American Geriatrics Society Care of Lesbian, Gay, Bisexual, and Transgender Older Adults Position Statement

Zhenya Hurd


J Am Geriatr Soc. 2015;63(3):423-426. 

There is ample evidence that lesbian, gay, bisexual, and transgender (LGBT) individuals face discrimination in the healthcare setting. Providing high-quality health care for older LGBT adults will require active steps by organizations, institutions, advocacy groups, and health professionals that create an environment that is free from discrimination. This position statement that the American Geriatrics Society (AGS) Ethics Committee developed addresses the vision of the AGS for the care of LGBT older adults and specific steps that can be taken to ensure that they receive the care that they need.

There is ample evidence that lesbian, gay, bisexual, and transgender (LGBT) individuals face discrimination in the healthcare setting. A 2010 study found that more than half of lesbian, gay, and bisexual respondents and 70% of transgender respondents had experienced discrimination by healthcare providers. Discrimination that LGBT individuals face ranges from refusal of care, biases or incorrect assumptions, to overt derogatory statements.[1] Some older adults may delay or avoid health care because of discrimination or the fear of discrimination, and others may hide their LGBT identity when seeking health care. In hospital and long-term care settings, LGBT individuals face overt prejudice and subtle forms of discrimination and may be denied access to visitation by their families of choice or designated healthcare proxies.

Our Vision for Care of LGBT Older Adults

Providing high-quality health care for older LGBT adults will require active steps by organizations, institutions, advocacy groups, and health professionals to create an environment free from discrimination.

1. Healthcare organizations should take steps to create, implement, and evaluate policies that require equal treatment for LGBT individuals, regardless of age, and should make these policies available to staff, patients, and families.

2. Healthcare organizations should ensure that education for healthcare providers who care for older adults includes training in LGBT health concerns focused on the older adult population, the effect of discrimination on healthcare delivery, the social circumstances of LGBT individuals, and the relationship between social history (including gender identity, relationship status, and sexual behavior) and health and health care.

3. Healthcare organizations and professionals should ensure that care for older LGBT persons recognizes and incorporates the particular healthcare and social circumstances of those persons, including:

  • Consideration of the role of partners or other chosen family in healthcare decision-making and caregiving and the individual's right to choose a healthcare proxy who may be a partner or friend.

  • Creation of a culture of respect for LGBT older persons in supportive living situations (e.g., assisted living facilities and nursing homes), including training for all types of healthcare workers, including physicians, nurses, and nursing assistants.

  • The medical needs of aging LGBT persons, including the reality of health disparities that have resulted from past discrimination.

  • The reality of unequal treatment under laws and social service programs.

  • Recognition of the preferred name and gender identity of transgender individuals, regardless of legal or biological gender status.

4. Research funding should be allocated to support high-quality research addressing LGBT health, including the effect of discrimination on health, appropriate management of risk factors, and medical management of LGBT older adults.

Equal Treatment for LGBT Individuals

Several government organizations and advocacy groups have outlined specific standards for equal treatment of LGBT individuals. The AGS strongly supports full adherence to these guidelines. The Centers for Medicare and Medicaid Services and the Joint Commission both require that healthcare facilities "allow visitation without regard to sexual orientation or gender identity."[2,3] The Joint Commission now also requires that accredited healthcare facilities prohibit discrimination based on sexual orientation, gender identity, and gender expression. There has been progress in implementing these requirements. In 2012, 74% to 92% of organizations reporting to the Human Rights Campaign Health Care Quality Index Survey reported compliance with these requirements,[4] but AGS believes that there is an ongoing need for continued advocacy to eliminate discrimination in all healthcare organizations and achieve 100% compliance with existing regulations.

AGS believes that it is essential that healthcare organizations explicitly include the following in their organizational policies:[4]

  • Sexual orientation should be included in the patient nondiscrimination policy.

  • Gender identity and gender expression should be included in the patient nondiscrimination policy.

  • The visitation policy should grant equal access for same-sex and transgender couples and should allow equal access to support persons that the patient designates who may not be legal family members.

  • The visitation policy for children should grant equal access for same-sex and transgender parents.

The Need for Training in LGBT Health Concerns

Cultural competence and patient-centered care are widely acknowledged to be central to effective medical care.[5] The medical care of LGBT individuals has been hampered by lack of knowledge and understanding of their health needs and experiences. In addition to overt prejudice, clinicians may impede care of LGBT individuals because of lack of knowledge or tacit assumptions. For example, standard questions about social history, such as, "Are you married?" may unintentionally imply bias by suggesting that the provider assumes each patient is heterosexual. Bias may also exist in written or electronic forms that do not account for transgender experiences. Many paper forms and electronic medical records do not allow options for patient sex other than male or female, and electronic medical records may not be configured to allow a change in sex or name after an individual transitions from one sex to another. Patients may also sense clinicians' discomfort and lack of knowledge. LGBT persons of different ages or races and ethnicities may vary in the words they use to define themselves, and healthcare providers need training to ask appropriately about self-definition. Education for healthcare providers who care for older adults should include training in LGBT health concerns focused on the older adult population, the effect of discrimination on healthcare delivery, the social circumstances of LGBT individuals and the relationship between social history (including gender identity, relationship status, and sexual behavior) and health and health care. Healthcare professionals should be aware of existing training and educational materials,[6–9] which should be used to create a workforce that is capable of providing high-quality care for this population.

Specific skills required to provide patient-centered care to LGBT individuals include:

  • Taking a social history that is inclusive of the LGBT experience. Taking a social history is integral to any good medical history. Clinician questions and written forms in clinical settings should ask questions in a manner that does not assume heterosexuality when asking about sexual behavior or relationship status.

  • Taking a medical history that is inclusive of the transgender experience. When medically appropriate, clinicians should inquire sensitively about a transgender history. Clinicians should understand the effect of transgender hormone use or surgery on the correct diagnosis and screening of medical conditions.

  • Taking a sexual history and discussing sexuality in a nondiscriminatory manner. Discussing sexuality is also an important part of the social history. Organizations such as the Gay and Lesbian Medical Association and the Transgender Law Center have published guidelines to assist clinicians in working with LGBT individuals in a manner that builds trust and encourages disclosure.[6,8]

Health Care and Social Circumstances of LGBT Individuals

Consideration of the Role of Partners or Other Chosen Family in Healthcare Decision-making and Caregiving and the Individual's Right to Choose a Healthcare Proxy who may be a Partner or Friend. Older adults are at greater risk of being unable to make their own medical decisions because of dementia and other conditions that lead to cognitive impairment. Choosing a healthcare proxy is thus an important part of good medical care and is especially important if the individual's preferred proxy is not a biological or legal relative. A recent survey of LGBT baby boomers found that 64% identify a "chosen family" to whom they are not legally or biologically related.[10] Many LGBT individuals are cared for by their partners and chosen family during serious illness. Many also identify a partner or friend as their preferred healthcare decision-makers in the event of incapacity. The right of same-sex partners to marry currently varies according to state; as of 2011, 40 U.S. states did not recognize unmarried same-sex or domestic partners as potential surrogate decision-makers, and approximately 30 states did not recognize close friends.[11] Without a healthcare proxy document, many states would not recognize these individuals as legally authorized surrogate decision-makers.[12] The same survey found that only 34% of LGBT individuals had completed a healthcare proxy. LGBT individuals should be educated, empowered, and helped to complete appropriate state healthcare representative documents. Help facilitating the completion of these documents is needed in some clinical settings. Clinicians should be aware of the important role friend and partner caregivers may play for an LGBT person with a serious illness.

Creation of a Culture of Respect for LGBT Older Persons in Supportive Living Situations (e.g., Assisted Living Facilities and Nursing Homes), Including Training for all Types of Healthcare Workers, Including Physicians, Nurses, and Nursing Assistants. Adults in long-term care facilities may lose the privacy they have experienced in their own homes. Because of this, special attention is needed to ensure that LGBT identity is respected in residential facilities. Older adults who live in residential facilities may be especially vulnerable to abuse and neglect because of impaired functional status or cognition. LGBT residents may respond by hiding their sexual orientation or gender identity, and may feel afraid to display personal items in their rooms such as books or pictures that may reveal their identity. A 2011 survey of LGBT older adults found that only 22% of older adults perceived that they could be open about their sexual orientation or gender identity, with the staff in a nursing home or other supportive living facility.[13] There is anecdotal evidence of negative staff and resident attitudes and several reports of discriminatory treatment from staff and other residents in long-term care settings, such as refusing to allow visits from same-sex partners or refusing to call a transgender person by his or her preferred name.[11,13,14] Because of the greater vulnerability and potential for social isolation, LGBT individuals in residential facilities have a particular need for advocacy. Staff at all levels, including physicians, nurses, and nursing assistants, should receive training on LGBT health. Best practices for transgender individuals include placing individuals by their gender identity rather than by their biological or legal status.[15]

The Medical Needs and Health Disparities of Aging LGBT Persons. Experiences of discrimination and health disparities affect the medical needs of many LGBT persons. There is evidence that LGBT older adults have experienced stigma and discrimination across their life span and may have more lifetime experiences with interpersonal violence.[16] In the healthcare setting, 19% of transgender persons report refusals of care, and 28% report harassment.[17] Although there is inadequate research on this topic, such experiences may place LGBT older adults at greater risk of physical and mental health disorders. One survey found that 41% of transgender participants had attempted suicide, compared with 1.6% in the general population.[17] Because many LGBT older adults lived through an era of workplace discrimination, they are less likely to have received regular health or retirement benefits.[18] The historical inability to marry legally has further reduced access to health insurance and other financial and emotional benefits of marriage.[19] LGBT older adults also have higher rates of tobacco and alcohol use.[16] LGBT older adults also may not seek early treatment for medical conditions because of discrimination or fear of discrimination. LGBT older adults from diverse ethnic backgrounds may bear the dual burden of disparities due to their sexual orientation and minority status. Some may also have challenges associated with limited English proficiency and limited health literacy. Recent immigrants are especially at risk because they are not acculturated into the mainstream culture and may have limited resources and be socially isolated because of lack of transportation resources.

The Reality of Unequal Treatment Under Laws and Social Service Programs

LGBT individuals are subjected to substantial legal and financial burden due to discrimination and lack of legal recognition of marriage by many states.[11,19] As of this writing, there is uncertainty about whether many of the 1,000 federal benefits conferred by marriage (including social security benefits, insurance benefits, veterans' benefits, and estate and inheritance laws) will be available to same-sex couples who reside in states that do not recognize same-sex marriage. This places particular burdens on same-sex spouses who are informal caregivers. Caregivers may not be able to arrange time off under the Family Medical Leave Act to care for a same-sex spouse or partner. Lack of access to these benefits place LGBT older adults at greater financial risk as they experience functional decline or serious illness.[20] Insurance plans often do not cover transgender medical care, leading to tremendous financial burdens for individuals who must pay for treatment out of pocket.

Research in LGBT Health

A 2002 study found that only 0.1% of articles in the Medline data base addressed LGBT health.[21] A more recent study examining PubMed citations found that, although the absolute number of studies addressing LGBT health has risen, the percentage of total publications is still less than 0.3%.[16] National Institutes of Health funding for LGBT health remains less than 1% of all studies, when human immunodeficiency virus research is excluded.[22] There are inherent challenges in studying the LGBT population, such as concerns of LGBT individuals about identifying themselves to researchers. The Center for Population Research in LGBT Health has identified the following important steps for improving the quantity and quality of research: include assessment of sexual orientation and gender identity in large-scale population health studies and increase funding for studies of LGBT health.[23] Given the growing awareness of including appropriate stakeholders in research development, studies of LGBT health should include involvement of LGBT persons throughout the research process.