This type of scenario is all too familiar. LGBTQIA+ older adults often face layered vulnerabilities. These include stigma related to sexual orientation or gender identity, age-related health changes, and increasing reliance on family members who may not be supportive. When these factors combine, they create heightened risks for psychological and physical harm. While gender-affirming care (GAC) can buffer against these harms, discriminatory or dismissive encounters in health care settings often have the opposite effect (Pereira H and Banerjee D, Front Psychiatry 2021;12:756649).

Globally, about one in six older adults experiences some form of elder abuse. LGBTQIA+ older adults are at even greater risk (Yon Y et al, Eur J Public Health 2019;29(1):58–67). Abuse can take many forms and may come from institutions, caregivers, romantic partners, or even housemates. It is often not physical. More commonly, it involves subtle patterns of power and control, especially when the older adult depends on others for housing, transportation, or help with daily tasks.

Risks for LGBTQIA+ older adults
LGBTQIA+ older adults often face unique challenges when making decisions about their care. Family members may try to override the wishes of a same-sex or gender-diverse partner. In some cases, individuals are pressured to change their gender presentation or even stop gender-affirming treatments like hormones, a process sometimes referred to as forced detransition (Lampe NM et al, Int J Aging Hum Dev 2024;98(1):39–55).

Although certain legal protections exist in the US, recent policy shifts have shown that rights can be rolled back. Many LGBTQIA+ adults, especially those now in older age, have spent their lives finding ways to protect themselves legally. This includes adopting their children, drawing up legal paperwork for their partners, or even moving abroad. These additional stressors often overlap with other forms of disadvantage, compounding the impact on mental and physical health (Desjardins G et al, Psychoneuroendocrinology 2022;145:105916).

Without strong legal planning, ­LGBTQIA+ older adults are at risk of losing control over how they live and how they express their identities in later life. This can affect both social and medical aspects of gender expression. For example:

Older adults may be pressured to stop hormone therapy or discouraged from expressing their gender identity through clothing or personal items.

Family members or caregivers may withhold access to gender-affirming items (eg, makeup, jewelry, specific clothing).

In institutional settings, staff may use a person’s former name (an act known as deadnaming) or fail to use correct pronouns.

You offer Petra referrals to local clinicians who provide GAC and connect her with trusted community resources. Petra has decision-making capacity, so her niece does not need to be involved in care decisions. You reinforce Petra’s rights and discuss the option of naming a health care proxy to preserve her autonomy if her capacity changes in the future.

Supporting LGBTQIA+ older adults 

Gender and sexuality
Gender and sexuality may be explored at any age. Ask about important relationships using gender-neutral language. Don’t overlook bisexual patients—they’re often ignored in clinical settings and face higher rates of isolation and worse medical and mental health outcomes (Lampe et al, 2024). Ask intersex clients about childhood surgeries and their experiences with gender and sexuality—this signals safety and openness to disclosure.

Sexual activity in older adults can raise complicated feelings in caregivers. In institutional settings, follow policies regarding consensual sexual relationships. If you are concerned a patient is being penalized for their sexuality or gender expression, raise it directly with staff or through a compliance hotline. For patients living with family, ask how they manage privacy and mutual respect around intimacy. Always ask about non-consensual encounters, satisfaction with sexual activity, and understanding of STI risk. In private practice settings, inclusive imagery, like photos of same-sex couples or gender-diverse expression, can send a clear signal that your care is welcoming. Most importantly, in all settings, practice cultural humility and be willing to learn.

Gender expression
Ask every patient what pronouns they use, document them, and use them consistently. If a patient seems uncomfortable with the question, a calm, respectful response can ease the interaction: “I ask everyone and want to make sure I address you the way you’d like.”

Support the patient’s choices in clothing and adornment. Know the GAC clinicians in your area and only share information on medical transition from reputable sources. 

Familiarize yourself with terms used in LGBTQIA+ communities. For patients who are isolated, consider a referral to social work or peer support services. 

If staff routinely deadname a client, a gentle correction helps shift the culture: “I think you mean ­Johanna. I know it takes getting used to, but she’s asked us to use that name.” Leaders can post inclusive language tips in shared staff spaces to support broader culture change.

Family members may struggle to accept a patient’s identity. Offer to facilitate a family meeting and have educational handouts ready. Listen for financial or logistical barriers to accessing care, as some can be addressed through community-based resources or insurance advocacy.

Withholding care in ways that demean or harm the patient (such as blocking access to hormone therapy or gender-affirming items) may constitute abuse. In those cases, take appropriate steps, including filing a report and reviewing legal protections like health care proxies or guardianship arrangements.

Additional tools and referrals 
For curated resources for professionals and patients, visit: www.thecarlatreport.com/GACResourcesforOAs. 

CARLAT TAKE
LGBTQIA+ older adults face distinct and often overlooked risks, especially related to autonomy, identity, and safety. Factors like age, gender identity, sexual orientation, race, and disability interact with systems that were not built to support their needs. Ask about pronouns, preferred names, and key relationships. Stay alert for red flags such as family interference, pressure to stop GAC, or mistreatment framed as protection. Don’t assume silence means safety. Create space for honest conversation, document preferences clearly, and speak up when care systems fall short. Affirming identity isn’t just best practice; it’s part of your clinical responsibility.