Understanding Care Disparities Among Older Lesbian, Gay, Bisexual, and Transgender (LGBT) Adults: Recommendations for Culturally Competent Care

LGBT adults represent a growing, aging population. LGBT elders face significant health care disparities, and are often fearful of disclosing their sexual orientation or gender identity to practitioners. As a result, many older LGBT adults fail to receive appropriate screening or treatment. Various recommendations can be offered to help health providers offer more culturally competent, LGBT and age-affirming care.


Introduction
Estimates suggest that within the next 20 years, the number of older LGBT adults in the US alone may range from 2 to 7 million [1]. The term LGBT, as used here, is designed to be inclusive of a variety of subpopulations (e.g., individuals who self-identify as lesbian, gay, bisexual, transgender, intersex, gender nonconforming, and two-spirit, among others.) Although it is vital to remain inclusive, it is simultaneously essential to acknowledge that individual LGBT populations are unique and distinct from one another [2], in terms of both gender identity and sexual orientation. Because LGBT elders face significant health disparities and barriers to culturally competent and affirming health care, practitioners can be advised to provide more LGBT and age-affirming care.

Notable Care Disparities
Factors that influence LGBT elders' health include culture, religion, spirituality, exposure to the media, health and human service systems [3], ethnicity, urbanity, and age cohort (i.e., younger baby Boomers vs. the oldest-old) [4]. The influence of discrimination is particularly salient for older LGBT adults, and it affects their physical and mental health-related quality of life. Generally, the older the LGBT adult, the less likely they are to disclose their sexual orientation or history of physical, psychological, or sexual abuse to a care provider, and the less likely they are to receive appropriate assessment or treatment. A survey of older transgender adults revealed that 40% reported being denied care, or receiving inferior care, after they disclosed their gender identity to a health care practitioner [3].
Nearly 33% of older LGBT adults report that they are depressed, with more than 50% reporting that they feel socially isolated or lonely [3]. Older LGBT adults of color may not only face ageism and heterosexism like their White peers, but additional challenges related to racism. Disparities for LGBT elders are even more pronounced in long-term care settings [5] including nursing homes, assisted living, adult day care centers, and hospice care. Concerns of LGBT elders include fears of physical and emotional abuse, denial of personal care, having their LGBT status revealed to others without their permission, and not being able to dress consistent with one's gender [6]. Transgender elders have even reported making plans for euthanasia or suicide if faced with the need to enter long-term care [7].

Recommendations for LGBT and Age Affirming Practice
A variety of recommendations can be offered to practitioners across a variety of disciplines [6] to help make their practices more culturally competent, and LGBT and aging-friendly. Such recommendations appear to be needed; take for example a survey conducted by an American psychological association task force [8] in which less than one third of psychologists and graduate students understood the complex issues facing transgender adults. An essential change is to make intake and another forms LGBT inclusive. For example, questions on forms can inquire about relationship status (e.g., partner) as well as marital status, and family members "by choice" as well as traditional, biological or legal family members. Intake forms can also offer multiple options for gender (e.g., female, male, transgender, intersex), including preferred gender. Regardless of client age and gender, intake forms can also ask for information about sexual health and activities, including participation in high-risk behaviors.
To help LGBT elders, including LGBT ethnic minority elders, feel more comfortable in a clinical setting, practitioners can offer written materials and leaflets from local and national organizations such as SAGE (service and advocacy for lesbian, gay, bisexual, and transgender elders), and display posters and pictures featuring LGBT families and couples from a variety of ethnic and cultural backgrounds. Offering information about web-based resources can be useful, particularly for older, rural LGBT patients [9]. Providing at least one unisex, gender neutral, or family bathroom that is handicapped accessible is also important, particularly for older transgender adults who may feel more vulnerable in gender-segregated bathrooms [6].
Staff education and LGBT-affirming policies and initiatives are also essential, particularly in long-term care settings. Practitioners can take the responsibility to educate and train their staff members to follow all patients' wishes regarding the use of their preferred name and pronoun. Screening all older LGBT adults for depression and suicidal thoughts also is recommended [3]. Consistent with practice guidelines from the American geriatrics society [10], care providers can engage in advocacy for individual clients as well as LGBT elders at large. Lastly, practitioners can work with their older LGBT patients to recognize and capitalize upon sources of personal strength and resilience [11].

Conclusion
Older LGBT adults face significant care disparities, and often fear disclosing their sexual orientation or identity to their health care providers. To help address these disparities and fears, a variety of steps can be taken to help generate more LGBT friendly, culturally competent practices. Health care practitioners who seek to engage in LGBT and age-affirming practice will also serve as positive role models for their patients, regardless of their patients' age, sexual orientation, or sexual identity.