BACKGROUND

Older LGBTQ adults have less access to care owing to fear of stigma of their sexual orientation and therefore often have a lapse in general healthcare needs and are more prone to depression, anxiety, and substance abuse than non-LGBTQ adults. Nurses should assist in creating a welcoming environment free of judgment and stigma to ensure that the LGBTQ adults are comfortable to discuss their needs.

PRINCIPLES OF CARING FOR OLDER LGBTQ ADULTS

A.  Create LGBT-friendly environment by using appropriate language.

1. Inquire about sexual identity (Gay & Lesbian Medical Association, n.d.)
2. Discuss sexual orientation (Gay & Lesbian Medical Association, n.d.)
3. Ask about preferred pronouns (Gay & Lesbian Medical Association, n.d.)

B.  Assess risk factors for chronic medical conditions as appropriate.

1. Obtain a thorough sexual history (Gay & Lesbian Medical Association, n.d.).
   • Discuss sexual preferences, partner preferences, and routes of intercourse.
   • Assess barrier methods used.
   • Discuss addition of new sexual partners.
2. Assess social behaviors.
   • Inquire about smoking, alcohol, and recreational drug use.
   • Discuss current exercise regimen, diet.
3. Determine if patient is up to date with screening guidelines.
   • Follow nationally accredited guidelines as recommended according to risk factors (Meads & Moore, 2013; Quinn et al., 2015).
   • Assess for risk of anal cancer (Quinn et al., 2015).

C.  Assess for hormone therapy use in transgender patients and monitor for side effects.

1. Exogenous estrogen for transgender females
   • Estrogen formulations include oral, parenteral (either subcutaneous or intramuscular injections), or transdermal formulations (Unger, 2016).
   • Most significant risk is increase in venous thromboembolic events (VTE), so monitor for symptoms of VTE (Weinand & Safer, 2015).
   • Avoid ethinyl estradiol formulation, which carries the highest risk for VTE (Arnold et al., 2016).
   • Further increased risk for VTE exists if on estrogen and smoking, obese, have a history of prior VTE, or have a thrombophilia/hypercoagulable disorder, so ask about these risk factors when taking a health history (Shatzel et al., 2017).
   • Risk for elevation in triglycerides exists, so monitor serum lipid panels (Fernandez & Tannock, 2016).
   • Potential risk of cardiovascular disease and stroke exists, so monitor blood pressure and assess for symptoms of stroke (Defreyne et al., 2019).
   • No increased oncologic risk (Weinand & Safer, 2015).
2. Antiandrogens for transgender females
   • Addition of antiandrogen (when also on estrogen) decreases testosterone and lowers the dose of estrogen needed (Webb & Safer, 2019).
   • Most common option is spironolactone (Randolph, 2018).
   • Spironolactone is a potassium-sparing diuretic, so monitor for hyperkalemia, which increases in risk with age (Randolph, 2018).
   • Finasteride is another option; its main risk is liver toxicity (Unger, 2016).
   • Leuprolide, a gonadotropin-releasing hormone agonist, is another option but can be very expensive (Unger, 2016).
   • Leuprolide also carries risks of osteopenia and decreased libido (Weinand & Safer, 2015).
3. Exogenous testosterone for transgender males
   • Testosterone formulations available in the United States include transdermal, parenteral (either subcutaneous or intramuscular injections), or subcutaneous implant (Unger, 2016).
   • Risk for increase in serum hemoglobin and hematocrit (Irwig, 2017)
   • Risk for possible decrease in HDL cholesterol (Irwig, 2017)
   • Possibility for increase in serum triglycerides (Irwig, 2017)
   • Likely to increase BMI (Fernandez & Tannock, 2016)
   • No increased risk for VTE (Shatzel et al., 2017)
   • No known increased risk of cardiovascular or oncologic events (Gooren & T’Sjoen, 2018)

D.  Assess for psychosocial needs

1. Fears/history of discrimination
   • Many older LGBT adults are fearful of discrimination by their heterosexual peers and the healthcare practitioners they depend on as they age (Jablonski et al., 2013).
   • Past experiences of rejection and/or abuse cause many LGBT adults over 55 years old to remain closeted (Zelle & Arms, 2015).
   • LGBT older adults may return to the closet in a nursing facility and may be afraid that the nursing/healthcare staff will have their own personal biases that are not accepting of the LGBT identity and thus that the staff may neglect, abuse, or persecute them (Serafin et al., 2013).
   • Patients may hide their identity and present as heterosexual owing to fears of discrimination by heterosexual roommates or cohabitants in a long-term care facility (Serafin et al., 2013).
   • Transgender older adults may be afraid that they would be assigned a room based on the gender of their birth rather than the gender they identify with, especially if they have not had a surgical transition (Jablonski et al., 2013).
   • These fears and isolation are risks for psychologic distress and/or suicidal ideation (Putney et al., 2018).
2. Social support
   • For many older LGBT adults, their main support network is their friend group, or “chosen family” (-McParland & Camic, 2016).
   • LGBT adults are more likely not to have children, and a majority live alone and are at risk for self-neglect (McParland & Camic, 2016).
   • Social isolation can contribute to worsening cognitive function, coronary artery disease, stroke risk, depression, and/or suicidal ideation (Yang et al., 2018).
   • It is important to ensure documentation of a surrogate decision-maker if that person is “chosen family” or an unmarried partner (Marsack & Stephenson, 2018).
   • It is important to recognize an older LGBT patient’s spouse or partner during a time of loss, to avoid devalued bereavement, which can occur if that relationship is not valued or respected in the same manner socially (Hayman & Wilkes, 2016).
3. End of life
   • “Perceived successful aging” for LGBT older adults includes not only a large network of social support, but also the confidence that healthcare providers will treat them respectfully and with dignity at the end of life (Walker et al., 2017).
   • LGBT patients are more likely to be without children or a partner toward the end of life and have been described to be more likely to have fears of dying in pain or alone (de Vries & Gutman, 2016).
   • Some gay and bisexual men who lived through the HIV/AIDS epidemic may express the fear of reliving the losses of multiple friends again in older age (de Vries & Gutman, 2016).
   • Providing culturally sensitive and competent care can help to alleviate fears of recurrent discrimination in the hospice setting, which includes helping to discuss and formalize the patient’s wishes for surrogate decision-making and visitation (Maingi et al., 2018).
   • Avoid assumptions during palliative/end-of-life discussions, as LGBT older adults may want/request spiritual care during difficult times (Cloyes et al., 2018).
   • Promote team education of LGBT-sensitive care, as it is important to understand the legalities of surrogate decision-making (Hughes & Cartwright, 2014).

E.  Access appropriate resources specific to patient needs.

ABBREVIATIONS

AIDS           Acquired immune deficiency syndrome

BMI             Body mass index

HDL            High density lipoprotein

HIV             Human immunodeficiency virus

LGBT          Lesbian, gay, bisexual, transgender

LGBTQ       Lesbian, gay, bisexual, transgender, and queer/questioning

VTE            Venous thromboembolic events

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Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti PhD, RN, FAAN, E., Zwicker DrNP, APRN, BC, D., & Fulmer PhD, RN, FAAN, T. T. (2020). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed.). Springer Publishing. Retrieved November 4, 2020, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826188144.html#description

Chapter 33: Chaiyasit, J., & Lutz, A. (2021) LGBTQ Perspectives for Older Adult Care.  In M. Boltz, E. Capezuti, D. Zwicker & T. Fulmer (eds.).  Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed. pp 595-606).   New York: Springer.