Exploring Inequality At End-of-Life for the LGBTQ+ Community

In recognition of Pride Month, the End Well team is exploring the distinct challenges LGBT older adults face in healthcare, caregiving, and end-of-life planning.

An estimated 2.4 million Americans over age 65 identify as lesbian, gay, bisexual, or transgender, according to the American Psychological Association. Many will encounter greater obstacles when seeking care and support near the end of life.

Known disparities include:

• Poorer mental and physical health related to the cumulative stress of living within a marginalized community
• Discrimination based on sexual orientation, gender identity, and age
• A greater risk of social isolation

These inequalities affect nearly every aspect of aging, from housing and healthcare to caregiving and end-of-life support. Within the End Well community, we are also learning that the barriers can be especially pronounced for LGBT older adults who belong to other marginalized groups.

Identifying Bias and Discrimination in Healthcare

A provider’s beliefs can shape how they treat LGBT patients. Implicit bias may prevent older adults from receiving the care they need or discourage them from seeking care at all.

In a SAGE survey, nine percent of respondents reported that a physician had used harsh or abusive language while treating them. The percentage was even higher among transgender respondents.

The language used to describe gender, sexuality, and relationships in healthcare settings can also create fractured communication between patients and clinicians.

In a helpful series of posts, E. Kale Edmiston, PhD, explains the limitations of defining patients through marital status or gender identity alone.

Binary language can reinforce stereotypes and alienate LGBT people from the healthcare system. To provide more inclusive care, clinicians should ask patients how they describe themselves, their relationships, and the people who matter most in their lives.

Learning From LGBT Caregivers

A survey conducted by the Williams Institute found that only 29 percent of the LGBT population was raising children.

Care from a family member is never guaranteed, regardless of sexual orientation. But for LGBT older adults without children, and for those who are estranged from relatives, finding support can be especially difficult and may intensify anxiety about aging.

As 68-year-old Paul Glass asked:

“When we get older and we have to depend on others, how will we be treated?”

Many systems of elder care in the United States assume that biological children or grandchildren will care for older relatives.

“In a country where most elder care is left to family, many LGBTQ people are estranged from relatives and don’t have that option. Turning to others for care, in assisted living centers, nursing homes or hospice settings, makes them uniquely vulnerable.”

This traditional caregiving structure is often based on a heteronormative understanding of family. In cultures where care from children is strongly expected, LGBT older adults without that support may experience even greater stress.

LGBT older adults are twice as likely to age alone. Many rely instead on friends, neighbors, former partners, and coworkers, a model sometimes described as horizontal caregiving.

“Older gays and lesbians can’t always depend on close relatives as caregivers. The report found that LGBTQ seniors were three to four times less likely to have children than their heterosexual peers. But many have developed strong ‘peer-to-peer’ networks, sharing holidays and checking on each other, especially those who live far from where they grew up or who are estranged from their relatives.”

These chosen families and peer networks offer an important model of care built around mutual support rather than biological relationships alone.

Housing, Safety, and the Fear of Re-Closeting

More than half of LGBT older adults surveyed by AARP expressed concerns about housing discrimination.

Faced with limited options, some fear they will have to conceal their identities again when entering assisted living, nursing homes, or other long-term care settings.

Many LGBT older adults want facilities with staff who understand and respect their lives and identities. Those options remain limited by geography, availability, and cost.

Some residents have also reported bullying and abuse from homophobic staff members or other residents.

“Last summer, in Missouri, a married lesbian couple, Mary Walsh, 73, and Bev Nance, 69, sued a senior-living facility that denied their housing application. The Friendship Village assisted living center cited a ‘cohabitation policy’ that defines marriage as between one man and one woman as the reason.”

Creating Better Care

Too few healthcare and long-term care settings have created environments where people who have experienced discrimination feel safe and welcome.

As a result, LGBT older adults may be less likely to seek preventive care, increasing their risk of developing or managing serious health conditions without adequate support.

Those who are aging alone may also struggle to identify someone they trust to discuss their end-of-life wishes or act on their behalf.

“Talking about the end of one’s life can be exceedingly difficult for LGBT seniors, according to aging experts, because of their lack of trust in their health care providers or not having close familial or social connections, leaving them without a family member or friend they can turn to and discuss how they want to be cared for as they age.”

As we explore what it means to end well, we must listen to communities that have experienced exclusion and discrimination.

Creating spaces that are safer, more dignified, and more inclusive for LGBT older adults strengthens care for everyone. It moves us closer to a system that recognizes the full person, honors every form of family, and provides compassionate support through the very end.