By Karen I. Fredriksen-Goldsen
Only a few decades ago, the aging of lesbian, gay, bisexual, and transgender (LGBT) people was relegated to the shadows. The work of several courageous pioneers began to openly question common misconceptions of “old gays” as depressed, lonely, and sexually undesirable. Resisting prevailing stereotypes, they postulated that the positive management of a sexual minority identity was effective in supporting gay men and lesbians for successful aging (Adelman, 1990; Berger, 1980; Berger and Kelly, 1986; Butler and Hope, 1999; Gray and Dressel, 1985; Kehoe, 1986; Quam and Whitford, 1992; Sharp, 1997). Yet today, LGBT older adults remain largely invisible in aging services, policies, and research, despite the population’s rapid growth. An estimated 2.7 million adults ages 50 and older self-identify as LGBT in the United States, including 1.1 million who are ages 65 and older. By 2060, the number of older adults who self-identify as LGBT will exceed 5 million. These estimates more than double when considering same-sex behavior and romantic relationships (Fredriksen-Goldsen and Kim, in press).
"In this Pride month, it is my honor to dedicate the newly released Summer 2016 issue of Generations on LGBT Aging to all those who lost their lives in Orlando, to those who were wounded, to their loved ones, to all who have in the past endured hate and violence, and to my community that rallies together, moving ever forward with our allies to build a safe and loving world."
-Karen Fredriksen Goldsen
The dynamic nature of language reflects the shifting societal, cultural, and social meanings of sexuality and gender in American society. A few decades ago, when I started conducting this research, men often were referred to as “homosexuals,” a term now considered offensive by many. “Gay” often was used as a global term representing sexual minorities—men and women alike. Bisexuals were at times referred to as “fence-sitters,” a derogatory term suggesting unresolved sexual identity. “Transgendered” and “transsexual” were common terms; language now has shifted toward gender identity and expression, with trans, transgender, and gender non-conforming emerging as umbrella terms.
Moreover, there are cultural differences in terminology. Same-gender loving is sometimes used by African Americans, down-low by some African American men, and two-spirit by some Native Americans. Increasingly, adults ages 50 and older identify as queer, genderqueer, or other self-identified terms, which accounted for more than 14 percent in our most recent survey. (See sidebar, below, for a brief glossary of terms.)
This article shares personal reflections on the future of LGBT aging, informed by findings from two landmark studies I have had the honor to lead in collaboration with seventeen community partners (see Author’s Note at the end of this post): Aging with Pride: National Health, Aging, Sexuality and Gender Study (2009 to present), the first federally funded longitudinal study to investigate trajectories over time of aging, health, and quality of life in LGBT midlife and older adults. This project encompasses Caring and Aging with Pride, the first national study of LGBT aging, health, and well-being. An equity framework, incorporating structural exclusion, resilience, and resistance to inequities across the life course, is the foundation underlying the practice, education, and research models that have developed from these projects (Fredriksen-Goldsen et al., 2014a). I define equity as the pursuit of fairness and opportunity for all to reach their full potential, with the goal to better serve LGBT older adults, their kin, and their communities. Based on this framework, I outline a blueprint for action in services, policies, and research to address the growing needs of LGBT older adults now and for generations to come.
Key Terms from Aging with Pride: National Health, Aging, Sexuality and Gender Study
For additional key terms relevant to LGBT aging see www.Age-Pride.org.
LGBT Aging as a Generational Concern
Generational considerations are critical in LGBT aging given the shifting social and legal contexts surrounding sexuality, gender, and age. In our studies we focus on three generations that have received limited attention: the Invisible Generation, the Silent Generation, and the Pride Generation, each with its own configuration of resources and risks.
The Invisible Generation experienced the Great Depression (1929–1939) and many fought in WWII—at which time LGBT identities were largely absent from public discourse. In the 1950s, the Silent Generation came of age against the backdrop of the McCarthy trials and the “lavender scare,” with sexual and gender minority identities cast as a threat to the security of the nation; it was a time when same-sex behaviors, typically characterized as sodomy, were criminal, and the American Psychiatric Association had classified homosexuality as a psychiatric disorder.
The Pride Generation came of age at a time of tremendous social change, as evidenced by the Stonewall riots (1969) and other social and civil rights movements. At this time, LGBT people became more visible in American society, marking the beginning of the modern gay rights movement. Several other important changes occurred in the 1960s, including the beginning of decriminalization of same-sex behavior and the Civil Rights Act. In addition, homosexuality as a psychiatric disorder was removed from the revised Diagnostic and Statistical Manual of Mental Disorders (DSM-II-R) in 1973. A decade later, the AIDS pandemic began, further shifting cultural, social, and personal realities, and the need for care communities.
Despite the generations’ histories of marginalization, we consistently find most LGBT adults of the Invisible, Silent, and Pride generations are aging well and experiencing good health. Equally important, our studies have illuminated pockets of serious risk in these communities, with generational differences in risks and resources (Fredriksen-Goldsen et al., 2015).
For example, we find that while LGBT adults from the Invisible and Silent generations report higher degrees of internalized stigma and identity concealment, they are individually less likely to have experienced discrimination and victimization, suggesting identity concealment may be protective in hostile environments. Conversely, for those of the Pride Generation, internalized stigma and identity concealment are lower, but discrimination and victimization are higher, as are loneliness and social isolation. Informed by these differences, we are developing and evaluating the first cross-generational, community-engaged, evidenced-based solutions to the challenges facing LGBT older adults.
Equity over the life course
Early in our work, we found the prevailing minority stress models (Meyer, 2003; Hatzenbuehler et al., 2009) were insufficient to explain how the majority of LGBT older adults attain good health in the face of adversity. In our research we have framed LGBT aging within an equity approach, highlighting both the historical and contemporary forces at play over the life course. The Health Equity Promotion Model (Fredriksen-Goldsen et al., 2014b) expands upon earlier conceptualizations by considering how historical and social contexts, cultural meaning, and structural location influence the intersectionality of social positions and the interplay between age, sexuality, gender, and culture. It is important to recognize that LGBT older adults share risk and protective factors with older adults in the general population, while they also experience unique strengths and challenges due to the marginalization of their sexual and gender identities. The model incorporates both commonalities and differences by age, sex, sexuality, gender, race, ethnicity, culture, and socioeconomic status that span individual, community, and societal levels.
Addressing Historical and Contemporary Risks
Health disparities are differences in health, attributable to environmental, economic, and social disadvantage. While most early LGBT health research focused on mental health disparities, we found in our early studies that LGBT older adults also are at elevated risk of social, economic, and physical health disparities (Fredriksen-Goldsen et al., 2011; Fredriksen-Goldsen et al., 2013a), including social isolation, functional limitations, and disability. Many LGBT older adults also experience unique barriers to care, including fear of accessing services (Fredriksen-Goldsen et al., 2011).
While the acronym LGBT often is used, we find important variations and distinct needs between sub-groups. Heterogeneity and intersectionality within these communities must be considered. For example, we have documented different types of disparities by sexual orientation and gender identity (Fredriksen-Goldsen et al., 2011; Fredriksen-Goldsen et al., 2013a; Fredriksen-Goldsen et al., in press), with transgender (Fredriksen-Goldsen et al., 2014c) and bisexual older adults (Fredriksen-Goldsen et al., under final review) at elevated risk as well as differences among LGBT people of color (Kim and Fredriksen-Goldsen, 2012), lower socioeconomic status (Fredriksen-Goldsen et al., 2011); specific geographic regions, and those living with HIV (Emlet, Fredriksen-Goldsen, and Kim, 2013).
Reasons underlying the health disparities of LGBT older adults are complex. Lifetime experiences of social exclusion, discrimination, victimization, stigma, and identity concealment all have been associated with diminished health among LGBT midlife and older adults (Fredriksen-Goldsen et al., 2014c; Fredriksen-Goldsen et al., 2013b). Lesbian, gay, and bisexual older adults often do not have incomes that are commensurate with their education, which likely reflects experiences of discrimination and diminished economic opportunities over the life course. Social isolation among LGBT older adults is of real concern; for example, gay and bisexual men are two times more likely than heterosexual men to live alone and also have fewer children (Fredriksen-Goldsen et al., 2013a). Because most LGBT older adults have peer-based social support systems, long-term survivors may be especially vulnerable to social isolation (Fredriksen-Goldsen et al., in press), as their peers may face their own health challenges and they may outlive those who had provided support. Social isolation has been linked to poor health, cognitive impairment, and premature mortality in the general population (Fredriksen-Goldsen et al., 2011).
Resilience and Resistance: Forging Forward Together
Human agency refers to the thoughts and actions taken by either an individual or a collective that exert power and shape future experiences. LGBT midlife and older adults have over time engaged individual and collective human agency as they have built communities and systems of mutual support and resistance. The Mattachine Society, one of the first national gay rights organizations for men, was established in 1950; lesbians mobilized with the founding of The Daughters of Bilitis in 1955. When governments and other institutions failed to recognize HIV/AIDS in the early 1980s, those who are now midlife and older developed organizations and communities of care (de Vries, 2015; Orel and Fruhauf, 2015). Today, despite a long history of marginalization, most LGBT older adults display remarkable resilience. Through collective action, they resisted society’s repression, serving as catalysts for the changes we witness today.
In our work, we find that LGBT older adults have acquired key psychological, social, and community resources that likely offset many of the challenges they face and that buffer against adversity. Identity affirmation, a psychological resource defined as postive appraisal of one’s sexual and gender identities, is a stronger predictor of mental and physical health and quality of life than identity stigma (Fredriksen-Goldsen et al., in press). Social and community resources, including larger social networks and community engagement, predict better quality of life and well-being in the lives of LGBT older adults (Fredriksen-Goldsen et al., 2015; Fredriksen-Goldsen and Kim, in press; Fredriksen-Goldsen et al., in press).
Opportunities for Action: Next Steps
Certain steps must be taken to better support the optimal aging, health, and well-being of LGBT midlife and older adults. An equity perspective highlights several actionable innovations in services, policy, and research.
In developing services to address the unique needs of LGBT older adults and their kin, it is critical to recognize and build upon the strengths in these communities. The LGBT community has a rich history of collective action, advocating and developing services for its most vulnerable and disenfranchised members, as was evident during the AIDS pandemic. Yet as LGBT older adults age and experience increasing needs, many are not accessing services and healthcare because of traumatic histories and an acute fear of discrimination and victimization.
In addition, many have a fierce sense of independence cultivated through surviving in a hostile environment, which is an incredible strength, but may also result in a reluctance to seek help when needed. Yet, some LGBT older adults have distinct healthcare needs. With the growing number of people living with HIV and concurrently entering old age, there is a heightened need for HIV support programs for LGBT older adults. Furthermore, LGBT older adults, compared to heterosexuals of similar age, are more likely to report nine out of twelve chronic health conditions (Fredriksen-Goldsen and Kim, in press), so specialized services are needed.
Facilitating communication is one of the most important steps toward bridging these care gaps across the generations. Actively having LGBT older adults work with others—of all ages—to serve on organizational boards and committees strengthens organizations’ ability to create culturally responsive aging, health, and cross-generational services. Activism and community organizing can provide a model of caring that benefits the entire LGBT community (including older adults), as well as across other ages, creatively discovering new ways to support the growing and diverse older adult population, and the larger community. Programs to reduce isolation and loneliness by reducing stigmarelated stress (Lyons, 2015) and bolstering social networks would be widely beneficial. We are developing Generations: Aging with Pride, as one of the first LGBT organizations designed to create cross-generational opportunities and evidence-based solutions to address LGBT aging and build a stronger community now, and for generations to come. Moreover, provider trainings aimed at reducing bias and offering culturally competent care to older adults benefit not only LGBT older adults, but also the increasingly diverse older adult population.
Innovative strategies are needed to reach LGBT older adults who lack adequate services, supports, or resources, and those living alone, who are at elevated risk of social isolation and poor aging and health outcomes. With our longitudinal study, we now have information to help us reach those most at risk of adverse aging and health outcomes, and we are developing and testing ways to intervene early on to prevent social, economic, and health disparities. An important first step is to develop and implement screening mechanisms through which to identify midlife and older LGBT adults at elevated risk of poor physical and mental health. By identifying key determinants of health, and developing upstream and downstream interventions, we can reduce structural barriers and promote individual and community strengths that result in good health and quality of life.
There is a need for LGBT and aging organizations to engage in targeted educational outreach efforts to ensure that LGBT older adults are aware of their rights and mechanisms for redress under current law and regulation. With nationally legalized same-sex marriage, married same-sex couples now have access to Social Security survivor benefits, Medicaid spend-downs, bereavement leave, and tax exemptions upon inheritance of jointly owned real estate and personal property. In addition, effort must be made to address the rising income inequality and homelessness gaps that affect these and other historically disadvantaged communities.
LGBT older adults, like people of all ages, need protection from discrimination based on sexual orientation and gender identity in employment, housing, and public accommodations at federal, state, and local levels; this would support the economic security and safety of LGBT midlife and older adults. Comprehensive statewide protections in employment, housing, and public accommodations based on sexual orientation and gender identity still are absent in more than half of the states (Human Rights Campaign, 2016). Currently, there are no comprehensive federal laws prohibiting discrimination based on sexual orientation or gender identity. Federal employees and contractors are prohibited from discriminating based on sexual orientation or gender identity, as are many other federal entities, including the Department of Housing and Urban Development and the Equal Employment Opportunity Commission. The Equality Act, which at the federal level would amend existing laws to create explicit protections against discrimination based on sexual orientation or gender identity, has been introduced in Congress.
Local to global action must occur to protect LGBT older adults and their kin. Same-sex activity remains illegal in more than seventy countries, and is punishable by death in some. We need an international movement to protect all generations across borders.
The new LGBT+ National Aging Research Center serves as a clearinghouse on the most up-to-date research and information about the experiences and needs of LGBT midlife and older adults, their kin, caregivers, and allies. Yet gaps remain in our knowledge about LGBT aging, health, and well-being and data collection is necessary to better understand and address the needs of these older adults. But most health surveys today do not include sexual identity or gender identity questions; such omission often is based on the inaccurate assumption that these questions are too sensitive for older adults to answer. Some population-based surveys, such as the National Health Interview Survey (Ward et al., 2014), have taken that important step and added sexual identity questions, as have some state-level efforts made through the Behavioral Risk Factor Surveillance System (BRFSS) surveys. What little is known about transgender health primarily comes from community-based surveys (Fredriksen-Goldsen et al., 2014c; Grant et al., 2011); gender identity and expression questions also are needed in population-based aging and health surveys. When adding sexual and gender-related questions to any research, it is critical to determine what will be asked, why the information is being gathered, and how it will be used. See the sidebar, below, for best practices and recommendations for questions on sexual and gender identity (Fredriksen-Goldsen and Kim, in press).
It is critical in all phases of research to incorporate the heterogeneous nature of the LGBT community to identify those most at risk and to learn from those experiencing optimal aging and health outcomes. Our longitudinal study has been developed both to assess trajectories and mechanisms in aging and to better understand the full range of health outcomes and risk and protective factors in these communities. Because most LGBT aging studies to date rely heavily on self-reporting, we also include measures of physical, biological, and cognitive functioning (Fredriksen-Goldsen and Kim, in press). This research is designed to comprehensively address the diversity and sub-groups within LGBT older adult communities, and to identify underlying mechanisms of risk and resilience—the aim being to design and test the effectiveness of culturally appropriate, community-based interventions.
Best Practices for Sexual Identity and Gender Identity Data Collection
From our experience of testing sexual identity and gender identity questions with more than 4,000 older adults, we recommend the following types of questions:
Which of the following best represents how you think of yourself? (Check one box)
Which of the following was your assigned status at birth? (Check one box)
Currently, which of the following best represents your gender? (Check one box)
Do you consider yourself to be trans/transgender? (Check one box)
Additional data collection considerations: We recommend not including both sexual identity and gender identity in a single question because they are two separate aspects of people’s identities and are best asked about independently. Sex and gender should not be assumed by appearance, but asked about directly. It also is important to consider adding questions related to sexual behavior, romantic relationships, and attraction. Confidentiality and non-discrimination must be assured when asking these questions. Interviewers’ negative responses to sexual identity or gender identity disclosure can be detrimental to the health and well-being of LGBT older adults.
Despite tremendous social and cultural change, most LGBT older adults remain invisible in aging and health services, policies, and research. Yet, this invisibility is being challenged by LGBT older adults who are raising their voices, and by cross-generational efforts to transform our communities and society. An ongoing challenge must be embraced: to address the risks and manifestations of marginalization and concurrently support the resilience and strengths these individuals have forged in moving forward to build their lives and communities. Interventions must extend beyond the individual level, as they embrace kin, caregivers (Muraco and Fredriksen-Goldsen, 2014), communities, and the larger society.
This issue of Generations is designed to showcase the innovative work happening across the country in LGBT aging. In the following articles, community partners and researchers illustrate advances that are being made in services, policies, and research that respond to the growing needs of diverse LGBT older adults. Each article illuminates the expertise in assessing the strengths and disparities facing these communities, including the distinct needs of often hidden populations of LGBT older adults. Through careful attention to the aging and well-being of LGBT older adults, our contributing authors provide cutting-edge information needed to create culturally responsive programs and policies.
Such efforts contribute to equity by fostering community and a sense of belonging, which in turn can benefit physical and mental health over the life course. Equity is a basic human right best achieved through accountability in systems and communities, and through the engagement of citizens at all levels, including LGBT midlife and older adults and their communities. As a participant in Aging with Pride said, “The LGBT community has stepped up in the past to address coming out, AIDS, and civil rights. The next wave has to be aging.”
Karen I. Fredriksen-Goldsen, Ph.D., is professor and director of Healthy Generations: Hartford Center of Excellence at the University of Washington in Seattle, Washington. She leads the landmark study, Aging with Pride: National Health, Aging, Sexuality and Gender Study, the first federally funded longitudinal study of LGBT aging, health, and well-being.
Editor’s Note: This article is taken from the Summer 2016 issue of ASA’s quarterly journal, Generations, an issue devoted to the topic “LGBT Aging” ASA members receive Generations as a membership benefit; non-members may purchase subscriptions or single copies of issues at our online store. Full digital access to current and back issues of Generations is also available to ASA members and Generations subscribers at Ingenta Connect. For details, click here.
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Fredriksen-Goldsen, K. I., et al. 2014a. “Creating a Vision for the Future: Key Competencies and Strategies for Culturally Competent Practice with Lesbian, Gay, Bisexual, and Transgender (LGBT) Older Adults in the Health and Human Services.” Journal of Gerontological Social Work 57(2–4): 80–107.
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Fredriksen-Goldsen, K. I., et al. 2014c. “Physical and Mental Health of Transgender Older Adults: An At-risk and Underserved Population.” The Gerontologist 54(3): 488–500.
Fredriksen-Goldsen, K. I., et al. 2015. “Successful Aging Among LGBT Older Adults: Physical and Mental Health-related Quality of Life by Age Group.” The Gerontologist 55(1): 154–68.
Fredriksen-Goldsen, K. I., et al. In press. “The Cascading Effects of Marginalization and Pathways of Resilience in Attaining Good Health Among LGBT Older Adults.” The Gerontologist.
Fredriksen-Goldsen, K. I., et al. Under final review. “The Health of Bisexual Older Adults: Pathways of Risk and Resilience.” The Journal of Gerontology: Social Sciences.
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Muraco, A., and Fredriksen-Goldsen, K. I. 2014. “The Highs and Lows of Caregiving for Chronically Ill Lesbian, Gay, and Bisexual Elders.” Journal of Gerontological Social Work 57(2–4): 251–72.
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Sharp, C. E. 1997. “Lesbianism and Later Life in an Australian Sample: How Does Development of One Affect Anticipation of the Other?” International Journal of Sexuality and Gender Studies 2(3–4): 247–63.
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Authors Note: This research is funded in part by the National Institute on Aging of the National Institutes of Health under Award Number R01AG026526 (Fredriksen-Goldsen, P.I.). The content is solely the responsibility of the author and does not necessarily represent the official views of the National Institutes of Health.
The following organizations are community partners of Aging with Pride: Center on Halsted, FORGE Transgender Aging Network, Gay and Lesbian Services Organization, Generations: Aging with Pride, GLBT Generations, GRIOT Circle, LGBT Aging Project: The Fenway Institute, Los Angeles LGBT Center, Mary’s House for Older Adults, Inc., Milwaukee LGBT Community Center, Montrose Center, Openhouse, SAGE, SAGE Atlanta/The Health Initiative, SAGE Metro St. Louis, Utah Pride Center, and ZAMI NOBLA.