LGBT Older Adults Lynn M Wilson DO FACOFP

LGBT+ Older Adults Lynn M. Wilson, DO, FACOFP Section Chief of Geriatrics, Department of Family Medicine Lehigh Valley Health Network

Disclosures • I have no financial relationships or conflicts of interest to disclose.

Learning Objectives • • Describe the demographics of older LGBT+ adults • Describe the healthcare needs of LGBT+ older adults, including: • Explain how historic and current discrimination affects the healthcare of older LGBT+ adults • • • Unique medial concerns Unique mental health concerns Support networks, advance planning, long-term care Discuss creation of an LGBT+ welcoming medical practice

Demographics of LGBT+ Older Adults • Older LGB Adults (Age 65+): • • • ~1 -2. 8 million (currently) ~2 -6 million (by 2030) Racially Diverse Economically similar to heterosexuals, except lesbian/bisexual women and same sex female couples have higher rates of poverty More likely to live in urban areas • LGB couples counted in all states and over 90% of US counties • Less likely to be partnered • • • 20% of LGB are partnered vs. 50% of all elders More likely to live alone 65 -75% of LGB live alone vs. 36% of all elders No reliable data on transgender adults

Background of LGBT+ Older Adults • • • Those who have been out are more likely to: • • • Be estranged from children or grandchildren Be single or without children Have extensive ‘chosen family’ of support networks Many who have lived wholly or partially in the closet: • • Have elaborate constructs to protect their sexual orientation Are at risk of exposure with disability or sickness Are at risk of or have experienced discrimination in the medical community

Discrimination in Health Care • 21% of LGBT+ Older Adults reported that they did not tell their doctors about their sexual orientation or gender identity out of fear • 13 % of respondents had received inferior health care or been turned away for services at some point in their lives due to their known LGBT+ status. • Many professional caregivers are not accepting of, or trained to work with, LGBT+ elders. • Providers may be hostile, discriminatory, or simply unaware that LGBT+ elders exist.

In 1952, the American Psychiatric Association listed homosexuality in the Diagnostic and Statistical Manual (DSM) as a mental disorder. Homosexuality remained in the DSM until 1974. 1952 1974 1956 In 1956 the psychologist Evelyn Hooker performed a study that compared the happiness and well-adjusted nature of selfidentified homosexual men with heterosexual men and found no difference. Discrimination in Health Care

• The Stonewall riots were a series of spontaneous, violent demonstrations by members of the LGBT+ community in response to a police raid that began in the early morning hours of June 28, 1969, at the Stonewall Inn in the Greenwich Village neighborhood of Manhattan, New York City. • • Turning point for LGBT+ Activism Stonewall Riots “Pre-Stonewall” vs “Post-Stonewall”

• • • How to Ask On registration forms Ask for preferred name and pronouns During the visit/social history: • • • Tell me more about yourself. Who are the important people in your life? Who do you turn for support? Who do you live with? Are you in a relationship?

Try To Avoid… • Making assumptions about the gender of the patient’s partner(s) even if married • Assuming that patient’s sexuality is fixed, absolute, and/or lifelong • Assuming that being gay, lesbian, or bisexual is not a difficult issue for many patients • • Forcing labels or outing a patient if they are not ready • Assuming that older people do not have active sex lives Assuming that all transgender patients want full reconstructive surgery or complete hormonal transformation

Older Lesbian and Bisexual Women: Health Concerns • Receive Pap tests less frequently • • 70% report history of sex with men HPV transmitted women to women Lower rates of mammograms • • Due to perception that not at risk Avoidance of clinical care Higher rates of smoking, obesity, alcohol use

• Higher risk for STIs and HIV/AIDS • Older Gay and Bisexual Men: Health Concerns • Hepatitis A & B is also a concern • • Annual screening is recommended Vaccination is recommended Screen for Hepatitis C especially among HIV + Higher rates of smoking and alcohol use Higher risk for anal HPV and cancer • • 43 times more common 88 times more common when coupled with HIV infection

Older Transgender Adults: Health Concerns • • • Very little research Discrimination and Healthcare disparities Less likely to receive preventive care: • Underscores why it is important to learn about both gender identity, sex assigned at birth, and current anatomy. • Long-term effects of hormone therapy should be monitored • Higher risk for HIV in trans women, and risk of STI’s based on behavior • 12% of trans women and 1% of trans men transition after age 55

• According to the CDC: • • People over 50 account for 17% of new HIV cases 24% of new AIDS cases • Increasing prevalence of HIV in older adults who are living longer on ART. • • Comorbidities more common in older patients. 48% of LGBT Elders who are HIV+ have experienced the death of a loved one to the disease. HIV/AIDS in LGBT+ Older Adults

Discrimination in Health Care • About 8% of LGB individuals, 27% of transgender and gender-nonconforming individuals, and 20% of HIVpositive individuals report being denied needed health care outright. • Over 20% of LGBT+ people and individuals living with HIV/AIDS reported that they were subjected to harsh or abusive language by a health care professional and were blamed for their health problems. • Some LGBT+ were excessively questioned about their sexuality or unnecessarily examined by health care providers

• Sexual Health of Older LGBT+ Adults Elderly are sexually active: • • • 53% seniors 65 to 74 years old 26% of seniors 75 to 85 years old Elderly are at risk for HIV and other STIs: • • 92% of older adults do NOT use condoms 48% of older LGBT+ adults do not use condoms regularly, and 9% never do

• Mental Health of Older LGBT+ Adults Survey of 416 older LGB adults active with LGBT+ social agencies: • • • 33% reported depression 66% have been victimized three or more times 50% reported loneliness 39% considered suicide 12% had suicidal thoughts in the past year 13% reported suicide attempts with 4% occurring after age 60

Dementia in LGBT+ Older Adults • • Limited studies focusing or including sexual and gender minorities in dementia research 2018 study at UCSF showed 25% of the LGBT adults aged 50 and older in his study had subjective cognitive decline, a potential indicator of a future Alzheimer’s diagnosis Depression and functional impairment should be considered when screening LGBT+ older adults for cognitive impairment and dementia. Future research on cognitive impairment and dementia risk in LGBT older adults is needed.

• Isolation and Lack of Support • • Compared to the general population, LGBT+ older adults are: • • Significantly more likely to be isolated 50% less likely to have a significant other 50% less likely to have close relatives to call for help Four times more likely to have no children 49% of LGBT+ over age 50 live alone Support Systems: • • • Some rely on “families of choice” Some rely on networks of friends Some rely on combination of biological family and friend networks

• Several studies show that LGBT+ older adults access essential services less frequently than the general aging population. • These include: • • Visiting nurses Food stamps Senior centers Meal plans Accessing Services

• Estimates of 120, 000 -300, 000 LGBT+ seniors living in nursing homes by 2030 • Real/anticipated discrimination from: • • Staff members Fellow patients • • • Denial of visits from family of choice • • Refusal to respect gender identity Refusal to allow same-sex partners to room together Refusal to involve family of choice in medical decision-making Loss of friend network, chosen family or support system Long Term Care

Long Term Care • Survey of LGBT+ adults’ perception of retirement care facilities: • • • 73% believe discrimination exists 60% believe LGBT do not have equal access to social and health services 34% believed they would have to hide their orientation

Resilience in LGBT Older Adults • • 91% engage in wellness activities • 71% percent reported having a person in their life to love and make them feel wanted • 83% have people with whom to do something enjoyable 89% feel good about belonging to the LGBT+ community

Advance Care Planning • • • Living Will Health Care Proxy Health Care Power of Attorney Wills and estates Financial planning Long-term care planning

Financial Concerns • Survivor and retirement benefits • Taxation of domestic partner health insurance and sick-leave benefits • Federal employees cannot receive benefits for spouse • Joint assets, 401(k) and pensions taxed for surviving partner • No Medicaid protection for spouse or joint assets upon nursing home placement

Supporting LGBT+ Older Adults • LGBT+ more likely to be the caregivers • • 75% expect to be caregivers 20% unsure who will take care of them • Disenfranchised grief • Inadequate social support following the death of a partner

Welcoming Medical Office Space • • Adapt forms to be inclusive (for example spouse/partner rather than husband/wife) Talk with your registration staff and clinic director Encourage cultural competency training by your colleagues and staff Place an LGBT-friendly symbol, sticker or sign in a visible location Have an LGBT-specific magazine or newspaper in the reception area Have gender-neutral bathrooms Have an open dialogue with patients about their life circumstances

Resources • Services and Advocacy for Gay, Lesbian, Bisexual & Transgender Elders (SAGE) www. sageusa. org • • • Gay and Lesbian Medical Association www. glma. org American Society on Aging www. asaging. org National Lesbian and Gay Task Force www. thetaskforce. org Fenway Community Health Center www. fenwayhealth. org LGBT Aging Project www. lgbtagingprogect. org

References • Gary J. Gates and Frank Newport, Special Report: 3. 4% of U. S. Adults Identify as LGBT: Inaugural Gallup findings based on more than 120, 000 interviews, October 18, 2012, http: //www. gallup. com/poll/158066/special-report-adults-identify-lgbt. aspx • Still Out, Still Aging: The Met. Life Study of Lesbian, Gay, Bisexual, and Transgender Baby Boomers, March 2010, https: //www. metlife. com/assets/cao/mmi/publications/studies/2010/mmi-still-outstillaging. pdf • LGBT Movement Advancement Project, Improving the Lives of LGBT Older Adults, 2010, http: //www. americanprogress. org/issues/2010/04/pdf/lgbt_elders. pdf • Mc. Cabe SE, Bostwick WB, Hughes TL, West BT, Boyd CJ. The relationship between discrimination and substance use disorders in lesbian, gay, bisexual adults in the United States. Am J Public Health. 2010; 100(10): 1946 -52. • Grant, Jaime M. , Lisa A. Mottet, Justin Tanis, Jack Harrison, Jody L. Herman, and Mara Keisling. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington: National Center for Transgender Equality and National Gay and Lesbian Task Force, 2011. • • Bennett J. Invisible and overlooked. Newsweek. September 18, 2008. • • LGBT Health Disparities in NYC, Empire State Pride Agenda Foundation, 2013 • Cahill, S. , South, K. , Spade, J. (2000). Outing age: Public policy issues affecting gay, lesbian, bisexual and transgender elders. The Policy Institute of the National Gay and Lesbian Task Force. • • Appelbaum SM, J. HIV in older adults. Geriatrics. 2008; 63: 6 -12. • Hash K. Caregiving and post-caregiving experiences of midlife and older gay men and lesbians. J Gerontol Soc Work. 2006; 47: 121 -38. • Brotman, Ryan S. , and R. B. Cormier. “The Health and Social Service Needs of Gay and Lesbian Elders and Their Families in Canada. ” The Gerontologist 43(2): 192 -202. • Karen Frederiksen-Goldsen, The Aging and Health Report, Disparities and Resilience among LGBT Older Adults, 2011, National Institutes of Health (NIH) and the National Institute on Aging (NIA) Institute of Medicine (U. S. ). 2011. The health of lesbian, gay, bisexual, and transgender people: building a foundation for better understanding. Washington, DC: National Academies Press. CDC STD Screening Guidelines, 2010, http: //www. cdc. gov/std/treatment/2010/ Palefsky J. Anal squamous intraepithelial lesions (ASIL): diagnosis, screening and treatment. In: Rose BD, ed. Up. To. Date. Waltham, MA: Up. To. Date; 2006. LGBT Movement Advancement Project, Improving the Lives of LGBT Older Adults, 2010, http: //www. lgbtmap. org/file/improving-the-lives-of-lgbt-older-adults. pdf