Clinical Geriatrics

Case Vignette
A 66-year-old man presents to his new primary care physician for the first time with reports of chronic pain, anxiety, panic attacks, and poor concentration; upon further questioning from the physician, the patient also reports sexual dysfunction. His medical history is significant for hypertension, depression, and possibly alcohol abuse. The patient has never been married, has no children, and lives with a male roommate who accompanies him to the visit.

Due to the patient’s anxiety and poor concentration, the roommate provides much of the patient’s information, including intimate details of the patient’s medical history. The primary care physician suspects that the two men are in a relationship, and despite asking open-ended, nonjudgmental, gender-neutral, and lesbian, gay, bisexual, and transgender (LGBT)–affirming questions, the patient avoids answering any inquiries that might reveal his sexual orientation. He also refuses to give his physician any additional details about his social history that are necessary to address his concerns about his anxiety, depression, and sexual dysfunction.

Is it important for healthcare providers to know the sexual orientation of their older patients? Are there specific issues that need to be addressed differently in older LGBT adults? How does one inquire into the sexual and social history of an older adult?

Introduction
Older adults who are LGBT are a vulnerable group with specific healthcare needs that are largely unrecognized by healthcare professionals. LGBT populations have higher rates of common and life-threatening physical and mental health conditions. Unfortunately, very little research and education has focused on the healthcare needs of older LGBT adults, and how they differ from their aging heterosexual peers or from the younger LGBT population. LGBT Americans are recognized by the U.S. Department of Health & Human Services as 1 of 6 groups affected by health disparities.^1,2 In its document “Healthy People 2010,” a 10-year plan to eliminate health disparities among different segments of the population, sexual orientation was included in 29 specific objectives.² The recently released “Healthy People 2020” continues to address the health disparities of LGBT individuals, which are linked to societal stigma, discrimination, and denial of their civil and human rights.³ The report states that discrimination against LGBT persons has been associated with high rates of psychiatric disorders, substance abuse, and suicide. In addition, there are long-lasting effects on the individual and the community from frequent experiences of violence and victimization, as well as struggling with issues of acceptance (personal, family, and societal).³

In this review article, we will explore the important issues that are unique to the older LGBT adult, including the coming-out experience, medical and psychological concerns, feelings of invisibility and isolation, lack of social supports, and discrimination. We will also address the importance of healthcare providers being aware of their older patients’ sexual orientation to improve patient care, change communication techniques, and improve health outcomes. We searched MEDLINE to identify recent scientific articles, and we reviewed practice guidelines and primary care textbooks to gather information.

Background

Definitions
Lesbian, gay, and bisexual are terms used to describe a person’s sexual orientation, which describes orientation toward people of the same gender in sexual behavior, attraction, and/or self-identification (Table I).⁴ It is important to note that sexual orientation is much more than sexual behavior. One can have same-sex relations without identifying as homosexual, and, conversely, one can have same-sex attraction without engaging in homosexual behavior or identifying as homosexual.