Throughout the world, people are living longer, and their quality of life, to a large extent, is determined by their health status. Over the past century, a major shift occurred in the leading cause of death for all age groups, from infectious diseases and acute illnesses to chronic diseases and degenerative illnesses. Global estimates for disability are increasing due to population aging and the rapid spread of chronic diseases, as well as improvements in the methodologies used to measure disability (WHO 2011). Moreover, WHO (2011) suggests that disability is part of the human condition in which everyone will be temporarily or permanently impaired at some point in life. Persons who reach old age will experience increasing difficulties in functioning. Two out of every three older Americans have multiple chronic conditions and accounts for 66 % of the country’s healthcare budget (Centers for Diseases Control and Prevention 2013; National Institute on Aging [NIA], National Institutes of Health [NIH] 2011). The National Report on Healthy Aging reports on 15 indicators of older adult health, which are grouped into four areas: health status, health behaviors, preventive care and screening, and injuries. Eight of the 15 indicators are contained in Healthy People 2020. To date, the USA has met six of the Healthy People 2020 targets (i.e., leisure time physical activity, obesity, smoking, taking medications for high blood pressure, mammograms, and colorectal cancer screenings), with most states ahead of schedule on four health indicators for older adults (i.e., obesity, medications for high blood pressure, mammography, smoking), and with significant work to do on other indicators for older adults (i.e., flu vaccine, pneumonia) (Centers for Disease Control and Prevention). The Centers for Disease Control and Prevention identifies the areas where services are most needed for LGBT elders: housing, transportation, legal services, and chronic disease prevention.

Heart disease and cancer pose the greatest risks as people age, and for older adults, other chronic diseases and conditions including Alzheimer’s disease, diabetes, chronic lower respiratory, stroke, influenza, and pneumonia represent the major contributors to deaths (Centers for Disease Control and Prevention 2013; WHO 2011). Typically, older adults have multiple illnesses; the varied nature of these conditions requires intervention from multiple healthcare specialists, various treatment regimens, and prescription medications that may not be compatible. Because of these multiple conditions, older adults are at an increased risk for having conflicting medical advice, adverse drug effects, unnecessary and duplicative tests, and avoidable hospitalizations (Centers for Disease Control and Prevention).

Although disability correlates with disadvantage, not all persons with disabilities are equally disadvantaged. Women, the elderly, the poorest, and those with more severe impairments experience greater discrimination and barriers (WHO 2009, 2011). LGBT elders are represented consistently across these groups. The documentation of widespread evidence of barriers that are identified by WHO (2011) (see Table 33.3) for persons with disabilities parallels the barriers experienced by LGBT elders.

The status of aging, health, and disability discussed in this section is relevant to LGBT elders. In addition, LGBT older adults have complex outcomes for chronic illness and disabilities. The following section examines the occurrence of health and disability-related conditions that are specific to LGBT elders.

Physical disability occurs frequently in older adults and is “an outcome of diseases and physiological alterations with aging, with the impact of these underlying causes modified by social, economic, and behavioral factors as well as access to medical care” (Fried et al. 2004, p. 256). With the diversity of life span, health outcomes, and other individual variations among older persons, elders are frequently identified as vulnerable because of comorbidity (multiple chronic conditions), frailty, and disability. Fried et al. assert that these clinical entities are distinct but causally related in that both frailty and comorbidity predict disability , disability exacerbates frailty and comorbidity, and comorbid diseases may contribute, at least additively, to the development of frailty. No distinction is made between the older population and older LGBT adults for these clinical entities. Over two decades ago, Fine and Asch (1988) asserted that almost all research on adults with disabilities seemed to assume the irrelevance of sexual orientation and presume that having a disability eclipses social experience. To date the majority of research on aging and disability and chronic illness continues to ignore LGBT elders. For LGBT persons with disabilities, a disability is likened to living in the “second closet” (Benedetti 2011). Thus, only estimates of the full extent of LGBT health disparities are possible due to a consistent lack of data collection. The main areas of disparity are access to health care, HIV/AIDS, mental health, and chronic physical conditions (MAP and SAGE 2010).

Understanding chronic conditions and disability among LGBT elders is increasingly important for several reasons: (a) advances in medicine, public health, rehabilitation, and technology have increased life expectancy for persons with disabilities; (b) LGBT elders have limited access to culturally sensitive and LGBT-affirmative service; (c) older adults are remaining in the workforce longer; (d) LGBT elders are among the poorest of the poor, especially women; (e) LGBT elders have higher rates of health disparities; and (f) quality of life is compounded by the intersection of age, sexual orientation or gender identity, and disability (Harley 2015). Increasing numbers of older adults living to reach old age (including LGBT elders) have changed the demographics of disability (Sheets 2010). The case of Gloria below is an illustration of a lesbian who acquired a disability earlier in life and additional chronic illness es as she aged.

LGBT older adults are at an elevated risk of disability and mental distress, with 31 % reporting depression and more than 53 % of transgender older adults at risk of both disability and depression. The rates of disability among LGBT elders are also distinguishable by gender, with sexual minority women’s health being significantly lower than men and heterosexual women. Older gay and bisexual men are more likely to experience poor physical health compared to heterosexual men. Bisexual men have significantly higher rates of cardiovascular disease than gay men. Transgender older adults are more likely than non-transgender older adults to have obesity, cardiovascular disease, asthma, and diabetes. Lesbians and bisexual women have similar rates of vision, hearing, and dental impairments; bisexual men have more vision impairments than gay men, and transgender older adults have more sensory and dental impairments than their non-transgender counterparts. Older lesbians are significantly more likely to engage in heavy drinking as compared to older bisexual women (Fredriksen-Goldsen 2011; Fredriksen-Goldsen et al. 2011).

In a study of disparities and resilience among LGBT older adults, Fredriksen-Goldsen et al. found that 41 % of the participants in the project had limitations in their physical activities as a result of physical, mental, or emotional problems. Of this percentage, 21 % were using adaptive equipment. An examination of the combination of LGBT older adults with limits in physical activities and the use of adaptive equipment reveals that 47 % have a disability, including 53 % of lesbians, 51 % of bisexual women, 41 % of gay men, 54 % of bisexual men, and 62 % of transgender older adults. Collectively, LGBT elders have diagnoses of high pretension (45 %), high cholesterol (43 %), arthritis (35 %), cataracts (22 %), asthma (16 %), diabetes (15 %), hepatitis (11 %), and osteoporosis (10 %). It is unknown if the rate of Alzheimer’s disease among LGBT elders is different than the general elderly population.

The American Community Survey (ACS) is a general household survey conducted by the US Census Bureau and is designed to provide communities with reliable and timely demographic, economic, and housing information. An examination of ACS (Population Association of America 2014) data, from the 2009–2011, reveals that the prevalence of disability among older adults in same-sex relationships varies by gender and relationship type, and by type of disability . Overall, 17.5 % of older men in same-sex relationships were living with a disability compared to 20.8 % of married men and 21.5 % of unmarried men in opposite-sex relationships. Men in same-sex relationships were less likely to report difficulty in cognitive, ambulatory, self-care, and sensory functions compared to married and unmarried men in opposite-sex relationships. However, men in same-sex relationships were slightly more likely to report difficulties with independent living. On the other hand, women in same-sex relationships reported higher levels of almost all disability types compared to their married and unmarried counterparts in opposite-sex relationships, including any disability and difficulty in ambulatory, self-care, sensory, and independent living functions. The prevalence of cognitive difficulty for women in same-sex relationships was less than that of women in unmarried opposite-sex relationships, but more than that of women in married opposite-sex relationships. In summary, these data provide evidence of national disparities in disability between older adults in same-sex relationships compared to older adults in opposite-sex relationships. And, this relationship is especially strong and consistent for women (Populations Association of America).

Overall, mental health of LGBT elders is good (70.8 on a scale of 0 = very poor to 100 = excellent). In rating satisfaction with their life, lesbians report (71.8), bisexual women (65.6), gay men (71.7), bisexual men (65.6), and transgender older adults (62.7). Thirty-one percent of LGBT elders report some type of depressive symptoms, with 53 % having been told by a doctor that they have depression. Transgender older adults have the highest rate of depression (48 %), and lesbians (27 %) and gay men (29 %) have the lowest, and 24 % of LGBT older adults have been told they have anxiety (Fredriksen-Goldsen et al. 2011). Two of the most alarming mental health issues for LGBT elder are loneliness and social isolation (see Chap. 30). Both of these issues can lead to negative health consequences or be the result of chronic illness and disability . Older bisexual women and men exhibit higher rates of loneness than lesbians and gay men. The rates of neglect experienced by LGBT elders are similar to the general elderly population, and their rates of mistreatment tend to be higher (see Chaps. 16, 17, and 21 in this text). Across the categories of physical and mental health, transgender older adults fair worst than other LGB elders. The prevalence of physical and mental health problems is elevated among LGBT elders even taking into account differences in age distribution, income, and education; however, those LGBT elders with lower incomes and lower education are at more heightened risk (Fredriksen-Goldsen et al.).

Much of the sparse research that has been done on LGBT elders with disabilities has looked at either physical or mental disabilities. There is a clear lack of focus on LGBT older adults with developmental disabilities. This is especially disconcerting for two reasons. First, many persons with developmental disabilities have the same life expectancy as the general population. Second, while most people begin to experience the effects of aging in their 40s, some persons with a developmental disability may require a greater level of support at a younger age than the general population. The later reason requires more attention be given to factors associated with aging such as changes in social roles, activity levels, behavior patterns, and response to occurrences in the environment and health conditions (Connect Ability 2010). Some characteristics of aging may mask symptoms of a developmental disability and vice versa. For example, an older adult with Alzheimer’s may exhibit a lack of insight or an inability to articulate what he or she is experiencing, both of which are characteristic of cognitive impairment associated with a developmental disability and Alzheimer’s disease.

LGBT elders with disabilities and chronic conditions may find themselves facing issues of coming out or coming out again as needs for social services increase (Sue and Sue 2013). It is important for them to understand and be prepared for the potential negative responses they may receive as they complete the application process for services. For example, the answers that they provide on an application may inadvertently expose them to discrimination. Thus, LGBT elders’ application for services because of a disability may be overshadowed by a service provider’s preoccupation and bias with their sexual orientation or gender identity. Discussion Box 33.1 provides some examples of implications for practice.

Disability is complex, and the interventions to overcome the challenges associated with disability are multiple and systemic, varying with the context (WHO 2011). An area of critical concern for elders is affordable housing as they age-in-place. LGBT elders identify housing as the number one priority for action in a needs assessment conducted by Senior Action in a Gay Environment (SAGE) (Funders for Lesbian and Gay Issue 2004). Moreover, housing discrimination is of primary concern, including “trepidation” about mainstream senior housing options (Knauer 2009; National Gay and Lesbian Task Force 2006). Implicit in affordability is accessible housing that will allow elders to maintain independence, quality of life, and safety in terms of both the condition of the dwelling and residential location. The ability to obtain adequate and safe housing affects all aspects of life (e.g., employment, proximity to friends and family, access to services), and the relationship between housing and other aspects of everyday life is particularly important for older persons who may be more restricted because of their mobility, income, and support systems (Equal Rights Center 2014).