Health, Economic, and Social Disparities among Lesbian, Gay, Bisexual, and Sexually Diverse Adults: Results from a Population-Based Study.

We investigated health, economic, and social disparities among lesbian, gay, bisexual, and sexually diverse adults, 18 years and older. Analyzing 2011-2019 Washington State Behavioral Risk Factor Surveillance System (N = 109,527), we estimated and compared the prevalence rates of background characteristics, economic and social indicators, health outcomes, chronic conditions, health care access, health behaviors, and preventive care by gender and sexual identity. Sexual minority adults reported heightened risks of poor general health, physical and mental health, disability, subjective cognitive decline, and financial barriers to health care, compared with their straight counterparts. Economic disparities and disability were evident for lesbians and both bisexual adult women and men. We found higher rates of smoking and excessive drinking among lesbians and bisexual women, and higher rates of smoking and living alone among gay men. Sexually diverse adults experience disparities in health care access. This study is one of the first to identify disparities among sexually diverse populations, in addition to lesbian, gay, and bisexual adults. More research is required to understand the mechanisms of disparities within these groups to address their distinct intervention needs.

Health, economic and social disparities among transgender women, transgender men and transgender nonbinary adults: Results from a population-based study.

We investigated health, economic, and social disparities among transgender adults (transgender women, men, and nonbinary) aged 18 years and older. Using population-based data from the Washington State Behavioral Risk Factor Surveillance System (WA-BRFSS), we pooled 2016 through 2019 data (n = 47,894). We estimated weighted distributions and prevalence by gender identity for background characteristics, economic, social and health indicators. We performed regressions of these indicators on gender identity, including transgender versus cisgender adults and transgender nonbinary adults compared to cisgender adults, followed by subgroup analyses: transgender women and men compared to each cisgender group and to one another, adjusting for covariates. Compared to cisgender adults, transgender adults overall were significantly younger and lower income with less education; more likely single with fewer children; and had several elevated health risks, including poor physical and mental health, and higher rates of chronic conditions and disability. Alternatively, transgender men and women had higher rates of flu vaccination than cisgender men. Between transgender subgroups, transgender men and transgender nonbinary adults were younger than transgender women; transgender men were significantly less likely married or partnered than transgender women; and, transgender women were more likely to live alone than nonbinary respondents. This is one of the first population-based studies to examine both between and within subgroup disparities among cisgender, transgender binary, and transgender nonbinary adults, revealing patterns of inequities across subgroups. More research understanding the mechanisms of these disparities and the development of targeted interventions is needed to address the unique needs of subgroups of transgender people.

Utilization of Recommended Preventive Health Screenings Between Transgender and Cisgender Older Adults in Sexual and Gender Minority Communities.

ObjectivesTransgender older adults are among the most health disparate populations in the United States; they also face some of the most significant barriers in accessing high quality, affordable, preventive healthcare services. We compare utilization rates of eight recommended preventive health screenings for adults aged 50 and older, by gender identity. Methods: We analyzed data from 2514 lesbian, gay, bisexual, and transgender adults aged 50 and older, testing associations between gender identities and screening service utilizations by applying a series of multivariate logistic regression analyses, controlling for sociodemographics. Results: Compared to cisgender LGB participants, transgender participants had significantly lower odds to have met four of the recommended screenings. Transgender men had significantly lower odds than transgender women to have met two of the recommended screenings. Discussion: Increasing transgender older adults' access to preventative health screening tests is critical to reduce the health burden in this aging population.

Accounting for HIV Health Disparities: Risk and Protective Factors Among Older Gay and Bisexual Men.

Objective: This study examines whether disparities exist in poor health and depressive symptomatology among older gay/bisexual men (50+) with (n = 371) and without (n = 973) HIV. If so, what risk/promoting factors account for those disparities? Method: These cross-sectional analyses used 2014 data from the Aging With Pride: National Health, Aging, and Sexuality/Gender Study. Results: Those with HIV reported poorer health and more depressive symptomatology accounted for by lower income, resilience and social support, and more lifetime victimization. Poorer health among those with HIV was associated with more chronic conditions. Higher depressive symptomatology was associated with diagnosed anxiety and drug addiction. Community engagement reduced disparities in poor health and depression. Implications: Older gay/bisexual men living with HIV infection are at greater risk for physical and mental health issues. Assessments should be conducted with attention to these risk factors. Interventions for improving social support, resilience, and community engagement are warranted.

Are Sexual Minorities Less Likely to Participate in Surveys? An Examination of Proxy Nonresponse Measures and Associated Biases with Sexual Orientation in a Population-Based Health Survey.

One of the implicit assumptions in survey research is lower response rates by sexual minorities than non-minorities. With rapidly changing public attitudes towards same-sex marriage, we reconsider this assumption. We used data from the 2013 and 2014 National Health Interview Survey (NHIS) that include contact history data for all sample families (n=117,589) as well as sexual orientation information about adults sampled from responding families (n=71,110). We created proxy nonresponse indicators based on contact efforts and reluctance from contact history data and linked them to sexual orientation of the sample adult and simulated nonresponse. The data did not support the assumption: straight adults were more difficult to get cooperation from than non-straights. With female sexual minorities showing higher nonresponse than the male counterpart, special considerations are required. Replication analyses may provide insights into what factors influence study participation decisions, which will inform how nonresponse may impact the accuracy of research findings.

Plan of Action for Real-World Translation of LGBTQ Health and Aging Research.

Despite accumulating evidence of health disparities, there exists limited translational research to enhance optimal health and aging of lesbian, gay, bisexual, transgender, and queer-identified * (LGBTQ) older adults. Based on the Health Equity Promotion Model that addresses the distinct needs and strengths of LGBTQ older adults, we underscore the important role of collaborations among researchers, practitioners, and communities to build community capacity. Given the rapidly shifting context, we advance principles to guide future work that will enhance translational research and the development of evidence-based practice so that LGBTQ older adults can reach their full health potential.

Chronic Health Conditions and Key Health Indicators Among Lesbian, Gay, and Bisexual Older US Adults, 2013-2014.

OBJECTIVES: To examine disparities in chronic conditions and health indicators among lesbian, gay, and bisexual (LGB) adults aged 50 years or older in the United States. METHODS: We used data from the 2013 and 2014 National Health Interview Survey to compare disparities in chronic conditions, health outcomes and behaviors, health care access, and preventive health care by sexual orientation and gender. RESULTS: LGB older adults were significantly more likely than heterosexual older adults to have a weakened immune system and low back or neck pain. In addition, sexual minority older women were more likely than their heterosexual counterparts to report having arthritis, asthma, a heart attack, a stroke, a higher number of chronic conditions, and poor general health. Sexual minority older men were more likely to report having angina pectoris or cancer. Rates of disability and mental distress were higher among LGB older adults. CONCLUSIONS: At substantial cost to society, many disparities in chronic conditions, disability, and mental distress observed in younger LGB adults persist, whereas others, such as cardiovascular disease risks, present in later life. Interventions are needed to maximize LGB health.

The Unfolding of LGBT Lives: Key Events Associated With Health and Well-being in Later Life.

PURPOSE OF THE STUDY: Life events are associated with the health and well-being of older adults. Using the Health Equity Promotion Model, this article explores historical and environmental context as it frames life experiences and adaptation of lesbian, gay, bisexual, and transgender (LGBT) older adults. DESIGN AND METHODS: This was the largest study to date of LGBT older adults to identify life events related to identity development, work, and kin relationships and their associations with health and quality of life (QOL). Using latent profile analysis (LPA), clusters of life events were identified and associations between life event clusters were tested. RESULTS: On average, LGBT older adults first disclosed their identities in their 20s; many experienced job-related discrimination. More had been in opposite-sex marriage than in same-sex marriage. Four clusters emerged: "Retired Survivors" were the oldest and one of the most prevalent groups; "Midlife Bloomers" first disclosed their LGBT identities in mid-40s, on average; "Beleaguered At-Risk" had high rates of job-related discrimination and few social resources; and "Visibly Resourced" had a high degree of identity visibility and were socially and economically advantaged. Clusters differed significantly in mental and physical health and QOL, with the Visibly Resourced faring best and Beleaguered At-Risk faring worst on most indicators; Retired Survivors and Midlife Bloomers showed similar health and QOL. IMPLICATIONS: Historical and environmental contexts frame normative and non-normative life events. Future research will benefit from the use of longitudinal data and an assessment of timing and sequencing of key life events in the lives of LGBT older adults.

Race/Ethnicity and Health-Related Quality of Life Among LGBT Older Adults.

PURPOSE OF THE STUDY: Few existing studies have addressed racial/ethnic differences in the health and quality of life of lesbian, gay, bisexual, and transgender (LGBT) older adults. Guided by the Health Equity Promotion Model, this study examines health-promoting and health risk factors that contribute to racial/ethnic health disparities among LGBT adults aged 50 and older. DESIGN AND METHODS: We utilized weighted survey data from Aging with Pride: National Health, Aging, and Sexuality/Gender Study. By applying multiple mediator models, we analyzed the indirect effects of race/ethnicity on health-related quality of life (HRQOL) via demographics, lifetime LGBT-related discrimination, and victimization, and socioeconomic, identity-related, spiritual, and social resources. RESULTS: Although African Americans and Hispanics, compared with non-Hispanic Whites, reported lower physical HRQOL and comparable psychological HRQOL, indirect pathways between race/ethnicity and HRQOL were observed. African Americans and Hispanics had lower income, educational attainment, identity affirmation, and social support, which were associated with a decrease in physical and psychological HRQOL. African Americans had higher lifetime LGBT-related discrimination, which was linked to a decrease in their physical and psychological HRQOL. African Americans and Hispanics had higher spirituality, which was associated with an increase in psychological HRQOL. IMPLICATIONS: Findings illustrate the importance of identifying both health-promoting and health risk factors to understand ways to maximize the health potential of racially and ethnically diverse LGBT older adults. Interventions aimed at health equity should be tailored to bolster identity affirmation and social networks of LGBT older adults of color and to support strengths, including spiritual resources.

Who Says I Do: The Changing Context of Marriage and Health and Quality of Life for LGBT Older Adults.

PURPOSE OF THE STUDY: Until recently, lesbian, gay, bisexual, and transgender (LGBT) adults were excluded from full participation in civil marriage. The purpose of this study is to examine how legal marriage and relationship status are associated with health-promoting and at-risk factors, health, and quality of life of LGBT adults aged 50 and older. DESIGN AND METHODS: We utilized weighted survey data from Aging with Pride: National Health, Aging, and Sexuality/Gender Study (NHAS) participants who resided in states with legalized same-sex marriage in 2014 (N = 1,821). Multinomial logistic regression was conducted to examine differences by relationship status (legally married, unmarried partnered, single) in economic and social resources; LGBT contextual and identity factors; health; and quality of life. RESULTS: We found 24% were legally married, and 26% unmarried partnered; one-half were single. Those legally married reported better quality of life and more economic and social resources than unmarried partnered; physical health indicators were similar between legally married and unmarried partnered. Those single reported poorer health and fewer resources than legally married and unmarried partnered. Among women, being legally married was associated with more LGBT microaggressions. IMPLICATIONS: LGBT older adults, and practitioners serving them, should become educated about how legal same-sex marriage interfaces with the context of LGBT older adults' lives, and policies and protections related to age and sexual and gender identity. Longitudinal research is needed to understand factors contributing to decisions to marry, including short- and long-term economic, social, and health outcomes associated with legal marriage among LGBT older adults.

The Cascading Effects of Marginalization and Pathways of Resilience in Attaining Good Health Among LGBT Older Adults.

PURPOSE OF THE STUDY: Lesbian, gay, bisexual, and transgender (LGBT) older adults comprise a diverse and growing health disparate population. In the present study, using the Health Equity Promotion Model, we investigated pathways by which LGBT older adults experience resilience, risk, and marginalization and their relationship to attaining positive health outcomes. DESIGN AND METHODS: Aging with Pride: National Health, Aging, and Sexuality/Gender Study (NHAS) is the first longitudinal research project designed to examine the health, aging, and well-being of LGBT adults aged 50 and older. Using data from 2014 (N = 2,415), we tested a structural equation model linking lifetime marginalization, identity affirmation and management, social and psychological resources, and health behaviors to positive health outcomes. RESULTS: Identity affirmation positively predicted social resources and mental health, and social resources positively predicted mental health. Marginalization was associated with fewer social resources for LGBT older adults with an open identity management style, lower identity affirmation for LGBT older adults who strategically concealed their sexual identity, and poorer mental health. Mental health was associated with better health behaviors, which in turn predicted positive physical health outcomes. IMPLICATIONS: Although a health disparate population, good health among LGBT older adults appears to be attained via multiple resilience and risk pathways. Providers must remain aware of the historical contexts in which LGBT older adults lived and the strengths they developed in order to understand their health and to develop tailored and targeted prevention and intervention services.

Disparities in Mental Health Quality of Life Between Hispanic and Non-Hispanic White LGB Midlife and Older Adults and the Influence of Lifetime Discrimination, Social Connectedness, Socioeconomic Status, and Perceived Stress.

We assessed factors contributing to ethnic and racial disparities in mental health quality of life (MHQOL) among lesbian, gay, and bisexual (LGB) midlife and older adults. We utilized cross-sectional survey data from a sample of non-Hispanic White and Hispanic LGB adults aged 50 and older. Structural equation modeling was used to test the indirect effect of ethnicity/race on MHQOL via explanatory factors including social connectedness, lifetime discrimination, socioeconomic status (SES), and perceived stress. Hispanics reported significantly lower levels of MHQOL, compared to non-Hispanic Whites. In the final model, the association between ethnicity/race and MHQOL was explained by higher levels of perceived stress related to lower SES, higher frequency of lifetime discrimination, and lack of social connectedness among Hispanic LGB adults. This study suggests that perceived stress related to social disadvantage and marginalization plays an important role in MHQOL disparities among Hispanic LGB midlife and older adults.

Health Equity and Aging of Bisexual Older Adults: Pathways of Risk and Resilience.

OBJECTIVES: Bisexual older adults are a growing yet largely invisible, underserved, and understudied population. Utilizing the Health Equity Promotion Model, we examined hypothesized mechanisms accounting for health disparities between bisexual older adults and lesbian and gay older adults. METHOD: Based on data from Caring and Aging with Pride, the largest national survey of LGBT older adults, this study (N = 2,463) utilized structural equation modeling to investigate direct and indirect associations between sexual identity (bisexual vs. lesbian and gay) and health via sexual identity factors (identity disclosure and internalized stigma), social resources, and socioeconomic status (SES). RESULTS: Bisexual older adults reported significantly poorer health compared with lesbian and gay older adults. Indirect effects involving sexual identity factors, social resources, and SES explained the association between bisexual identity and poorer health. A potentially protective pathway was also identified wherein bisexuals had larger social networks after adjusting for other factors. DISCUSSION: Bisexual older adults face distinct challenges and health risks relative to other older adults, likely because of the accumulation of socioeconomic and psychosocial disadvantages across the life course. Interventions taking into account older bisexuals' unique risk and protective factors may be helpful in reducing health inequities.

A Collaboration for Health and Wellness: GRIOT Circle and Caring and Aging with Pride.

Despite growing racial and ethnic diversity among lesbian, gay, bisexual, transgender, and queer (LGBTQ) older adults in the United States, LGBTQ older adults of color largely are invisible in aging services, research, and public policy. GRIOT Circle and Caring and Aging with Pride are pioneering efforts in community-based services and research. This article describes innovative and effective ways to reach and serve LGBTQ older adults of color, how research can be designed collaboratively to address strengths and disparities in social, health, and economic well-being, and barriers to accessing aging services in these populations.

Count me in: response to sexual orientation measures among older adults.

Health disparities exist among sexual minority older adults. Yet, health and aging surveys rarely include sexual orientation measures and when they do, they often exclude older adults from being asked about sexual orientation. This is the first population-based study to assess item nonresponse to sexual orientation measures by age and change over time. We compare response rates and examine time trends in response patterns using adjusted logistic regressions. Among adults aged 65 and older, the nonresponse rate on sexual orientation is lower than income. While older adults show higher nonresponse rates on sexual orientation than younger adults, the nonresponse rates have significantly decreased over time. By 2010, only 1.23% of older adults responded don't know/not sure, with 1.55% refusing to answer sexual orientation questions. Decisions to not ask sexual orientation among older adults must be reconsidered, given documented health disparities and rapidly changing social trends in the understanding of diverse sexualities.

The health equity promotion model: Reconceptualization of lesbian, gay, bisexual, and transgender (LGBT) health disparities.

National health initiatives emphasize the importance of eliminating health disparities among historically disadvantaged populations. Yet, few studies have examined the range of health outcomes among lesbian, gay, bisexual, and transgender (LGBT) people. To stimulate more inclusive research in the area, we present the Health Equity Promotion Model-a framework oriented toward LGBT people reaching their full mental and physical health potential that considers both positive and adverse health-related circumstances. The model highlights (a) heterogeneity and intersectionality within LGBT communities; (b) the influence of structural and environmental context; and (c) both health-promoting and adverse pathways that encompass behavioral, social, psychological, and biological processes. It also expands upon earlier conceptualizations of sexual minority health by integrating a life course development perspective within the health-promotion model. By explicating the important role of agency and resilience as well as the deleterious effect of social structures on health outcomes, it supports policy and social justice to advance health and well-being in these communities. Important directions for future research as well as implications for health-promotion interventions and policies are offered.

Health Disparities among LGBT Older Adults and the Role of Nonconscious Bias.

This paper describes the significance of key empirical findings from the recent and landmark study Caring and Aging with Pride: The National Health, Aging and Sexuality Study (with Karen I. Fredriksen-Goldsen as the principal investigator), on lesbian, gay, bisexual, and transgender aging and health disparities. We will illustrate these findings with select quotations from study participants and show how nonconscious bias (i.e., activation of negative stereotypes outside conscious awareness) in the clinical encounter and health care setting can threaten shared decision-making and perpetuate health disparities among LGBT older adults. We recognize that clinical ethicists are not immune from nonconscious bias but maintain that they are well situated to recognize bias and resulting injustice by virtue of their training. Further, we discuss how clinical ethicists can influence the organization's ethical culture and environment to improve the quality and acceptability of health care for LGBT older adults.