Grey is the New Pink: Caring For LGBT Elders

After enduring years, if not decades, of discrimination, many older LGBT adults fear accessing health care outside the LGBT community because they fear that they might be judged or given inferior care. This population will be seven million strong by 2030, and by some estimates more than 40 percent of them don’t disclose their sexual orientation to health care providers. This silence can be devastating, exacerbating pronounced health disparities that include a greater risk of depression, substance abuse, social isolation, certain cancers, and complications from HIV than the heterosexual population.

Evidence of a health care system that fails to meet the needs of LGBT older adults isn’t hard to find. Despite a surge of support for marriage equity in many U.S. states in recent years, older LGBT adults may lack the right to visit hospitalized partners, make health decisions for spouses, or share in medical insurance benefits. This lack of autonomy also extends to long term care facilities, where LGBT adults may not be able to reside with partners or spouses, and where they may feel forced back into the closet.

Conquering the fear of disclosure is a critical first step in reversing health disparities in the older LGBT population, according to Jeffrey Kwong, DNP, ANP-BC, director of the Adult Gerontology Primary Care Nurse Practitioner program at Columbia University School of Nursing.  In a keynote address at Grey is the New Pink, a forum last month at Columbia University Medical Center, he urged clinicians to ask every patient about relationships and sexuality, and not to assume that advanced age signals the end of an active sex life.

“Inclusive language and open-ended questions that encourage honest dialogue are crucial,” Kwong said. “Use partner or significant other instead of gender-specific terms like husband or wife. Allow people to come out in their own time and don’t assume that they are out to everyone.”

Kwong offered up his own patient experience as an example of what not to do as a clinician. He recounted a time in the early 1990s when he asked his primary care physician for an HIV test. She looked down on him when he said he had sex with men. She said, “As a health care provider, don’t you know better? You’re going to get AIDS and die.”

This kind of encounter has a chilling effect, silencing communication before it starts. Lack of disclosure means that people will not be able to talk with providers about sexual health, risk of certain cancers, HIV, or hormone therapy for transgender clients. This translates into health disparities in the LGBT population. There are higher rates of disability, mental illness and depression.

Social isolation is also prevalent among older LGBT adults, who may not have spouses, children, or supportive family members to care for them. Many people who live alone as they age are at greater risk of physical decline, cognitive impairment, premature chronic disease or death.

“There is tremendous need for mental health care accessible and sensitive to the specific needs of LGBT elders,” Walter Bockting, PhD, professor of medical psychology at Columbia Nursing, said at the forum.  “Depression is more common among the LGBT population, often related to stigma and isolation, yet not enough knowledgeable mental health professionals who accept Medicare are available.”

Some cope with psychological issues by turning to cigarettes, alcohol and drugs, leading to substance abuse rates in the LGBT community that are much higher than in the general population. LGBT adults are twice as likely to use tobacco, for example, and this puts them at greater risk for cardiovascular disease, certain cancers, COPD, and other complications.

Preventive health screenings can also fall by the wayside. Somebody who identifies as a transgender male and who doesn’t have gender reassignment surgery still has a cervix and a uterus. This is a person who still needs a gynecological exam and may not go get screened because they don’t want to be judged. Or for men who have sex with men, there’s a recommendation for anal cancer screenings because the rates of human papilloma virus, a precursor to cancer, are much higher. 

While clinicians can’t overcome state laws that fail to honor health proxies or spousal rights for LGBT adults, new models of culturally competent care can encourage a frank discussion of sexuality and gender identity that results in better outcomes.

Kwong is leading one project to eliminate health disparities in the LGBT population in New York City. As the project director of the newly established Elder LGBT Interprofessional Care Program (E-LINC), Kwong secured a $1.5 million cooperative agreement from Health Resources and Service Administration to help address common medical and mental health needs of the aging LGBT adult population. Walter Bockting is associate director of the project.

In partnership with SAGE (Services & Advocacy for Gay, Lesbian, Bisexual & Transgender Elders), interprofessional collaborative practice (IPCP)  teams that include  nurse practitioners, social workers, psychiatrists, psychologists, physical therapists, and occupational therapists will provide culturally competent care to LGBT older adults in New York City. One goal of the project is to train a new generation of nurses to collaborate with other health professionals in providing appropriate care to LGBT people across the lifespan.

“We are living in a time of tremendous advances in terms of LGBT equality that will have an incredible impact on the health and well-being of future generations,” Kwong said. “But even as we celebrate these moments of progress, we have to remember that the oldest LGBT adults have endured decades of discrimination that will continue to color how they interact with health care providers.”