1. Kristin J. Anderson, MD, MPH 4 January 2011

2. http://vimeo.com/6896301

3.  Defining/Finding the Population  Elders in America  LGBT Elders in America  Putting into Perspective  Barriers to Successful Aging  Health Disparities  Access to Healthcare  HIV/AIDS  Cancer  Chronic Disease  Mental Health  Resources  Recommendations for Further Learning Outline

4.  In 2010, 37.9M Americans were 65+ (12.6% population, 1:8 Americans)  21.9M women, 16M men  65-74yo: 51%  75-84yo: 34%  85+: 15%  In 2011 the baby boomers start turning 65  Between 2010-2030, the population of 65+ will nearly double to 72.1M (1:5 Americans)  Increasingly Diverse  2010, 20% Elders are people of color  By 2030, 28% people of color (11% Hispanic, 10% Black, 5% Asian)  Living on Limited Incomes  Older women higher poverty rate (12%) than men (6.6%)  Elders living alone or with nonrelatives, more likely to be poor (17.8% ) compared to those living with families (5.6%)  Of Elderly: 1:14 Whites, 1:4 Black, 1:6 Hispanic, 1:10 Asian are poor

5. The Urban Institute, 2003 Where to find your elderly LGBT patients…

6.  Despite extensive data on elders, there are only handful of state and federal demographic and health surveys on LGBT elders  Most data is qualitative, or extrapolated from limited samples  Most data from social science research is based on white gay men, smaller number on lesbians.  Very few studies on transgender or bisexual elders  How many LGBT elders are there?  Current estimates of LGBT community is 5-10% of the population  In US, est that in 2010: approx 2M, but in 2030: 7M+

7.  Like all older adult populations, the LGBT community is not homogenous. Differences in:  Generational. A 60yo LGBT person is very different than a 90yo LGBT person  In or Out. Some LGBT are out about their sexual orientation or gender identity and others are not.  Location. LGBT older people live in urban settings, rural settings, small towns and suburban communities  Multiple Identities. Race, ethnicity, gender and other factors create even more differences within the LGBT community  Family ties. Having a partner and/or children is different than living alone* “Researchers in the field of aging often note that people age as they have lived. LGBT elder resilience will vary greatly relative to the challenges these older adults have faced and depending on the resources to which they have had access across the lifespan and across cultures.” (OutingAge2010, pg 29) *LGBT Aging: What Makes it Different? Oct 2009.

8.  A 90 year-old gay Jewish man would have been 25 at the end of World War II. He survived the camps because he wore the yellow rather than the pink triangle.  A 75 year-old Cuban-American would have been 24 when Castro came to power, and shortly thereafter would be putting homosexuals into labor camps.  A 73 year-old lesbian would have been 32 when Betty Friedan announced that the National Organization for Women was being threatened by a “lavender menace.”  A 70 year-old black gay man would have been 39 when the March on Washington took place. He may have known that the organizer of the event, Bayard Rustin, was an openly gay man hounded out of the movement’s leadership by Adam Clayton Powell.  A 65 year-old bisexual Vietnam Vet going into the VA for treatment would have been 48 when President Clinton implemented the “Don’t Ask, Don’t Tell” policy.

9. LGBT seniors are:  Less likely to be connected to biological family  Less likely to have children (4x less likely)  More likely to live alone (2x as likely)  Less likely to reach out to mainstream services Barriers to Successful Aging

10. Improving the Lives of LGBT Older Adults. March 2010

11. The Social Security benefits denied to LGBT elders include the “spousal benefit,” the “survivor benefit” and the “death benefit.” Improving the Lives of LGBT Older Adults. March 2010

12. “The largely unspoken but widely held assumption that elders are sexually inactive, heterosexual, and monogamously coupled or widowed does a disservice to all older adults – but it places LGBT elders at perhaps the greatest risk for neglect, discrimination and abuse.” Health Disparities

13.  Particular concern under age 65, before Medicare benefit  Few providers trained/experienced in LGBT-specific healthcare, with Medicare, provider choice is limited  “Don’t Ask, Don’t Tell”- did not prohibit LGBT elders from accessing Veterans health benefits- however policy may have led to fear of discrimination with disclosure  Partner benefits under state same-sex marriage/civil union laws must pay federal taxes on insurance premiums because not recognized under federal law.  Costs the average LGBT employee $1,069/yr  Employers pay $57M in additional payroll taxes

14.  LGBT Elders grew up during era where homosexuality routinely stigmatized as an illness requiring intervention  National Transgender Discrimination Study, 2009  25% of 65+yo reported delay or avoiding needed medical care because of disrespect or discrimination  LGBT people have low-levels of self-disclosure of sexual orientation and sexual behaviors.  Statistics that 75% of LGBT elders said they were not completely open about their sexual orientation to health care workers* “widespread presumption that all elders are heterosexual as a matter of identity and asexual as a matter or practice.”** *No Need to Fear, No Need to Hide, SAGE. 2004 **OutingAge2010, pg 72.

15.  New HIV diagnoses in people over 50yo is on the rise  15% of newly diagnosed people are 50+  Additionally, HAART has increased life expectancy. In the US:  29% HIV+ are 50+yo (*double that of people < 24yo)  70% HIV+ are 40+yo  Older adults at risk for long-term effects of HAART: increased risk and earlier onset of cognitive decline, kidney failure, depression, cancer, & osteoporosis  Almost no HIV prevention programs targeted to older adults, risks not often discussed with healthcare providers  Infection rate in older adults likely to be severely underreported  Lack of attention reflected in 2006 CDC guidelines which recommends routine testing for HIV in persons only up through age 64

16.  Some LGBT populations are at increased risk for certain cancers  One risk factor: higher rates of smoking among LGBT populations  Lesbians seek routine breast and cervical cancer screening less often than heterosexual women  Lesbians and providers may underestimate risk factors of cervical cancer  Increased risk of anal cancer for MSM  HIV+ persons: increase risk of Kaposi’s sarcoma, non-Hodgkin’s lymphoma, and HPV-related cancers  Transgender individuals with retained pre-transition organs require careful follow-up (prostate, breast, cervical, ovarian CA)

17.  No significant evidence of higher levels of chronic disease among LGBT people, however: higher rates of risk factors including: smoking, drinking, drug use, and obesity  A San Francisco study found LGBT people age 50+ reporting problems such as asthma and diabetes at rates usually found among people a decade older (perhaps related to higher rates risk factors, as above).  Little is known about aging transgender people. Some concern of:  Higher risk of DM from hormone therapy  High rates of PCOS and strokes among transgender men  HTN risk and blood clots in transgender women using progesterone and estrogen.

18.  Until 1973, the American Psychiatric Association classified homosexuality as a mental illness  “Gender Identity Disorder” is still in the DSM-4  No surprise that LGBT elders struggle with mental health problems as a result of many years of discrimination, violence, isolation and enforced social invisibility  Inherent distrust in mental health system  Studies of substance abuse focused on younger people, effects for elders not yet well studied  However, ONE report on LGBT baby boomers, MetLife 2010, found 38% respondents said they have developed positive character traits/greater resilience as a consequence of being gay…

19.  LGBT elders’ health disparities are overlooked and ignored. Governments and service providers rarely track, and are largely unaware of, the health disparities of LGBT elders.*  There is limited government and social support for families of choice. Family-of-choice caregivers do not receive the same legal or social recognition  Health care environments often are inhospitable to LGBT elders  Nursing homes often fail to protect LGBT elders.  Visitation policies and medical decision-making laws often exclude families of choice. *This is changing!

20.  Increase funding for and provision of LGBT Elder Programs  Provide Immediate Access to Volunteer-Based Care  Provide Education, Tools, and Legal Services to LGBT Elders  Create and Support Advocacy Infrastructure  Build a Strong Coalition of Allies  Advocate for Greater Research on LGBT Older Adults  Create a National Public Discussion about LGBT Aging Issues Improving the Lives of LGBT Older Adults. March 2010 Broad Recommendations for Change *

21.  There is a large and underserved population of LGBT Elders  They are your patients- become informed  There is a need for more research, more programs, more policy changes… and these are in the works Take Home Points

22. Websites  SAGE (Services and Advocacy for Gay Elders)  www.sage.org  National Resource Center on LGBT Aging  www.lgbtagingcenter.org  OLOC (Old Lesbians Organizing for Change)  www.oloc.org  National Coalition for LGBT Health  www.lgbthealth.net  Transgender Aging Network  www.forge-forward.org/tan  Lamda Legal  www.lambdalegal.org Films  Edie and Thea: A Very Long Engagement, 2009  Gen Silent, directed by Stu Maddox, 2010 http://www.youtube.com/watch?v=lL83Yl4-9Vc

23.  Improving the Lives of LGBT Older Adults. March 2010  Grant, Jaime M. Outing Age 2010: Public Policy Issues Affecting Lesbian, Gay, Bisexual and Transgender Elders. National Gay and Lesbian Task Force Policy Institute.  LGBT Aging: What Makes it Different? A Training Cufficulum from the New York State Health & Human Services network, compiled and edited by SAGE. Oct 2009.  Still Out, Still Aging: The MetLife Study of Lesbian, Gay, Bisexual, and Transgender Baby Boomers. March 2010.  Healthy People 2020. www.healthypeople.gov/2020www.healthypeople.gov/2020  Mayer, et al. “Sexual and Gender Minority Health: What We Know and What Needs to Be Done.” American Journal of Public Health. 98. (2008): 989-995.