Sexual Orientation, Socioeconomic Status, and Healthy Aging

By Bridget K. Gorman and Zelma Oyarvide

The older adult population in the United States is more diverse than ever before—including diversity based on sexual and gender minority status. Recent studies indicate that there are more than 2.4 million lesbian, gay, bisexual, and trans­gender (LGBT) adults ages 50 and older in the United States, and that this population will grow to more than 5 million by the year 2030 (Fredrik­sen-Goldsen et al., 2014). In recent years, LGBT older adults have been the focus of a small but growing body of research examining the charac­teristics and circumstances associated with their health and healthy aging (Institute of Medicine [IOM], 2011).
 
These studies paint a picture of a population that, on average, faces a variety of health chal­lenges, including stigma, discrimination, and re­­lated stressors; barriers to receiving formal and informal healthcare services; and financial insta­bility (Choi and Meyer, 2016). In this article, we discuss how sexual orientation relates to socio­economic status (SES) among older adults, and the importance of SES differences for the health sta­tus and healthy aging trajectories of selected sex­ual minority (lesbian, gay, and bisexual) adults.
 
Socioeconomic Status, Sexual Orientation, and Health
While healthy aging relates to a variety of fac­tors, socioeconomic resources loom large. Schol­arship has firmly established the fundamental role of socioeconomic status for health (Link and Phelan, 1995). Socioeconomic differences in health impairment accumulate across the life course, and education is an especially important cause of healthy aging due to its key role in the acquisition of material assets (e.g., good jobs, health insurance, income, and wealth), as well as the development of health-related habits, skills, and abilities (Ross and Mirowsky, 2010). While education acts as an intrinsic resource that helps delay the onset of chronic health conditions and functional limitations, income operates more as a coping resource that helps slow the progression of health prob­lems after they occur (Herd, Goesling, and House, 2007). Considered together, the educa­tion and income profile of older adults is a crucial factor shap­ing their likelihood of living a long life relatively free from disease and impairment.
 
Due to the fundamental role of education, income, and other aspects of socioeconomic sta­tus for healthy aging, the wide disparities seen in SES across sociodemographic groups is troubling, especially for older adults. To illustrate, we calcu­lated estimates for SES by gen­der, sexual orientation, and age using data from the 2011–2015 waves of the Behavioral Risk Factor Surveillance System. Table 1 shows how low education (less than a high school diploma) and high edu­cation (college degree or more), as well as low annual house­hold income (less than $25,000) and higher income ($75,000 or more) differ by sexual orienta­tion and gender among older adults in three age cohorts: ages 50 to 64, ages 65 to 79, and ages 80 and older. Overall, it shows that across groups, completed schooling and household income decline with increasing age.
 
Socioeconomic and Health Status of Bisexual Older Adults
Table 1 also highlights the socioeconomic dis­advantages of bisexual older adults. Across age groups, bisexual elders have the lowest rates of completed schooling, and they live in lower-income households than do heterosexual, gay, or lesbian older adults. While the percentages of their disadvantage vary by gender and age cohort, SES disparities can be quite high. For ex­­ample, among older women ages 65 to 70, 22.4 percent of bisexual women did not complete high school—this compares to 12.6 percent of hetero­sexual women, and just 6.6 percent of lesbians.
 
As another example, Table 1 shows that an­­nual household income varies strongly among the oldest men; while about one-third of hetero­sexual and gay men ages 80 and older report an annual income of less than $25,000, this rate is almost double among bisexual men (62.8 per­cent). As recent assessments have concluded (Fredriksen-Goldsen and Muraco 2010; IOM, 2011), previous research on older adults has dis­proportionately focused on gay men and lesbi­ans, while bisexuals and other sexual minority groups rarely were examined. Yet the data pat­terns in Table 1 illustrate the risks associated with only considering gay or lesbian adults (or lumping together subgroups into an umbrella “sexual minority” category). Doing so would obscure or ignore the poorer socioeconomic standing of bisexual older adults relative to their heterosexual and gay or lesbian peers—a key factor shaping health disparities across the life course that are based on sexual orientation.
 
A recent study by Fredriksen-Goldsen and col­leagues (2016) concluded that the poorer socioeco­nomic standing of bisexual older adults operated as a strong explanatory mechanism for their poorer health reports, compared to heterosexual and gay or lesbian older adults. Recent reviews of LGBT aging issues have discussed how finan­cial instability is a major concern for many sexual minority older adults (e.g., Movement Advance­ment Project [MAP] and Sage, 2010).
 
As summarized by Choi and Meyer (2016): “Lifetime disparities in earnings, employment, and opportunities to build savings, as well as dis­criminatory access to legal and social programs that are traditionally established to support aging adults, put LGBT older adults at greater financial risk than their non-LGBT peers.” The findings shown in Table 1 and from previous scholarship indicate that financial stress may be especially high among bisexuals in later life.
 
This finding about financial stress more gener­ally reflects a growing body of research document­ing substantial financial and other health-related risks among bisexuals. Scholarship focused upon adults in general has shown that, compared to het­erosexual and gay or lesbian adults, those who identify as bisexual report poorer socioeconomic circumstances, higher participation in health-damaging behaviors like smoking and heavy alcohol use, and poorer mental and physical 
health status (Conron, Mimiaga, and Landers, 2010; Gorman et al., 2015; Veenstra, 2011).
 
Bisexuals also report lower averages of life satisfaction and less emotional support than either gay or lesbian or heterosexual adults (Gorman et al., 2015). Additionally, Fredriksen-Goldsen and colleagues (2016) show that older bisexual adults report more internalized stigma as well as a lower sense of community belong­ing and perceived social supports than their gay or lesbian peers. This study also showed a lower rate of sexual identity disclosure among bisex­uals—a finding that applies not only to friends, family, and co-workers, but also to medical care providers (see also IOM, 2011).
 
Considered together, these studies indicate that a variety of health-related risks—includ­ing economic vulnerability, participation in un­­healthy behaviors (e.g., smoking), stress, and lower levels of social support—may be elevated among bisexual older adults. Furthermore, the lower rate of sexual identity disclosure to medi­cal professionals among bisexuals is worrisome, because research on the medical experiences of sexual minorities highlights the importance of sexual identity disclosure for a positive medical encounter (Daley, 2012; Sherman et al., 2014).
 
Analyzing SES Similarities
Looking again at Table 1, it also shows more pos­­itive socioeconomic profiles for gay men and lesbian older adults relative to same-age heterosexuals. Depending upon the contrast, gay men and lesbians often report similar or better levels of completed schooling and annual household income. This is seen most strongly for education: with just one exception (among men ages 80 and older), gay men and lesbians report higher levels of completed schooling, on average, than their heterosexual peers. This educational advantage is especially stark when we look at the percentage with a college degree, where the proportion with a college degree is markedly higher among gay men and lesbians. For example, among adults ages 50 to 64, 48.3 percent of lesbians have a college degree, com­pared to 30.1 percent of heterosexual women. Among men ages 50 to 64, 41.3 percent of gay men have at least a college degree, compared to 30.8 percent of heterosexual men.
 
Looking at annual household income among older women, we see a more muted but generally similar pattern. The proportion of older women reporting a household income below $25,000 is lower among lesbians than heterosexuals in each age group, and (with the exception of women ages 80 and older) a higher proportion also re­­port a household income of $75,000 or above.
 
Among older men, however, the proportion in either income group is very similar between gay and heterosexual men in most age groups. The biggest difference occurs among men ages 50 to 64, where a higher proportion of gay men (28.5 percent) report an annual household income of less than $25,000, compared to 21.8 percent of heterosexual men.
Previous studies also have found higher levels of educational achievement among gay men and lesbians in comparison to comparably aged het­erosexual adults (IOM, 2011). Additionally, work by Fredriksen-Goldsen and colleagues (2013) found a similar pattern wherein gay and lesbian adults ages 50 and older report higher levels of education, but fairly equivalent rates of poverty in comparison to similar-age heterosexuals—a pat­tern they attribute to discrimination and blocked opportunities across the life course, which lim­ited the ability of sexual minorities to fully capi­talize on the economic benefits associated with their educational achievement. That we see this more strongly among older gay men than among lesbians (in Table 1) may relate to elevated expe­riences with stigma and discrimination among gay men. Herek (2002) has documented that U.S. adults (especially heterosexual men) hold more negative attitudes toward gay men than they do toward lesbians, and gay men experience sub­stantially higher rates of harassment, verbal abuse, violence, and property crimes than either lesbians or bisexuals (Herek, 2009).
 
Healthy Aging Among Sexual Minorities
As detailed in Healthy People 2020, improving the health and well-being of sexual minorities is an important public health goal for the United States (U.S. Department of Health and Human Services, 2010). Existing health disparities re­­search provides a framework for understanding how SES contributes to sexual orientation dif­ferences in health status, because SES often is implicated as one of the strongest contributors to health stratification (Link and Phelan, 1995). Overall, the poor health standing of bisexuals documented across an increasing number of studies may be due in large part to their lower socioeconomic standing, on average, than mem­bers of other sexual orientation groups.
 
In particular, our understanding of how edu­cation and income relate to disease onset and progression is important, because the poorer socioeconomic profile of bisexual older adults suggests that they may face particular hardships in navigating the health challenges associated with aging. Older sexual minority adults are more likely to be single, living alone, and with­out children than heterosexual elders, and they rely more on partners and friends to provide caregiving assistance (Fredriksen-Goldsen and Muraco, 2010; MAP and Sage, 2010).
 
The fact that bisexual older adults report ele­vated rates of low income and education indicates that they may face difficult challenges in secur­ing quality housing and medical care services as they age. While survey data suggest that gay or lesbian adults do not experience the same educa­tion deficits as bisexuals, it appears that older les­bians and gay men especially have been less able to capitalize economically on their education. As such, policy makers and healthcare providers need to realize how financial stress and instabil­ity in later life may play a large role in shaping not only the health status of sexual minorities, but also how successful their management of health problems may be as they seek to maintain a high quality of life as they age.
 
Bridget Gorman, Ph.D., is professor and chair of Sociology at Rice University in Houston, Texas. Zelma Oyarvide is a doctoral student in the Department of Sociology, and a research affiliate at the Kinder Institute for Urban Research, at Rice University.
 
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