20. Healthcare, Sexual Practices, and Cultural Competence with LGBT Elders

This chapter focuses on healthcare practices with lesbian, gay, bisexual, and transgender (LGBT) elders. Attention is given to the current state of healthcare practices with LGBT elders and the challenges and opportunities they present. Further, this chapter explores methods for best practices for healthcare professionals who provide care for this population.

We begin this chapter by reviewing the history and healthcare practices with LGBT elders. Next, we explore major issues surrounding healthcare practices with LGBT elders, for instance common misconceptions about sexuality of patients, training needs of staff, (e.g., cultural competency), data collection and clinical interviews, sexual intimacy, and HIV/AIDS . This chapter also reviews implications for improving service delivery from an interdisciplinary perspective.

LGBT elders represent an extremely marginalized population, as a result of age and sexual orientation or gender identity. The number of older adults in the USA is increasing rapidly; in fact approximately 10,000 individuals turn 65 every day. Healthcare needs often increase with age, for instance Medicare beneficiaries on average have at least three chronic conditions (Center for Medicare and Medicaid Service [CMS] 2012). Among Medicare enrollees, physician visits and consultations increased from 11,395 per 1000 in 1999 to 15,437 per 1000 in 2009 (Federal Interagency Forum on Aging-Related Statistics [FIFAR] 2012). The LGBT population is not exempt from this reality. This rapid population aging will significantly impact the lives of LGBT individuals who often grow old without sufficient support, including health care. In fact, it may be compounded by healthcare needs that are unique to the LGBT population,  such as sexual orientation, gender identity, and a history of marginalization. In recent years, we have seen cultural shifts that have allowed segments of the LGBT population to achieve legal rights making it easier for some to live openly as LGBT individuals. Some of the recent changes have brought the barriers and needs of LGBT elders more visibility; however, there are still many issues to be addressed including the healthcare practices of LGBT elders.

The history and practice relating to health care with LGBT elders is relatively short. In recent years, there has been recognition of the importance of conducting research in order to better understand the needs of LGBT individuals and establishing the best practices in order to increase the quality of health care for LGBT individuals. However, research efforts specifically regarding healthcare practices with LGBT elders have lagged behind. In the USA, we are experiencing a tremendous increase in the number of “out” LGBT elders, which is very different from what has been seen, in the past there were relatively small numbers of “out” LGBT elders; however, by the year 2030, it is expected that the number of LGBT older adults in the USA will increase to more than 4 million (Fredriksen-Goldsen et al. 2011).

The available research on healthcare practices with LGBT elders has focused on the provision and awareness of services specifically for LGBT elders (Knochel et al. 2012; Hughes et al. 2011), promoting awareness of LGBT aging issues in nursing programs (Lim and Bernstein 2012), and surveying the training of healthcare providers and nursing home social service directors (Bell et al. 2010; Rogers et al. 2013; Porter and Krinsky 2013). Services and Advocacy for GLBT Elders (SAGE) has released several publicly available documents with recommendations for policy and practice. Furthermore, the National Resource Center on LGBT Aging published a document on collecting health-related data from LGBT elders. Unfortunately, very few practices have implemented the recommendations provided by these organizations. While there is a limited amount of available research specifically regarding LGBT elders, some of the available research on LGBT individuals in general can be applied to older adults. For instance, The Fenway Institute’s (2012) publication on gathering data on sexual orientation and gender identity in clinical settings can be used with older adults.

In light of the growing number of LGBT older adults in the USA and elsewhere, there is a definite need for more research aimed at understanding the needs and desires of LGBT elders regarding their interaction with health care and for the development of best practices for healthcare providers. An initial step in developing best practices for providers should be striving to eliminate commonly held misconceptions about the sexuality of patients.

Within our society, there is an extremely prevalent misconception that older adults are not sexual beings and that the desire to engage in sexual activity diminishes with age; research does not support this misconception (Lindau et al. 2007; Trompeter et al. 2012). All existing literature suggests the desire to engage in sexual activity is present among all human beings and continues into later life. In fact, many older people continue to have satisfying sex lives into their seventies, eighties, and even nineties (Vann 2014). Unfortunately, many healthcare providers also hold these common misconceptions and therefore potentially miss opportunities to discuss sexuality with their older patients. Discussions surrounding sexuality with older patients are extremely important because older adults maintain an interest in and desire to engage in sexual activity, but may face challenges that may then cause them to miss opportunities for sexual activity and/or to place themselves at risk for contracting sexually transmitted infections and diseases. The number of older adults being diagnosed with HIV is increasing. In 2010, individuals aged 50 and older accounted for approximately one-fifth of those living with HIV infection (CDC 2013a). The number of older adults infected with other sexually transmitted infections is also increasing. For example, the number of individuals aged 55 and over diagnosed with chlamydia increased from 4,311 in 2009 to 6,801 in 2013, those diagnosed with Gonorrhea increased from 2,766 in 2009 to 4,327 in 2013, and those diagnosed with syphilis increased from 607 in 2009 to 912 in 2013 (CDC 2014b). Oftentimes, healthcare providers make assumptions regarding older adult’s sexual orientation, assuming that the majority of older adults are heterosexual (National Resource Center for LGBT Aging, n.d.). The possibility that an older patient is lesbian, gay, bisexual, or transgendered is rarely considered.

Another common misconception regarding older adults and sexuality is that due to their advanced age, they should know how to protect themselves from sexually transmitted infections and diseases when in fact the opposite is true (Centers for Disease Control and Prevention [CDC] 2013a). The current generation of older adults grew up in a time when sexual health education was not a part of general education and thus never learned how to properly protect themselves.

Misconceptions surrounding drug use among older adults also exist and impact their sexuality. Many healthcare practitioners, as well as other members of society, generally believe that older adults do not use illicit drugs and thus are less likely to ask older patients questions about illicit drug use. While research does suggest that illicit drug use declines with age, research now shows that the baby-boom generation (individuals born between 1946 and 1964) has relatively higher rates of illicit drug use than previous generations (Wu and Blazer 2010). Illicit drug use can increase the risk of transmitting sexually transmitted diseases and infections—particularly among older adults who may be unaware of how to protect themselves against disease and infection (CDC 2013a). In addition to illicit drugs, the sharing of equipment (e.g., needles) for non-illicit drugs can increase one’s risk for diseases and infections. For example, if two older adults share diabetic injection medication, there is the potential to spread sexually transmitted diseases and infections. Many older adults internalize these common misconceptions and in turn feel embarrassed or ashamed that they have a continued interest in sexual activity. Thus, many older adults are unwilling to bring the subject of sexuality up to their healthcare provider. Older adults should not be embarrassed or ashamed to ask their healthcare provider questions regarding their sexuality. Sexual contact is correlated with better health, higher relationship satisfaction, and better stress management (American Association of Retired Persons [AARP] 2011). There is a great need to increase the training and preparedness of healthcare providers who see older adults, so that they inquire about older patients’ sexuality and are able to field questions about their sexuality.

Adults maintain the need for intimacy as they age. Most need to feel close to others as they grow older (National Institute on Aging [NIA] 2013). The type of intimacy that an adult seeks may change with age; for instance, holding hands, touching, and kissing may be sought by more older adults as opposed to having sexual intercourse.

There are normal age-related changes that affect both men and women. These changes can sometimes affect the ability to have and enjoy sex (NIA 2013). As women age, the vagina can shorten and narrow, and the vaginal walls can become thinner and stiffer (NIA 2013). Women may also have less vaginal lubrication (NIA 2013). These changes can affect the ability to enjoy sex and can increase a women’s risk for contracting sexually transmitted infections and diseases. The thinning and reduced lubrication of the vagina can lead to increased risk of a vaginal tear, thus increasing the susceptibility to sexually transmitted infections and diseases. As men age, erectile dysfunction (ED) becomes more common (NIA 2013). ED is the loss of ability to achieve and maintain an erection suitable for sexual intercourse (NIA 2013). It may take a man a longer time to achieve an erection, and the erection may not be as firm or as large as it used to be in a man’s earlier years (NIA 2013). The loss of the erection after an orgasm may take less time, and the time in between erection may become longer (NIA 2013). An occasional problem with  erection is not a problem, but if it occurs regularly, then medical attention should be sought. Healthcare providers should be willing and able to aid older adults in addressing concerns with sexual intimacy.

In addition to normal age-related changes that can affect the sexual lives of both older men and women, several chronic conditions also affect the sexual lives of older adult. Older adults who suffer from joint pain associated with arthritis can experience pain and discomfort during sex. The National Institute on Aging (NIA 2013) suggests that exercise, drugs, and possibly joint replacement surgery may relieve some of the arthritic pain. Rest, warm baths, and changing the position or timing of sexual activity can be helpful in reducing arthritic pain that may interfere with sexual activity (NIA 2013). Chronic pain can interfere with intimacy, it is not a normal part of aging, and can often be treated with medications. However, some pain medicines can interfere with sexual function. Some people with dementia show increased interest in sex and physical closeness and may have difficulty determining appropriate sexual contact (NIA 2013). Furthermore, individuals with severe dementia may not recognize their spouse or partner but may still have sexual desires and exhibit sexual behavior (NIA 2013). This can cause some discomfort for the spouse or partner. Working with a healthcare professional who has training in dementia care can be very helpful. Diabetes is one of the illnesses that can cause ED in some men (NIA 2013). Women with diabetes are more likely to have yeast infections, which can cause sexual activity to be uncomfortable or undesirable (NIA 2013). Medications can help with the side effects of diabetes on sexual intimacy for both men and women. Heart disease can affect both men and women in regard to sexual intimacy due to narrowing and hardening of the arteries, which can change the blood vessels, so that the blood does not flow freely. Thus, men and women with heart disease may have problems with orgasm (NIA 2013). Heart disease may also cause problems with obtaining and maintaining erections for men (NIA 2013). Loss of bladder control or leakage of urine can be problematic for many older adults, especially in women. Extra pressure on the stomach during sex can cause bladder leakage, which may cause some individuals to avoid sex (NIA 2013). Changing positions during sex or seeking treatment for incontinence can help the problem. Also, depression can affect both men and women’s desire for sexual intimacy. Depression is fairly common among older adults and should be treated appropriately. A 2011 national study on LGBT older adults found that more than half of LGBT elders had been told by their doctor that they had depression, approximately 39 % had seriously considered suicide, and approximately 53 % felt isolated from others (Fredriksen-Goldsen et al. 2011).

Sexual intimacy can be problematic in certain environments such as nursing care facilities. The desire for sexual intimacy does not go away with age, and this is true for those in nursing and assisted living facilities, as well. Unfortunately, conditions in nursing and assisted living facilities may hamper the ability to satisfy a need for sexual intimacy. Personal barriers (e.g., physical disabilities, the adverse effects of prescribed medications, cognitive impairment, and lack of partners) inhibit sexual intimacy (Katz 2013). In addition, residents also lack privacy, as they are often encouraged to leave their doors open and unlocked, and staff members often come in and out frequently. The attitudes of staff and families often cause significant barriers to sexual expression in nursing facilities (Katz 2013). Due to the fact that many nursing facilities lack policies designed to help guide and support staff responses, much is left up to personal interpretation of the staff (Katz 2013). Nursing facilities should be encouraged to develop policies surrounding sexual expression by residents. Such policies may help provide guidance for the safe expression of sexual desire and provide training for staff in how to handle these situations. Specifically, staff training on LGBT older adult’s needs should be mandated. It should be made clear that anti-LGBT discrimination will not be tolerated. Advocates should push for laws mandating training for nursing home personnel and residents (Redman 2011). For example, in 2008, California passed a law requiring the Department of Public Health to design and implement regular cultural competency training on LGBT issues (Redman 2011). Furthermore, Ombudsman programs must take a stronger advocacy role in protecting LGBT residents from bullying and discrimination (Redman 2011). Further research and data collection is needed to uncover additional problems LGBT residents face in nursing homes.

It is important for healthcare providers to remember that older adults maintain desires for sexual intimacy. It is important for healthcare providers to work with older adults to maintain their sexual health and to help them meet their intimacy goals and to avoid the transmission of diseases.

On June 5, 1981, the CDC first published a report about the occurrence of a disease later referred to as acquired immune deficiency syndrome (AIDS). This report is often referred to as the “beginning of AIDS” in the USA, as it described the symptoms of five homosexual men with what are now known as “opportunistic infections” (US Health and Human Services [HHS], n.d.). Initially, the disease was thought to affect only homosexual men, and so by 1982, the disease had acquired the name gay-related immune deficiency syndrome (GRID).

However, by mid-1982, the disease was reported among injection drug users, and soon hemophiliacs presented with the disease. By 1983, the retrovirus that causes AIDS was identified and given the name it has today, human immunodeficiency virus (HIV). In 1985, the identification of HIV prompted researchers to develop a test for the disease. A few years later, the first anti-HIV drug, AZT (Zidovudine), was approved by the Food and Drug Administration (FDA). With the ability to test for the virus and to provide medications for it, prevention efforts commenced. While there have been major advancements in regards to HIV/AIDS over the past 33 years, there is currently no cure or effective vaccine for HIV/AIDS. Prevention remains the best and most effective strategy for reducing incidences of HIV/AIDS among older adults (Powderly and Mayer 2003). A comprehensive prevention program should include the provision of education, screening/testing for HIV/AIDS, and the prompt treatment of those who are infected.

Currently, more than 35 million people worldwide are living with HIV (The Joint United Nations Programme on HIV/AIDS [UNAIDS] 2014). In the USA, approximately 1.1 million individuals are living with HIV (UNAIDS 2014); furthermore, it is estimated that one in five individuals with HIV/AIDS are unaware that he or she is infected (UNAIDS 2014). A growing number of people aged 50 and older are living with HIV infection; older adults accounted for approximately 19 % or 217,300 of the estimated 1.1 million cases of HIV in the USA (CDC 2013a). Of the estimated 47,500 new HIV infections in 2010, older adults aged 55 and over accounted for approximately 2,500 (5 %) of the new infections (CDC 2013a) and is expected to increase. In 2010, 44 % of the estimated 2,500 new HIV infections among people aged 55 and older were among gay, bisexual, or other men who have sex with men (MSM) (CDC 2013a). Research suggests that the LGBT population has been disproportionately affected by the AIDS epidemic, marginalizing particular subgroups within LGBT older adult populations (i.e., men who have sex with men, transgender elders, and older lesbians) (Services and Advocacy for Gay, Lesbian, Bisexual and Transgender Elders [SAGE] 2010). Older adults of color are disproportionately affected by HIV. The CDC (2013a) reports that older African Americans and Latinos were 12 and 5 times, respectively, more likely to contract HIV as compared to their white counterparts. Because the risk of female-to-female transmission of HIV is relatively low; oftentimes, lesbian and bisexual women are overlooked regarding their risk for HIV by themselves and by healthcare providers. However, lesbian and bisexual women can engage in high-risk behaviors just like anyone else. For example, lesbians can increase their risk for HIV by having oral sex without a protective barrier, sharing sex toys without disinfecting them or using a barrier, and sexual play that involves the exchange of vaginal fluids or blood (SAGE 2010). Also, lesbian and bisexual women can have unprotected sex with male partners and inject drugs and share needles.

The risk factors for HIV are the same for everyone. HIV is transmitted through blood, semen, pre-seminal fluid, rectal fluids, vaginal fluids, and breast milk from an HIV-infected person. The fluids must come in contact with a mucous membrane found inside the rectum, the vagina, the opening of the penis or the mouth or damaged tissues or be directly injected into the bloodstream in order for transmission to occur (CDC 2014a). These risk factors are the same for everyone regardless of race, sexual orientation, gender identity, sex, or age. Older adults are often considered to be at greater risk for HIV due to lack of awareness about HIV and how to prevent transmission, and as a direct result, unknowingly place themselves at risk for HIV and other sexually transmitted infections. For example, many widowed and divorced people are dating again and are less likely to protect themselves because of their lack of awareness of how the disease is transmitted. Again, as mentioned in the previous section, there are physiological changes among older men and women that can increase their risk for contracting HIV. Due to older adults’ increased risk for HIV, it is extremely important to increase educational efforts aimed at increasing older adults’ knowledge about HIV and to screen older adults for HIV (Davis 2013). Early detection improves infected persons’ chances of living longer, particularly for older adults.

Unfortunately, older adults are more likely to receive a late diagnosis and to have a short progression between HIV and AIDS. Older adults are more likely to have a delayed diagnosis because symptoms of HIV resemble symptoms of other chronic illness common among many older adults or normal aging. For example, loss of energy, short-term memory loss, and weight loss are all symptoms of HIV, but they also may be associated with normal aging or associated with other common conditions among older adults (SAGE 2010). A late diagnosis means a late start to treatment and possibly more damage to an already weakened immune system (CDC 2013a).

Despite the fact that we know that early detection is essential to improving older adults’ chances of survival, many healthcare providers still fail to acknowledge older adults risk for HIV and do not ask questions about sexual partners or drug use (SAGE 2010). Additionally, many LGBT elders fear discrimination from healthcare providers because they are not open and honest about their needs. Between the lack of recognition of older adults’ HIV risk factors among many providers and the fears of many elders, HIV screening rarely occurs and early detection is minimal (SAGE 2010). Again, as with previously discussed issues (e.g., sexual orientation or sexual intimacy) in older adults there is a great need to increase the training and preparedness of healthcare providers who see older adults, so that they better prepared to inquire  and address questions about older patients sexuality.

In comparison to their heterosexual counterparts, LGBT people exhibit more risky behaviors and have worse health outcomes (IOM, Institute of Medicine 2011; US Department of Health and Human Services [DHHS], Health Resources and Services Administration 2011). The health of this population, including older adults, is made more challenging because of the unique needs and concerns related to their sexual minority status, and which contribute to health disparities with some variations within subgroups. For instance, within the LGBT population, there are higher rates of risky behaviors such as smoking, higher levels of breast cancer and obesity among lesbian women; anal cancer in gay and bisexual men, and violence/abuse in personal relationships (IOM 2011; Barbara et al. 2007). Additionally, LGBT people when compared to their heterosexual counterparts exhibit higher rates of mental health problems such as suicidal ideation/attempts, anxiety and mood disorders, and higher rates of substance abuse (Durso and Meyer 2012). See Chaps. 23 and 24 for further discussion on mental health and substance abuse. Table 20.1 provides a breakdown by condition and subgroup.

The overall tendency toward poor health status has been attributed to a number of factors that act as barriers to health. Major contributory factors include lack of or inadequate training of healthcare professionals on how to address LGBT healthcare needs, minority stress , and disclosure or non-disclosure of LGBT sexual orientation or gender identity to healthcare providers. Inadequate training is a barrier against optimum health because it inhibits professionals who are uninformed about the unique healthcare needs of LGBT patients. Minority stress theory posits that members of disadvantaged groups suffer stress—for instance, the discrimination, stigma, and homophobia experienced by LGBT as a disadvantaged minority cause them to suffer chronic stress, which contributes to poor health (Durso and Meyer 2012). Below, we consider how a patient’s non-disclosure and/or disclosure of sexual minority status (i.e., sexual orientation or gender identity) can act as a barrier or obstacle to health care.

The Centers for Disease Control and Prevention’s (CDC) report, The State of Aging and Health in America 2013, provides “a snapshot of the health and aging landscape in the United States” (CDC 2013b, p. 2). According to this report and as mentioned earlier, longevity and the aging of the baby boomers, one of the largest cohorts in history has resulted in an unprecedented growth in the size of the population aged 65 and over. Of this segment of the population, two-thirds live with multiple chronic conditions and account for 66 % of US healthcare expenditures (CDC 2013b).

Generally, older adults consume a disproportionate amount of healthcare and long-term care services, as the demand for these services tend to increase as age increases, requiring the skills of a variety of staff and personnel in mental health, physical health, long-term care, and other aging services (McGinnis and Moore 2006). According to a report by the LGBT advocacy group, Services and Advocacy for Gay, Lesbian, Bisexual and Transgender Elders (SAGE), healthcare settings can be challenging environments for LGBT elders (SAGE 2010). Factors that create barriers and/or influence the care received by LGBT elders are often driven by heterosexism and homophobia. These factors include open discrimination by staff which may create a hostile environment, lack of familiarity with the needs of LGBT elders, as well as, LGBT elders’ own reluctance to engage because of past negative experience. For instance, in a report about how inhospitable the healthcare environment is for LGBT people, the organization Services and Advocacy for Gay, Lesbian, Bisexual and Transgender Elder (SAGE) cites a 2006 study by MetLife Mature Market Institute that indicates that more than 50 % of LGBT baby boomers believed they would not receive respectful and dignified treatment from healthcare professionals (SAGE 2010).

The level of provider/staff knowledge, awareness, and comfort when dealing with LGBT elders and the issues they present is a key factor. Research indicates that many providers or staff who work in the aging industry (e.g., healthcare organizations, long-term care facilities, and other aging services) lack the education or training to enable them to care for LGBT elders because of LGBT issues in education and training curricula. For instance, a study that examined LGBT-related content in 150 undergraduate medical education programs in USA and Canada between 2009 and 2010 concluded that on average, five hours were devoted to LGBT issues. In addition, a large degree of variation existed across programs in terms of quantity and content covered, as well as perceptions regarding the quality of instruction received (Obedin-Maliver et al. 2011). In another study of social services in Michigan, Hughes et al. (2011) found that “perceptions of invisibility” make it difficult to recognize the concerns of LGBT elders and provide culturally appropriate services. These barriers have implications for the health of LGBT elders because they increase the likelihood of failure or delay in seeking health care, which in turn adversely affects overall health status and may result in poorer or negative health outcomes, as well as increased rates of premature need for institutional care. Institutionalized LGBT elders suffer additional challenges because many LTC staff such as social services directors, certified nursing assistants, and other caregivers lack adequate training in LGBT issues and concerns, in addition to homophobia and heterosexism (Bell et al. 2010).

Staff Training. LGBT older adults constitute a community despite the variations across these subgroups, as discussed previously. The increasing recognition that the needs of this community and its unique challenges must be addressed is evidenced by the statement attributed to Kathy Greenlee, Assistant Secretary of Aging, during the award of $900,000 for the development of a national resource center on LGBT aging in 2010 (SAGE 2010). In the same vein of recognition, reporting on the state of aging and health in the USA in 2013, the CDC issued a series of calls to action that included a call for communities, professionals, and individuals to address aging and health issues that affect the LGBT community (CDC—The State of Aging and Health in America 2013b). LGBT older adults have a shared culture that reflects their sexual minority status, history of marginalization, bias, prejudice and stigma, as well as health, social and economic disparities. This shared culture must be understood in order to appropriately address LGBT needs generally and is essential to ensuring that LGBT older adults have access to and receive relevant, quality health services in an inclusive, non-discriminatory fashion (National Resource Center on LGBT Aging 2012). To do so, professionals and staff of service agencies and organizations who work with LGBT older adults must learn to provide culturally competent care. Proper training of staff can help reduce or eliminate these barriers by providing sensitivity awareness to combat discrimination, as well as useful education and information to increase awareness of the particular health care and related social needs of LGBT elders.

According to the National Resource Center on LGBT Aging, cultural competence occurs when an organization has established systems and has trained staff members to identify and address the needs of LGBT elders (Meyer 2011). A variety of formats can be used for increasing awareness such as incorporation into medical school/training curricula, inclusion in licensure board examinations, on-the-job training using webinars, online self-paced learning with evaluations, as well as through continuing medical education (CMEs). In order to effectively care for LGBT elders, personnel in HCOs, LTC facilities, and other caregivers require cultural competency training.

The need for cultural competency extends to research (i.e., data collection) and to the clinical interview. Healthcare providers, researchers, and other individuals must be culturally competent when collecting data and conducting clinical interviews. Collecting LGBT data in clinical settings is extremely important step toward understanding the healthcare needs of LGBT persons and working toward reducing health disparities among this population, thus promoting health equity (Bradford et al. 2011). Unfortunately, patient information regarding sexual orientation and gender identity is often not collected or discussed with providers. The majority of providers do not know how to have discussions about sexual orientation and gender identity with their patients, which further contributes to the invisibility of LGBT patients in clinical settings and contributes to the lack of LGBT-inclusive cultural competency and clinical training for providers (Bradford et al. 2011).

Many societal and structural barriers still exist that prohibits the collection of data on sexual orientation and gender identity. For instance, structural barriers include poverty in LGBT communities (Badgett et al. 2013), lack of provider training to address the specific healthcare needs of LGBT people (Obedin-Maliver et al. 2011), low rates of health insurance coverage for LGBT individuals, and lack of access to culturally appropriate health care (Mayer et al. 2008). Anti-LGBT discrimination still continues to occur in healthcare settings, thus creating additional barriers to care. Surveys of both providers and patients indicate that LGBT people experience prejudicial treatment in clinical settings and that some providers maintain anti-LGBT attitudes (Lambda Legal 2010; Smith and Matthews 2007). Consequently, many LGBT individuals report culturally incompetent care, and as a result fail to seek health care because of fear of poor treatment (Bradford et al. 2011).

The Fenway Institute in Boston, Massachusetts, has suggested that information regarding sexual orientation and gender identity be collected in two ways: on the patient registration forms with demographic information and by having providers gather the information directly from patients (Bradford et al. 2011). LGBT individuals can be hesitant to provide information about the sexual orientation or gender identity due to fears about privacy and confidentiality. These fears are only made worse with the recent computerization of health information and highly publicized cases of breaches in confidentiality (Forsyth 2011). With proper techniques and standards, these threats are manageable. Providers should ask permission to include information about patients’ sexual orientation and gender identity in their medical record (Bradford et al. 2011). Patients should be assured that all information will be kept confidential and that the information will allow healthcare practitioners to provide comprehensive care.

The Fenway Institute has developed several suggestions on how to collect the necessary data. For example, the Fenway Institute suggests including the following question on intake forms: “Do you think of yourself as: lesbian, gay, or homosexual, straight or heterosexual, bisexual, something else, or do not know.” The Institute also suggests that providers ask questions directly of patients about sexual orientation, behavior, and gender identity during initial patient visits. Providers should start with open-ended questions, such as “Tell me a little bit about yourself” (Bradford et al. 2011). While sharing information about themselves, patients may bring up information about issues related to sexual orientation or gender identity, which may open the door for discussions. Healthcare settings can create an environment in which individuals might feel more comfortable discussing issues of sexual orientation and gender identity by conveying the message that LGBT people are welcome in the clinical setting (Bradford et al. 2011). For instance, posting a rainbow flag, the logo of the Gay and Lesbian Medical Association (Cahill and Valadez 2013), or including brochures and advertisements specifically for LGBT individuals can help to convey the messages that LGBT people are welcomed in a healthcare setting.

It is important to acknowledge that there is still a long way to go in improving the collection of data from LGBT individuals in healthcare settings. It is inevitable that some patients will not disclose information about sexual orientation or gender identity in clinical settings. However, collecting this information can improve health outcomes of LGBT patients, will help in advancing the understanding of LGBT health (Bradford et al. 2011), and enhance the delivery of culturally competent care.

See Experiential Learning Activity #2 in Appendix.

Health assessment procedures provide a useful mechanism for collecting data to help increase knowledge about issues, which affect the health of LGBT older adults. Appropriately designed and administered assessments provide data necessary to inform evidence-based practices that support the delivery of quality, patient-centered care. Such data are useful both to improve patient care as well as to improve our knowledge and understanding of factors that influence or impact the health status of LGBT older adults such as needs, disparities, barriers, both across the life course and as they age.

As discussed earlier, the fact that LGBT older adults have added health challenges and disparities related to their sexual minority status, obtaining information regarding the individual’s sexual orientation and gender identity, must be a key component of every health assessment conducted on all older adults. The importance of such data collection has been recognized by a number of entities such as the Institute of Medicine, which recommends that these data be included on electronic health records (IOM 2011). In Healthy People 2020, The US Department of Health and Human Services advocated that healthcare providers ask questions about and support the sexual orientation of patients in order to improve patient–provider interactions and enhance LGBT health (HHS 2010). In addition, Section 4302 of the Patient Protection and Affordable Care Act (ACA) encourages collection of this information in healthcare encounters (SAGE n.d. [c]).

Beyond demographic questions about sexual orientation and gender identity, health assessments should also cover other issues found to affect the health status and overall well-being of LGBT older adults. For example, providers should assess mental health and psychological well-being, with questions which address depression, anxiety, and substance abuse, as well as factors such as isolation, the presence of social supports, and delays or other barriers to seeking care or accessing services (Fredriksen-Goldsen et al. 2011). Collating this information will help document, elucidate, and develop best practices for enhancing the health of LGBT older adults (Gay and Lesbian Medical Association [GMLA] 2001). In addition to being a mechanism for data collection, the health assessment sets the stage for a healthcare encounter where LGBT older adults can be their “authentic selves” in an inclusive, safe, and supportive environment (National Resource Center on LGBT Aging n.d.).

See Experiential Learning Activity #3 in Appendix.

Globally, some countries are making great strides to recognizing same-sex couples, while other countries seem to be going in the opposite direction. In the USA, we are beginning to see a change, as evidenced by the number of states supporting same-sex unions. However, extreme challenges for same-sex couples remain. Regardless, the LGBT population is increasing as more individuals are coming out. As the aging population increases in number, we can expect a parallel increase in the number of LGBT older adults. The current paucity of LGBT research has negative implications for health care and services, hence the push for cultural competency training for healthcare providers. Obviously, research must catch up with LGBT aging issues. Research has to repsond to the demand for knowledge, as well as document current realities of LGBT older adults and project future needs. To begin, we need a better idea of the demographic scope of LGBT older adults and the perceived needs among this population. In addition, rather than treating LGBT as a homogenous group, we need research on the health disparities and needs of various subgroups within this population. Additionally, we should use the life course perspective to examine cohort differences among older adults in health care, particularly in light of current political shifts. In terms of research, we need research aimed at designing culturally appropriate preventative care for this population based on the information from current generations. Among healthcare providers, interventions should be developed and tested to increase knowledge regarding providing care to the LGBT population and the various subgroups and to increase cultural competence among providers.