Differences by Sexual Orientation in Expectations About Future Long-Term Care Needs Among Adults 40 to 65 Years Old

Objectives. We examined whether and how lesbian, gay, and bisexual (LGB) adults between 40 and 65 years of age differ from heterosexual adults in long-term care (LTC) expectations.Methods. Our data were derived from the 2013 National Health Interview Survey. We used ordered logistic regression to compare the odds of expected future use of LTC among LGB (n = 297) and heterosexual (n = 13 120) adults. We also used logistic regression models to assess the odds of expecting to use specific sources of care. All models controlled for key socioeconomic characteristics.Results. Although LGB adults had greater expectations of needing LTC in the future than their heterosexual counterparts, that association was largely explained by sociodemographic and health differences. After control for these differentials, LGB adults were less likely to expect care from family and more likely to expect to use institutional care in old age.Conclusions. LGB adults may rely more heavily than heterosexual adults on formal systems of care. As the older population continues to diversify, nursing homes and assisted living facilities should work to ensure safety and culturally sensitive best practices for older LGB groups.According to some estimates, approximately 4% of American adults aged 18 years or older self-identify as lesbian, gay, or bisexual (LGB),1 including more than 1.5 million LGB adults aged 65 years or older.2 This number is projected to grow to nearly 3 million by 2030.2 Research has shown that LGB individuals report worse physical and mental health outcomes and are more likely to engage in harmful health behaviors than their heterosexual peers.3,4 Public health studies often attribute LGB health disparities to minority stress, or the chronic stress associated with being a member of a marginalized minority group.5–9Elderly LGB individuals are particularly vulnerable to poor health outcomes owing to minority stress because of their experiences of stigma, discrimination, and violence.10–12 Recent studies involving data from California and Washington State indicate that LGB adults aged 50 years or older are more likely than their heterosexual counterparts to report symptoms of psychological distress, physical disability, and chronic disease; they are also more likely to report that their overall health status is poor.13–15Older LGB adults in same-gender relationships, especially women, are more likely than older heterosexual adults to need assistance with activities of daily living (ADLs) such as dressing, bathing, and doing errands alone,16 signaling a greater need for long-term care (LTC) services and support in later life.17 Such services and support might include assistance with ADLs (e.g., dressing, bathing, eating), instrumental ADLs (e.g., running errands, managing medications, preparing meals), and clinical or nursing tasks (e.g., pain management, physical or occupational therapy, management of incontinence). LTC may be provided in the home or community setting, by paid or unpaid caregivers, or in institutional settings. Although LGB individuals may have an elevated need for LTC services in later life, we are not aware of any studies examining differences in LTC expectations according to sexual orientation.Most Americans will need LTC at some point in their lives.18 According to current projections, nearly three quarters of all Americans will use LTC during their lives, and nearly half of Americans aged 65 years or older will spend time in a nursing home.18,19 However, middle-aged Americans have unrealistically low expectations of needing LTC,20 and very few people plan for it by either purchasing LTC insurance or making other advanced arrangements.21 This situation may be partly attributable to the high cost of LTC insurance premiums.22 Another major reason why people may not plan ahead for LTC is that they expect family members or close relatives to step in and provide care should they need it.20 This aligns with current use of unpaid caregivers, with approximately 80% of older adults reporting that family members provide the majority of their noninstitutional care.23However, older LGB adults may have different family structures than older heterosexual adults1; for example, they are less likely to be married, less likely to have children, and more likely to experience conflict with their family of origin.2,24,25 Older LGB adults, especially men, are more likely than their heterosexual counterparts to live alone,13,15,26,27 which is a major risk factor for both needing LTC and having unmet care needs.28–30Furthermore, although LGB individuals often exhibit distrust in formal LTC systems,31,32 one study showed that older LGB adults are only half as likely as older heterosexual adults to depend on close relatives for help.2 More than a quarter of LGB older adults report apprehension about discrimination as they age and how it may be manifested in institutional discrimination on the part of health care providers, including LTC providers.33 This should concern practitioners and policymakers given that the older LGB population is growing and our current system of LTC may be inappropriate to meet the needs of this group.Unfortunately, very little is known about LTC expectations among LGB populations. Research on the general population has shown that LTC expectations and planning behaviors are patterned according to demographic characteristics. Characteristics that may promote LTC planning include older age, female gender, being married, being White, having a college education or above, and having previous experience with LTC.21 Research suggests that LGB older adults are poorer and less financially secure than heterosexual older adults, in part because of limited employment opportunities resulting from institutional and personal discrimination34 and limited (or lack of) ability to receive partner benefits or property inheritances.35 Yet, as noted, there is a dearth of literature examining differences in LTC expectations by sexual orientation.3The few studies that have examined LTC expectations in older LGB populations indicate that these individuals may use nursing homes sooner than the general population owing to a lack of caregivers at home.2,33 LGB older adults in institutional facilities may be at heightened risk of neglect and abuse as a result of limited knowledge and training among providers and, sometimes, blatant discrimination on the part of staff and fellow residents.36One survey of LGB older adults and their families indicated that LGB adults were more likely than heterosexual adults to be harassed or mistreated in LTC facilities.37 Altogether, 328 respondents reported 853 instances of mistreatment among LGB older adults in LTC settings.37 Thus, some LGB older adults may avoid nursing homes because of barriers such as fear of discrimination and abuse, concerns about going “back into the closet,” and a reluctance to be separated from their partners.2,32 Instead of using formal LTC settings, some older LGB adults rely on friends and LGB-specific community organizations for assistance in later life.33 Older LGB adults who do reside in institutional settings may keep their sexual orientation a secret or seek out welcoming service providers.In this study, we sought to fill gaps in existing research by comparing LTC expectations among LGB and heterosexual adults aged 40 to 65 years. Whereas older heterosexual adults may expect to rely on their children and spouses for support in later life, the same may not be true for LGB adults. The findings of this study will be especially important for public health practitioners and policymakers planning for future LTC needs in aging populations.