National Health, Aging, and Sexuality/Gender Study (NHAS) Karen I
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The Gerontologist cite as: Gerontologist, 2017, Vol. 57, No. S1, S1–S14 doi:10.1093/geront/gnw212 The Science of Conducting Research With LGBT Older Adults- An Introduction to Aging with Pride: National Health, Aging, and Sexuality/Gender Study (NHAS) Karen I. Fredriksen-Goldsen, PhD,* and Hyun-Jun Kim, PhD School of Social Work, University of Washington, Seattle. *Address correspondence to Karen I. Fredriksen-Goldsen, School of Social Work, University of Washington, 4101 15th Avenue NE, Box 354900, Seattle, WA 98105. E-mail: [email protected] Introduction 2014), we estimate that 2.4% of older adults in the United We are pleased to present this supplemental issue of The States currently self-identify as LGBT, accounting for 2.7 Gerontologist dedicated to reporting on the 2014 data from million adults aged 50 and older, including 1.1 million aged Aging with Pride: National Health, Aging, and Sexuality/ 65 and older. The population will increase dramatically Gender Study (NHAS), the largest national survey to date over the next few decades given the significant aging of the focused on the health and well-being of lesbian, gay, bisex- population (U.S. Census Bureau, 2014); by 2060 the num- ual, and transgender (LGBT) older adults. The articles in this ber of adults aged 50 and older who self-identify as LGBT issue explore a breadth of topics critical to understanding will likely more than double to over five million. Recent the challenges, strengths, and needs of a growing and under- U.S. population-based data have also shown that many indi- served segment of the older adult population. This introduc- viduals who do not identify as a sexual or gender minority tion to the supplement provides foundational information report same-sex sexual behavior or attraction. In one recent to frame the papers that follow. We begin by reviewing pop- study, for example, while just more than 5% of Americans ulation-based findings regarding the size and health status aged 18–44 self-identified as lesbian, gay, or bisexual, 12% of the LGBT older adult population. Next, we summarize had engaged in same-sex sexual behavior (men who had sex the Health Equity Promotion Model (HEPM; Fredriksen- with men, and women who had sex with women), and 13% Goldsen, Simoni, et al., 2014), the conceptual framework were sexually attracted to members of the same sex (Copen, that guides our study. We then briefly review some of the key Chandra, & Febo-Vazquez, 2016). Thus, the total number methodological challenges that exist in conducting research of older adults who self-identify as LGBT, have engaged in in this hard-to-reach population. Next, we present an over- same-sex sexual behavior or romantic relationships, and/or view of study design and methods as well as the study’s pri- are attracted to members of the same sex is estimated to mary substantive and content areas. Lastly, we provide an increase to more than 20 million by 2060. overview of the articles in this issue, which cut across three Although the numbers of sexual and gender minority major themes: risk and protective factors and life course older adults are growing rapidly, they remain a largely events associated with health and quality of life among invisible and under-researched segment of the older adult LGBT older adults; heterogeneity and subgroup differences population. The Institute of Medicine (2011) has identified in LGBT health and aging; and processes and mechanisms sexual orientation and gender identity as key gaps in health underlying health and quality of life of LGBT older adults. disparities research, with LGBT older adults as an espe- The landscape of gerontological research, practice, cially understudied population. Healthy People 2020 (U.S. and policy is shifting as the U.S. older adult population Department of Health and Human Services, 2012), a set becomes increasingly diverse, including by sexual ori- of 10-year national health improvement objectives, high- entation and gender identity and expression. By harmo- lighted LGBT people for the first time as a health dispa- nizing available data across population-based studies rate population and outlined goals to improve their health, (e.g., California Health Interview Survey, 2014; Gates & safety, and well-being. Aging with Pride: NHAS represents Newport, 2012; Massachusetts Department of Public one step toward filling the research gap that lies at the inter- Health, 2014; Washington State Department of Health, section of sexual orientation and gender identity and aging. © The Author 2017. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. S1 For permissions, please e-mail: [email protected]. S2 The Gerontologist, 2 0 1 7, Vol. 57, No. S1 Health Disparities of LGBT Older Adults LGBT populations; for example, we observed heightened risks of smoking, asthma, and disability among Hispanic A primary goal of current national health objectives is lesbian and bisexual women compared to Hispanic hetero- to reduce health disparities and adverse health outcomes sexual women (Kim & Fredriksen-Goldsen, 2011). When resulting from social, economic, and environmental con- compared to non-Hispanic White sexual minority women, ditions (U.S. Department of Health and Human Services, Hispanic bisexual women showed more frequent mental dis- 2012). In some of the first population-based studies of les- tress and Hispanic lesbians showed a higher rate of asthma. bian, gay, and bisexual older adult health, utilizing state- These findings highlight the importance of assessing sub- level data, we documented significant health disparities group differences to gain a more nuanced understanding of (Fredriksen-Goldsen, Kim, Barkan, Muraco, & Hoy-Ellis, aging and health in these diverse communities and to gener- 2013). More recently, using multi-year national popula- ate effective ways to reduce health inequities among LGBT tion-based data from the National Health Interview Survey older adults, which if left unchecked will result in substan- (NHIS, 2013-2014), we further investigated health dispari- tially rising healthcare costs as the population grows. ties by sexual orientation, gender, and age. Lesbian, gay, and bisexual adults aged 50 and older, compared to het- erosexuals of similar age, were more likely to report higher prevalence of disabling chronic conditions. They reported The Health Equity Promotion Model higher rates of 9 out of 12 chronic conditions, compared Existing research shows that, while a health disparate pop- with heterosexual peers, including low back pain, neck ulation, many LGBT older adults manifest resilience and pain, and weakened immune system; other disparities were good health despite marginalization (Fredriksen-Goldsen, elevated rates of stroke, heart attack, asthma, and arthri- Kim, Shiu, Goldsen, & Emlet, 2015). Yet, to date much tis as well as comorbidity of chronic health conditions for of the sexual minority research has been driven by stress- sexual minority older women, and angina pectoris and related mental health models, such as the Minority Stress cancer for sexual minority older men (Fredriksen-Goldsen, Model (Meyer, 2003), which articulates ways in which 2016a). Lesbian, gay, and bisexual older adults were also stigma, discrimination, and hostility lead to chronic stress, more likely to report poor general health, mental distress, in turn causing mental health problems and unhealthy cop- disability (especially problems with vision, ambulation, and ing behaviors. While deficit-driven models help explain cognition), sleep problems, and smoking; sexual minority poor health outcomes in LGBT populations, they are less older women were more likely to report excessive drinking. suited to address the resources, good health, and well-being There are insufficient population-based data to observed in these communities. assess health disparities in some subgroups of sexual The Health Equity Promotion Model (HEPM) differs and gender minority older adults, leaving community- from previous models used to examine LGBT mental and based data as the best available evidence. For instance, physical health by incorporating a life course development robust national population-based data to assess the perspective to understand the full range of contexts and health and well-being of transgender older adults is not experiences, both adverse and positive, that may influence available. Utilizing community-based data, we found individuals’ opportunities to achieve their full potential for transgender older adults were at higher risk of poor good health and well-being. By identifying potential explan- health outcomes compared to nontransgender sexual atory mechanisms that may predict changes in health and minority older adults; they were more likely to experi- well-being over time, the model highlights both enduring ence poor general health, disability, and mental distress, characteristics (e.g., age cohort) and modifiable factors that which were associated with elevated rates of victimiza- may become targets for intervention (e.g., management tion, discrimination, and lack of access to responsive of identity stigma and affirmation, health-promoting and care (Fredriksen-Goldsen, Cook-Daniels, et al., 2014). risk behaviors, function and quality of social relations, and Community-based data have also shown elevated risks community norms); Figure 1 (for a full description of the of poor health among bisexual older adults when com- model see Fredriksen-Goldsen, Simoni, et al., 2014).