Linda A Travis, PsyD, Beatitudes Campus, Phoenix, Arizona

June 2017

TIPS ABOUT PROVIDING CARE FOR LGBT OLDER ADULTS Revise practice/clinic websites, brochures, waiting rooms, and forms to be inclusive and welcoming to LGBT older adults. Involve all team members and office staff in changes. Work to build trust and gain credibility by improving communication, and by becoming informed about unique strengths, stressors, and legal challenges in the lives of LGBT older adults. Seek LGBT health resources for best practice guidelines and for clinical decisions.

In response to the call to improve clinicians' cultural competency with older adults from minority groups, attention is also focused on an overlooked segment of the aging population: lesbian, gay, bisexual, and transgender (LGBT)* older adults. Estimates are that 5-10% of older adults are LGBT. However, LGBT older adults often opt for invisibility and silence throughout their interactions with the health care system due to fears of discrimination by clinicians; concern about exclusion from or marginalization in community aging programs; and decades of encounters with social stigma and prejudice.

Moreover, most clinicians are not optimally trained to offer effective care for LGBT older adults. Nonetheless, the impending arrival of aging Baby Boomers will amplify both the voice and visibility of LGBT needs. For all of the above reasons, it is critical  that clinicians improve the quality of care for LGBT older adults. Five recommendations for improvement are discussed below.

1. Convey LGBT Awareness before the Office Visit

Welcoming LGBT older adults to practices may require changes in office procedures. Clinicians and office staff must assess if websites, brochures, and forms convey positive, explicit communication about the healthcare needs of aging LGBTs. Standard office forms should be revised to use LGBT-sensitive language (Table 1). LGBT magazines or newsletters and a clearly displayed non-discrimination policy statement are important in waiting rooms.

Table 1. Recommendations for LGBT-Sensitive Language on Office Forms* Ask about "relationship status" instead of "marital status" to be inclusive of same-sex relationships not recognized by the law in most states. Ask about sexual orientation identity (bisexual, lesbian-gay, and heterosexual). Consider using the term homosexual with older adults, as LGBTs older than the Baby Boomer cohort may feel more at ease with this term. Ask if current sexual partners are female, male, or both. Ask if past sexual partners were female, male, or both. Ask if a patient prefers to be called "he" or "she" and when asking about gender identity, offer options of female, male, and transgender. Within the transgender choices on forms, offer selections for female-to-male transgender and male-to-female transgender. NOTE: For transgender persons, the psychological sense of gender identity does not match the social expectations typically associated with the physical/ anatomical sex at birth. Although sex and gender are often viewed as identical concepts, intake forms should distinguish between the anatomical status (preferences to be "he" or "she") and gender identity (female, male, transgender). All questions should include "don't know," "not sure," and "other" options to encourage discussion of matters not easily captured by predetermined categories. * These recommendations are adapted, in part, from the 2006 Guidelines for Care of Lesbian, Gay, Bisexual, and Transgender Patients, published by the Gay and Lesbian Medical Association.

2. Build Trust with LGBT Older Adults

Fear of discrimination by providers is pervasive (Table 2). Many LGBT adults manage these fears by electing to forego routine or emergency health care. To build trust, clinicians must understand LGBT wariness about the health care system and be clear about confidentiality procedures and limits. Offering rationales when asking about partners or relationships can help patients understand why disclosure is beneficial to their care. LGBT older adults, compared with heterosexual peers, are more likely to exchange emotional support and care with friends rather than with relatives. These "families of choice" offer continuity, belonging, and resilience. Clinicians must address the unique role and meaning of friends in the lives of LGBT's.

Table 2. LGBT Older Adults' Fears of Discrimination Fear of inadequate health care Fear of inappropriate verbal and/or nonverbal responses from providers and office staff Fear of careless management of private information and being "outed" Fear of disrespectful treatment of partners and friends

Clinicians also gain credibility by becoming informed about the changing landscape of LGBT legal rights and lack thereof. For example, the Supreme Court's 2015 decision that individual states could not bar same-sex marriage opened the door for aging LGBT couples to marry and access benefits from key federal programs, such as Social Security. Nonetheless, not all states provide full legal protections for aging LGBTs. In fact, many states do not prohibit discrimination on the basis of gender identity or gender expression. Clinicians must grasp the ongoing vulnerabilities experienced by LGBT older adults (Table 3).

Table 3. Areas of Vulnerability for LGBT Older Adults Workplace discrimination Family caregiving decisions and involvement National and international travel Senior housing discrimination Cohabitation for couples in assisted living and/or long term care facilities

3. Improve Communication with LGBT Older Adults

Poor clinician-patient communication is associated with decreased adherence to recommendations and lower satisfaction with care. As communication skills are modifiable with feedback, improved communication may alter the way in which LGBT patients respond to clinicians' advice and the way in which clinicians understand LGBT older adults.  For example, "coming out" is not the goal of good communication. Rather the goal of good communication is for clinicians and patients to be able to discuss behaviors, partners, relationships, and identities in ways that may not initially be "heard" or understood by many clinicians. Overall, developing competencies in providers' LGBT communication skills should be integrated throughout interprofessional health care education.

4. Recognize Diversity Among LGBT Older Adults

The LGBT older adult community is diverse within itself. LGBT individuals have diversity of race, ethnicity, socioeconomic status, gender, acculturation status, and geographical region, and all of these identities can influence resources and health.

Additionally there are unique challenges faced by each of the four groups making up LGBT. One example is that lesbians, as women, encounter lifelong income disparities that result in fewer financial resources at the time of retirement. Another example is that transgender persons face unknown health implications from long-term hormone use.

5. Seek LGBT Resources to Guide Clinical Decisions

There is limited research on the best ways to address health disparities facing LGBT older adults. Until such research is conducted, clinicians can seek guidance from their professional associations as well as from LGBT health resources, some of which are included below in the list of resources and references.

* "Q" for "queer or questioning" is included with younger LGBTQs but is less commonly used and potentially offensive in communication with older LGBTs. However, the "Q" will become more commonplace with aging of younger Baby Boomers.

References and Resources

• Gay and Lesbian Medical Association (GLMA).  
• Grant JM. Outing age 2010: Public policy issues affecting lesbian, gay, bisexual, and  transgender elders. Washington DC: The National Gay and  Lesbian Task Force Policy Institute. 
• Guidelines for the Care of Lesbian, Gay, Bisexual, and Transgender . Gay and Lesbian Medical Association, 2006.   
• Lambda Legal-Seniors (Toolkit for Life and Financial Planning).  
• LGBT Movement Advancement Project (MAP) and Services and Advocacy for Gay, Lesbian, Bisexual and Transgender Elders (SAGE) (2010). Improving the lives of LGBT older adults. 
• National Academies Press, Institute of Medicine. The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding, 2011. National Academy of Sciences, Washington DC.  
• National Institute of Minority Health and Health Disparities. 
• Services and Advocacy for LGBT Elders (SAGE).  
• World Professional Association for Transgender Health. 

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Interprofessional care improves the outcomes of older adults with complex health problems

Elder Care Editors: Editor-in-Chief: Barry D Weiss, MD;  Deputy Editor: Mindy Fain, MD
 
 National Editorial Board:  Theodore M Johnson II, MD, MPH, Emory University; Jenny Jordan, PT, DPT, Sacred Heart Hospital, Spokane, WA;  Jane Marks, RN, MS, FNGNA, Johns Hopkins University; Josette Rivera, MD, University of California San Francisco; Jean Yudin, CRNP, University of Pennsylvania
 
 Interprofessional Associate Editors: Carleigh High, PT, DPT; David Coon, PhD; Marilyn Gilbert, MS, CHES; Jeannie Lee, PharmD, BCPS; Marisa Menchola, PhD;  Francisco Moreno, MD; Linnea Nagel, PA-C, MPAS; Lisa O'Neill, DBH, MPH; Floribella Redondo; Laura Vitkus, MPH, CHES

Published by: The University of Arizona, PO Box 245027, Tucson, AZ 85724-5027  |  (520) 626-5800  | https://uofazcenteronaging.com

 This project was supported by the Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS) under grant number U1QHP28721, Arizona Geriatrics Workforce Enhancement Program.   This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by HRSA, HHS or the U.S. Government.