountain and Southern States. The document outlined social climates and demographics of LGBTQ individuals who resided in states without non-discrimination provisions. The document developed a LGBTQ Social and Political Index with a range of 45 to 92, with the highest score promoting inclusiveness, social acceptance, and state non-discriminatory policies. The U.S. mean is 60. Specifically, the report examined the 29 states that lacked protection for GSM. As a whole, the states in the Pacific and Northeast regions were known for inclusiveness of all individuals and protection of residents' civil and human rights. The 21 states primarily in the Pacific and Northeast region that included laws to protect the rights of GSM had an aggregate climate score of 70. States in the southern region scored the lowest, with an aggregate score of 55 (Table A, available in the online version of this article). Ironically, the southern region is home to the highest number of LGBTQ individuals, with approximately 3.3 million or 35% of GSM (Hasenbush et al., 2014). These individuals have poorer health outcomes with the greatest number of newly reported HIV infections among men who have sex with men (CDC, 2019).
Social Climate Index by Region & State
Housing and Long-Term Care
Services & Advocacy for LGBT Elders (SAGE; 2014) is the nation's largest advocacy organization supporting and encouraging initiatives to protect America's LGBTQ older adults. SAGE, which has been in existence since 1978, is a resource to individuals and organizations by providing education for culturally competent care for LGBTQ older adults. One of the major concerns focuses on accessing LGBTQ-friendly affordable housing and inclusive long-term care communities without the fear of discrimination (SAGE, 2014). SAGE (2014) affirms approximately 13% of LGBTQ older adults experience discrimination when searching for affordable housing.
There are several accounts of LGBTQ older adults' failure to disclose sexual orientation to long-term care facilities for fear of rejection of admission or mistreatment (Woody, 2016). Approximately 73% of LGBTQ individuals residing in retirement communities believed discrimination was present and could be found in staff and fellow residents. Furthermore, 34% of those surveyed indicated they would attempt to conceal their sexual orientation when they had to move into such a facility (Johnson et al., 2005). In the same setting, researchers subsequently surveyed heterosexual residents. Results from that study suggested the heterosexual residents had little awareness about the perceived discrimination experienced by LGBTQ older adults (Jackson et al., 2008). Recent estimates suggest approximately two thirds of GSM have concerns about potential discrimination and abuse in long-term care settings leaving them feeling insecure about accessing needed health care services as they age (AARP, 2018; SAGE, 2014). Facing a lifetime of stigma and discrimination, many LGBTQ older adults begin to question if they should hide their sexual identities to access quality long-term care services (Johnson, 2018).
Health Care Policy Issues
Section 1577 of the Patient Protection and Affordable Care Act (ACA; USDHHS, 2010) protects Americans from discrimination by health care providers and programs that receive federal funding on the basis of race, color, national origin, age, disability, and sex. Specifically, sex discrimination is defined by the act as “including but not limited to discrimination on the basis of pregnancy, gender identity, and sex stereotyping” (USDHHS, 2010, p. 3). For the LGBTQ community, the provision provided full access to federally funded health care programs, including health insurance through programs administered by the Centers for Medicare & Medicaid Services (CMS) and the Health Care Marketplace. In addition to mandates, provisions were made to protect the civil rights of transgender individuals by further limiting federally funded health programs from discrimination of individuals whose sex may be different from their sex assigned at birth.
In the 2016 legislative session, the Council of the District of Columbia, Washington, DC passed B21-168 spearheaded by its co-chairpersons, the Honorable Yvette Alexander and the Honorable David Gross. The bill, termed the “LGBTQ Cultural Competency Continuing Education Amendment Act of 2015,” amended the District of Columbia's Health Occupations Revision Act of 1985 to include 2 hours of cultural competency education focusing on LGBTQ issues for all licensed health care professionals' continuing education requirements. The legislation passed unanimously, and the law went into effect April 6, 2016 (Council of the District of Columbia, 2016).
Movement toward equality and protection for LGBTQ health care consumers was threatened by a recent proposal by several federal entities who sought to propose changes that would create significant barriers for LGBTQ individuals in health care accessibility. On June 14, 2019, two entities of the USDHHS, CMS, and the Office for Civil Rights called for public opinion on their proposal to revise section 1577 of the ACA. Stakeholders cited rising health care costs, confusion in federal laws protecting civil rights, and religious freedom of providers as stimuli for the revisions (Musumeci et al., 2019). The USDHHS ended its 60-day call for public opinion on August 13, 2019. Major revisions to section 1577 were summarized by Musumeci et al. (2019) and include:
eliminating general prohibitions on discrimination based on gender identity, as well as specific health insurance coverage protections for transgender individuals; and
eliminating provisions preventing health insurers from varying benefits in ways that discriminate against certain demographics, such as persons identifying as LGBTQ and/or persons with HIV.
Revisions of current policies enacted could create significant barriers for accessibility to health insurance coverage for LGBTQ individuals. In addition, these revisions could prevent GSM from receiving quality health care by providers and health care agencies that are federally funded, including long-term care facilities.
In response to growing diversity in our client population, state regulatory agencies and national certifying bodies have responsibilities to ensure health care professionals are astutely prepared to meet the needs of their client population. One way to accomplish this task is by adopting similar standards as the District of Columbia, such as requiring a certain number of hours of continuing education to emphasize culturally competent care in vulnerable populations. The establishment of a trusting client and provider relationship is key to facilitating important conversations about making health care decisions while seeking to eliminate health disparities.
Nurses represent the nation's largest demographic in health care with an estimated 3.8 million RNs nationwide (American Association of Colleges of Nursing [AACN], 2019). Members of the nursing profession are well-equipped to provide testimony and expert positions on issues facing health care policy yet remain vastly uninvolved in the legislative process. Professional nursing organizations should unite members to be a stronger voice impacting laws to change the profession and the way health care is delivered.
According to NASEM (2017), community leaders and policy makers need to engage in community-driven collaboration on taxation and income disparity, housing development, education, civil rights, criminal justice, and health care policies to create an atmosphere of health care equity. The AACN's (2008) The Essentials of Baccalaureate Education for Professional Nursing Practice charges nurses to create an awareness of the vulnerabilities and health disparities experienced by LGBTQ populations. LGBTQ older adults may have been victimized during their lifetime creating a reluctance to identify sexual preferences, leaving knowledge gaps in health care assessments. Nurses should advocate for person-centered care and health care promotion, education, and disease prevention to create an awareness and visibility of potential health care disparities. Each nurse must also review one's own personal biases and beliefs to assess capacity to deliver inclusive care. Nurses can engage in scholarship and dissemination of research and evidence-based practice regarding LGBTQ health disparities to key stakeholders and policy makers, playing an active role in influencing health care policies to promote a holistic approach for positive health care outcomes in the LGBTQ community.
Some vulnerable populations including GSM remain vastly under-represented in research. Variability on population estimates and health factors exists within the literature. Health care providers are still ill equipped to properly assess sexual orientation and often omit asking questions about sexual orientation. The IOM and Joint Commission recommend providers screen and document all patients' sexual and gender orientation in efforts to provide high-quality patient-centered care for all heterosexual individuals and GSM (National LGBTQ Health Education Center, n.d.). The IOM (2011b) report The Health of Lesbian, Gay, Bisexual, and Transgender People recommends the National Institutes of Health encourage grant applicants to specifically identify whether research samples include or exclude GSM. In addition, the IOM (2011b) report recommends electronic health records include areas for data collection on sexual orientation. Accurate demographic data will allow nurses to provide more culturally competent, holistic care for GSM by addressing specific health issues faced by this vulnerable population.
According to the National League for Nursing (2017), the nursing workforce must demonstrate an awareness of global health needs as seen in vulnerable and marginalized populations, such as persons classified as indigenous, refugees, immigrants, and migrants. Health care policies are known to directly and indirectly impact the health care system (AACN, 2008). Policy amendments to void protection of LGBTQ individuals could weaken health care coverage and directly impact immediate health care needs. The AACN (2008) demonstrates how nurses who promote continued policy planning and implementation can assist regulatory bodies to correctly identify and address the health care needs of not only the LGBTQ population, but other vulnerable populations.
As with any health care policy, there are multiple viewpoints. Key stakeholders must review the benefits and detriments of any legislative act and provide comment regarding implications of proposed policies. Nurses are ideally positioned, with their direct experience of the implications of discriminatory policies on the people they serve, to have a voice in health care policies. The impact of their professional voice predicated with knowledge and experience in evidence-based practice can influence the conversation about health care policies that promote positive health care outcomes for the LGBTQ community.
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Social Climate Index by Region & State
|Northeast Region (71)||Pacific Region (68)||Midwest Region (59)||Mountain Region (56)||South Region (55)|
|New Hampshire||68||Washington||68||Michigan||63||New Mexico||65||Florida||60|
|Rhode Island||73||North Dakota||55||Mississippi||46|