Many older people who identify as LBG have lived through a period when their only protection against heterosexist violence and discrimination was to publicly deny their sexual orientation in order to pass as ‘heterosexual’.
It is important to remember that homosexuality was not removed from the Diagnostic and statistical manual of mental disorders (DSM) until 1973, and disclosure could result in enforced ‘cure’ treatments (eg electroconvulsive therapy, lysergic acid diethylamide, psychotherapy).6 Disclosure could also result in incarceration, criminal prosecution or the loss of family, friends and employment.4 Older LGB people’s senses of self and place in society were shaped by their experiences of institutionalised discrimination.5
There are several health issues that are more prevalent in older LGB people than their heterosexual counterparts. GPs should be aware of the heightened risk for several conditions that result from experiences of discrimination and marginalisation, as well as specific lifestyle factors.
Abuse and violence
Experiences of violence among older LGB people can arise in multiple situations, including:
- family violence as children, adolescents or adults
- intimate partner abuse (refer to Part B. Abuse of older people)
- workplace violence
- random abuse from strangers.
The effect of structural stigma is also significant, from societal barriers to full social inclusion (eg marriage inequality). For example, LGB Australians who lived in regions with a higher proportion of ‘No’ voters in the same-sex marriage plebiscite had worse life satisfaction, mental health and overall health than their counterparts who live in more affirming areas.7
Bisexual people are even more likely to have experienced violence than gay and lesbian people; this is thought to be related to ostracisation from both the gay and lesbian, and heterosexual communities.8
More information on the appropriate identification and response in clinical practice to patients experiencing abuse and violence is available in The Royal Australian College of General Practitioners’ (RACGP’s) Abuse and violence: Working with our patients in general practice.
Mental health concerns
Mental health concerns, particularly depression and anxiety, are of significant concern among older LGB people. Mental health issues among older LGB people relate to lifelong and repeated experiences of discrimination, which has been termed ‘minority stress’.9 Minority stress is even more likely in more conservative social settings (eg rural, outer urban locations).10 Bisexual people have a higher prevalence of serious mental health problems than gay and lesbian people, which is in part related to poverty, lack of social connection and violence experiences.11,12
Lesbian, bisexual and queer women are more likely than their heterosexual counterparts to:13
- drink alcohol at harmful levels
- have initiated drinking at a younger age
- persist with heavy drinking to an older age.
More information on reducing the risk of alcohol-related harm is available at the National Health and Medical Research Council’s (NHMRC’s) Australian guidelines to reduce health risks from drinking alcohol.
LGB people are more likely to smoke and less likely to respond to mainstream health promotion initiatives for smoking cessation than their heterosexual counterparts. GPs should therefore consider more personalised approaches to encourage smoking cessation.14,15
More information on the smoking cessation is available in the RACGP’s Supporting smoking cessation: A guide for health professionals.
LGB people are more likely than their heterosexual counterparts to use illicit drugs, and to continue using illicit drugs at an older age.14
Alcohol misuse and illicit drug use in older gay and bisexual men who are human immunodeficiency virus (HIV) positive is particularly prevalent and affects their general health and wellbeing.16
Cardiovascular and diabetes
Midlife and older lesbian and bisexual women have higher risk factors for cardiovascular diseases,17 which relate to their lifestyle factors (eg smoking, drug misuse, obesity, lower likelihood of pregnancy, reduced access to health screening).18
Gay and bisexual men are also more likely to develop diabetes.19 Older gay and bisexual men with HIV have a higher chance of developing neuropathy, heart disease and diabetes than gay and bisexual men without HIV.16
An emerging theory suggests the physical role of persistent minority stress leads to a ‘cascade of health-relevant events’.20 This cascade can include repeated social stressors that create a high level of vigilance, resulting in psychological and physiological stress responses (eg immune system responses) and leading to altered health behaviours and risk taking.
More information on the early identification and optimal management of people with type 2 diabetes is available in the RACGP’s General practice management of type 2 diabetes.
More information on the management and prevention of cardiovascular diseases is available in the RACGP’s Guidelines for preventive activities in general practice.
There is a higher prevalence of risk factors for cancer among LGB people, including smoking, alcohol misuse, obesity, stress and reduced cancer screening practices.21 Seven common cancer sites that need particular attention for LGB people include:
The incidence of anal human papilloma virus (HPV) infection among gay men and other men who have sex with men is higher than their heterosexual counterparts, and even higher for those who are HIV-positive. However, there is no current anal cancer incidence data.22
More information on the prevention, diagnosis and treatment of various cancers is available on the Cancer Council Australia’s Wiki page.
LGB people aged ≥50 years are more likely to have a disability (refer to Part B. Disability in aged care).19 A recent review and study of the experiences of LGBTI Australians living with a disability found that they were disproportionately likely to:23
- have experienced abuse and violence
- be less able to express their gender and sexual identities because of constraints from carers and living arrangements
- have found it difficult to connect with LGBTI communities.
Isolation and loneliness
Older LGB people are more likely to be single and live in relative isolation in their community because of a long-term inclination to conceal their lifestyle to avoid negative attitudes.24 They are also more likely to be estranged from their family of origin, and less likely to have children themselves. However, many single LGB people are actually well connected to their chosen community and can have a close-knit group of friends who they regard as family.25
Dementia and abuse of older people
Older LGB people living with dementia face particular challenges related to their decreased capacity for independent decision making (refer to Part A. Dementia). Family members and service providers who do not respect same-sex relationships may restrict the older person from access to intimate partners, and take actions to undermine or override decision making by intimate partners.5
In addition, the myth that older LGB people with dementia will ‘become straight’ may result in a lack of support for LGBTI community connections and fail to create LGBTI-inclusive dementia services.26
LGBT Australians are two to three times more likely to experience homelessness during their lifetime than their heterosexual counterparts.27
For young LGBT people, this is particularly due to family rejection and violence; however, for older LGBT people, it is more related to:
- discrimination in the workplace
- loss of employment
- difficulty accessing housing support.
Human immunodeficiency virus
Ageing with HIV is increasingly common, as the use of effective antiretroviral medications has become widespread. Most gay and bisexual men with HIV are able to live healthy lives into older age, and specific health promotion messaging is starting to focus on this population group.28 However, long-term HIV infection can increase the risk for dementia, specific cancers and general immune dysfunction.29
LGB people are more likely to be a carer for a member of their family of origin, partner or friend. Many LGB people rely more heavily on their domestic partner to be their carer, particularly if they are reluctant to access health services.25
Equally, the role of same-sex partners is emerging as important to positive survivorship after cancer.30
Open disclosure about LGB status to a GP has been found to improve health and wellbeing via more comprehensive exploration of health risk factors and more tailored health promotion. For example, open disclosure can increase cervical screening31 and improve access to alcohol treatments.32 The lack of identification and disclosure of LGB people in general practice is a major barrier to inclusive care, as this perpetuates misbeliefs that silence is the preferred option for LGB people.33
LGB patients, especially older people, can be reluctant to openly discuss their sexual identity and behaviour because of fears of negative attitudes and previous negative experiences. GPs can encourage disclosure by discussing sexual orientation when it is relevant to the presenting issue, and as part of a comprehensive social and contextual history. This discussion should be framed as a normal set of questions that provide an important context for care, rather than a stigmatised or embarrassing discussion. Documentation of sexual orientation in the patient’s medical record is essential to ending health inequalities.34