Grey and Gay

1. Grey and Gay A Discussion of Determinants of Health and Health Disparities of LGBT Elders Kristin J. Anderson, MD, MPH 21 January 2014

2. A Documentary Film by Stu Maddox2010 http://vimeo.com/6896301

3. Grey and GAY • Defining/Finding the Population • Elders in America • LGBT Elders in America • Health Disparities • Barriers to Successful Aging • Access to Healthcare • Life After the Downfall of DOMA • Disease Specific • HIV/AIDS • Cancer • Chronic Disease • Mental Health • Resources- National, State & Local • Recommendations for Further Learning… Outline

4. Elders in America • In 2010, 37.9M Americans were 65+ (12.6% population, 1:8 Americans) • Between 2010-2030 , the population of 65+ will nearly double to 72.1M (1:5 Americans)

5. LGBT Elders in America • How many LGBT elders are there? • Current estimates of LGBT community is 5-10% of the general population • Approx 9M persons ( = the population of NJ) • In US, estimated number of LGBT elders: • 2010: approx 2 million • 2030: 7M+

6. LGBT Elders in America Where do you find your elderly LGBT patients? Gates, Gary. The Urban Institute, 2003

7. LGBT Elders in America • Limited state and federal demographic and health surveys • Of 3.8M citations in National Library of Medicine between 1980-1999, only 0.1% related to gay or transgender issues • 61% of these articles were disease-specific, mostly focused on STDs/HIV • 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

8. What is the Typical LGBT Older Person Like? • Like all older adult populations, the LGBT community is not homogenous. • Differences: generational, “in” or “out”, geographical, family ties, multiple identities… “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.

9. Health Disparities Grey and GAY -Outing Age 2010, National Gay & Lesbian Task Force Policy Instititute

10. “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.” Grey and GAY -Outing Age 2010, National Gay & Lesbian Task Force Policy Instititute

11. LGBT Health Disparities • A result of a cumulative impact of many factors: • Barriers to Successful Aging • Reduced Financial Security • Healthcare Access • Lack of Insurance • Social Stigmas • Lack of cultural competence

12. Barriers to Successful Aging

13. Barriers to Successful Aging 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) • 5x less likely to access mainstream senior services

14. Barriers to Successful Aging • The effects of stigma- past and present • LGBT elders came of age in an era when homosexuality was on the DSM list of mental health disorders, and individuals were openly persecuted and institutionally discriminated against • Reliance on informal “families of choice” who lack social and legal recognition • Unequal treatment under laws and programs for older adults • = Reduced financial security Improving the Lives of LGBT Older Adults. March 2010

15. Reduced Financial Security 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

16. Changing Financial Security…with the downfall of DOMA

17. Changing Financial Security…with the downfall of DOMA • Gay and Lesbian Advocates & Defenders (glad.org), published collection of fact sheets outlining changes in regard to: • Benefits & Protections for Civil Federal Employees & their Spouses • FLMA Leave act for non-federal employees • Federal Taxes • Medicaid • Medicare Spousal Protections • Military Spousal benefits • Veteran’s Spousal benefits • Immigration http://www.glad.org/current/post/after-doma-fact-sheets

18. Healthcare Access Lack of Insurance • 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 • Reduced access to employer-provided health insurance • Partner benefitsunder 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 • 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 • Reduced access to employer-provided health insurance • Partner benefitsunder 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

19. Healthcare Access Lack of Insurance • This is changing! http://strongfamiliesmovement.org/lgbt-health-care-guide

20. Healthcare Access Fear of Stigma • 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/avoiding medical care because of disrespect or discrimination

21. Healthcare Access Fear of Stigma • 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 of practice.”** *No Need to Fear, No Need to Hide, SAGE. 2004 **OutingAge2010, pg 72.

22. Healthcare Access Fear of Stigma • “Disparities and Resilience among Lesbian, Gay, Bisexual and Transgender Older Adults” (Fredrickson-Goldsen, 2012) • > 20% of LGBT older adults do not disclose their sexual orientation or gender identity to their physician • Of those surveyed: • 68% experienced verbal harassment • 43% experienced physical violence • >50% identified assisted living, referral services, in-home health services, meals delivered to home, short-term help for caregivers, and fitness and exercise programs as needed services

23. Healthcare Access Cultural Competence • Stigma → Nondisclosure → Ignorance • Lack of data and studies on LGBT persons, particularly elderly • Recent studies indicate nearly ½ of all medical schools have no training on LGBT care in their curriculum Krehely, Jeff. “How to Close the LGBT Health Disparities Gap” Center for American Progress. Dec 21,2009.

24. Healthcare Access Cultural Competence • “Improving the lives of LGBT Older Adults” (SAGE and MAP, 2010) • < 50% of lesbian and gay Boomers were strongly confident that health care professionals would treat them with dignity and respect • 12% have no confidence that they will be treated with respect and dignity

25. Healthcare Access Cultural Competence • 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.* • 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!

26. Healthcare AccessImproving CulturalCompetence • Discrimination in health care settings • Nov 2010- Hospital Visitation Rule : • For Medicare- and Medicaid-participating hospitals dictates patients’ right to choose their own visitors during a hospital stay, including a visitor who is a same-sex domestic partner • Summer, 2013: • Further clarification that this rule applied to all long term care facilities accepting Medicare/Medicaid • Development of cultural competency curricula • HRSA-funded HEALE (Health Education About LGBT Elders) nursing curriculum • National Resource Center on LGBT Aging

27. Disease-Specific Health Discrepancies • HIV/AIDS • Cancer • Chronic Disease • Mental Health

28. HIV/AIDS

29. HIV/AIDS • Increase in new HIV dx in persons 50+ • 15% of new dx are 50+ • HAART has increased life expectancy • By 2015 50% of all HIV+ in the US will be 50+

30. HIV/AIDS • Older adults at risk for long-term effects of HAART: • increased risk and earlier onset of cognitive decline, kidney failure, depression, cancer, & osteoporosis • Very few 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

31. Cancer • 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) • http://www.cancer-network.org/

32. Chronic Disease • No significant evidence of higher levels of chronic disease ,however: higher rates of risk factors including: smoking, drinking, drug use, and obesity • One 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

33. Until 1973, the American Psychiatric Association classified homosexuality as a mental illness • “Gender Identity Disorder” is still in the DSM-4 • Increased rates as a result of 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… Mental Health

34. Education & Resources

35. Recommendations for Patient Education National Resource Center on LGBT Aging www.lgbtagingcenter.org SAGE (Services and Advocacy for Gay Elders) www.sageusa.org AARP-Pride www.aarp.org/pride Estate Planning for LGBT Couples Social Security & Older Women Strong Families Movement www.strongfamiliesmovement.org/lgbt-heatlh-care-guide National LGBT Cancer Network http://www.cancer-network.org/

36. Local Resources Senior Services: non profit with mission “to promote the emotional, social, and physical well-being of older adults” http://www.seniorservices.org/lgbt/Home.aspx http://www.seniorservices.org/lgbt/CommunityEvents.aspx NW LGBT Senior Care Providers Network http://seniorservices.org/lgbt/NWLGBTSeniorCareProvidersNetwork.aspx SAGE-Olympia http://sageolympia.org/

37. Recommendations for Further Learning National Resource Center on LGBT Aging www.lgbtagingcenter.org SAGE (Services and Advocacy for Gay Elders) www.sageusa.org LGBT Aging Issues Network www.asaging.org/lain AARP Pride www.aarp.org/pride National LGBT Cancer Network www.cancer-network.org

38. Recommendations for Further Learning National Coalition for LGBT Health www.lgbthealth.net Transgender Aging Network www.forge-forward.org/tan Fenway Health Institute www.fenwayhealth.org Lamda Legal www.lambdalegal.org Gay and Lesbian Advocates & Defenders www.glad.org Howard Brown Health Center Health Education About LGBT Elders (HEALE) curriculum Http://www.howardbrown.org/hb_services.asp?id=2224

39. Film Recommendations • Ten More Good Years, 2008: • www.tenmoregoodyears.com • Edie and Thea: A Very Long Engagement, 2009: • http://www.blessblessproductions.com/ediethea.html • Gen Silent, 2010: • http://stumaddux.com/GEN_SILENT.html • Before You Know It, 2013: • http://beforeyouknowitfilm.com/about/ http://www.youtube.com/watch?v=lL83Yl4-9Vc

40. LGBT Elders are everywhere • Including YOUR clinic! • Limited data -> but this is changing • Influence of internal, historical and Institutional homophobia • Historically, federal laws contributed to financial insecurities • Downfall of DOMA has widespread implications • Disease-specific health discrepancies • There are resources out there, make yourself familiar with them! Take Home Points

41. Thank you

42. Thank you

43. Resources 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/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. Gay and Lesbian Advocates & Defenders http://www.glad.org