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Research on health maintenance and medical issues for older LGBT adults is unfortunately limited. There are certain issues that require particular attention in LGBT patients because of health disparities that affect this group (Table 73–2). In addition, older LGBT people may be more susceptible to mental health disorders as a result of the stresses associated with long-term concealment of sexual identity, many years of exposure to discrimination, and greater risk of inadequate support.
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Health Issues for Older Gay and Bisexual Men
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Sexual health (function, activity, and safer sex methods) should be discussed with older gay and bisexual men so as to assess for and reduce the risk of sexually transmitted diseases. Although the Centers for Disease Control and Prevention (CDC) currently recommends routine HIV testing for all people younger than age 65 years, it is important to consider testing in any sexually active person at any age, especially in the presence of risk factors. Human papillomavirus (HPV) screening should also be offered to men who have sex with men in the form of a routine anal pap smear every 2–3 years, especially in men who have unprotected receptive anal intercourse, or who have HIV, to screen for early signs of precancerous cells caused by certain strains of the HPV virus that can lead to anal cancer.
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Younger gay and bisexual men are more likely to smoke cigarettes, and while older gay men appear to have similar rates of smoking compared to heterosexuals, the effects of previously higher rates of smoking in this group may continue to be a risk factor for cardiovascular disease, including stroke and heart attacks. There are also several cancers which may be more common among gay and bisexual men. These include anal cancer, caused by the human papillomavirus; lung cancer caused by smoking; colon cancer, perhaps attributable to reduced rates of screening; liver cancer related to an increase in hepatitides B and C infections.
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Older Lesbian and Bisexual Women’s Health
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There is good evidence that lesbians receive less preventive care, access health care services less often, and enter the health care system later, than heterosexual women. Most of the health disparities experienced by women who have sex with women relate to difficulty in accessing the health care system, which in part is due to prior discrimination or fear of being treated poorly as a result of being lesbian/bisexual. Lesbians have lower rates of Pap screening and mammograms as compared to heterosexuals. In addition, older lesbians and bisexual women should be counseled on safer sex practices and engaged in conversations about sexual health and function. Sexually active lesbians and bisexual women should be screened for cervical cancer, domestic abuse, and sexually transmitted infections. Clinicians should avoid assuming heterosexuality of older patients, and keep in mind that some women are or have been sexually active with both men and women, even if they identify as “straight” or lesbian. Also keep in mind that sexual identity and behavior can change over time, and that many lesbians have had children and grandchildren from heterosexual or homosexual relationships.
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Lesbian and bisexual women may be at an increased risk of heart disease because of higher rates of risk factors for cardiovascular disease, such as cigarette smoking and obesity. On average they have a higher body mass index (BMI) than their heterosexual counterparts. They may be at greater risk of cervical and breast cancer as a result of decreased access to screening. Because of increased smoking rates, lesbian and bisexual women may also have greater risk of lung cancer.
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Older Transgender Health
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Although there has been little research on the health issues of older gay and lesbian patients, there are even fewer studies on transgender health, and the particular challenges of caring for older transgender patients. As transgender adults age, they may encounter health issues that correspond to their biologic sex, leading to additional stress as they cope with a disease or condition associated with the gender they have left behind. Appropriate health screenings for the birth gender is important preventive care for transgender patients. Disease prevention and health education are key for transgender patients, who are often marginalized by society. Prejudice remains a major barrier to appropriate health care for transgender adults. Many lack health insurance or have insurance programs that do not cover health care related to transgender issues, including hormone treatment. The consequence is that many transgender adults use “black market” hormones, lack preventive care, and do not have their mental health needs addressed. Rates of HIV and viral hepatitis infections, as well smoking and substance abuse, are higher in this group compared with the LGB community and heterosexual counterparts. The University of California San Francisco’s Center of Excellence for Transgender Health is a rich resource for the care of transgender folks, and provides a primary care protocol, including recommendations for general prevention and screening. For example, they recommend routine mammogram screening in transwomen (MTF: male-to-female transgender persons) older than age 50 years with additional risk factors (estrogen and progestin use >5 years, positive family history, or BMI >35).
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There is a link between mental health and health disparities. Communities that suffer health disparities are more likely to have higher rates of mental health issues, particularly depression and anxiety. Older LGBT people who have lived in the closet for much of their lives can have significant stress, loss of self-esteem, and less-fulfilled lives. Trying to manage stigma, marginalization, and self-esteem, can lead to higher rates of depression, suicide, risky sexual behavior, and substance abuse. More research is needed regarding the prevalence of mental health disorders in LGBT older adults. Older LGBT adults appear to have elevated levels of current or lifetime depression, with rates possibly being the highest among transgender people. Very little research has explored mental health problems in transgender adults; what is known is that they have experienced a major life change and many have faced tremendous discrimination. They are more likely to have adjustment disorders, anxiety disorder, posttraumatic stress disorder, depression, and substance abuse.
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Although the topic of HIV is covered in Chapter 47, “Common Infections,” it is worth noting that there is not only an increasing prevalence of older adults living longer with HIV, but also an increasing incidence of new HIV infections in older adults. More than 37% of all those infected with HIV in the United States are older than age 50 years, and by 2015, more than half will be older than age 50. More than 17% of new HIV infections occur in older patients, and men who have sex with men remain a large percentage of those infected. Minorities with HIV/AIDS have higher mortality rates: the death rates are 5 times higher among older Hispanics, and 12 times higher in older blacks. Health care providers need to better educate older patients about safer sex, and also need better detect and screen for HIV in older adults. The HIV and Aging Consensus Project is a resource for suggested treatment strategies for caring for older adults with HIV/AIDS.