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General Principles in Older Adults

Older adults who are lesbian, gay, bisexual, or transgender (LGBT) are a vulnerable group with specific health care needs that are largely unrecognized. Health care professionals and society in general too often fail to address the sexuality, and sexual orientation, of older adults. However, LGBT older adults are also much more likely than other generations of LGBT adults to hide their sexual orientation, as a result of a lifetime of experiencing discrimination from a society that has only recently evolved to become more accepting of homosexuality.

The general LGBT population is affected by health disparities, and as such, has higher rates of common and life-threatening physical and mental health conditions, and these disparities carry over into older years as well. Older LGBT adults continue to be affected by unequal treatment and ongoing social stigma, which we explore in this chapter. This chapter also describes specific health concerns related to LGBT aging, in addition to psychosocial concerns that are of tremendous importance.

Definitions

Homosexuality is an orientation toward people of the same gender in sexual behavior, affection, attraction, and/or self-identity. Bisexuals have an orientation toward people of both genders. Transgender includes people whose gender identity and expression do not match, including transsexual, transvestite, androgyne, and intersex individuals; they may or may not also consider themselves homosexual or bisexual.

It is important to note that sexual orientation is much more than just sexual behavior. For instance, some who have same-sex attractions may never engage in same-sex behavior, and those who engage in same-sex behavior may not identify as being homosexual. For some people, sexuality is more fluid, and so sexual orientation may change over time. This may also be more prevalent in older generations who felt the need to hide their sexual orientation, thus “staying in the closet,” by pretending to be heterosexual in order to avoid discrimination and rejection. “Coming out of the closet” refers to the process of disclosing that one identifies as LGBT, and for many, this is a life-long process. As described below, this process has been especially difficult for the older LGBT population.

Demographics

It is difficult to determine the number of LGBT Americans older than age 65 years because of the lack of reliable statistics, and major challenges recording such statistics such as unwillingness to report sexual orientation, but the best estimates are 1–3 million, based on a range of 3% to 8% of the general population being LGBT. By 2030, there will be an estimated 2–6 million older LGBT Americans. U.S. census data from 2000 and 2010 showed that same-sex–headed households existed in >90% of all counties, and that more than 1 in 10 same-sex couples included a partner older than age 65 years.

History of Stigma and Prejudice Linked to Issues of Coming Out and Disclosure

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