Optimizing the Clinical Care of Lesbian, Gay, Bisexual, and Transgender Older Adults

Lesbian, gay, bisexual, and transgender older adults have specific health concerns that are often unmet by the medical system. There is growing awareness of these health needs, however, because people who recently reached 65 years or older are part of the first generation in which many have chosen to be open about their sexual orientation or gender identity. Although some health needs may be specifically related to gender identity or sexual orientation (such as hormone therapy for transgender persons), inequalities in health have also arisen from discriminatory treatment in health care systems and society, including clinicians who refuse to care for patients based on sexual orientation or gender identity or who are demeaning or disrespectful.1,2 Recent population-based studies have documented differences in psychological distress, mental health, and physical health for lesbian, gay, and bisexual persons, and transgender individuals are less likely to have health insurance and more likely to report poor health.3,4 To provide high-quality care, clinicians and health care organizations can welcome gay, bisexual, and transgender older adults, and appropriately address health concerns.1,5,6

In this Viewpoint, we make several recommendations for quality care that are informed by research evidence and expert opinion, including a recent position statement from the American Geriatrics Society that one of us (A.M.T.) drafted and edited.58 It should be noted, however, that there is limited high-quality research on health for lesbian, gay, bisexual, and transgender older adults. Researchers face challenges identifying appropriate populations and recruiting participants owing to fear of discrimination, and funding is low.8 More recent higher-quality surveys rely on national population databases.3,4 Based on the existing evidence and expert opinion, there are several steps clinicians and health systems can take.

Use Language That Is Inclusive of the Lesbian, Gay, Bisexual, and Transgender Experience

Clinicians should become familiar with appropriate language regarding sexual orientation and gender identity. Transgender is a term used by many individuals whose gender identity does not conform to their biologic sex or the sex assigned at birth. Individuals may transition from male to female or female to male or may identify with neither sex. Although the number of transgender individuals is not well researched, a study9 found that approximately 0.3% of the population of US adults identify as transgender. Transgender persons should be addressed by their preferred name and pronoun (eg, he/his). Clinicians should not make assumptions about past or current sexual behavior based only on sexual orientation. For example, some men who identify as heterosexual may also have sex with men.

As a result of prior discrimination, individuals may be reluctant to disclose their identity or sexual behavior with clinicians or may delay seeking care at all. Communicating acceptance and avoiding assumptions can reduce this barrier. For example, when asking about marital status or relationships, ask about a spouse or partner, rather than asking a woman if she has a husband. When recording sexual history, ask about both male and female partners. Forms disclosing sex should include options for transgender patients such as “male-to-female” and should include a place to indicate a preferred name. However, some older adults will be unwilling to disclose this information. For example, if a patient defines their closest support as a “friend” or “roommate,” clinicians should use the terminology preferred by the patient even if they suspect the relationship may be more intimate. At an organizational level, health care systems should include sexual orientation and gender identity in their nondiscrimination policies and should post this information where it can be easily viewed by patients. The Human Rights Campaign, a national lesbian, gay, bisexual, and transgender civil rights organization, has established best practices for health care organizations and publishes an annual report documenting implementation.1 The core criteria address nondiscrimination and staff training, patient services and support, employee benefits and policies, and patient and community engagement.

Learn About the Experience of Unequal Treatment, Which May Have Had Financial, Social, and Health Consequences

Lesbian, gay, bisexual, and transgender adults report worse physical and mental health than heterosexual adults.3,4 They may have not have access to regular health insurance as a result of employment discrimination or lack of access to insurance as a spouse. Although The Human Rights Campaign has noted that a growing number of health care organizations meet the standards for quality care they have established, such care is far from universal; lesbian, gay, bisexual, and transgender individuals may be refused medical care or encounter policies that discriminate against them or their family members.1,2 Physicians may also register as an “ally” or “safe physician” with organizations such as the Gay and Lesbian Medical Association, which can make it easier for older adults to find medical care free of discrimination.

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