Special Considerations in the Mental Health Evaluation of LGBT Elders

Clinical Vignette

When I first met “Ms. B,” she was sitting in the common area of the nursing home inviting anyone who walked through the door to join her for a fireside chat. I was 20 years old at the time and pre-med. I took her up on the offer. As we settled into our cups of tea, she began to tell me about her nursing career days and her roommate of 50 years named Helen. Listening to her story touched me deeply. It became clear that Ms. B’s feelings toward Helen went beyond a typical roommate relationship.

Ms. B grew up in the era in which any indication of homosexuality was met with widespread stigma. Thus, accurate and reliable data about the elderly lesbian, gay, bisexual, and transgender (LGBT) population is difficult to come by. Some investigators estimate that there are over 2.4 million LGBT adults over the age of 50 in the United States, with the projection that this number will double by 2030 (1). The purpose of the present article is to shed light on some of the history of this population and the health disparities that they face. Appropriate clinical considerations are also discussed.

Historical and Social Context

Many older LGBT adults came of age during a time when homosexuality and any gender nonconformity were criminalized, and many have remained invisible (2). Impactful movements for social acceptance began with the Civil Rights Movement in the 1960s; this generated the gay liberation movement, which allowed younger LGBT adults to begin to emerge from the borders of society. Stonewall riots incited widespread protest for equal rights and acceptance in 1969. It was only in 1973 when the American Psychiatric Association ceased designating homosexuality as a disorder (3) and not until 2015 that same-sex marriage became legal nation-wide. The life experiences of the older LGBT group range from growing up in the Great Depression to being a part of the baby boom generation. Many of these older adults have spent the bulk of their lives concealing their sexual orientation and/or gender identity, with a major part of their life story ignored or invalidated. With this complex history, our older generations of LGBT individuals are different than the current generation and deserve special consideration.

Social and Mental Health Disparities

The health of LGBT older adults was mostly ignored until more recently (1). In the present article, “older adults” are defined as individuals over 50 years old, since this is the age cutoff that is utilized in most literature.

LGBT older adults are at risk for significant mental and physical health disparities. They have higher rates of anxiety, depression, and substance use disorders and also are at increased risk for certain medical conditions, such as obesity, breast cancer, and HIV compared with a heterosexual cisgendered similar-aged population (1). D’Augelli et al. (4) reported that 13% of the LGBT population between the ages of 60 and 91 years old has attempted suicide. In this same study, it was noted that older men reported significantly more internalized homophobia, alcohol abuse, and suicidality related to their sexual orientation compared with similar-aged LGBT women. (4) Another study found that the prevalence of excessive alcohol use, smoking, and high-risk sexual behaviors is higher in older LGBT populations compared with non-LBGT older adults (5). LGBT older adults are also more likely to avoid or delay health care or hide their sexual and gender identity from health care providers and/or social services personnel due to fear of discrimination (6). In a survey of 2,560 diverse LGBT older adults across the nation, ranging in age from 50 to 95 years old (with 10% age 80 and older, 25% age 70–79, 41% age 60–69, and 24% age 50–59), 68% had experienced verbal harassment, 43% had been threatened with violence, 21% did not disclose their sexual or gender identity to physicians, and 15% feared accessing health care outside the LGBT community (7).

Part of what may underlie the disparity of health outcomes for LGBT older adults is the difficulty they face in receiving formal health care and social supports compared with heterosexual cisgender adults. Until recently, same-sex couples faced discrimination in accessing federal government benefits. The U.S. Supreme Court, in U.S v. Windsor (2013), ruled that the federal government must treat married same-sex couples the same as married opposite-sex couples for the purposes of federal benefits.

Despite recently receiving this equal protection to health care access under federal law, stressors and other factors that disproportionately affect this population have not disappeared. Stressors include coming out, prejudice, stigmatization, and anti-LGBT violence, as well as internalized homophobia. Risk factors associated with poorer health among LGBT older adults compared with heterosexual cisgendered older adults include social isolation/small social networks, minimal connection to the LGBT community, lack of connection to the larger community, income uncertainty, inability to access affordable housing, lack of health insurance or underinsurance, and chronic undertreated medical conditions due to lack of primary care (5, 7–9). Those who are “out” are more likely to be estranged from children or grandchildren, be single or without children, and have an extensive “chosen family” (composed of close friends) of support that can be threatened with aging and illness (8).

Discrimination is at the center of the substantial risk factors for this population and their communities, since it hinders both access and utilization of care (10). In one study of LGBT older adults (age >50 years; N=72 individuals) and their caregivers, one-half of the care recipients reported discrimination based on sexual orientation. Other types of discrimination they experienced included discrimination based on disability status (58%), age (47%), race or ethnicity (39%), gender identity and expression (29%), and gender (28%) (11). Likely both historical and current experiences of victimization hinder access and utilization of needed health and social support services (12). More research is needed to ascertain whether background features among LGBT older adults, such as biological sex, race and ethnicity, and gender roles and identity play into their ability to seek care (13).

The Way Forward

We are only beginning to understand the impact and etiology of health disparities facing the older LGBT population, but the existing data point to practices that mental health providers can immediately implement to better promote successful aging in this population.

One comprehensive approach is the “successful aging framework” proposed by Van Wagenen et al. (14) in their 2013 study of LGBT older adults, which is based on findings from semi-structured guided interviews of 22 different LGBT older adults aged 60 years and older. They recommend incorporating the patient’s perspectives and experiences, seeking to understand their perceptions of positive and negative aging, and attending to the social contexts of the patient’s lives in clinical practice (14). Above all, they emphasize that LGBT older adults must be treated with dignity, while giving due consideration to their unique backgrounds and social experiences. The change begins at the individual provider level.

Others have identified actions providers can take to foster a more welcoming and responsive clinical environment for LGBT older adults (see Table 1). These recommendations come from literature that has previously been cited, as well as from a variety of guides, including recommendations from SAGE [Services and Advocacy for GLBT Elders], the Williams Institute, and the National Resource Centers on LBGT Aging (16–18). Many of these guides relied on multidisciplinary expertise, including economics, sociology, psychology, epidemiology, public health, and political science, pooled from decades of research. The goal is to change the system to diminish discrimination and stigma, which will in turn empower patients and enable them to access needed services (16, 17). Many LGBT older adults are also members of other groups that face discrimination, such as on the basis of race, language, ethnicity, degree of disability, and many more other demographic categories. However, LGBT older adults are largely overlooked in gerontology and gender and sexual minority research.

Conclusions

As we think about addressing healthy aging in our increasingly diverse society, we need to pay attention to the large portion of LGBT older adults living across the United States. At the foundation, their needs are the same as those for other groups of seniors—they need access to comprehensive primary care, as well as social support resources; however, their ability to access these services may be adversely affected by their unique backgrounds and feared or experienced discrimination. They deserve the ability to age with dignity in their communities, have access to services responsive to their particular needs, and protection from abuse and neglect.

Fortunately, Ms. B had the desire to share her story and was surrounded by a caring staff that listened. It would have been a disservice to her if they did not. It is key in practice to not assume that the patient is heterosexual and cisgendered. Not every patient will be as forthcoming as Ms. B. The practice of cultural sensitivity starts in training. The LGBT aging population is expected to increase in the coming years, and thus it is critical that we increase awareness of this at-risk population, who would best be served by more research to help determine how we can best address their specific needs.

Key Points/Clinical Pearls