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.   

  • LGBTQIA+ elders will have many of the same health needs and conditions as cis/heterosexual patients.   However, it is important to recognise areas in which they may have avoided care due to fears of bias and discrimination, including avoidance of  necessary screenings such as cervical smears and mammograms. 

    Don’t forget the effects of intersectional disparities—e.g. Māori people also have poorer health outcomes so takatāpui may suffer disproportionately from these effects. Read more about takatāpui health here.

    Consider the ways in which history has affected your patient—ask them questions about their history in relationship to social events that may have taken place during their younger years to gain insight into some of the strengths and traumas they may bring with them.

    Make sure to inquire about whānau in a way that makes the person feel safe to talk about their partners, children, and those from whom they may be estranged, particularly due to their sexuality or gender identity.

    Be aware that some older LGBTQ+ people may never have come out or have only come out later in life.  Some gay/lesbian people may still be in heterosexual marriages. Don’t make assumptions based on current relationships, and educate yourself about resources to offer older adults who are just coming to terms with their identity

    Ask about sexuality.  As is the case with older heterosexual people, older LGBTQIA+ patients may start new relationships when a spouse or partner dies or a long term relationship ends.  Screening for STIs, HIV risk, and discussions around STI prevention may be necessary.  

  • HIV in older adults may be more complex than in younger people due to co-morbid conditions and the possibility of antiviral resistance. It is important to know how to factor in the effects of HIV on other health conditions and vice versa.

    Medications taken for HIV may also be more dangerous in this group as the likelihood of drug intolerance/adverse effects and interactions increase. 

    Antiviral medications, including PrEP, which is discussed further here, can cause renal impairment and loss of bone density. These conditions are already of concern for the older population and can be exacerbated by medications and conditions that more specifically affect LGBTQIA+ individuals.

  • Older trans people face a number of unique issues which must be considered.

    Gender affirmation — Some trans people may still be coming out later in life and need help navigating decisions around hormones and surgery in later life.  They may have medical conditions or be taking medications that interact with the commencement of hormones.  If you are uncomfortable with the safety of starting GAHT in this age group, a referral to an endocrinologist or general medical specialist may be necessary (for example, a cardiologist if there are concerns that starting hormones may aggravate an underlying cardiovascular condition.  Underlying health issues also need to be considered when advising about surgery.

    Older trans people may have been on hormones for many years and due to health complications may need to face decreasing doses or discontinuing HRT. 

     Trans people need to be included in appropriate screening programmes depending on what body parts they possess.  Transwomen may need mammograms and prostate screening. Transmen may still need mammograms as well as cervical screening.

    Trans people are likely to face more bias and discrimination in all areas of healthcare so it’s especially important to  provide safe spaces for them to openly discuss issues that affect their health.

    Be aware of the ongoing stresses of misgendering and possible difficulties that can arise when planning hospitalisation and placement in aged care facilities where patients may be separated by gender.

    Click here for further information on transgender adults.

  • Many LGBTQ+ people are afraid of having to go back into the closet when they go into aged care facilities.  Be an advocate for them with staff and whānau to make sure they are treated with respect. This includes being treated according to their correct gender (correct names, pronouns, preferences for clothing/hair styles, etc) and acknowledging their sexual identities and relationships. 

    Caregivers often find it awkward to discuss sexuality with older people and this may apply even more to those in same-sex relationships.  A 2021 New Zealand study by Mark Henrickson, et. al., addressed varying attitudes about sexual diversity in aged-care and found definite generational differences in attitudes toward same-sex relationships in older people. 

    Older LGBTQIA+ people have the same needs as anyone else for advance directives and EPOA documents.  It is important to help navigate people through these discussions, especially as those whose families are not supportive of their relationships may receive opposition when they designate their spouse or partner as their EPOA.

  • The bottom line is to listen to and respect the unique experiences of LGBTQ+ elders and work to improve health outcomes by providing them safe places to bring their whole selves and making them feel respected and comfortable.

    The US organisation SAGE (Advocacy and Services for LGBTQ+ Elders) has many good resources. Click here to access the website.

    Click here to download an article on attitudes towards aging sexual gender minorities around the world.