An Evidence-Based Framework for Supporting Older LGBTQ+ Adults in Rural Communities: Findings From the LGBTQ+ Social Networks, Aging, and Policy Study

Tremendous growth in research over the past decade has delivered breakthroughs in understanding lesbian, gay, bisexual, transgender, and queer (LGBTQ+) health disparities. However, nearly all of this work has focused on younger people. Just 7.6% of all LGBTQ-related projects funded by the National Institutes of Health examine aging or age-related health conditions (NIH, 2022), despite 23% of LGBTQ+ people being age 50 or older and documented disparities in age-related conditions and outcomes (Flores & Conron, 2023; Fredriksen-Goldsen & Muraco, 2010; Gonzales & Henning-Smith, 2015), including cognitive decline and Alzheimer’s disease and related dementias (Correro & Nielson, 2020; Flatt et al., 2021; Tran et al., 2023) and earlier mortality (McKetta et al., 2024).

Prior work has characterized several drivers of health disparities among older LGBTQ+ adults, including obstacles to health care, discrimination and violence, and lack of support from families of origin (Fredriksen-Goldsen, 2011). Here, we explain how many of these drivers are accentuated for LGBTQ+ older adults who live in rural areas, where LGBTQ+ people are more likely to report poorer physical and mental health than their heterosexual and urban LGBTQ+ counterparts (Henning-Smith et al., 2022; MacDougall et al., 2022).

Drawing on data from the LGBTQ+ Social Networks, Aging, and Policy Study (QSNAPS), we describe several challenges and opportunities for improving the health and aging experiences of older LGBTQ+ individuals in rural communities across the U.S. South, including lack of access to LGBTQ+ affirming health care, discrimination and stigma, and lack of community support. QSNAPS was one of the first longitudinal studies of midlife and older LGBTQ+ adults funded by the National Institute on Aging and follows a community sample of 1,256 LGBTQ+ adults aged 50–76 over three waves beginning in 2020 (McKay et al., 2023). We conclude with actionable recommendations for policymakers to foster supportive environments for older LGBTQ+ individuals in rural areas.

Access to LGBTQ+ Affirming Health Care

More than 190 rural hospitals have closed since 2005, with impacts highly clustered in the U.S. South (The Cecil G Sheps Center, 2024). These closures have left residents of rural areas with substantial gaps in access to emergency care, inpatient medical and surgical care, and outpatient services (Mullens et al., 2024), leading to increased mortality among racial/ethnic minorities and Medicare and Medicaid patients in some contexts (Gujral & Basu, 2019).

These challenges are particularly acute for LGBTQ+ people living in rural areas who experience additional health care barriers due to a lack of LGBTQ+ affirming providers (Rosenkrantz et al., 2017) and laws that explicitly exclude or do not provide adequate health care for LGBTQ+ people (Movement Advancement Project, 2021). LGBTQ+ affirming care that prioritizes creating safe and inclusive environments for all individuals regardless of their sexual orientation or gender identity has demonstrated benefits for midlife and older LGBTQ+ people, increasing uptake of preventative care (McKay et al., 2022, 2023) and improving retention in care (Yang et al., 2018).

“LGBTQ+ affirming care that prioritizes creating safe and inclusive environments for all has demonstrated benefits for older LGBTQ+ people”

In QSNAPS, midlife and older LGBTQ+ people in rural areas are two times more likely to report that they cannot find an LGBTQ+ affirming provider (OR = 1.94, 95% CI = 1.26–2.97) compared with their LGBTQ+ counterparts in urban/suburban areas. Among older LGBTQ+ adults who report having an affirming provider, those in rural areas are over four times more likely to travel distances of over 25 miles to their provider (OR = 4.44, 95% CI = 2.98–6.64).

“Older LGBTQ+ people in rural areas are nearly two times more likely to report that they cannot find an LGBTQ+ affirming health care provider”

Discrimination and Stigma

Beyond barriers to accessing care, LGBTQ+ people in rural areas also report high levels of medical discrimination. Conscientious objection laws in several U.S. states allow health care providers to deny care based on firmly held beliefs. Multiple studies document the disproportionate and negative impact of denial-of-service laws on mental health and preventive care uptake among LGBTQ+ populations (Raifman et al., 2018; Tran, 2024). The impacts of denial-of-service laws are likely to be more pronounced in contexts where care is already scarce. Consistent with this, we find that midlife and older LGBTQ+ adults in rural areas are significantly more likely than those in urban/suburban areas to report that a doctor or other health care provider advised them to seek care elsewhere (14.1% vs 10.9%; p < .05).

Outside of medical contexts, LGBTQ+ older adults in rural areas may encounter more discrimination and stigma. In QSNAPS, rural LGBTQ+ older adults are 1.5 times (OR = 1.55, 95% CI = 1.16–2.06) more likely to report that they had to watch what they said or did around heterosexual people and two times (OR = 2.14, 95% CI = 1.07–4.28) more likely to report that people had laughed or made jokes at their expense because of their LGBTQ+ status in the last year compared with their urban/suburban counterparts.

Lack of Community Support and Social Isolation

The negative effects of these experiences among LGBTQ+ populations are often compounded by a lack of social support. Traditional support systems, such as family and community networks, may be less accepting or nonexistent for LGBTQ+ individuals in rural areas (Butler, 2017). This lack of support can manifest in various forms, including limited access to informal caregiving, emotional support, or community resources tailored to the needs of LGBTQ+ individuals. In the absence of family support, LGBTQ+ older adults often turn to “chosen families”—networks of supportive individuals who are not legally or biologically related—for caregiver support (Lampe et al., 2024). Chosen families foster social connections and belonging for LGBTQ+ people and are especially important for those in rural areas (Dakin et al., 2020). However, LGBTQ+ older adults’ chosen families often consist of age peers, who are often also struggling with disease, disability, and resource constraints in later life (Fredriksen-Goldsen, 2016).

In QSNAPS, we identify clear gaps in family and community support for midlife and older LGBTQ+ adults. Those living in rural areas are significantly less likely to receive support for their LGBTQ+ identity from family members (61.8% vs 68.7% in urban areas; p < .01) and friends (88.6% vs 92.5% in urban areas; p < .01). Their social networks may also include a smaller percentage of other LGBTQ+ people (p < .1). Older LGBTQ+ adults in rural areas are twice as likely (OR = 2.28, 95% CI 1.19–4.34) to report that they have “very few people they can talk to about being LGBTQ+” compared with their urban/suburban counterparts. Despite this, we find that midlife and older LGBTQ+ adults who reside in rural areas are more likely to have received practical help (e.g. doing repairs or errands) from others (OR = 1.12, 95% CI 1.01–1.26) in the past year, suggesting that the networks of older LGBTQ+ adults may be robust in some areas (e.g. practical help) but more fragile in others (e.g. emotional support and identity affirmation).

Discussion

These findings highlight key gaps in health care access, legal protections, and community support among midlife and older LGBTQ+ adults living in rural areas in the U.S. South. Together with other QSNAPS findings demonstrating the benefits of accessing LGBTQ+ affirming health care overall (McKay et al., 2022, 2023), they underscore the urgency of expanding LGBTQ+ and geographically-inclusive data, developing targeted funding, and deploying policy initiatives that disrupt upstream social forces driving LGBTQ+ and rural health disparities (see Table 1 for summary of policy recommendations for supporting LGBTQ+ adults in rural areas).

Telehealth provides new opportunities for expanding LGBTQ+ affirming care. Rural LGBTQ+ populations can now access LGBTQ+ telehealth services (including primary care, counseling, therapy, and gender affirming medications), which may connect them to urban-based LGBTQ+ affirming clinics. However, challenges remain due to lower digital literacy in rural communities and among older adults (Edmiston & Alzubi, 2022). Additionally, some U.S. states, like Florida, are pursuing laws to limit access to gender affirming care via telehealth (Miller, 2024). Such laws may ultimately affect in-state telehealth providers as well as out-of-state direct-to-consumer telehealth providers (Barbee & McKay, 2023). Last, insurers like Medicare play an important role, with COVID-19-related expansions in telehealth coverage substantially improving access to care for transgender and other populations (Mintz et al., 2022); however, it is not yet clear that coverage will remain permanently (Saharkhiz et al., 2024).

Strengthening rule-based strategies at the federal level could support the expansion of LGBTQ+ affirming care and aging services. In April 2024, the Department of Health and Human Services issued a final rule under Section 1557 of the Affordable Care Act explicitly stating that discrimination based on sex includes LGBTQ+ patients (Office for Civil Rights, 2024). To enhance access to LGBTQ+ affirming care and aging services, institutions receiving federal funding through Medicare, the Older Americans Act, and other programs should be required to adopt explicit nondiscrimination policies recognizing LGBTQ+ individuals as a protected class and to implement training on how to better support LGBTQ+ patients and staff in health care settings. In general, physicians and nurses have few or no reservations about providing care to LGBTQ+ populations; however, they often feel unprepared to support LGBTQ+ patients across a range of health needs (Keuroghlian et al., 2017; Nowaskie & Sewell, 2021). Requiring health care institutions to address LGBTQ+ nondiscrimination via linkage to receipt of federal funding would be a critical first step toward improving access to LGBTQ+ affirming care in rural areas.

At the community level, we must invest in LGBTQ-tailored and age-friendly community resources, such as LGBTQ-inclusive senior centers. Scarcity of LGBTQ-inclusive age-friendly community resources often forces many older LGBTQ+ residents in rural areas to rely on alternative support (e.g. friends, faith communities) or to seek paid caregiver services despite substantial concerns about LGBTQ+ discrimination or mistreatment (Williams et al., 2022). Virtual programming may help overcome the logistical challenges of providing LGBTQ+ community resources in more remote and isolated rural areas (Prasad et al., 2022). Other locally-based service organizations may generate new opportunities for community support through inclusive initiatives. One example is the Virginia Rural Health Association’s Pride of Rural Virginia initiative, which established a network of LGBTQ+ affirming providers and provides training to rural hospital and clinic staff at every level (Tuttle et al., 2022).

These initiatives acknowledge the diversity of the rural aging population, encouraging individuals and organizations to advance inclusivity, thereby helping older LGBTQ+ adults in rural areas live and age well.

Funding

The LGBTQ+ Social Networks, Aging, and Policy Study is funded by the National Institute on Aging (R01AG063771), Vanderbilt University, the Vanderbilt University LGBTQ+ Policy Lab, and the University of Texas at Austin’s Center on Aging and Population Sciences (P30AG066614) and Population Research Center (P2CHD042849). During the writing of this manuscript, Lampe was supported by an award from the Alzheimer’s Association (AARFD-23-1145127) and Prasad was supported by the Vanderbilt Center for Research on Inequality and Health.

Conflict of Interest

None.

References