Equal but different! Improving care for older LGBT+ adults

Abstract

International human rights movements have improved the visibility and equality of lesbian, gay, bisexual and transgender+ (LGBT+) communities and their members. Health outcomes for LGBT+ people remain, however, worse than for their non-LGBT+ peers. Older LGBT+ people have experienced fewer positive changes, in part due to their lived experience of discrimination and their ongoing, unintentional invisibility in medical and social care. This article highlights the impacts of societal structure, health and social care on the lives of older LGBT+ people including physical and mental health, End of Life, Dementia, Housing and Care Settings, and a focus on the experiences of trans-people. We look at the existing improvements developed by LGBT+ communities (and their allies) and propose refreshing Person-Centred Care to improve inclusivity. Finally, we provide a framework for looking at the areas in which service challenges arise and suggest ways to address these to make health and social care services more ready to meet the needs of older LGBT+ people.

Key Points

• This article describes some of the adverse health and wellbeing outcomes experienced by older LGBT+ people.

• These outcomes are due to societal issues and the set-up of health and social care.

• Change is possible through education and cultural shifts.

• Refreshing person-centred care to include sexual orientation and gender identity is key.

• We propose some target areas to improve inclusivity and the lives of older LGBT+ people.

Introduction

In the 20th century, legal and social movements improved the visibility and equality of LGBT+ (The acronym for lesbian, gay, bisexual and transgender) community members in many countries. Stigma, discrimination (and their legacies) persist however, in varying degrees in different countries. International studies show that LGBT+ people have worse health outcomes than their cis-gender and heterosexual peers (cis-het). They also show that older LGBT+ people have benefitted less from changing attitudes towards sexual and gender minorities than younger LGBT+ people [1], as they are more likely to have personal histories that include lifetimes of discrimination, stigma and mistreatment including within the medical environment [2]. Medical and social care may also unintentionally exclude older members of LGBT+ communities, which is associated with negative effects on their physical and mental health [3]. This commentary aims to discuss the distinct life and health experiences of older LGBT+ communities, the impact these may have on their health and welfare, and how medical and social care practice can improve to become more inclusive, generating better outcomes for older LGBT+ communities.

Social context

While many of the issues that older LGBT+ people face are similar to their cis-het peers, there are unique challenges associated with ageing as an LGBT+ person:

• Heteronormativity within the society and ageism within their communities [4].

• Reduced access to community supports, due to living alone and being single [5].

• Strained or absent relationships with families of origin [1].

• Reliance on non-traditional sources of support with little socio-legal recognition [1].

• Reduced social support as they age, particularly for transgender older adults whose support networks include the fewest family connections [1].

• Research has consistently reported that LGBT+ older adults disproportionately live in urban centres, are single, live alone and without children [6].

Despite all of the above challenges, LGBT+ people have demonstrated great resilience, adaptability and creativity in establishing relationships and communities of care and action (e.g. particularly evolving from experiences during the HIV/AIDS pandemic, including a political presence [7]) and ‘Families of choice’ (non-kin, long-term friends) to offer and receive support [4].

Impact of health and social care

Negative interactions with healthcare and social-care providers affect the way in which older LGBT people access these services [8]. In the UK and USA, surveys of older LGBT+ people show:

• Concern about disclosing their orientation and/or gender identity to their healthcare providers, particularly among bisexual and gender diverse people [1].

• Experience of discrimination, hostility or poor treatment because of their orientation [9], potentially exacerbated in LGBT+ members of racial and ethnic minority groups [1].

• Reluctance to seek formal help, from either medical or in-home services, even if affordable and available due to fear of neglect, rejection or other humiliations [10].

• A lack of confidence that mental health, social care and support services will understand and meet their needs [5].

In response, LGBT+ groups and their allies have developed cultural competence training and education materials to both inform health care providers and improve quality of care, e.g. training to serve.

Physical health

Physical health behaviours and outcomes for older LGBT+ people are worse than those of their heterosexual peers [11], exacerbated by delays in seeking medical care, as noted above. These include:

• Increased likelihood of long-term illness, or limitations in activities of daily living due to poor health outcomes or illness [12];

• Worse self-rated health [3];

• Engagement in high-risk behaviours, including increased alcohol consumption and likelihood of drug use [12];

• Higher risk of cancer [13] and cardiovascular disease [14];

• Increased likelihood of living with HIV, including late-stage HIV diagnosis with a greater risk of complications [15], along with risk of ‘Accelerated Ageing’ after HIV infection [16].

LGB older adults do engage, however, in more regular exercise than their heterosexual peers [9] and are more responsive to public health initiatives, particularly seen during COVID-19 [17].

End of life

Stigma, isolation, and the risks of disclosure of the nature of a relationship, sexual orientation and/or gender identity influence end of life (EOL) preparations for LGBT+ older adults [8]. Care providers, social networks, and families can dismiss and trivialise their grief [18] (e.g. of ‘non-kin’ relations). There is a hypothesis that the experience gained by LGBT+ people during the HIV/AIDS pandemic either complicates grief or provides a foundation for action/response [19].

Mental health/wellbeing

LGBT+ people have higher rates of mental illness and are more likely to have received a diagnosis of depression and anxiety [9] than their cis-het peers [20]. Older members of these communities are more likely to have concerns about their future mental health [9].

At the same time, LGBT+ individuals and communities show resilience and hardiness as they demonstrate crisis competence [21] and empathy/compassion drawing upon their experiences of stigma and discrimination [7].

Dementia

The experience of older LGBT+ adults with dementia has only recently been the subject of investigation; it appears that LGBT+ people have a higher incidence of risk factors (including HIV) and engage in lifestyle behaviours that increase their risk of developing dementia [22].

Dementia poses specific challenges for LGBT+ people including:

• Potential loss of LGBT+ identity, with a risk of ‘re-closeting’, ‘de-closeting’ or ‘de-transitioning’ sometimes due to the preferences of family [8];

• Emotional strain, stigma and social isolation [23].

• Less access to care from friends/family (i.e. based on a higher likelihood of being single/living alone) and a risk of economic insecurity [22].

The evidence around LGBT+ communities living with dementia is still quite limited, highlighting the importance of expanding research and knowledge in this area.

Experiences of trans people

The older trans community experiences unique challenges that warrant specific attention. Many services lack the knowledge and experience to provide quality care for older trans people, leading to worse health outcomes [24]. There are reports of mis-gendering, ‘outing’ and hostility in care environments and trans people feel unable to express their gender identity by maintaining their personal appearance [25]. Due to greater isolation, there is intensification of the risk of potential discrimination [1].

Older trans people experience:

• Poorer physical health, less physical activity and higher rates of obesity compared to LGB individuals [26].

• Later access to hormone therapy and the recognised protective mental health benefits it confers [27].

• Complex interactions between hormone therapy and co-morbidities [27].

Additionally, within the LGBT+ community, older trans people experience the highest levels of perceived stress, discrimination and depressive symptomatology [26].

Housing and care settings

Research has reported that older LGBT+ people rate living in an affirming area as more important that community size [1]. The provision of either LGBT+ specific or accredited care that is respectful, safe, and recognises their lives and histories is paramount [1, 25].

Older LGBT+ people share the same concerns about moving into long-term care as their cis-het peers, but they face distinct challenges due to the operational practices of these facilities:

• Facilities appearing heteronormative and unliberated, due to the practice of ‘Treating everyone the same’, i.e. cis-het [28], and not routinely asking questions about gender identity and sexual orientation [29], leading to assumptions that there are no older LGBT+ clients in the service [30].

• ‘Re-closeting’ or ‘de-transitioning’, due to feeling invisible, family pressure, and perceiving hostility or experiencing it directly [1, 8].

• Under-confident or inadequately trained staff who lack communication tools to discuss gender identity or sexual orientation, even if they have favourable attitudes to LGBT+ people [29, 30].

• Housing discrimination, a particular concern among older Black and minority ethnic LGBT+ groups [1].

What the communities are already doing

LGBT+ communities are adaptable and resilient. Whilst they experience negative outcomes due to the provision of services, LGBT+ communities (and allies) have moved towards changing and developing services to meet their needs (Table 1). There is a risk of ‘ghettoising’ LGBT+ people into dedicated LGBT+ services, but until mainstream services become more inclusive, a mixed approach might be best.

Conclusion—What could we do to improve outcomes?

We have described some of the adverse health and wellbeing outcomes that older members of LGBT+ communities experience. We have proposed that these are not due to intrinsic characteristics of the people from these communities, but to the current societal structure and models of health and social care provision. Solutions are possible and available, but they will have repercussions on services, in terms of education, training and resources. Change is required at an organisational level, but this is only achievable through education and changing the culture within those organisations.

We believe that health and social care workers are conscientious and motivated to help other people, but a lack of knowledge and confidence in providing care for older LGBT+ older people can lead to adverse outcomes. We propose refreshing person-centred care to consider, understand and recognise the individuality of each person, including their sexual orientation and gender identity. Through this, we will uncover and connect with essential aspects of their individual experience and deliver truly inclusive and holistic care that will lead to tangible improvements to their lives. In addition to applying the overarching principle of person-centred care, we propose some specific target areas, their challenges and proposed solutions [23] to boost healthcare services’ preparedness to meet the need of older LGBT+ communities (Table 2).

Declaration of Conflicts of Interest

None.

Declaration of Sources of Funding

None.

Reference