Older LGBTQIA + Adults

Key Points:

  • Older LGBTQIA+ adults will have the same health needs of any aging adult but are more prone to issues of marginalisation, discrimination, isolation, leading to avoidance of screening tests (e.g. mammograms or cervical smears) or reticence to present for chronic or acute health concerns

  • Don’t assume all LGBTQIA+ adults are “out.”  Some may not even be out to their spouses and children.  Ask questions sensitively and make sure to reassure patients that you will guard their privacy and not judge them

  • Be aware of the complex medical issues specific to trans people who may have been on HRT for many years as hormone dosages may need to be adjusted and interactions with age-related medical conditions or medications need to be considered.

  • Address issues related to end-of-life care planning with extra sensitivity as fears of discriminatory treatment by family and care-givers are not necessarily unfounded.

Introduction

While much of the research and education around healthcare in the rainbow community has focussed on youth, LGBTQIA+ people have ongoing health needs and disparities as they age.  In fact, it is well known that the population as a whole is aging, owing largely to the “Baby Boomer” generation.  In spite of this, however, research into the health needs of older LGBTQIA+ people is proportionately lacking. 

Historical context 

Older LGBTQIA+ people will have experienced significant periods and events in the history of the rainbow community:

  • Sex between members of the same sex was illegal until the passage of the Homosexual Law Reform Bill in 1986. As a result, many queer people were in the closet.  Some lived with same-sex partners for many years as “friends,” hiding their relationships from family, employers, and even friends.  Others may have been married to a member of the opposite sex (and while some of these people may have been bisexual, many were not) and had children, only coming out later in life, if at all.  

  • The height of the AIDS epidemic (1980s-1990s)  took the lives of many gay men.  Many gay and lesbian elders have witnessed the deaths of large numbers of friends and partners and there is likely to be a degree of “survivor guilt” amongst gay men in that age group who are still alive.  Some may be living with HIV/AIDS as they survived long enough to obtain the effective antiviral medications that are readily available today and which turned AIDS from a death sentence to a chronic condition.

  • Legal recognition of relationships: Same-sex couples weren’t given the same rights to property and inheritance as opposite-sex couples until the 2001 passage of the Property [Relationships] Amendment that applied to de-facto couples of any gender. Same-sex marriage was only legalised in 2013 and the first marriage to record no gender was in 2019.


Overview of older LGBTQIA+ adults’ health needs

As with any patient, it is important to understand the context and the stories our patients bring to us.  In the case of rainbow people, there may be decades of trauma and minority stress related to experiences of discrimination, abuse, grief, abandonment by family and friends,  and bias in healthcare, employment, housing, and many other facets of life.   Discussion of “life events” from a heteronormative perspective may include things like marriage, having children, family life, divorce/widowhood, grandchildren, etc.  While LGBTQIA+ people may have experienced some or all of these things, their stories will often be much more varied.

Studies of LGBTQIA+ people indicate that older rainbow people have certain strengths in the areas of resilience and community resources (Stats NZ) and years of oppression and being in the closet for various reasons have added to health disparities and considerations for this population. For older adults who have spent years in the closet, they may find it difficult to disclose their relationships or their sexual or gender identities to their doctors. A NZ based study published in 2020 showed that staff at aged-care facilities felt personal discomfort when encountering older people of diverse sexualities and gender identities.  The combination of ageism, in which the sexuality of older people is dismissed or ignored, combined with ignorance about or bias toward LGBTQ+ people leads to a substantial gap in healthcare provided to older LGBTQIA+ people.

Conversations about advanced directives, aged care facilities, and end of life care must be undertaken with sensitivity and open-mindedness.  It is just as important with older patients as it is with younger ones that their GP is seen as a safe person with whom to discuss these delicate issues.