6
Later Adulthood

The cohort of LGBT people currently in later life grew up and moved into adulthood in much less supportive environments than those experienced by younger cohorts. Before entering adulthood, the oldest of this cohort would have seen, in 1952, the creation of an official diagnosis that listed homosexuality as a sociopathic personality disturbance (Bayer, 1987) and watched Senator McCarthy include gay men and lesbians on his blacklist. As adults, this cohort witnessed routine harassment by authorities, as well as the Stonewall Rebellion in 1969 and the American Psychiatric Association’s removal of homosexuality from the Diagnostic and Statistical Manual of Mental Disorders in 1973 (see Chapter 2 for a full historical overview).

For all adults, later life is known as a period of both growth and decline (Baltes et al., 1999), with studies on the latter vastly outnumbering those on the former. Significant research effort has begun focusing on the diseases and disorders that accompany old age and the lifestyles of the elderly, including dementia; the living environments of later life; the need for and delivery of care from both interpersonal and institutional perspectives; the related social, and especially family, relations of older persons; end-of-life preparations; bereavement; and the personal and environmental characteristics of successful aging. These areas of research are certainly not restricted to heterosexual persons; the experiences of aging LGBT persons may be similarly characterized, with the addition of the legacies and experiences of stigma. In fact, studies of aging among LGBT elders will generate new knowledge about aging in general as questions are framed and concepts considered that fall outside of traditional “heteronormative” perspectives.



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6 Later Adulthood T he cohort of LGBT people currently in later life grew up and moved into adulthood in much less supportive environments than those experienced by younger cohorts. Before entering adulthood, the oldest of this cohort would have seen, in 1952, the creation of an official diagnosis that listed homosexuality as a sociopathic personality disturbance (Bayer, 1987) and watched Senator McCarthy include gay men and lesbians on his blacklist. As adults, this cohort witnessed routine harassment by authorities, as well as the Stonewall Rebellion in 1969 and the American Psychiatric Association’s removal of homosexuality from the Diagnostic and Statistical Manual of Mental Disorders in 1973 (see Chapter 2 for a full historical overview). For all adults, later life is known as a period of both growth and decline (Baltes et al., 1999), with studies on the latter vastly outnumbering those on the former. Significant research effort has begun focusing on the diseases and disorders that accompany old age and the lifestyles of the elderly, including dementia; the living environments of later life; the need for and delivery of care from both interpersonal and institutional perspectives; the related social, and especially family, relations of older persons; end-of-life preparations; bereavement; and the personal and environmental character- istics of successful aging. These areas of research are certainly not restricted to heterosexual persons; the experiences of aging LGBT persons may be similarly characterized, with the addition of the legacies and experiences of stigma. In fact, studies of aging among LGBT elders will generate new knowledge about aging in general as questions are framed and concepts considered that fall outside of traditional “heteronormative” perspectives. 251

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252 THE HEALTH OF LGBT PEOPLE The committee chose to define the start of later life, while a vague and contested concept, as generally coinciding with retirement. The bulk of the empirical literature on LGBT aging, however, makes reference to a variety of (mostly younger) ages than this traditional cut-off point and is included in the discussion that follows. Ages younger than the traditional retirement age are included in this chapter in the context of preparations for later life, mainly as pertains to the well-known “baby boomer” cohort, the next in line to become seniors. This age issue is part of the recurring pattern noted throughout this report: much of the empirical literature on which the report draws either does not provide an age breakdown or uses a breakdown that does not match the age ranges used to organize the chapters of the report. Thus, the text that follows builds upon, and sometimes includes references to, studies and observations from the preceding chapter on early/middle adulthood. In so doing, it highlights the continuous nature of the life course while at the same time elucidating the particular circumstances of the later years. In general, LGBT elders have not been the subject of extensive research; a recent publication reviews some of the extant literature and echoes this statement (see Fredriksen-Goldsen and Muraco, 2010). Just as aging is infrequently considered in LGBT research, the field of gerontology has infrequently considered LGBT aging issues (Scherrer, 2009). The studies in this area that have typically been reported have used small and mainly regional samples, often recruited from public venues, such as community centers, street fairs, and pride festivals. The vast majority of studies include self-identified LGBT persons; if studies describe samples of LGBT persons otherwise identified, they are highlighted below. The studies in this area also focus disproportionately on gay men and lesbians; few studies have focused on bisexual or transgender elders. Most studies, moreover, have a high representation of white individuals; very few articles have been written on racial/ethnic minorities. Although many samples include LGBT older persons of color, they are often in proportions insufficient for further analysis; thus, very little is known about these groups. The same is true for other metrics of diversity (such as rural residence, culture, or religion). Finally, almost no published research exists on the very later years of LGBT persons—ages 85 and older. Given the limited research in this area, this chapter draws significantly on the few large-scale studies that have included older LGBT persons (and those approaching later life). It also includes a variety of more regional studies with less representative and smaller samples, as noted above. When possible, these restricted samples are described within the limiting param- eters of the cited studies. This chapter examines research that has been conducted on the health of LGBT elders and factors that influence their health outcomes. It begins

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253 LATER ADULTHOOD by describing research on the development of sexual orientation and gen- der identity in this age group. The next two sections examine first mental health status and then physical health status. The chapter then addresses in turn risk and protective factors; health services; and contextual influences, including demographic characteristics, the role of the family, and end-of-life issues. The final section presents a summary of key findings and research opportunities. DEVELOPMENT OF SEXUAL ORIENTATION AND GENDER IDENTITY Although the age at which gay men and lesbians come out appears to be earlier today than in previous cohorts, there remains great variability in the time of coming out and evidence that the process may extend over the life course (Brown et al., 2001; de Vries and Blando, 2004). Grov and colleagues (2006) conducted a cross-sectional street-intercept survey with 2,733 participants at a series of LGB community events in New York City and Los Angeles. Their sample was broken down into five age cohorts, the oldest of which was 55 and older. The authors found that women and men in the youngest cohort (aged 18–24) reported coming out to themselves at younger ages than women and men in the oldest cohort. The average age of coming out to self and coming out to others for the youngest women was 15.88 and 16.87 years, respectively; the average comparable ages for the oldest cohort of women were 24.90 and 27.38, respectively. The average age of coming out to self and coming out to others for the youngest men was 15.01 and 16.94 years, respectively; the average comparable ages for the oldest cohort of men were 20.31 and 24.11, respectively. Uneven and smaller subsamples of racial and ethnic minority LGB persons prevented fuller analyses; however, within-cohort analyses revealed no racial differ- ences in the age at which participants came out to themselves and others. In the Still Out, Still Aging: The MetLife Study of Lesbian, Gay, Bi- sexual and Transgender Baby Boomers (MetLife, 2010) national survey of LGBT people aged 45–64 (n 5 1,201), the extent to which LGBT respon- dents reported being out varied significantly. Transgender and bisexual respondents were far less likely to be out: only 39 percent of transgender and just 16 percent of bisexual people were completely or mostly out, com- pared with 74 percent of gay men and 76 percent of lesbians. The major- ity of gay men and lesbians reported having completely or very accepting families; for transgender and bisexual respondents, these percentages were lower (42 and 24 percent, respectively). Almost one-third (31 percent) of bisexuals said family members were not very or not at all accepting, a far higher percentage than the next least-accepted subpopulation of transgen- der people (12 percent).

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254 THE HEALTH OF LGBT PEOPLE LGBT respondents were also asked about the extent to which they disclosed their sexual orientation and/or gender identity with a variety of people. Although more than a quarter (29 percent) said they were open with anyone, many reported that they were guarded with some people. For example, 33 percent had not disclosed to their neighbors, and more than 30 percent had not disclosed at work (32 percent for coworkers and 30 per- cent for supervisors); 20 percent were guarded with their siblings and their parents, while 28 percent were guarded with other family members. There were also other groups of people to whom the participants had not come out—acquaintances (30 percent), people at the place where they attended religious services (16 percent), health care providers (16 percent), and even “closest friends” (12 percent). Bisexual people were less likely to disclose their sexual orientation than the other subpopulations; only 12 percent of bisexual people said they were open with anyone, compared with 30 percent of lesbians, 38 percent of gay men, and 28 percent of transgender respondents (MetLife, 2010). In his secondary analysis of 372 men aged 50–85 in the Urban Men’s Health Study—a probabilistic sample of men who have sex with men obtained in San Francisco, Los Angeles, Chicago, and New York using a modified random-digit dialing approach—Rawls (2004) found that almost 5 percent of the men in this sample had never told someone they were gay or bisexual; half of the men had not told someone else they were gay or bisexual until after the age of 21 and about one-quarter of the men until after age 26. Considered by current age, the proportion of men who reported that they had disclosed their orientation to many in their so- cial environment significantly decreased over the three age groups in the sample—50–59, 60–69, and 70 and older. Of interest, among the older two groups, there were no significant differences between those with lower and higher levels of disclosure in their experience of distress and depression. This latter finding in particular is reminiscent of results of earlier research, particularly Lee’s (1987) study of older Canadian gay men and Adelman’s (1990) study of a small sample of gay men and lesbians over age 60 in the San Francisco Bay Area. In both of these studies, those with lower disclo- sure reported greater happiness and life satisfaction, leaving open questions about the time/cohort and/or life-course consequences of coming out. Transgender persons who are visibly gender role nonconforming in childhood tend to come out at an early age (Bockting and Coleman, 2007). For the older generations, this was typically during adolescence or early adulthood; today’s generation typically comes out in childhood or shortly after the onset of puberty (Möller et al., 2009; Wallien and Cohen-Kettenis, 2008). However, transgender persons who are not visibly gender role non- conforming in childhood typically do not come out until much later in life, during midlife or beyond. This is a particularly common developmen-

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255 LATER ADULTHOOD tal pathway among transgender women (as opposed to transgender men) (Doctor, 1988; Landen et al., 1998). Some transgender people who were not visibly gender role nonconforming in childhood do retrospectively report cross-gender feelings in childhood, whereas others do not. Most do, how- ever, recall cross-dressing during adolescence. Initially, such cross-dressing is often sexually arousing, and may be restricted to particular articles of clothing (e.g., lingerie) and, possibly, compulsive (i.e., fetishistic). After many years of cross-dressing in private, the main motivation for cross- dressing may shift toward more fully doing so for comfort and, eventually, to express a cross-gender identity. This developmental pathway has been described as late onset (as opposed to early onset [Doorn et al., 1994]), secondary (as opposed to primary [Person and Ovesey, 1974]), marginal (as opposed to nuclear [Buhrich and McConaghy, 1978]), or autogynephilic (as opposed to homosexual) transsexualism1 (Blanchard, 1989). Thus, according to these typologies, most transsexual men and many transsexual women experience a strong cross-gender identity starting in childhood (primary transsexualism). For many transsexual women, how- ever, the cross-gender identity develops more gradually over the life course and increases in intensity, and after years of compartmentalizing this iden- tity privately, these transsexual women come out during midlife or beyond to transition and pursue hormone therapy and/or surgery to feminize. At a later age, however, hormone therapy is less effective at feminizing, either because it cannot reverse the long-term masculinizing effects of testosterone or because only lower doses of feminizing hormones can be prescribed given the higher prevalence of medical contraindications and chronic disease among older individuals (Dahl et al., 2006). For these individuals, years of being “in the closet” and in effect delaying experiences of felt stigma may have mental health implications, although research comparing the mental health of those who come out early versus later in life has yielded mixed findings (see Lawrence, 2010, for a review). What is clear is that the majority of transsexual individuals who come out later in life benefit from treatment of gender dysphoria and are satisfied with sex reassignment (Lawrence, 2003, 2010). For transgender people, coming out later in life also means working through developmental events commonly experienced earlier in life, such as a kind of “second adolescence,” first experiences in the other gender role (including dating and sexual experimentation), and exploration of 1 As a reminder, transgender is an umbrella term that encompasses a diverse group of individuals who depart from traditional gender norms. Transsexuals are those who desire to feminize or masculinize their appearance through the use of hormone therapy and/or surgery (or have already done so), and they are included in the broader category of transgender people. This discussion refers to a specific type of transsexualism that involves a developmental process occurring later in life.

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256 THE HEALTH OF LGBT PEOPLE one’s masculinity or femininity (Bockting and Coleman, 2007). Many who come out later in life are heterosexually married and have a family, whose members face their own process of coming to terms with their loved one’s transgender identity (Emerson, 1996; Lev, 2004). MENTAL HEALTH STATUS Some significant literature examines the potential challenges faced by LGBT persons in later life; there have been few empirical studies in this area, however. Some of the many challenges reported include the present and past effects of stigma and discrimination and a greater reliance on nontraditional sources of support, such as friends and other non–family members, in an environment in which such support frequently is not rec- ognized either formally (by policy, for example) or informally (by social organizations and family members, for example) (see Barker, 2002, for a discussion of “friend” caretakers to the elderly in general). Confronting these challenges is believed to tax the mental health of LGBT elders, as discussed below. It is important to note, however, that LGBT people in later adulthood typically are well adjusted and mentally healthy. Studies using probability samples indicate that the majority of older LGB adults do not report men- tal health problems (Cochran and Mays, 2006; Herek and Garnets, 2007). While national probability samples of the transgender population are not available, studies based on nonprobability samples similarly show that the same is true for many if not most transgender adults (Clements-Nolle et al., 2001; Nuttbrock et al., 2010). Mood/Anxiety Disorders Limited data are available on mood or anxiety disorders among older LGBT individuals. The reports available in the literature typically are for an adult population undifferentiated by age, obscuring the particular experi- ences of older adults. Depression Among older adults in the general population, estimates of the preva- lence of major depression range from less than 1 percent to approximately 5 percent, but can reach 13.5 percent for those who require home health care (NIMH, 2007). Compared with these estimates, studies of both older gay men and older lesbians have found elevated levels of depression. Shippy and colleagues (2004) found that 30 percent of a sample of 233 gay men aged 50–87 reported depression. Bradford and colleagues (1993), reporting

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257 LATER ADULTHOOD on the National Lesbian Health Care Survey of 1,925 self-identified lesbians aged 17–80, found that among the approximately 3 percent of the sample over age 55, 24 percent reported having experienced depression at some point in their lives. Valanis and colleagues (2000), analyzing data from the Women’s Health Initiative (n 5 93,311), found that 15–17 percent of lesbians aged 50–79 had been depressed. In a household probability sample of 2,881 men who have sex with men (analyzed by age decade), Mills and colleagues (2004) found a rate of depression of 17 percent among men aged 50–69 (n 5 397) and 5 percent among men aged 70 and older (n 5 41). Not having a domestic partner, a recent history of antigay threats or violence, not identifying as gay, and feeling highly alienated from the gay community were associated with both distress and depression. Based on data gathered from 416 self-identified lesbian, gay, and bisexual adults aged 60–91, Grossman (2006) found that most older LGB adults in the study appeared to have developed some resilience to the minority stress in their lives. However, signs of emotional distress were still present in their lives. For example, 27 percent reported feeling lonely, 10 percent reported sometimes or often considering suicide, and 17 percent still wished they were hetero- sexual. For 93 percent of participants, having known people who were HIV-positive or had died of AIDS was an additional factor that caused emotional distress. Several authors have commented that older transgender adults have particularly high rates of depression (e.g., Cook-Daniels and Munson, 2010). Empirical evidence is sparse on this point, however. A recent study by Fredriksen-Goldsen and colleagues (2011) offers some data on this and other points of relevance. The study was based on an 11-site sample with a total of 2,560 self-identified LGBT persons between the ages of 50 and 95 (including 175 transgender persons) recruited through agency lists, respondent-driven sampling, and in-depth interviews. Thirty-one percent of the LGBT persons in this sample were depressed; transgender persons reported significantly higher levels of depression than nontransgender per- sons, although the exact percentages were not known. Suicide/Suicidal Behavior The National Institute of Mental Health (NIMH, 2007) identified a national average of 11 suicides per 100,000 in the general population; persons over age 65 died by suicide at a rate of 14.7 per 100,000. From another perspective, the proportion of older adults in the United States is about 12 percent, but the elderly account for 18 percent of the nation’s suicides (Statewide Office of Suicide Prevention, 2009). These statistics differ dramatically by gender: men die by suicide at a rate five times that among women.

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258 THE HEALTH OF LGBT PEOPLE Even against this backdrop, the lifetime risk of suicide attempts appears particularly high among gay and bisexual men, as reported in a metareview by King and colleagues (2008), although this analysis had no age-specific focus. Others have reported an elevated risk of suicide attempts and suicid- ality in samples including older gay men and lesbians. For example, Paul and colleagues (2002) examined suicidality by age cohort using data from the Urban Men’s Health Study—a household probability sample of 2,881 men who have sex with men in four major U.S. cities, 14 percent of whom were age 25 in 1970 (meaning they were 55 in 2000). The authors found that 12 percent of this group had attempted suicide (equivalent to the per- centage in all other age cohorts), with the mean age of first attempt being 37.4 years (one-quarter of men in this cohort who had attempted suicide had done so before age 25). In a study using the previously described data set of 416 self-identified lesbian, gay, and bisexual adults aged 60–91, D’Augelli and Grossman (2001) found that 13 percent of their sample had attempted suicide (an attempt was especially likely among those who had been victimized at some point in their lives, as described further below). Among the study par- ticipants, better mental health was correlated with higher self-esteem, less loneliness, and lower internalized homophobia. Compared with women, men reported significantly more internalized homophobia, alcohol abuse, and suicidality related to their sexual orientation. Less lifetime suicidal ide- ation was associated with lower internalized homophobia, less loneliness, and more people knowing about participants’ sexual orientation (D’Augelli and Grossman, 2001). Although some studies examining suicidal ideation and attempts among transgender adults include individuals in later adulthood, these studies typically do not provide analyses of their data according to the age of par- ticipants. Therefore, it is difficult to identify findings that are specifically pertinent to transgender individuals in later adulthood. These studies are discussed in the previous chapter on early/middle adulthood. As noted frequently throughout this chapter, research on LGBT elders is sparse, an observation that is apparent in this section. It is also important to note that much of what is known about suicide attempts or ideation is for “any time in the lives” of these persons as currently assessed. Many of these behaviors and thoughts may well have occurred in much earlier years and thus are not related to experiences in later life (and perhaps even intimate particular resilience among older, surviving adults). Transgender-Specific Mental Health Status Studies on the mental health of transgender people include partici- pants in later life, yet data for this age group typically are not presented

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259 LATER ADULTHOOD separately. One recent study, however, does provide some insight into the mental health of older transgender individuals. While this study en- compasses midlife participants, its focus on older in comparison with younger adults makes its inclusion appropriate. Nuttbrock and colleagues (2010) conducted Life Chart Interviews with a convenience sample of 571 transgender women in New York City and compared data from older (aged 40–59, n 5 238) and younger (aged 19–39, n 5 333) participants. Two-thirds (66.3 percent) of the older as opposed to 84.1 percent of the younger participants reported coming out in one or more interpersonal contexts (family, friends, work, school). Lifetime prevalence of depression was 52.4 percent for the older group and 54.7 percent for the younger group. Among the older group, 35.5 percent reported depression during two or more life stages (early adolescence, late adolescence, early/young adulthood, early middle age, later middle age); depression was high during early adolescence (23.5 percent) and remained relatively constant into early (24.8 percent) and later (26.1 percent) middle age. This pattern differed from that of the younger group, in whom depression was extremely high during early adolescence (38.4 percent) but then declined significantly into early middle age (19.1 percent). Lifetime prevalence of suicidal ideation, planning, and attempts among the older group was 53.5 percent, 34.9 per- cent, and 28.0 percent, respectively; 6.7 percent reported suicide attempts during two or more life stages. For both the older and younger groups, gender-related stigma (gender-related psychological and physical abuse) was associated with depression. PHYSICAL HEALTH STATUS The now well-known health concomitants of aging are similarly rep- resented among heterosexual and LGBT older adults, although they may be exacerbated by factors associated with gender identity and sexual ori- entation. These factors are rarely studied, and thus are fertile ground for subsequent research. For example, data suggest that LGBT adults, including older persons, rate their health more poorly than heterosexual adults. The Massachusetts Department of Public Health issued a report in 2009 that included 1,598 LGBT and heterosexual adults (with mean ages in the range of middle adulthood). Among participants, 67.3 percent of transgender adults (n 5 35), 73.5 percent of bisexual adults (n 5 100), and 78 percent of gay and lesbian adults (n 5 749) rated their overall health as “excellent” or “very good,” compared with 82.5 percent of heterosexual adults (n 5 371) (Massachusetts Department of Public Health, 2009). In a national study comparing more than 1,200 LGBT people aged 45–64 with a group of just over 1,200 individuals aged 45–64 from the general population, the MetLife (2010) survey found that the percentage

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260 THE HEALTH OF LGBT PEOPLE reporting recent receipt of (and need for) care was greatest (19 percent) among the 5 percent of the sample identifying as transgender—comparable to the percentage of lesbians, somewhat greater than the percentage of bisexual women and men (17 percent), and much higher than the percentage of gay men as well as women and men from the general population (9 percent). Finally, Fredriksen-Goldsen and colleagues (2011) found that almost one in four (23 percent) of their sample of 2,560 LGBT adults aged 50 and older reported that their general health was poor. Sexual/Reproductive Health Although the study of sexuality has seen tremendous growth over the last 60–70 years, beginning with Kinsey’s groundbreaking research in the 1940s and 1950s, research on sexuality and aging has lagged. It is likely that research in this field is largely undeveloped as a result of ageism and inaccurate beliefs about sexuality ending in later life. As Schlesinger (1996) has noted, myths surrounding older persons and sexuality (i.e., that older persons are sexually undesirable and are not desirous of or capable of sexual expression) continue to influence our culture’s perspectives on sexu- ality and the elderly. Research has shown that these beliefs are false and that many adults continue to be sexually active throughout their lives (Lindau et al., 2007). While the very notion of a gay and lesbian gerontology raises the issue of sexuality directly (de Vries and Blando, 2004), limited research has explored sexual health among older LGBT people. In contrast, there is some research on sexual dysfunction in these groups. Erectile dysfunction has been associated with aging among men, although no research has investigated the extent of the problem among men who have sex with men. Rawls (2004) reports on a reanalysis of existing data on men who have sex with men who either identified as gay or reported same-sex contact in the Urban Men’s Health Study (Catania et al., 2001). Of the total sample of 2,881 men, 372 between the ages of 50 and 85 were included in the analysis. Among these men, 38.5 percent reported some “sexual difficul- ties” in the year prior to their interview. Of those reporting sexual difficul- ties, just under two-thirds cited health problems and/or medications as a contributing factor, and more than one-third cited psychological problems. Some reference to sexual dysfunction is included in research on pros- tate cancer, as noted by Asencio and colleagues (2009) in their qualitative focus group study of 36 midlife and older gay men (the majority being aged 50–70). The authors found that the fear of sexual dysfunction would influ- ence respondents’ decisions about how to treat prostate cancer, with age, socioeconomic status, and race moderating this association. Little empirical research has explored sexual functioning among older lesbians, bisexuals, and transgender persons. In terms of reproductive

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261 LATER ADULTHOOD health, Moore and colleagues (2003) report high rates of polycystic ovar- ian disease in transgender men, with implications for the risk of endometrial cancer. The literature includes some discussion (and controversy; see, e.g., Garnets and Peplau, 2006) about “lesbian bed death.” Early research (e.g., Kehoe, 1989) on older lesbians found large numbers reporting no sexual experience in the previous year and low rates of sexual satisfaction. Kehoe’s study was conducted with 100 self-identified lesbians over age 60 who re- sponded to calls for participants posted in lesbian and feminist newsletters and bookstores, women’s centers, and college and university campuses and associations. Little published research has followed this early, groundbreak- ing work to support or challenge its findings, and the concept remains in the lexicon of the literature. Valanis and colleagues (2000) report on the Women’s Health Initiative study, which included women aged 50–79 of postmenopausal status (n 5 93,311). Women were placed into five sexual orientation groups based on their responses: heterosexual (n 5 90,578), bisexual (n 5 740), lifetime lesbian (sex only with women ever) (n 5 264), adult lesbian (sex only with women after age 45) (n 5 309), and never had adult sex (n 5 1,420). The authors compared reproductive health outcomes and behaviors among the participants. Their results demonstrate similarities in oral contraceptive use and rates of pregnancy and hormone replacement therapy among the five sexual orientation groups. The rate of oral contraceptive use was highest for bisexual women (54.6 percent), and also high for adult lesbians (52.1 per- cent) and heterosexual women (45.4 percent). Heterosexual women had the highest rate of hysterectomy (41.5 percent), although the rates were similar for adult lesbians (35.0 percent) and bisexual women (39.6 percent). Adult lesbians, lifetime lesbians, bisexual women, and heterosexual women had similar rates of ever using hormone replacement therapy (HRT) (66–71 percent), higher than the rate among the no adult sex group (48 percent). These results reveal that, despite differences in sexual orientation, rates of hysterectomy, oral contraceptive use, and HRT use are extremely similar. Valanis and colleagues also found high rates of ever being pregnant among the bisexuals (80.8 percent) and adult lesbians (63 percent) com- pared with the lifetime lesbians (35 percent). In the aggregate, these data indicate that pregnancy and parenting may play a significant role in the lives of many women who have sex with women, with relevance for psychosocial and physical well-being. Cook-Daniels and Munson (2010) have been among the very few to study sexual practices and behaviors among transgender elders. They report on a sample comprising 272 transgender participants and/or their intimate partners aged 50–79, generated by means of an online survey in which par- ticipants were recruited through listservs directed to transgender adults and

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282 THE HEALTH OF LGBT PEOPLE Mental Health Status • Depression levels and suicidality appear to be elevated among older lesbians and gay men. Less research has been conducted in this area among bisexual and transgender elders. Physical Health Status • It appears that rates of hysterectomy, oral contraceptive use, and hormone replacement therapy may be similar for lesbians, bisexual women, and heterosexual women. • Lesbians and bisexual women may have higher rates of breast cancer than heterosexual women. • Data on whether lesbians have a higher risk for cardiovascular disease are conflicting. • Limited research suggests that transgender elders may experience negative health outcomes as a result of long-term hormone use. • HIV/AIDS impacts not only younger but also older LGBT in- dividuals. However, few HIV prevention programs target older adults, a cohort that also has been deeply affected by the losses inflicted by AIDS. • Disability among LGBT elders is a topic rarely considered in research. Risk and Protective Factors • LGBT elders experience stigma, discrimination, and victimization across the life course. • Little research examines violence experienced by LGBT elders, but some studies suggest that LGBT elders report high rates of lifetime experiences with violence. • Some research suggests that, compared with their heterosexual counterparts, LGB elders may have higher rates of tobacco and al- cohol use. Research on tobacco and alcohol use among transgender elders is largely lacking. • There is some evidence of crisis competence (resilience and perceived hardiness) within older LGBT populations; however, this concept is not yet well understood and has not been thoroughly researched. • Very limited data suggest that education may play a protective role in the lives of some older LGBT people. Health Services • Limited research suggests that LGBT elders may be less likely to seek health services than the general population.

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283 LATER ADULTHOOD • Some research suggests that older LGBT individuals do not believe they will receive respectful care in old age and may delay seeking care for fear of discrimination. • Long-term care for LGBT elders has not been the subject of many empirical studies. Contextual Influences • Research on the influence of sociodemographic characteristics on the health of LGBT elders is very limited. • The role of families in the lives of older LGBT people has been underresearched. Lesbian and gay elders are less likely than their heterosexual peers to have children, and their other kinship ties are not well understood. Families of choice appear to be a source of support for LGBT people in later life. Research Opportunities While the above findings provide some information on the health status of LGBT elders, there is a dearth of data on a number of topics in this area. Even among the studies that exist, lesbians, gay men, bisexual men and women, and transgender people are not equitably represented. Very little is known about transgender and bisexual aging in particular. Similarly, more research has focused on the first part of later life, while almost no published research exists on LGBT populations aged 85 and above. In studies whose participants represent a wide range of ages, age is rarely considered as a factor. Thus, while the potential exists to better understand this cohort, researchers often miss this opportunity by fail- ing to include age as a variable. Both cross-sectional and longitudinal research is especially needed to explore the demographic realities of LGBT aging in an intersectional and social ecology framework, to allow an understanding of the mechanisms of both risk and resilience in LGBT elders, and to identify appropriate interventions for working effectively with this cohort. These parameters could be brought to bear in research in the following areas: • Demographic and descriptive information, including the percentage of elders who are LGBT and how that percentage varies by such de- mographic characteristics as race, ethnicity, socioeconomic status, geography, and religion; also, the general experiences and health status of older LGBT adults and how these vary by demographic characteristics, the percentage of LGBT elders who are parents, and the trajectory of LGBT identity and experiences (particular bisexual identity) over the life course.

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284 THE HEALTH OF LGBT PEOPLE • Family and interpersonal relations, including the experience of LGBT aging and family life (e.g., experiences with biological kin across generations, “chosen family” ties and relations), the effect of the greater likelihood of childlessness (particularly among older gay men), and experiences of grief and loss (including multiple losses); also intrafamily and domestic violence (e.g., caregiver/provider abuse, intimate partner violence) and anti-LGBT victimization. • Health services, including barriers to access (particularly related to identity disclosure and interactions with providers), utilization rates, long-term care issues for older LGBT persons, quality of care received, and end-of-life issues (e.g., preparations, fears, and plans). • Mental health, including depression and suicidality (about which little has been written), the effects of stigma and discrimination (over the course of a lifetime), and the experience of and prepara- tions for late life among older LGBT persons. • Physical health, including cancer rates, risks, and treatment (par- ticularly for prostate cancer among older gay and bisexual men and transgender women and anal cancer among older men who have sex with men); the effects of long-term hormone use among older transgender persons; and the effects of disabilities among older LGBT persons. • Sexual and reproductive health, including HIV rates and interven- tions (and the experience of aging with HIV) and sexual well-being and sexual dysfunction (particularly among older lesbians and transgender elders, about whom little is known). REFERENCES Adelman, M. 1990. Stigma, gay lifestyles, and adjustment to aging: A study of later-life gay men and lesbians. Journal of Homosexuality 20(3/4):7–32. Adelman, M., L. Gurevich, B. de Vries, and J. Blando. 2006. Openhouse: Community building and research in the LGBT aging population. In Lesbian, gay, bisexual, and transgender aging: Research and clinical perspectives, edited by D. Kimmel, T. Rose, and S. David. New York: Columbia University Press. Altekruse, S. F., C. L. Kosary, M. Krapcho, N. Neyman, R. Aminou, W. Waldron, J. Ruhl, N. Howlader, Z. Tatalovich, H. Cho, A. Mariotto, M. P. Eisner, D. R. Lewis, K. Cronin, H. S. Chen, E. J. Feuer, D. G. Stinchcomb, and B. K. Edwards. 2010. SEER Cancer Sta- tistics Review, 1975–2007. Bethesda, MD: National Cancer Institute. Asencio, M., T. Blank, L. Descartes, and A. Crawford. 2009. The prospect of prostate cancer: A challenge for gay men’s sexualities as they age. Sexuality Research & Social Policy: A Journal of the NSRC 6(4):38–51. Balsam, K. F., E. D. Rothblum, and T. P. Beauchaine. 2005. Victimization over the life span: A comparison of lesbian, gay, bisexual, and heterosexual siblings. Journal of Consulting & Clinical Psychology 73(3):477–487. Baltes, P. B., U. M. Staudinger, and U. Lindenberger. 1999. Lifespan psychology: Theory and application to intellectual functioning. Annual Review of Psychology 50:471–507.

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