The Invisible Elderly, Lesbian, Gay, Bisexual, And Transgender Older Adults

8/12/2019 The Invisible Elderly, Lesbian, Gay, Bisexual, And Transgender Older Adults

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Approximately 2 million older adults identify as lesbian,gay, or bisexual (Fredriksen-Goldsen et al., 2011); how-

ever, this may be an underestimation given the reticencemany have about disclosing their status. This estimation is fur-ther complicated by some who practice same-sex behaviors, butby and large, identify themselves as heterosexual. Likewise, thenumbers of individuals who identify as transgender are some-what more difficult to measure also due to ambivalence aboutdisclosing; regardless, such estimates range from 0.3% to 0.5%(Fredriksen-Goldsen, Cook-Daniels, et al., 2013).

Rita A. Jablonski, PhD, CRNP; David E. Vance, PhD, MGS; and 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 environ-

ments that will meet the needs of this invisible, and often misunderstood, group of

people. [Journal of Gerontological Nursing, 39(11), 46-52.]

Lesbian, Gay, Bisexual, and

Transgender Older Adults

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When asked if they provided servicestailored to the needs of lesbian, gay, bi-sexual, or transgender (LGBT) older

adults, only 15% of the Area Agencieson Aging replied in the affirmative (Kno-chel, Croghan, Moone, & Quam, 2012).The remaining agencies did not offertailored services to LGBT individualsbecause they never received a request forsuch services; in fact, some respondentsbelieved that all older adults require thesame services, regardless of sexual ori-entation. LGBT older adults may alsocontribute to their invisibility by decid-ing not to disclose to health professionalsand agencies. Many LGBT older adultshave lived lives filled with discrimi-nation and, as a result of negativeexperiences with health care agenciesand personnel, are at greater risk forpoorer health than their straightcounterparts (Fredriksen-Goldsen etal., 2011, Fredriksen-Goldsen, Cook-Daniels, et al. 2013; Fredriksen-Gold-sen, Emlet, et al., 2013).

In the first federally funded na-tional survey of LGBT older adultsand their caregivers, researchers

found that the majority of respon-dents identify as gay men (61%),followed by lesbians (33%), trans-gender (7%), bisexual men (3%), bi-sexual women (2%), and queer (aterm used with few but a pejorativecomment to many [Haber, 2009]) orother (1%) (Fredriksen-Goldsen etal., 2011). The majority of individualswho identified as transgender weremale-to-female (60%). Twenty-sixpercent of individuals identified as

female-to-male, whereas the remain-ing either chose other or declinedto answer (Fredriksen-Goldsen et al.,2011). The numbers of transgenderindividuals may be higher because ofhow these older adults classify them-selves. After completing the transitionprocess, which includes sexual reas-signment surgery, some older adultsno longer identify as transgender;they instead identify as either male or

female (Fredriksen-Goldsen, Cook-Daniels, et al., 2013). For the sake ofsimplicity and clarity, the abbrevia-

tion LGBT will be used in this articleto denote the lesbian, gay, bisexual,and transgender community.

The purpose of this article is topresent an overview of the physicaland mental health needs of LGBTolder adults to sensitize nurses to thespecific needs of this group. We con-clude with specific suggestions as tohow nurses can create health care en-vironments that will meet the needsof this invisible, and often misunder-stood, group of people within ourcare.

HEALTH DISPARITIES OF LGBTOLDER ADULTS

The LGBT community is as het-erogeneous as any other group ofolder adults who come from differ-ent racial/ethnic, religious/spiritual,educational, and socioeconomicbackgrounds. For most of these olderadults, it is fair to say they grew upin a family and a society that was un-

aware or misinformed about what be-ing LGBT was or how people becamethat way. Sadly, the current cohortof LGBT older adults may have ex-perienced a lifetime of discrimination:being shunned by family, friends, re-ligious organizations, and the medi-cal community; ridiculed or physi-cally attacked; or labeled as criminals,perverts, or sinners (Haber, 2009). Infact, it was not until 1973 that homo-sexuality was removed as a mental

disorder from the Diagnostic and Sta-tistical Manual of Mental Disordersof the American Psychiatric Asso-ciation (Institute of Medicine, 2011).Yet, despite this unprecedented andbold stand, the lack of informationand misrepresentation in the mediaof what it meant to be LGBT un-doubtedly contributed to continueddiscrimination and prejudice, whichwas often expressed in victimization

such as threats or attacks to onesbody, job, or property. In fact, in onesurvey, 82% of LGBT older adults re-

ported having been victimized at leastonce, whereas 64% reported havingbeen victimized three or more timesin their lifetime (Fredriksen-Goldsenet al., 2011). Approximately 25%have experienced discrimination atwork, either through denial of a po-sition or a promotion, or simply be-ing fired once their sexual orientationor gender identity become known(Fredriksen-Goldsen et al., 2011).Thirteen percent reported either re-ceiving inferior care or being deniedcare because of their sexual orienta-tion or gender identity (Fredriksen-Goldsen et al., 2011). Given thecumulative effect of such negative ex-periences, it is surprising that as manyas 80% disclose their sexual or gen-der identity to a health care provider(Fredriksen-Goldsen et al., 2011;Fredriksen-Goldsen, Cook-Daniels,et al., 2013); however, those who weretreated worse may not identify as gayat all anymore out of fear of such vic-

timization.Fortunately, given the slowly

changing political climate for socialjustice for LGBT issues over the pastfew decades since the Stonewall Riotswhen the LGBT civil rights move-ment began in New York City, someage-related differences among thecurrent LGBT cohort must be con-sidered. Older adults ages 50 to 64 aremore likely to disclose their sexual ori-entation or gender identity than those

65 or older (Fredriksen-Goldsen etal., 2011). To understand this inclina-tion between these two groups, it isimportant to consider whether suchindividuals realized they were LGBT;for those who came out to them-selves before the Stonewall Riots,they did not have any political clout;these individuals would be 65 andolder now. For those who came outafter the Stonewall Riots, they were in

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the midst of growing self-identity asa proud community in a changingpolitical landscape; these older adultswould be ages 50 to 64 now.

In addition to such historical dif-ferences that influence perceptionsamong LGBT older adults, differ-

ences among lesbians, gay men, bisex-ual men and women, and transgenderolder adults themselves obviouslyexist. Lesbians, for example, report atriple threat of insignificance due tocombined marginalization from het-erosexism, sexism, and ageism (Av-erett, Yoon, & Jenkins, 2011, p. 216);and this could be a quadruple threatof social insignificance if one is a per-son of color or has other unfavor-able societal attributes (e.g., mentalillness, physically disabled, poor).

LGBT older adults face significanthealth disparities, even after control-ling for income, educational level,and age. Almost half of LGBT olderadults have a disability, defined as theneed for specialized equipment orphysical activity limitations. Nearlytwo thirds of transgender older adultsexperience disability compared tohalf of lesbians and bisexual men andwomen (Fredriksen-Goldsen et al.,2011). Gay men had the lowest rates

of disability at 41% (Fredriksen-Goldsen et al., 2011). Obesity is asignificant problem for many LGBTolder adults as well. Forty percentof transgender older adults are obese(Fredriksen-Goldsen, Cook-Daniels,et al., 2013). Lesbians and bisexualwomen have the same rates of obe-sity, 34%. The obesity rates for gaymen and bisexual men are also similar,19% and 18%, respectively (Fredrik-sen-Goldsen et al., 2011).

Living arrangements are anotherdistinction to be considered amongLGBT older adults. In the heterosex-ual population, older women are morelikely to live alone than men. In theLGBT population, this is reversed: Gayand bisexual men are more likely tolive alone compared to lesbians and bi-sexual women (Fredriksen-Goldsen etal., 2011). Thus, gay and bisexual olderadults may require more social support

to age in place. Also, it is important toconsider that not all families are accept-ing of ones partners. Families may beuncomfortable including their unclesroommate in family events; and assuch, couples may not be integratedinto other families of orientation. Thus,

this may be an important area for spe-cial attention at senior centers and othervenues so that the roommate is notleft home isolated from the rest of thecommunity.

Mental health problems are an-other health disparity that should beconsidered in LGBT older adults. Inparticular, transgender individualsexperience more mental health prob-lems than lesbian, gay, and bisexualolder adults. Forty-eight percent of

transgender older adults report de-pression, compared to the overall de-

pression rates for LGB older adultsat 31% (Fredriksen-Goldsen, Cook-Daniels, et al., 2013). When examinedindividually, lesbians and gay menhave lower depression rates (27% and29%, respectively) whereas bisexualmen and women have similar depres-sion rates (35% and 36%, respective-ly) (Fredriksen-Goldsen, Emlet et al.,2013). In regard to anxiety, 39% oftransgender older adults have this di-

agnosis, compared to 22% of gay andlesbian older adults. Bisexual oldermen and women fare differently: Bi-sexual older men have similar anxietyrates as gay men (24%), whereas 34%of bisexual older women experienceanxiety (Fredriksen-Goldsen et al.,

2011). Serious thoughts of suicide fol-lowed similar patterns: 71% of trans-gender older adults considered suicideat some point in their lives comparedto 35% of lesbians, 37% of gay men,39% of bisexual men, and 40% of bi-sexual women (Fredriksen-Goldsenet al., 2011). Fortunately, not all of thenews is bad. The majority of LGBTolder adults (89%) feel positive aboutbelonging to the LGBT community(Fredriksen-Goldsen et al., 2011).Also, there is some literature thatsuggests that once someone has dealtsuccessfully with a difficult life chal-lenge, such as coming out to oneselfand others, this produces crisis com-petence (i.e., hardiness, resilience); assuch, this life skill can help one withsuccessful aging as well (Vance, Struz-ick, & Masten, 2008).

LONGTERM CARE AND LGBTOLDER ADULTS

Although older adults rarely relish

the thought of requiring long-termcare, LGBT older adults have addi-tional unique concerns. Many olderadults who have come out of thecloset grapple with whether to maketheir LGBT status known to nursinghome staff for fear of facing discrimi-nation during a period of increasedvulnerability (National ResourceCenter on LGBT Aging, 2012b; Stein,Beckerman, & Sherman, 2010). Theyalso fear being ostracized and mal-

treated by other nursing home resi-dents, especially roommates (Stein etal., 2010). LGBT older individualsmay constantly self-censor to appearstraight. Although non-LGBTnursing home residents are free toreminisce about their lives and fami-lies, LGBT older adults worry aboutoffending others by talking abouttheir lives as gay individuals (Stein etal., 2010).

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.



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Transgender individuals also ex-pressed concerns about long-termcare. After experiencing a lifetime of

harassment and violence, the thoughtof being vulnerable and frail and re-quiring care from others is fright-ening. Although some may havecompletely changed their physicalappearance via sexual reassignmentsurgery, many older adults have not(Fredriksen-Goldsen, Cook-Daniels,et al., 2013; Kaufman, 2010). Individ-uals who wish to appear female mayuse prosthetic breasts, whereas indi-viduals wishing to appear male may

use compression vests to minimizeexisting breasts (Kaufman, 2010).Nursing home staff and fellow resi-dents may respond to the discoverythat Paula is biologically Paulwith a range of reactions, includingastonishment, shock, anger, and con-fusion (Kaufman, 2010). Transgenderolder adults may find themselves be-ing addressed by the non-preferredpronoun and the wrong name, while

being assigned to a room based ontheir biological gender instead of theiridentified gender.

AGING WITH HIVAnother particular area of concern

in the LGBT older adult communityis aging with HIV. Nine percent ofLGBT older adults have HIV. Most ofthese infections are in gay or bisexualmen; in fact, 14% of gay or bisexualmen are HIV positive (Fredriksen-Goldsen et al., 2011). Fortunately, les-bians experience a lower rate of infec-tion compared to the larger straight

community; this is probably due tothe type of biological risk associatedwith the different modes and amountof fluid exchange during sexual in-teraction between gay/bisexual men,heterosexuals, and lesbians. Regard-less, aging with HIV can affect sev-eral areas that affect successful agingincluding physical, cognitive, social,and spiritual health in both LGBTand heterosexual individuals (Vance,

Bayless, Kempf, Keltner, & Fazeli,2011; Vance, Brennan, Enha, Smith,& Kaur, 2011).

Fortunately, data are reflecting thatthose who respond well to combina-tion antiretroviral therapy (cART) forHIV and avoid any detrimental healthissues (e.g., intravenous drug use) tendto have survival rates similar to thosewithout HIV (Rodger et al., 2013).This news is encouraging; clearly,cART has been shown to help protectand reconstitute the immune systemand prevent AIDS progression. Yet,despite such encouragement, HIV is

associated with increased systemicinflammation and cART is associatedwith increased metabolic syndromesthat can promote hypertension, hy-percholesterolemia, heart disease, dia-betes, liver disease, renal disease, andcertain carcinomas (Vance, Mugave-ro, Willig, Raper, & Saag, 2011). Assuch, there is concern that these con-ditions will accelerate the aging pro-cess in those living with HIV. There-

TABLE

HELPFUL LESBIAN, GAY, BISEXUAL, AND TRANSGENDER LGBT CAREGIVER RESOURCES

Name Site Description

Services and Advocacy forGay, Lesbian, Bisexual, and

Transgender Elders (SAGE)

http://www.sageusa.org This group was begun in the late 1970s and started out asSenior Action in a Gay Environment. The purpose of thegroup is to provide LGBT older adults with the unique resourc-

es they need to age successfully. The site is very comprehen-sive, with information for consumers and clinicians alike.

National Resource Centeron LGBT Aging

http://www.lgbtagingcenter.org This is a project operated by SAGE. The site contains excel-lent and free information for LGBT older adults, agingorganizations, 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 ateam of nurses who have experience in LGBTQ communi-ties, both as members of the communities and as providers,researchers, and educators. Of special interest are the twoPowerPoint presentations free for downloading: Intro-duction to LGBTQ Healthcare Issues and Culture is Morethan Ethnicity: Best Practices for LGBTQI Communities.

The presentations can be accessed directly at http://www.lavenderhealth.org/educationFiles/mediaEd.html.

National Gay and LesbianTask Force

http://www.thetaskforce.org The Task Force works to identify and correct discriminatorypractices against LGBT individuals. Free downloadable re-search reports and resources specific to aging are available.

Note. LGBTQ = lesbian, gay, bisexual, transgender, and queer; LGBTQI = lesbian, gay, bisexual, transgender, queer, and intersexed.



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KEYPOINTSJablonski, 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 sexualorientation or gender identity than those 65 or older.2 As people age with HIV, the development of cognitive deficitsmay result in poorer everyday functioning, inability to meet work-

related demands, poorer financial management, and decreaseddriving ability, all of which can impact social functioning as well.

3When caring for transgender older adults, clinicians need to un-derstand that physical examinations and screening tests are predi-cated on the organs actually present instead of the appearance ofthe person.

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

are predicated on the organs actuallypresent instead of the appearance ofthe person (Kaufman, 2010). Manytransgender older adults use, or haveused, exogenous hormones. Thesehormones raise the risk of breast, ovar-ian, uterine, and prostate cancers. For

example, a male-to-female older adultwho used exogenous female hormoneswill require mammograms to screenfor breast cancer (Feldman, 2010).

IMPLICATIONS FOR NURSESContent about the specific care

needs of LGBT individuals, espe-cially older adults, is virtually nonex-istent in nursing textbooks (Eliason,Dibble, & DeJoseph, 2010). Onlyeight of 5,000 nursing journal ar-ticles concentrated on LGBT healthissues (Eliason et al., 2010). Withoutthis information, nurses cannot pro-vide culturally competent care. Thefirst step nurses can take to care forLGBT older adults is to realize thatthey already have LGBT patients orresidents. Given lifetime experiencesof negativity at best and violence atworst, LGBT older adults may notalways openly share their identitywith health care providers. Further-more, LGBT older adults may have

prior life experiences, such as havingbeen married or having children, thatcause nurses to assume heterosexu-ality (National Resource Center onLGBT Aging, 2012b).

Nurses can also change the waythey ask for information, both ver-bally and in writing. Questions aboutsexual orientation and gender iden-tity should be routinely asked of allpatients or residents. Given the dis-crimination faced by LGBT older

adults, the nurse must preface thisinformation with why the questionsare being asked: To provide the bestand most sensitive care for all of ourpatients, we ask questions that mayseem different. Also, questionsabout sexual orientation and genderidentity need to be asked separately,as they are unrelated. On forms, ablank line can be included after themale and female choices, to al-

low older adults to label their owngender (National Resource Center onLGBT Aging, 2012b). Another op-tion is to ask What is your gender?and leave a blank to allow for an indi-vidual to complete the question as heor she believes appropriate (NationalResource Center on LGBT Aging,2012a). Questions such as maritalstatus may need to be amended; onepossibility is to offer the choice mar-

ried/partnered. The Table includeshelpful resources for nurses and otherhealth care providers. Additionally,the nurse should inquire about so-cial support and the size of the olderadults social network. A recent studyfound that higher levels of social sup-port and larger social networks actedas 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 suf-fer from depression and overall poorhealth (Fredriksen-Goldsen, Cook-Daniels, et al., 2013).

If an older adult identifies as trans-gender, the nurse must ask how theclient wishes to be addressed. Also,the nurse must inquire as to how theolder adult prefers his or her informa-tion recorded on permanent medicalrecords (National Resource Center

on LGBT Aging, 2012a). The nursemust also ask what surgeries havebeen completed. For male-to-femalesexual reassignment surgery, a vaginamay have been created using the glanspenis; the prostate is not routinelyremoved. In this case, the older adultwould need both a prostate surfaceantigen test or digital rectal examina-tion and a Pap smear (Feldman, 2010).The nurse should query about medi-

cations, especially hormones such asestrogen and testosterone. For ser-vices that are segregated accordingto gender, such as room assignmentsand restrooms, the decision shouldbe based on the older adults genderidentity, not biological gender (Na-tional Resource Center on LGBTAging, 2012a,b).

CONCLUSIONThe current cohort of LGBT older

adults has encountered a lifetime ofdiscrimination, violence, and evenpersecution. These experiences haveleft many suspicious of health careproviders and systems. Nurses firstneed to acknowledge that they are al-ready providing care to LGBT olderadults in a variety of settings thatare heterocentric. The next step is tochange how nurses obtain informa-tion regarding gender, identity, and



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significant others. In the case of trans-gender older adults, nurses requiretact and sensitivity when obtainingmedical and surgical histories, as wellas during physical examinations andintimate procedures. By adopting in-clusive language and practices, nurses

are in the best position to providethoughtful and culturally appropriatecare to these older adults.

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ABOUT THE AUTHORS

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

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

Address correspondence to Rita A.Jablonski, PhD, CRNP, Associate Professor,School of Nursing, The University of Ala-bama at Birmingham, NB 520, 1720 2ndAvenue South, Birmingham, AL 35294-1210; e-mail: [email protected].

Received: July 24, 2013Accepted: August 15, 2013Posted: September 24, 2013doi:10.3928/00989134-20130916-02



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Documents

The Invisible Elderly, Lesbian, Gay, Bisexual, And Transgender Older Adults