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Karen I. Fredriksen-Goldsen, PhD University of Washington

Health, Aging and Sexuality in Marginalized Communities: LGBT Older Adults Emerging from the Margins. Karen I. Fredriksen-Goldsen, PhD University of Washington (Funded in part by NIH/NIA, 1R01AG026526-01A2 ; 2R01AG026526-03A1 )

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Karen I. Fredriksen-Goldsen, PhD University of Washington

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  1. Health, Aging and Sexuality in Marginalized Communities:LGBT Older Adults Emerging from the Margins • Karen I. Fredriksen-Goldsen, PhD • University of Washington • (Funded in part by NIH/NIA, 1R01AG026526-01A2; 2R01AG026526-03A1) • CCBAR Annual Meeting ▪ University of Chicago ▪ October 17, 2013

  2. Marginalization, Health & Aging • Health and Aging in Marginalized Communities • HIV and Medication Adherence in China • Healthy Hearts in Tulalip Native Community • National Health, Aging and Sexuality: Caring and Aging with Pride Over Time

  3. Diversity in Aging • Global worldwide aging • By 2050, 130 million 50 and older (U.S. Census, 2012) • 42% people of color (Vincent & Velkoff, 2010) • Two million LGBT adults, age 50 and older • Increasing number of diverse LGBT older adults

  4. Research Gaps • Sexual orientation key gap in health research (NIH, 2012; CDC, 2011) • LGBT people at-risk and underserved (Institute of Medicine, 2011) • First time in Healthy People 2020 (DHHS, 2011) • Rapidly changing social context, policies and laws

  5. Closing the Gap • Behavioral Risk Factor Surveillance System (BRFSS-WA) • Caring and Aging with Pride: Community-based • 2,560 LGBT older adults, age 50 to 95 • Testing of Complex Social Network Driven Sampling • Continuation: Longitudinal Study

  6. Figure 1. Non-response: Sexual Identity Question Over Time Time Trends in Rates of “Refuse to Answer” on Sexual Orientation by Age: Washington State Behavioral Risk Factor Surveillance System (BRFSS-WA), 2003-2010

  7. Table 1. Non-response to Sexual Orientation Questions by Race and Ethnicity Note. ref=the reference group; AOR=adjusted odds ratio; CI=confidence interval; those who self-identified as “heterosexual or LGB” were treated as the baseline group; the analysis controlled for age, income, education, and year of interview. *P<.05; **P<.01; ***P<.001 Kim. H.-J. & Fredriksen-Goldsen, K. I. (2013). Nonresponse to a Question on Self-Identified Sexual Orientation in a Public Health Survey and its Relationship to Race and Ethnicity. American Journal of Public Health, 103(1), 67-69. doi:10.2105/AJPH.2012.300835. NIHMSID: NIHMS503953

  8. Table 2. BRFSS-WA Health Disparities: Disability and Mental Distress by Sexual Orientation and Gender AOR = Adjusted Odds Ratio. Reference Group = Heterosexuals *p < .05. **p < .01. ***p < .001 Data source: Washington State Behavioral Risk Factor Surveillance System, 2003-2010. Fredriksen-Goldsen K. I., Kim, H.-J., Barkan, S. E., Muraco, A., & Hoy-Ellis, C. P. (2013). Health Disparities among Lesbian, Gay, and Bisexual Older Adults: Results from a Population-Based Study, American Journal of Public Health, 103(10), 1802-1809. doi: 10.2105/AJPH.2012.301110

  9. Health Disparities: Distinct Risks • Lesbians and bisexual women: CVD risk and obesity • Gay and bisexual men: Poor physical health and living alone • “LGBT” is often used in research and services yet they are distinct groups with specific needs

  10. Figure 2. Health Equity Model Social Positions (intersectionality) Multi-level context Structural levels (social exclusion, institutional heterosexism) Individual levels (micro-aggressions, discrimination, victimization) Health Physical (physical health-related quality of life, HIV, obesity, cancer, CVD, disability) Mental (mental health-related quality of life, anxiety, depression, suicidal ideation) • Adverse and Health-Promoting Pathways • Psychosocial (distinct social relations, social support, social network, LGBT community integration) Behavioral (exercise, diet, preventative care, sexual behavior, smoking) • Biological (higher cortisol levels, allostatic load) Life course (risks and opportunities)

  11. Life Course Perspective • Social context • Cultural meaning • Structural location • Pre-and Post-Stonewall • Silent Generation • Baby-Boomer

  12. Research Hypotheses Based on the Health Equity Development model: • We hypothesize that when controlling for social positions, elevated degrees of discrimination, stigma and non-disclosure of sexual orientation will be significantly associated with lower levels of physical and mental health related quality of life. • We hypothesize that the configuration of structural, psychological, and behavioral explanatory factors predicting physical and mental health related quality of life, including degrees of discrimination, stigma and non-disclosure of sexual orientation, will be dissimilar for three age groups (age 50-64, age 65-79, and age 80 and older) of LGBT midlife and older adults.

  13. CAP Survey: Risk & Protective Factors • Community Participatory Integrated Research (CPIR) • Eleven community partners • West, central and east regions • Reach across 48 states • 2,560 LGBT older adults, age 50 to 95 • Response rate: 63% • Service users: 28%

  14. Table 3. Measures

  15. Table 3. Measures (cont)

  16. Table 4. Background Characteristics

  17. Table 5. Explanatory and Outcome Variables

  18. Table 6. Explanatory and Outcome Variables

  19. Table 7. Model Fitting for Physical HRQOL

  20. Figure 3. Lifetime Discrimination and PHQOL by Age Groups

  21. Table 8. Model Fitting for Mental HRQOL

  22. Figure 4. Lifetime Discrimination and MHQOL by Age Groups

  23. Summary of Key Findings • Identifies potentially modifiable factors associated with physical and mental health related quality of life of LGBT mid-life and older adults. • Lifetime discrimination, lack of physical activities and poverty are common correlates of physical and mental health quality of life of LGBT adults, midlife and older. • Social positions, structural and psychosocial processes and health behaviors differ by age groups. • Even among the common correlates, the degree of influence may differ by age groups. • The degree of lifetime discrimination is lower for older age groups, while the degree of internalized stigma is higher and the degree of sexual orientation disclosure is lower for older age groups. Non-disclosure for LGBT older adults may reduce risk of discrimination. Younger age group has higher degrees of discrimination, lower stigma and more disclosure. • Limitations of study: cross-sectional, not generalizable, participants connect to community agencies, self-report measures.

  24. Moving Forward National Health, Aging and Sexuality Study: Caring and Aging with Pride Over Time Next phase: LGBT mid-life and older adults, over time in order to test the theoretically specified model to understand the temporal relationships that may be amenable to change through targeted interventions. Participants, 50 and older, 3 points in time

  25. Cohorts Baby Boom Generation (born between 1947-1963) Silent Generation (born before 1947) Cohort differences and changing social context Multiple birth cohort design Analysis of cohort effects from age effects

  26. Sample Hard to reach communities Some subgroups hidden within hidden populations Goal: Obtain a demographically diverse sample of LGBT older adults Ensure coverage of the heterogeneous nature of the populations Address noncoverage, overrepresentation, and other selection biases

  27. Perceived Stress Lifetime Victimization Everyday Discriminationa Health and Quality of Lifea Adverse Health Behaviorsa Physiological Response to Stressa Sexual Identity Management & Social Resources Longitudinal Model Age effect, Cohort effect, Social positions (Gender and Race/Ethnicity)

  28. Biological Measures • Investigate link of poor physical health via allostatic load (AL), a physiological stress-related mechanism linking the psychosocial environment to physiological dysregulations • AL measures: waist-to-hip ratio, blood pressure, cortisol, DHEA-S, total cholesterol, HDL cholesterol, hemoglobin A1c (blood sugar), and C-reactive protein. • Non-invasive dried blood spots (DBS) • Hypothesis: Controlling for lifetime victimization and other confounding variables, changes in physiological response to stress and health behaviors will partially mediate the effect of change in discrimination on subsequent health and QOL

  29. Discussion – How can we maximize the use of bio-measures in this study and obtain quality information given limited resources?  Next Steps

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