33. Disabilities and Chronic Illness Among LGBT Elders: Responses of Medicine, Public Health, Rehabilitation, and Social Work

Aging is frequently marked by chronic conditions and disability involving physical, psychological, and sensory disorders. Normal age-related changes occur within various body systems, affecting physiological, pharmacological, behavioral, and cognitive responses. The rate of disability is higher in the elderly population in comparison with the general population and disproportionately higher in LGBT elders than non-LGBT elders, with the highest rates among ethnic minorities (Espinoza 2011). A disability may be due to a developmental stage of the aging process, the result of an accident, environmental factors, lifestyle, or congenital factors. Although the prevalence of various disabilities gradually increases with advancing age, it starts to accelerate after age 70 and causes a growing need for assistance, especially after age 80 (Heikkinen 2003). However, most elderly persons report good health in the presence of chronic illness , in part because they may expect illness as a natural consequence of aging and therefore alter their definition of health (Fredriksen-Goldsen 2011). The purpose of this chapter is to discuss disabilities and chronic conditions that affect LGBT older adults. Information is presented on the definitions of disability and chronic illness; the status of aging, health, and disability; characteristics and challenges of chronic illness and disability among LGBT elders; targets for intervention; and health care and policy issues.

Individuals with adult or later onset of chronic illness or acquired disability (CIAD) tend to experience more adjustment difficulties than do those with early onset. It is hypothesized that those with early onset and longer duration have had more time to adjust to a disability. Individuals with CIAD are faced with significant changes in their social and familial relationships, vocational functions, and life roles while dealing concurrently with psychosocial distress, physical pain, loss of role identity and status, prolonged medical treatment, and gradually decreasing performance of self-care and daily activities (Bishop 2012; Falvo 2014). In addition, mental health plays an important role in physical health; poor mental health can increase risk of developing chronic health conditions or aggravate existing conditions (Fredriksen-Goldsen et al. 2011).

The prevalence of disability among LGBT elderly is approximately 50 % (Fredriksen-Goldsen et al. 2011; Fredriksen-Goldsen et al. 2013). Wallace et al. (2011) found that LGB adults aged 50–70 had higher rates of physical disability compared to their heterosexual counterparts. Further inspection of these results based on the gender reveals that about 31 % of lesbians and 24 % of gay men report a disability as defined as a condition that substantially limits one or more basic instrumental activities of daily living (IADL). Heikkinen (2003) asserts that on the one hand disability in old age has identified non-modifiable risk factors such as age, gender, and genetics. On the other hand, disability in old age has modifiable risk factors such as age-related diseases, impairments, functional limitations, poor coping strategies, sedentary lifestyles and other unhealthy behaviors, as well as social and environmental obstacles, many of which stem from earlier phases of life and the prevalent socioeconomic conditions. Moreover, diseases, particularly multiple chronic illnesses, are the main causes of old-age disability. LGBT elders with disabilities must also contend with ableism; like homophobia and transphobia, it is pervasive in society.

The information in this chapter is not intended to stereotype elders as sick, depressed, cognitively or physically impaired, or fragile. Nevertheless, because most elderly adults remain healthy throughout the aging process and reside in their homes (Zians 2011), many other older adults, especially LGBT elders, develop chronic conditions and disabilities that affect their health and successful aging. Successful aging is identified with three important components: (a) avoiding disease, (b) staying engaged in life, and (c) maintaining high cognitive and physical functioning (Zians 2011). Nevertheless, the literature is consistent in the acknowledgment that with increasing age comes increased likelihood of disability.

The term “successful aging,” which emphases that not all aging is negative, may inadvertently stigmatize older adults who have a disability (Chappell and Cooke 2010). Thus, Chappell and Cooke advance the notion of Kennedy and Minkler (1998), who argue that aging consists of both able bodies and disabled bodies and the notion of Zola (1993) that for individuals, disability “is not whether but when, not so much which one, but how many and in what combination” (p. 10). Disability is defined from various aspects including medical, vocational, and perceptual, and is interpreted from conceptual, legal, and cultural perspectives. In the broadest sense, disability refers to the functional limitations of activity that result from impairment (Falvo 2014). Conceptually, disability is not a condition that is inherent in the individual, but rather the result of the interaction between the person and the environment that imposes limitations on the person. The concept of disability has historical, social, legal, and philosophical influences on its interpretation (Disability World 2012). In some contexts, disability is considered a social phenomenon; however, the ability to carry out one’s roles in life is also a medical entity (Fried et al. 2004). Culturally, a person may not consider him or herself as having a disability because he or she is still able to perform many activities of self-care and maintain a certain level of social interaction.

In the USA, legally, disability is defined in Section 504 of the Rehabilitation Act of 1973 and the Americans with Disabilities Act of 1990 as (a) “a physical or mental impairment that substantially limits one or more of the major life activities of such individuals, (b) a record of such an impairment, or (c) being regarded as having such an impairment” (Colker 2005, p. 101). The World Health Organization (WHO) (2011) defines disability as an umbrella term, which covers impairments (i.e., a problem in body function or structure), activity limitations (i.e., a difficulty encountered in executing a task or action), and participation restrictions (i.e., a problem experienced in involvement in life situations). Although there is no universal international legal definition of disability (Degener 2006), increasingly, the global community is utilizing the International Classification of Impairments, Disabilities and Handicaps (ICIDH) definition of disability, which describes three dimensions: impairment, disability, and handicap in the context of health experience (see Table 33.1). A new version of ICIDH is currently being drafted and may be published simultaneously with the release of this book. The new ICIDH will allow for more specific recognition of the third dimension of disability, with renaming it “participation” and recognition of the critical role played by the environment or contextual factors in restricting fill participation of persons with disabilities (Disability World 2012).

Across the life span, disability is typically defined in terms of difficulties in one or more physical activities of daily living (PADLS) (e.g., bathing, dressing, feeding, and toileting) or in one or more IADLs (e.g., walking, housekeeping, shopping, using the phone, taking medication, climbing stairs, reaching, and lifting or carrying large objects) (Heikkinen 2003; Wallace et al. 2011). Loss of the ability to care for oneself appropriately results in further loss of independence and can lead to the need for care in an institutional setting (Centers for Disease Control and Prevention [CDC] 2013). Moreover, Heikkinen contends that the general pattern of an increase in disability with advancing age is fairly consistent across industrialized countries, even though there may be significant differences in the prevalence of particular disabilities and underlying factors.

Just as development is not static or finite, neither is disability. The effects of chronic illness and disability may differ depending on individual attributes and on different stages of development, impeding the development of certain skills associated with a particular stage of life. For example, for older adults, illness or disability can present physical or cognitive limitations in addition to those commonly associated with the aging process. An individual grows old gradually and does not suddenly become old when he or she turns age 60, 65, or 70 (Chappell and Cooke 2010). Disability is a process of continuous adaptation to changes across the life span (Sheets 2010). Eventually, disability limits autonomy, introduces dependence, reduces quality of life, and increases risk of assisted living or custodial care and premature death (Fried et al. 2004; Heikkinen 2003).

One of the essential functions to an individual’s everyday life is mobility. In fact, mobility is considered central to an understanding of health and well-being among older populations. Limited or lack of mobility significantly narrows an older person’s world and ability to do things that bring enjoyment and meaning to life (Centers for Disease Control and Prevention 2013). The physical environment offers the potential to assist an individual to intrinsic disability (i.e., ability to perform an activity regardless of context) through the removal or modification of environmental barriers. Thus, for persons with disabilities the goal is to enhance an individual’s actual ability (i.e., ability to perform an activity when supported by the physical or social environment) (Chappell and Cooke 2010; Verbrugge and Jette 1994). The challenge for many older adults with disabilities and chronic illness is that aging-in-place (remaining at home) may be compromised by environmental hazards and barriers, common in the homes of older adults (Chappell and Cooke). Table 33.2 identifies modifications often needed for older adults to remain at home as they age. In addition, fear of discrimination and stigma drives many LGBT elders to avoid services that might enable them to stay in their homes and avoid premature institutionalization (Funders for Lesbian and Gay Issues 2004).

Without traditional support systems that allow them to age-in-place, many LGBT elders end up relying on nursing homes or other facilities to provide long-term care (MAP and SAGE 2010).

Throughout the world, people are living longer, and their quality of life, to a large extent, is determined by their health status. Over the past century, a major shift occurred in the leading cause of death for all age groups, from infectious diseases and acute illnesses to chronic diseases and degenerative illnesses. Global estimates for disability are increasing due to population aging and the rapid spread of chronic diseases, as well as improvements in the methodologies used to measure disability (WHO 2011). Moreover, WHO (2011) suggests that disability is part of the human condition in which everyone will be temporarily or permanently impaired at some point in life. Persons who reach old age will experience increasing difficulties in functioning. Two out of every three older Americans have multiple chronic conditions and accounts for 66 % of the country’s healthcare budget (Centers for Diseases Control and Prevention 2013; National Institute on Aging [NIA], National Institutes of Health [NIH] 2011). The National Report on Healthy Aging reports on 15 indicators of older adult health, which are grouped into four areas: health status, health behaviors, preventive care and screening, and injuries. Eight of the 15 indicators are contained in Healthy People 2020. To date, the USA has met six of the Healthy People 2020 targets (i.e., leisure time physical activity, obesity, smoking, taking medications for high blood pressure, mammograms, and colorectal cancer screenings), with most states ahead of schedule on four health indicators for older adults (i.e., obesity, medications for high blood pressure, mammography, smoking), and with significant work to do on other indicators for older adults (i.e., flu vaccine, pneumonia) (Centers for Disease Control and Prevention). The Centers for Disease Control and Prevention identifies the areas where services are most needed for LGBT elders: housing, transportation, legal services, and chronic disease prevention.

Heart disease and cancer pose the greatest risks as people age, and for older adults, other chronic diseases and conditions including Alzheimer’s disease, diabetes, chronic lower respiratory, stroke, influenza, and pneumonia represent the major contributors to deaths (Centers for Disease Control and Prevention 2013; WHO 2011). Typically, older adults have multiple illnesses; the varied nature of these conditions requires intervention from multiple healthcare specialists, various treatment regimens, and prescription medications that may not be compatible. Because of these multiple conditions, older adults are at an increased risk for having conflicting medical advice, adverse drug effects, unnecessary and duplicative tests, and avoidable hospitalizations (Centers for Disease Control and Prevention).

Although disability correlates with disadvantage, not all persons with disabilities are equally disadvantaged. Women, the elderly, the poorest, and those with more severe impairments experience greater discrimination and barriers (WHO 2009, 2011). LGBT elders are represented consistently across these groups. The documentation of widespread evidence of barriers that are identified by WHO (2011) (see Table 33.3) for persons with disabilities parallels the barriers experienced by LGBT elders.

The status of aging, health, and disability discussed in this section is relevant to LGBT elders. In addition, LGBT older adults have complex outcomes for chronic illness and disabilities. The following section examines the occurrence of health and disability-related conditions that are specific to LGBT elders.

Physical disability occurs frequently in older adults and is “an outcome of diseases and physiological alterations with aging, with the impact of these underlying causes modified by social, economic, and behavioral factors as well as access to medical care” (Fried et al. 2004, p. 256). With the diversity of life span, health outcomes, and other individual variations among older persons, elders are frequently identified as vulnerable because of comorbidity (multiple chronic conditions), frailty, and disability. Fried et al. assert that these clinical entities are distinct but causally related in that both frailty and comorbidity predict disability , disability exacerbates frailty and comorbidity, and comorbid diseases may contribute, at least additively, to the development of frailty. No distinction is made between the older population and older LGBT adults for these clinical entities. Over two decades ago, Fine and Asch (1988) asserted that almost all research on adults with disabilities seemed to assume the irrelevance of sexual orientation and presume that having a disability eclipses social experience. To date the majority of research on aging and disability and chronic illness continues to ignore LGBT elders. For LGBT persons with disabilities, a disability is likened to living in the “second closet” (Benedetti 2011). Thus, only estimates of the full extent of LGBT health disparities are possible due to a consistent lack of data collection. The main areas of disparity are access to health care, HIV/AIDS, mental health, and chronic physical conditions (MAP and SAGE 2010).

Understanding chronic conditions and disability among LGBT elders is increasingly important for several reasons: (a) advances in medicine, public health, rehabilitation, and technology have increased life expectancy for persons with disabilities; (b) LGBT elders have limited access to culturally sensitive and LGBT-affirmative service; (c) older adults are remaining in the workforce longer; (d) LGBT elders are among the poorest of the poor, especially women; (e) LGBT elders have higher rates of health disparities; and (f) quality of life is compounded by the intersection of age, sexual orientation or gender identity, and disability (Harley 2015). Increasing numbers of older adults living to reach old age (including LGBT elders) have changed the demographics of disability (Sheets 2010). The case of Gloria below is an illustration of a lesbian who acquired a disability earlier in life and additional chronic illness es as she aged.

LGBT older adults are at an elevated risk of disability and mental distress, with 31 % reporting depression and more than 53 % of transgender older adults at risk of both disability and depression. The rates of disability among LGBT elders are also distinguishable by gender, with sexual minority women’s health being significantly lower than men and heterosexual women. Older gay and bisexual men are more likely to experience poor physical health compared to heterosexual men. Bisexual men have significantly higher rates of cardiovascular disease than gay men. Transgender older adults are more likely than non-transgender older adults to have obesity, cardiovascular disease, asthma, and diabetes. Lesbians and bisexual women have similar rates of vision, hearing, and dental impairments; bisexual men have more vision impairments than gay men, and transgender older adults have more sensory and dental impairments than their non-transgender counterparts. Older lesbians are significantly more likely to engage in heavy drinking as compared to older bisexual women (Fredriksen-Goldsen 2011; Fredriksen-Goldsen et al. 2011).

In a study of disparities and resilience among LGBT older adults, Fredriksen-Goldsen et al. found that 41 % of the participants in the project had limitations in their physical activities as a result of physical, mental, or emotional problems. Of this percentage, 21 % were using adaptive equipment. An examination of the combination of LGBT older adults with limits in physical activities and the use of adaptive equipment reveals that 47 % have a disability, including 53 % of lesbians, 51 % of bisexual women, 41 % of gay men, 54 % of bisexual men, and 62 % of transgender older adults. Collectively, LGBT elders have diagnoses of high pretension (45 %), high cholesterol (43 %), arthritis (35 %), cataracts (22 %), asthma (16 %), diabetes (15 %), hepatitis (11 %), and osteoporosis (10 %). It is unknown if the rate of Alzheimer’s disease among LGBT elders is different than the general elderly population.

The American Community Survey (ACS) is a general household survey conducted by the US Census Bureau and is designed to provide communities with reliable and timely demographic, economic, and housing information. An examination of ACS (Population Association of America 2014) data, from the 2009–2011, reveals that the prevalence of disability among older adults in same-sex relationships varies by gender and relationship type, and by type of disability . Overall, 17.5 % of older men in same-sex relationships were living with a disability compared to 20.8 % of married men and 21.5 % of unmarried men in opposite-sex relationships. Men in same-sex relationships were less likely to report difficulty in cognitive, ambulatory, self-care, and sensory functions compared to married and unmarried men in opposite-sex relationships. However, men in same-sex relationships were slightly more likely to report difficulties with independent living. On the other hand, women in same-sex relationships reported higher levels of almost all disability types compared to their married and unmarried counterparts in opposite-sex relationships, including any disability and difficulty in ambulatory, self-care, sensory, and independent living functions. The prevalence of cognitive difficulty for women in same-sex relationships was less than that of women in unmarried opposite-sex relationships, but more than that of women in married opposite-sex relationships. In summary, these data provide evidence of national disparities in disability between older adults in same-sex relationships compared to older adults in opposite-sex relationships. And, this relationship is especially strong and consistent for women (Populations Association of America).

Overall, mental health of LGBT elders is good (70.8 on a scale of 0 = very poor to 100 = excellent). In rating satisfaction with their life, lesbians report (71.8), bisexual women (65.6), gay men (71.7), bisexual men (65.6), and transgender older adults (62.7). Thirty-one percent of LGBT elders report some type of depressive symptoms, with 53 % having been told by a doctor that they have depression. Transgender older adults have the highest rate of depression (48 %), and lesbians (27 %) and gay men (29 %) have the lowest, and 24 % of LGBT older adults have been told they have anxiety (Fredriksen-Goldsen et al. 2011). Two of the most alarming mental health issues for LGBT elder are loneliness and social isolation (see Chap. 30). Both of these issues can lead to negative health consequences or be the result of chronic illness and disability . Older bisexual women and men exhibit higher rates of loneness than lesbians and gay men. The rates of neglect experienced by LGBT elders are similar to the general elderly population, and their rates of mistreatment tend to be higher (see Chaps. 16, 17, and 21 in this text). Across the categories of physical and mental health, transgender older adults fair worst than other LGB elders. The prevalence of physical and mental health problems is elevated among LGBT elders even taking into account differences in age distribution, income, and education; however, those LGBT elders with lower incomes and lower education are at more heightened risk (Fredriksen-Goldsen et al.).

Much of the sparse research that has been done on LGBT elders with disabilities has looked at either physical or mental disabilities. There is a clear lack of focus on LGBT older adults with developmental disabilities. This is especially disconcerting for two reasons. First, many persons with developmental disabilities have the same life expectancy as the general population. Second, while most people begin to experience the effects of aging in their 40s, some persons with a developmental disability may require a greater level of support at a younger age than the general population. The later reason requires more attention be given to factors associated with aging such as changes in social roles, activity levels, behavior patterns, and response to occurrences in the environment and health conditions (Connect Ability 2010). Some characteristics of aging may mask symptoms of a developmental disability and vice versa. For example, an older adult with Alzheimer’s may exhibit a lack of insight or an inability to articulate what he or she is experiencing, both of which are characteristic of cognitive impairment associated with a developmental disability and Alzheimer’s disease.

LGBT elders with disabilities and chronic conditions may find themselves facing issues of coming out or coming out again as needs for social services increase (Sue and Sue 2013). It is important for them to understand and be prepared for the potential negative responses they may receive as they complete the application process for services. For example, the answers that they provide on an application may inadvertently expose them to discrimination. Thus, LGBT elders’ application for services because of a disability may be overshadowed by a service provider’s preoccupation and bias with their sexual orientation or gender identity. Discussion Box 33.1 provides some examples of implications for practice.

Disability is complex, and the interventions to overcome the challenges associated with disability are multiple and systemic, varying with the context (WHO 2011). An area of critical concern for elders is affordable housing as they age-in-place. LGBT elders identify housing as the number one priority for action in a needs assessment conducted by Senior Action in a Gay Environment (SAGE) (Funders for Lesbian and Gay Issue 2004). Moreover, housing discrimination is of primary concern, including “trepidation” about mainstream senior housing options (Knauer 2009; National Gay and Lesbian Task Force 2006). Implicit in affordability is accessible housing that will allow elders to maintain independence, quality of life, and safety in terms of both the condition of the dwelling and residential location. The ability to obtain adequate and safe housing affects all aspects of life (e.g., employment, proximity to friends and family, access to services), and the relationship between housing and other aspects of everyday life is particularly important for older persons who may be more restricted because of their mobility, income, and support systems (Equal Rights Center 2014).

The Equal Rights Center (2014) conducted an investigation to determine the extent of adverse, differential treatment experienced by a senior seeking housing for oneself and a same-sex spouse. The study used matched pair testing (i.e., one LGB senior tester and one heterosexual senior tester) in 200 tests across 10 states. In 96 (48 %) of the 200 tests conducted, the LGB tester experienced at least one type of adverse, differential treatment as compared to the heterosexual tester with an opposite-sex spouse. The differential treatment was not as blatant as refusal or rejection by a housing provider. Instead, barriers to equal housing opportunity ranged from differences in availability, pricing, fees and costs, incentives to rent, amenities available, and application requirements. Sometimes, housing providers refused to recognize the same-sex couples, encouraging them to apply separately or restricting them from living together. More blatant cases of differential treatment include housing providers making degrading remarks, being less than inviting, or being hostile. Although this study did not include transgender persons, discrimination is also a widespread problem against them, regardless of their sexual orientation, which typically results in being denied a home or apartment, being evicted because of being transgender or gender non-conforming, and homelessness (Grant et al. 2011). Other studies found that gay or lesbian home seekers were subject to unfavorable treatment 27 % of the time (Michigan Fair Housing Centers 2007), and when emailing the same housing provider to inquire about housing availability, opposite-sex couples were more likely to receive a response than same-sex couples (Davis et al. 2013). See Chap. 21 for additional discussion on housing concerns of LGBT elders.

Many older adults with disabilities rely on assistive animals (e.g., service animals, support animals, assistance animals, therapy animals) to perform tasks or provide support that alleviates at least one of the functional limitations or effects of a disability. Persons with an assistive animal who are refused rental housing or required to pay an additional fee or deposit essentially deny persons with disabilities access to housing. Despite legal protection, persons who use assistive animals are frequently denied required accommodations (Equal Rights Center 2012). The Equal Rights Center found that housing providers or leasing agents either do not know the reasonable accommodation policies in place for their properties, or do not obtain and provide this information for a potential tenant with a disability on request.

Healthcare and Other Services. Often, providing healthcare services, counseling, and other social services to LGBT elders is challenging because of stigma and discrimination from service providers. According to the American Medical Association (2009), the failure of physicians to recognize patient’s sexual orientation and gender identity and patients non-disclosure can result in serious medical problems, inferior health care, or denial of appropriate services. The distribution of discrimination by service providers against LGBT elders is even more so against transgender elders. In a survey of 320 area agencies and state units on aging, Knochel et al. (2011) found that more than one in four reported that transgender older adults would either not be welcomed by local service providers or the agency was unsure of how welcome they would be. The Institute of Medicine (2011) verifies that major research gaps in transgender aging, elder abuse, substance abuse, risk and best practices for long-term hormone therapy, sexual health, and cancers as areas in which more transgender researches are needed. Often, both fear and reality of discrimination lead to underutilization of services (Tobin 2011). Table 33.4 contains examples of discrimination and victimization experienced by LGBT elders and that create obstacles to accessing and utilizing necessary health and social support services. In addition, racism affects the health and healthcare experiences of ethnic minority LGBT elders differently than their non-minority counterparts (see Chaps. 5–8, and 10 in this text). The combination of ageism and homophobia or transphobia serves to demean, devalue, and denigrate older LGBT adults and pathologize their lives. Furthermore, the discriminatory behavior of practitioners may result in inaccurately assessing LGBT elders presenting problems, refraining from providing appropriate services and referrals, increasing LGBT elders dependency on caregivers and service providers, and offering inappropriate treatments (Crisp et al. 2008).

Another area of critical concern for LGBT elders with disabilities is the need of support systems, both informal (e.g., family and friends) and formal (e.g., institutional care). Overreliance on informal support system often results in emotional stress, physical fatigue, and financial burden for those individuals. Reliance on institutional supports can result in increased dependency for LGBT elders. An overlapping and critical concern for LGBT elders with disabilities and chronic conditions is decision making about end-of-life issues (see Chap. 22). In the absence of a living will or healthcare directive, older LGBT adults may rely on members in their informal network to make decisions. These members may be denied access to an elder at the end of the life due to provisions in the Health Insurance Portability and Accountability Act (1996), one intention of which was to provide greater safeguards concerning medical records.

Most importantly, LGBT elders with disabilities and chronic conditions need to achieve recognition as a distinct minority group with needs unique from their heterosexual counterparts. The assumption of heterosexuality by service providers serves to not only relegate LGBT elders to secondary status because of age, disability , sexual orientation, and gender identity, but also to dismiss the reality that they exist. This belief informs the delivery of health care, social services, and social programs (Kimmel 2014). In fact Kimmel et al. (2015) use very explicit adjectives to describe the perceptual impact on LGBT elders by implicit heterosexual assumptions in various service arenas. These descriptions include how assumptions “limit” the language used in intake forms and communication, “prevent” discussion, “interfere” with, “preclude,” “marginalize,” and “alienate” LGBT seniors. In an effort to counteract these negative and aversive assumptions, the guidelines developed by The Joint Commission (2011) for hospitals and medical settings can be implemented by various human and social service entities (see Table 33.5).

The intent of identifying health disparities and other service needs of LGBT elders is to illuminate and define them in a way that advances the formulation of public policy and legislation (Gamble and Stone 2006). Too often, policies have discriminated against LGBT persons, failed to recognize them as deserving of equal protection under the law, and erected barriers to seeking and securing needed services for health and mental health. The overall objective of policy should be to decrease, eventually eliminate discriminatory practices, and level the playing field. The following section discusses policy implications for LGBT elders with disabilities.

Almost half of the LGBT elders over age 50 have a disability. LGBT elders are at an elevated risk of disability, chronic conditions, and mental distress. Some of the disabilities and chronic health conditions of LGBT elders are a result of the aging process and others are related to stressor experienced as a result of a lifetime of stigma and discrimination. Similar to other groups, LGBT elders possess both strengths and resilience and challenges and barriers that impact their health outcomes. Not all aging is negative. They must address the pervasiveness of ableism, homophobia, and transphobia. Certain health behaviors are more prevalent among older LGBT adults as compared to their heterosexual counterparts.

As a group, LGBT elders are one of the least understood in terms of their chronic health conditions and aging-related needs. The types of chronic conditions among LGBT elders vary according to gender. The severity of disability also affects the person’s level of independence, mobility, their ability to age-in-place, and social inclusion.

Overwhelmingly, research on adults with disabilities has not focused on LGBT elders. Understanding LGBT elders within the context of disability has implications for the development of services and programs and policy. LGBT elders with disabilities have different attributes and characteristics that interact with age than their differently able peers, and deserve no less than having their differing and unique needs understood and served.