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Purpose: Lesbian, gay, bisexual, and transgender (LGBT) people are a health disparate
population as identified in Healthy People 2020. Yet, there has been limited attention
to how LGBT older adults maintain successful aging despite the adversity they face.
Utilizing a Resilience Framework, this study investigates the relationship between physi-
cal and mental health-related quality of life (QOL) and covariates by age group.
Design and Methods:A cross-sectional survey of LGBT adults aged 50 and older
(N=2,560) was conducted by Caring and Aging with Pride: The National Health, Aging,
and Sexuality Study via collaborations with 11 sites across the U.S. Linear regression
analyses tested specified relationships and moderating effects of age groups (aged
5064; 6579; 80 and older).
Results: Physical and mental health QOL were negatively associated with discrimination
and chronic conditions and positively with social support, social network size, physical
and leisure activities, substance nonuse, employment, income, and being male when
controlling for age and other covariates. Mental health QOL was also positively associ-
ated with positive sense of sexual identity and negatively with sexual identity disclosure.
Important differences by age group emerged and for the oldold age group the influence
of discrimination was particularly salient.
Implications: This is the first study to examine physical and mental health QOL, as an
indicator of successful aging, among LGBT older adults. An understanding of the con-
figuration of resources and risks by age group is important for the development of aging
and health initiatives tailored for this growing population.
Key words: Lesbian, Gay, Bisexual, Transgender, (LGBT) Aging, Health, Diversity, Healthy aging, Successful aging,
Life course
Reflective of the increasing diversity of older adults, lesbian, 50 and older identify as lesbian, gay, bisexual, or transgender
gay, bisexual, and transgender older adults are a growing pop- (LGBT) (Fredriksen-Goldsen, Kim, Barkan, Muraco, & Hoy-
ulation. Based on population estimates, 2.4% of adults aged Ellis, 2013; Fredriksen-Goldsen & Kim, 2014), accounting
The Author 2014. Published by Oxford University Press on behalf of The Gerontological Society of America. All rights reserved. Page 1 of 15
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The Gerontologist, 2014, Vol. 00, No. 00 Page 2 of 15
for more than 2.4 million older adults. Given the number of 2002; Wahler & Gabbay, 1997); in fact, some maintained
older adults in the United States is projected to more than that through crisis competence, first coined by Kimmel
double by 2030 (Jacobsen, Mather, Lee, & Kent, 2011), (1978), successful adjustment to being gay in earlier life,
LGBT adults aged 50 and older will number more than 5 as a stigmatized identity, enhanced sexual minority older
million within a few decades. adults ability to adjust to old age. In one of the few recent
In Healthy People 2020 LGBT people are for the first studies to address positive aspects of aging among LGBT
time identified in the U.S. national health priorities (U.S. older adults, Van Wagenen, Driskell, and Bradford (2013),
Department of Health and Human Services [DHHS], 2012), drawing upon qualitative interviews with 22 older adults,
with the Institute of Medicine (2011) concluding that insuf- identified ways of coping that led to variations in success-
ficient information exists on the health of LGBT people. ful aging across physical, mental, emotional, and social
Although LGBT older adults remain a largely invisible and domains.
under-studied group, there is accumulating evidence of For the current study, we shift our focus from our previ-
health disparities among LGBT older adults, as an at-risk ous research investigating health disparities to factors asso-
multidimensional factors and age group differences among (Thompson, Zack, Krahn, Andresen, & Barile, 2012),
LGBT older adults. and socioeconomic resources (Robert etal., 2009) may be
important predictors of physical and mental health QOL in
Resilience Framework these populations.
To better understand the ways in which LGBT older Equally important, the Resilience Framework allows us
adults achieve full health potential and successful aging, to assess the moderating role of age groups (aged 5064,
a resilience model incorporating a multidimensional and youngold age group; 6579, middleold age group; 80
life course perspective including the larger social con- and older, oldold age group), using terminology similar to
text as well as personal and social resources is essential. that which was first conceptualized by Neugarten (1974).
Resilience, defined as behavioral, functional, social, and Because this is the first study of LGBT aging with a major-
cultural resources and capacities utilized under adverse ity of participants over the age of 60 and a sizable group
circumstances (Fredriksen-Goldsen, 2007), is important aged 80 and older, we are able to examine differences
for cultivating successful aging. In fact, resilience is critical across these age groups.
specified in the model (including social risks, identity with 11 sites across the United States. Inclusion criteria for
management resources, social resources, health-promot- the study included age 50 and older and self-identification
ing behaviors, socioeconomic resources, and background as LGBT. Utilizing organizations contact lists, potential
characteristics) are significantly associated with physical participants were invited to complete and return a ques-
and mental health QOL (main effects), independent of age tionnaire, with two questionnaire reminder/thank you let-
group effect and other covariates; and, (c) there are age ters in one week intervals. A total of 2,560 participants
group differences in the influence of the explanatory factors meeting eligibility criteria completed the questionnaire
on physical and mental health QOL among LGBT older (including 2,201 hard-copy questionnaires for a response
adults (interaction effects). rate of 63% and 359 online). This analysis, N = 2,463,
included those who self-identified as gay, lesbian, or bisex-
ual, including transgender and nontransgender LGB older
Methods adults.
To test these hypotheses, we use data from Caring and All measures included in the study are detailed in Table1.
Variables Descriptions
Outcome variables
Physical and mental We measure physical and mental health QOL using eight items from the SF-8 Health Survey (Ware,
health QOL Kosinski, Dewey, & Gandek, 2001). The SF-8 Health Survey, a short version of SF-36, consists of two
components: physical and mental health. The physical health component asks participants to rate their
health over the previous four week period on physical functioning, limitations due to physical problems,
bodily pain, and general health. The mental health component assesses vitality, social functioning and
roles, and general mental health. The summary score for each component is standardized with a mean
of 0 and a standard deviation of 1, with higher scores indicating better perceived physical (Cronbachs
=.89) and mental health QOL (Cronbachs =.86).
Explanatory variables
Social risks Lifetime victimization and discrimination is measured using modified versions of the Lifetime
Victimization Scale (DAugelli & Grossman, 2001) and the Lifetime Discrimination Scale (Inter-
University Consortium for Political and Social Research, 2010). Participants are asked how many times
in their lives, because of their actual or perceived sexual and/or gender identity, they had experienced 16
different types of victimization and discrimination including physical, verbal or sexual threat or assault,
threat of being outed, property damage, being hassled or ignored by police, job-related discrimination,
being denied health care or receiving inferior health care, and being prevented from living in a
neighborhood they wanted. A4-point Likert scale was used, with summed score ranging from 0 to 46
(Cronbachs =.86).
Identity management Positive sense of sexual identity is measured with a modified version of the Homosexual Stigma Scale
resources (Liu, Feng, & Rhodes, 2009). Participants rate to what extent they agree with five statements such as
I feel that being lesbian, gay, bisexual, or transgender is a personal shortcoming for me and I have
tried to not be lesbian, gay, bisexual, or transgender. We reverse-coded the ratings. The summary score
ranges from 1 to 4, with higher scores indicating more positive sense of sexual identity (Cronbachs
=.78). Identity disclosure is measured with a modified version of the Outness Inventory scale (Mohr
& Fassinger, 2000). Participants were asked to what extent family members, a best friend, supervisor,
neighbors, faith community, and primary physician know the participants sexual and/or gender
identity. A4-point Likert scale is used, with summary scores ranging from 1 (definitely do not know) to
4 (definitely know), and Cronbachs is .92. Time length of sexual identity disclosure is measured, as
suggested by DAugelli and Grossman (2001), by subtracting the age of sexual orientation awareness
from the age of first disclosure and dividing by current age. We further subtracted the proportion from
1 in order to calculate the time proportion of sexual identity disclosure. The score ranged from .05 to 1
with higher scores indicating a longer time of disclosure.
Page 5 of 15 The Gerontologist, 2014, Vol. 00, No. 00
Table1. Continued
Variables Descriptions
Social resources Relationship status is dichotomized into being partnered or married (= 1)and not being partnered or
married (= 0; including single, widowed, separated, and divorced). Social network size is determined
by asking participants to report the number of people (e.g., friends, family members, colleagues,
and neighbors) they have interacted within a typical month by sexual and gender identity (gay men,
lesbians, bisexuals, transgender older adults, and heterosexuals) and age (age 50 and older or younger
than 50). We sum the total size and coded by quartiles with 1 indicating lowest 25% (small) and 4
indicating highest 25% (large). Religious or spiritual activity is measured by the frequency of attending
spiritual or religious services and activities in the last 30days. The degree of social support is measured
with the 4-item abbreviated Social Support Instrument (Sherbourne & Stewart, 1991). The summary
score ranged from 1 to 4, with higher scores indicating greater social support (Cronbachs =.85).
We measure community connectedness by 2 items asking the extent participants have positive feeling
(relationship status, social network size, religious or spirit- variables on the outcome variables. Robust estimator is
ual activity, social support, and community connectedness); used to calculate standard errors for statistical inferences.
health-promoting behaviors (physical activity, leisure activ- In the first model (Model 1), we examine the association
ity, routine health check-up, and substance nonuse); and between age group and outcome variables, controlling for
socioeconomic resources (household income, education, background characteristics. We add explanatory variables
and employment status) and other background characteris- indicated in the hypotheses in the second model (Model
tics (sexual identity, gender, gender identity, race/ethnicity, 2). In the last model (Model 3), to test whether or not the
geographic area, and number of chronic health conditions). relationship between explanatory variables and outcome
variables differ by three age groups, we add interaction
terms between selected variables and age group with the
Analyses youngold age group as the reference group. Because there
First, descriptive statistics and bivariate analysis are con- are three age groups, post hoc F tests are conducted to
ducted to explore the distributions of the outcome and detect potential differences between middleold and old
explanatory variables in the sample and across the three old age groups. Interaction terms that were at least margin-
age groups. Second, multivariate linear regression is used ally related to the outcome variables (p < .1) in the presence
to test the independent contributions of the explanatory of other covariates or whose corresponding post hoc tests
The Gerontologist, 2014, Vol. 00, No. 00 Page 6 of 15
reached .1 significance level, were retained in the model. To results of Monte Carlo error analysis, 40 imputations
better manage potential issues of multicollinearity associ- were adequate to provide stable and reproducible esti-
ated with interaction terms, all continuous variables were mation results (White, Royston, & Wood, 2011). All the
centered to 0 before they were entered to the model (West, statistical computations were carried out with Stata 13
Aiken, & Krull, 1996). (StataCorp, 2013).
Multiple imputation (MI) techniques were applied to
handle missing values across the analyses. Because MI
requires the missing mechanism be at least missing at Results
random (MAR), we first conducted a series of sensitiv- The distribution of the background characteristics and
ity analyses, as recommended by Carpenter , Kenward, explanatory variables by the three age groups is illustrated in
and White (2007). The results showed that with 40 Table2. By age group, 44% are aged 5064 (youngold age
imputations the estimations were stable and robust in group), 46% are 6579 (middleold age group), and 10% are
relation to the MAR assumption. Consistent with the 80 and older (oldold age group). The three age groups are
Total sample Age 5064 young Age 6579 middle Age 80+ oldold 2 or F test
(N=2,463) old (N=1,078) old (N=1,138) (N=247)
Background characteristics
Sexual identity < .001
Gay/lesbian 92.940 91.370 94.640 91.900
Bisexual 7.060 8.630 5.360 8.100
Gender, female 36.480 44.200 32.420 21.460 <.001
Transgender 4.120 6.520 2.660 .400 <.001a
Race/ethnicity .013a
White 86.850 84.790 87.360 93.500
African American 3.430 4.200 3.090 1.630
Hispanic 4.250 5.220 3.710 2.440
Other 5.470 5.780 5.840 2.440
Geographic area, urban 96.950 97.000 96.700 97.940 .588
Chronic conditions 1.945 (0.029) 1.642 (0.041) 2.164 (0.042) 2.259 (0.096) <.000
Social risks
Lifetime victimization and discrimination 6.406 (0.146) 7.404 (0.229) 6.067 (0.213) 3.608 (0.304) <.000
Identity management resources
Positive sense sexual identity 3.537 (0.011) 3.549 (0.017) 3.547 (0.017) 3.436 (0.040) .014
Identity disclosure 3.487 (0.013) 3.622 (0.108) 3.435 (0.085) 3.137 (0.440) <.001
Time length of disclosure .897 (0.003) .904 (0.005) .896 (0.005) .878 (0.014) .103
Social resources
Partnered or married 44.360 47.860 43.810 31.560 <.001
Social network size 2.492 (0.024) 2.556 (0.035) 2.474 (0.035) 2.294 (0.077) .006
Religious activity 2.028 (0.095) 2.014 (0.137) 2.056 (0.142) 1.962 (0.301) .948
Social support 3.103 (0.016) 3.123 (0.025) 3.102 (0.023) 3.016 (0.048) .163
Community connectedness 3.420 (0.015) 3.468 (0.023) 3.413 (0.023) 3.240 (0.051) <.001
Health-promoting behaviors
Physical activity 85.220 86.750 85.920 75.210 <.001
Leisure activity 5.136 (0.050) 4.771 (0.073) 5.405 (0.068) 5.563 (0.149) <.001
Routine health check-up 82.790 76.410 87.540 88.800 <.001
Substance nonuse 75.110 68.640 78.860 87.390 <.001
Socioeconomic resources
Income, above 200% FPL 70.070 74.370 67.610 61.990 <.001
Employment 43.920 65.550 29.860 14.230 <.001
Education, some college 92.260 93.280 91.640 90.650 .215
heterogeneous regarding their background characteristics, Next we test whether the influence of explanatory
with the exception of urbanicity. The majority of the partici- variables on the outcome variable differs by age group
pants (93%) self-identify as gay or lesbian, although the mid- by adding interaction terms and coding the youngold
dleold age group shows a higher proportion of those gay or group as the reference group (Table3, Model 3; hypoth-
lesbian compared to the youngold and oldold age groups. esis c). For example, the regression coefficient for lifetime
The proportions of female, transgender adults, and racial and victimization and discrimination (b = .021; p < .01)
ethnic minorities are the highest for the youngold age group indicates negative influence of lifetime victimization and
and the lowest for the oldold age group. On average, partici- discrimination on physical health QOL for the youngold
pants have two chronic health conditions with the youngold age group. The negative sign of regression coefficient for
age group having the lowest number of chronic conditions. the interaction term, Age 80 Lifetime victimization and
In terms of social risks the participants, on average, discrimination (b=.020; p < .10), indicates that the neg-
report 6.5 lifetime victimization and discrimination ative influence for the oldold age group is marginally sig-
events; the youngold age group shows the highest, and nificantly stronger when compared to the youngold age
Table3. The Results of Linear Regression of Age Group and Key Study Variables on Physical Health QOL
SE SE SE
Background characteristics
Age
5064 (Ref) (Ref) (Ref)
6579 .027 0.040 .056 0.042 .281 0.158
80 and older .213** 0.066 .142* 0.068 .371 0.240
Sexual identity
Gay/lesbian (Ref) (Ref) (Ref)
Bisexual .095 0.079 .034 0.071 .009 0.072
< .1; * < .05; ** < .01; [.] represented the comparisons between middleold and oldold using post hoc F test.
for the middleold age group, although the positive influ- more likely to be influenced by routine health check-up
ence of substance nonuse is stronger for the youngold and chronic conditions compared to the youngold age
and middleold age groups. The middleold age group is group.
Page 9 of 15 The Gerontologist, 2014, Vol. 00, No. 00
Table4. The Results of Linear Regression of Age Group and Key Study Variables on Mental Health QOL
SE SE SE
Background characteristics
Age
5064 (Ref) (Ref) (Ref)
6579 .168** 0.042 .153** 0.040 .167 0.175
80 and older .055 0.068 .074 0.067 .079 0.340
Sexual identity
Gay/lesbian (Ref) (Ref) (Ref)
Bisexual .210* 0.089 .084 0.075 .067 0.076
Table4. Continued
SE SE SE
< .1; * < .05; ** < .01; [.] represented the comparisons between middleold and the oldold group using post hoc F test.
The LGBT older adult participants in the youngold The lower levels of social network size and commu-
group came of age in the 1970s when the modern gay nity connectedness are of particular concern for the old
movement emerged, with an emphasis on identity disclo- old LGBT age group. LGBT individuals in the oldold
sure and coming out of the closet as a new way of life age group rely more heavily on peer-based support than
and valuable political praxis. For the oldold age group, older adults of comparable age in the general population,
concealing their sexual and gender identities seems to have which may dwindle with aging due to death, relocation,
been protective and in fact may have resulted in lower and impairment of peers. This may place the LGBT old
rates of lifetime victimization and discrimination, a func- old, the long-term survivors, at serious risk of social isola-
tion of the realities of the historical time, including laws tion, which in the general population has been linked to
that criminalized same-sex sexual behavior. Yet, these pro- poor mental and physical health, higher levels of cognitive
tective mechanisms may have simultaneously heightened impairment, and premature disease and death (Ailshire &
their vulnerability to the potential negative consequences Crimmins, 2011). Although it is common for social net-
of victimization and discrimination. Although this cross- work size to diminish over time in old age, Johnson and
extends earlier work by investigating the association of the need of an education to support themselves financially.
leisure activity as a potential health-promoting behavior Further research is needed to examine whether the poten-
among LGBT older adults, consistent with other studies of tial cumulative effect of education on health-related QOL
older adults in the general population (Hutchinson, Bland, gets stronger with age in these populations.
& Kleiber, 2008). Although leisure activities among LGBT The levels of physical and mental health QOL for
populations have rarely been included in empirical studies, women in this study are lower than those for men.
it has been suggested by Iwasaki and Ristock (2004), that Whereas a previous study observed no gender differences
leisure space is considered an oasis for gays and lesbians in mental health among LGB older adults (Grossman,
that re-charge[s] themselves physically, emotionally, and DAugelli, & OConnell, 2002), other studies of older
psychologically and facilitates a sense of empowerment adults in the general population find a similar pat-
to proactively cope with stress in a world where homopho- tern (Orfila et al., 2006; Pinquart & Sorensen, 2001).
bia and heterosexism still exist. Although we observe a significant difference in mental
The result of interaction effect analyses indicates that health QOL among Hispanics compared to White LGBT
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