A surgeon who spots a wedding ring and asks if the patient's wife can take care of him after surgery, not realizing the man's spouse is actually a husband.
Staff in long-term care facilities who express puzzlement or even disgust about same-sex sexuality.
Emergency room personnel who convey alarm when they discover the woman the hospital just admitted was once a man.
Such situations are more than just awkward. They can keep lesbian, gay, bisexual and transgender (LGBT) older adults from getting the care they need. The result is disparities, with LGBT older adults at higher risk of many negative health outcomes, including worse mental health and unhealthy behaviors. Psychologists are working to change that by investigating the special challenges — and resiliencies — of LGBT people and calling for health-care providers who work with older people to create a welcoming environment for LGBT patients.
"A lot of general practitioners in the field of gerontology assume that everyone who walks into their office is heterosexual," says Douglas C. Kimmel, PhD, co-chair of the Committee on Aging of APA's Div. 44 (Society for the Psychological Study of LGBT Issues). "But instead of making assumptions about someone's sexual history or practices, their relationship status or their gender identity, they need to be aware that they can't assume anything but need to ask intelligent questions."
Diversity within difference
Of course, it's difficult to generalize about a group as large as LGBT older adults, says Kimmel. According to Services and Advocacy for Gay, Lesbian, Bisexual and Transgender Elders (SAGE), about 1.5 million people age 65 and older in the United States are lesbian, gay or bisexual, and that population may double by 2030.
As a 2011 Institute of Medicine report called "The Health of Lesbian, Gay, Bisexual and Transgender People: Building a Foundation for Better Understanding" points out, while LGBT people are often lumped together for advocacy and research purposes, each letter of the acronym represents a distinct population with its own characteristics and health needs.
Knowing that an older person is LGBT doesn't tell you much, agrees Kimmel. "You have to grasp all the dimensions of diversity," he says.
Consider the life experiences of different age groups within the broad category of "older," says Kimmel. The oldest may have spent a lifetime in the closet, he points out, while older baby boomers may have had much more open lives.
And whether you're L, G, B or T also makes a huge difference, says Kimmel. Older gay men, for example, may be partnered or married to men, still in the closet, or single and suffering from age discrimination within the gay community. They may once have been married to women and have children with them. They may have faced employment discrimination or worked for themselves because they couldn't find jobs in corporate America. They may be HIV-positive and dealing with complications from antiretroviral therapy or simply surprised to still be alive.
Older lesbians often experience triple discrimination because of their status as women, older adults and lesbians, while ethnic and racial minority LGBT older adults face a quadruple whammy. Some older lesbians may have only embraced their lesbian identities later in life, after marrying and raising children with men. Others, such as Edie Windsor — who had to appeal to the U.S. Supreme Court to have her marriage recognized — may have been in same-sex partnerships for decades.
Bisexuals — a community Kimmel describes as "incredibly diverse and often under-represented in any discussion of LGBT aging" — are more likely to have spouses, children and grandchildren.
And depending on when they made their transitions, transgender older adults may have friends and even some family members who may be unaware that they started life with a different gender presentation. "Transgender people very often wind up educating physicians and other medical professionals about their transgender history and what it means instead of being able to go to a professional who already has that knowledge and is able to provide the care that's needed," says Kimmel.
Despite these different life experiences, LGBT older adults typically do have challenges in common, says Kimmel. He points to a 2013 study published in the American Journal of Public Health that examined data from almost 100,000 lesbian, gay and bisexual adults 50 and older. The analysis revealed that these older adults had a higher risk of poor mental health and disability than their heterosexual counterparts. They were also more likely to smoke and drink excessively.
In a paper published this year in Clinical Gerontologist, Kimmel notes that LGBT older adults are less likely to maintain ties with their biological families, are more likely to live alone and are four times less likely to be parents than their heterosexual counterparts. As a result of that isolation, they're more likely to require care from nonfamily caregivers. Lifetimes of discrimination and denial of spousal or partner benefits can create financial barriers to receiving medical care. And despite progress when it comes to acceptance, fear of discovery and an unwillingness to disclose their status remain a problem for many LGBT older adults.
The good news? Facing that lifelong discrimination forces LGBT older adults to develop strong coping skills that can give them an advantage over their straight counterparts, says Nancy Orel, PhD, co-editor of the 2014 APA book "The Lives of LGBT Older Adults: Understanding Challenges and Resilience."
"That resiliency enables them to deal with aging issues better than the heterosexual population," says Orel, associate dean of the College of Health and Human Services at Bowling Green State University.
Families of choice
Another source of resilience is the wide social support network many LGBT older adults enjoy, says Orel.While some LGBT older adults are estranged from their birth families, she says, they typically create what are known as "families of choice."
"That's another strength they've developed: recognizing that they do need support and may not have that support from biological families and creating their own families," she says.
This strategy should be a model for all older adults, says Orel. "Everyone should extend their network of support systems to include biological children, families of choice, families of origin and friends," she says.
But relying on friends for caregiving in old age may not be enough, warns Mark Brennan-Ing, PhD, director of research and evaluation at the ACRIA Center on HIV and Aging and an adjunct assistant clinical professor at New York University College of Nursing in New York. That's especially true for gay older adults with HIV, he says.
"Typically in Western countries, we rely on friends for emotional support, not so much for hands-on, instrumental assistance," says Brennan-Ing. "And a lot of friends have HIV themselves and may be in the same boat."
In a paper published in the Journal of Homosexuality opens in new window this year, Brennan-Ing and colleagues noted that for reasons still unconfirmed, people living with HIV age faster than their peers, showing high rates of age-related illnesses a decade or two before expected. With fragile social networks that can't provide the level of support needed, the authors say, those living with HIV will increasingly be forced to turn to community-based and government services that may not be ready for them.
"There's very little awareness of this impending wave of HIV-positive aging adults who need services, and there is a lack of knowledge and cultural competence in aging service providers about HIV issues," says Brennan-Ing, adding that U.S. Centers for Disease Control and Prevention data show that the number of people 50 and older living with HIV/AIDS has almost doubled since 2001.
An unwelcoming environment?
LGBT older adults as a whole are already facing problems in long-term care, home health care and other service arenas, says Linda A. Travis, PsyD, secretary of Div. 44 and a board member of the Gay and Lesbian Medical Association.
While some facilities in the very competitive long-term care market use their LGBT-friendly status as a marketing advantage, says Travis, others aren't so welcoming.
"I can't overstress the potential fears that people have about discrimination," she says. As a result, she says, LGBT older adults can be reluctant to see health-care providers until their problems become so bad they can no longer avoid doing so.
Travis, who trains health-care providers and students to be more LGBT-friendly, says even innocent questions about marital status and the like can make LGBT older adults feel unwelcome. Providers and intake forms should ask about relationship status instead, she says. And instead of making assumptions, they should ask about sexual orientation, gender identity and the pronouns patients use to describe themselves. Websites depicting same-sex couples and other forms of diversity can also help, says Travis, who has written fact sheets on LGBT aging for health-care providers (see "Further Reading").
It's not just service providers who may discriminate against LGBT older adults, however. Research by Weston Donaldson, a graduate student in counseling psychology at Colorado State University, reveals that fellow long-term care residents may cause problems, too.
In a small, qualitative study published this year in Clinical Gerontologist: The Journal of Aging and Mental Health, Donaldson and colleagues found that while some fellow residents had favorable views of LGBT individuals, others were ambivalent or even hostile. Interviewees typically assumed that none of their peers at the facility were gay or lesbian, although in fact some were. Many interviewees said it would be OK to have gay and lesbian residents — as long as they didn't talk about their orientation.
"The gay and lesbian people in the facility didn't feel safe or comfortable to be out there," says Donaldson, an intern at Aurora Mental Health Center.
Being forced to stay or go back in the closet like that can have serious health consequences, says Donaldson. "We know that social isolation has a significant negative impact not only on mental health but also on physical health," he says. "Gay and lesbian residents are at more risk of being socially isolated."
Meanwhile, sexual activity can be a particularly fraught area for staff and other residents alike, says Kate Martin Hinrichs, PhD, a psychologist at the VA Boston Healthcare System's Community Living Center. The problem goes beyond the usual concerns about whether long-term care facility residents have the cognitive capacity to consent to sexual activity, she says.
"There's often an ‘ick' factor when people imagine two older adults having sexual contact," says Hinrichs. "Most older adults are perceived as fairly asexual."
When the two adults are LGBT older adults, reactions can be even more intense, says Hinrichs. Long-term care staff may assume that gay or lesbian sex is pathological and must be stopped. And the fact that LGBT older adults may have life partners or legal spouses may not even cross staff members' minds, she adds, explaining that facilities need to accommodate couples' desire to share a room or just get some privacy.
The issue will come up more as a new generation of LGBT people ages, Hinrichs predicts.
"The oldest old — those from the World War II era — are folks who lived in the closet," she says. "The baby boom cohort has had more freedom to be who they are and are demanding the right not to have to go back into the closet as they age."
Rebecca A. Clay is a journalist in Washington, D.C.
