LGBTQ-Sensitive Care for Older Adult Patients

 

OVERVIEW

Older LGBTQ adults are less likely to seek healthcare owing to distrust but continue to have health needs that require medical attention and intervention.

 

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 LGBTQ adults are comfortable with discussing their needs.

PRINCIPLES OF CARING FOR OLDER LGBTQ ADULTS

A. Create LGBTQ-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 and diet.
  3. Determine if the patient is up-to-date with screening guidelines.
    • Follow nationally accredited guidelines as recommended according to risk factors (Clarke et al., 2022; Ceres et al., 2018).
    • Assess for risk of anal cancer (Ceres et al., 2018).

C. Assess for HT 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).
    • The most significant risk is increase in VTE, so monitor for symptoms of VTE (Weinand & Safer, 2015).
    • Avoid ethinyl estradiol formulation, which carries the highest risk for VTE (Goldstein et al., 2019).
    • 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 (Iwamoto et al., 2023).
    • Potential risk of cardiovascular disease and stroke exists, so monitor blood pressure and assess for symptoms of stroke (Defreyne et al., 2019).
    • There is no increased oncological 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).
    • The 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 the risk 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 of increase in serum hematocrit (Iwamoto et al., 2023)
    • Risk of possible decrease in HDL cholesterol (Iwamoto et al., 2023)
    • Possibility of increase in serum triglycerides (Iwamoto et al., 2023)
    • Likely to increase lean mass (Iwamoto et al., 2023)
    • No increased risk for VTE (Shatzel et al., 2017)
    • No known increased risk of cardiovascular or oncological events (Gooren & T’Sjoen, 2018)

D. Assess for psychosocial needs.

  1. Fears/history of discrimination
    • Many older LGBTQ 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 LGBTQ adults older than 55 years to remain closeted (Zelle & Arms, 2015).
    • LGBTQ 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 LGBTQ 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 psychological distress and/or suicidal ideation (Putney et al., 2018).
  2. Social support
    • For many older LGBTQ adults, their main support network is their friend group, or “chosen family” (McParland & Camic, 2016).
    • LGBTQ 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 LGBTQ 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 (Stein et al., 2020).
  3. End of life
    • “Perceived successful aging” for LGBTQ 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).
    • LGBTQ 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 fear of reliving the losses of multiple friends again in older age (de Vries & Gutman, 2016).
    • Providing culturally sensitive and competent care can help alleviate fears of recurrent discrimination in the hospice setting, which includes helping 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 LGBTQ older adults may want/request spiritual care during difficult times (Cloyes et al., 2018).
    • Promote team education of LGBTQ-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

HDL     high-density lipoprotein

HT       hormone therapy

VTE     venous thromboembolic events

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Updated: January 2025

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti, PhD, RN, FAAN, E.A., & Fulmer PhD, RN, FAAN, T. T. (2025). Evidence-Based Geriatric Nursing Protocols for Best Practice (7th ed.). Springer Publishing. Retrieved December 17, 2024, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826152763.html#tableofcontents

Chapter 16, Chaiyasit, J.J. & Lutz, A.R. (2025) LGBTQ Perspectives for Older Adult Care


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