Experiences of LGBTQ+ Older Adults in Healthcare: A Qualitative Systematic Review

Abstract

The purpose of this review is to synthesize the existing qualitative literature exploring healthcare experiences of older adults who identify as part of the LGBTQ+ community in all healthcare settings globally. While older adults are faced with numerous healthcare challenges, those within the LGBTQ+ community often experience stigma and discrimination when accessing care. Barriers to holistic care are associated with heterosexism, biphobia, and transphobia and a lack of health provider knowledge. Synthesis of the literature examining those experiences is the focus of the review. This review includes peer reviewed qualitative literature, from inception, up to and including December 2025 that focuses on LGBTQ+ older adults’ experiences in healthcare settings. Participants were individuals age (60+) who identify as part of the lesbian, gay, bisexual, transgender, or queer community or individuals who do not identify as being heterosexual and/or cisgender, who have access to the healthcare system. For this review, healthcare refers to any setting or service in which formal care is provided, including hospitals, clinics, physician offices, emergency departments, and long-term care homes, as well as community living settings. This also encompasses preventative, curative, rehabilitative, long-term and palliative care. This systematic review was conducted in accordance with the Joanna Briggs Institute methodology for systematic reviews of qualitative evidence. A systematic search of the peer-reviewed literature up to and including December 2025 was conducted using the following databases: CINAHL, Pubmed, PsycInfo, Ageline, ASSIA, social services abstracts, social work abstracts, Sociological Abstracts, SocINDEX with fulltext; JBI Database of Systematic Reviews and Implementation Reports; and Cochrane Database of Systematic Reviews. Article reference lists were cross-referenced with the search findings. Titles and abstracts were screened by two reviewers, and conflicts were resolved by consensus with input from a third reviewer. Screened articles were analyzed to ensure methodological quality using the JBI critical appraisal checklist for qualitative research. Two reviewers conducted data extraction. Findings were pooled with a meta-aggregation Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) approach. These synthesized findings were graded to establish confidence in the output. Twenty studies published between 2000 and 2024 were included in this review. Common themes derived from the review included: (1) discussions of the stigma and barriers to accepting and affirming identities, (2) references to the lack of knowledge and services regarding LGBTQ+ healthcare for aging individuals, (3) the importance of connection and community among LGBTQ+ older adults, and (4) the need for and recommendations for improving care for LGBTQ+ older adults. These findings were discussed with recognition of the multitude of multifaceted and complex identities and perspectives within the LGBTQ+ community with recommendations for future research, that is, inclusive of the diversity within this community, with consideration to structural influences on care.

1. Background

It is well understood that the global population is aging. According to the World Health Organization (WHO) [1], the population of people aged 60 years and older continues to climb significantly, now outnumbering children under 5 years. This population of older adults is expected to double to 2.1 billion by 2050. Older adults globally face specific health challenges as they are at risk of functional decline, poorer health outcomes, social isolation, and financial insecurity [2,3]. While older adults are often disadvantaged in their respective healthcare systems, there are unique challenges faced by lesbian, gay, bisexual, transgender, queer and other older adults who do not identify as heterosexual and/or cisgender (LGBTQ+) [4,5]. The intersection of age, sexual orientation, and gender identity and the associated impacts of ageism and stigma present many specific barriers in relation to health and healthcare for older LGBTQ+ adults. These barriers include the absence of LGBTQ+ older adults in health policy, a lack of attention to their specific needs [6], and a general mistrust of healthcare systems from LGBTQ+ older adults themselves [7,8,9]. This mistrust stems from the historical discrimination of people within the LGBTQ+ community, resulting in a reluctance to share their sexual orientation, to voice concerns to healthcare practitioners, and/or to use healthcare services [10,11].

The fear of stigma and discrimination is justified as medical discrimination against the LGBTQ+ community and has a long history which continues to shape health-seeking behavior and access to care for LGBTQ+ individuals [12,13]. For example, until the early 1970s, homosexuality was listed as a disorder in the Diagnostic and Statistical Manual of Mental Disorders; thus, many older adults have lived through a time with less acceptance for the LGBTQ+ community where explicit hostility and violence toward gay, lesbian, bisexual, and gender-diverse individuals were considered acceptable [14].

Everyday threats to LGBTQ+ health have been linked to current heterosexism, biphobia, transphobia, and a lack of health provider knowledge, which are embedded in all social institutions and which contribute to social exclusion, stigma, and negative experiences in healthcare [8,15]. An ongoing concern for LGBTQ+ older adults is that they will continue to experience various forms of discrimination and cultural violence in healthcare [10]. This discrimination impacts all facets of health and well-being. While homophobia is a common form of discrimination within the healthcare system, it is also important to note that discrimination against LGBTQ+ individuals may be subtle or hidden, which can happen through silence or by not affirming, acknowledging, or recognizing same-sex relationships, or assuming someone is straight or cisgender without asking [16]. Stigma and discrimination against the LGBTQ+ community can contribute to exclusion, discomfort with caregivers and healthcare professionals, fear of discrimination and disclosing health information, and unfair treatment [17].

As the global population continues to age, it is important to focus on healthcare accessibility for older adults, or individuals over 60 years of age. Consideration must be given to LGBTQ+ friendly long-term care and community care options [10,18]. The literature highlights the mental and social health impacts on LGBTQ+ older adults in relation to living in long-term care. For older adults who identify as LGBTQ+, the inability to share their identity to caregivers contributes to their risk of developing mental health issues [19]. Even outside of long-term living centers, depression and mental illness have been found to be the greatest mental health concerns of LGBTQ+ older adults, and some of these individuals have used unhealthy coping mechanisms, such as substance abuse, to cope with these issues [19]. For transgender people, lack of access to both hormonal and surgical treatment can adversely impact their mental health [20]. Likewise, research has shown that having strong social support is also an important asset that positively affects older adults’ healthcare experience [21]; however, often for LGBTQ+ older adults, their social and romantic relationships are not honored or respected in long-term living centers [22,23]. Quality care, therefore, should ensure recognition, acknowledgment, and remembrance of significant others and the provision of spaces for social interaction with other aging LGBTQ+ adults [24].

There is acknowledgement in the literature that age-related issues are often experienced earlier for those in the LGBTQ+ community due to issues of minority stress and discrimination. Findings from these studies highlight issues such as disclosure and concealment, issues of trust and affirming health relationships, and discrimination, as well as visibility and recognition in heteronormative environments [25,26,27,28]. These studies often highlight the need for inclusive care and resilience in navigating healthcare and are similar in many elements to the experiences of those 60+. While some researchers choose to expand inclusion criteria to include a younger age group, there is also come concern that this may dilute the examination of issues such as frailty, functional decline and residential or home care [29,30]. While several studies have been conducted that explore the experiences of the LGBTQ+ population in healthcare, fewer studies have been conducted that specifically address experiences of LGBTQ+ older adults. We chose a systematic review as the goal was to provide a synthesis of the existing qualitative literature related to the experiences of LGBTQ+ older adults in healthcare, unlike a scoping review, which does not typically synthesize experiential evidence [31,32].

Healthcare refers to any setting or service in which formal care is provided, including hospitals, clinics, physician offices, emergency departments, and long-term care homes, as well as community living settings. This also encompasses preventative, curative, rehabilitative, long-term and palliative care.

2. Aims and Research Question

This systematic review explored the experiences of LGBTQ+ older adults that were shared in peer-reviewed literature, from inception up to and including December 2025. It addresses the ever-present stigma and discrimination surrounding identity and sexuality, accessibility to services, quality of healthcare for LGBTQ+ older adults in long-term care facilities and other areas of healthcare such as hospitals, homecare, emergency departments, clinics, etc. Through this review, gaps within the healthcare system are identified, and a direction to overcome these barriers is explored in order to ensure safe and equitable healthcare for all. The review focused specifically on the qualitative literature, which allows for an in-depth understanding of the nuanced experiences and meaning making related to these experiences.

3. Review Question

What are the healthcare experiences of older adults who identify as members of the LGBTQ+ community?

4. Methods

The systematic review was conducted in accordance with the Joanna Briggs Institute (JBI) methodology for systematic reviews of qualitative evidence using the JBI critical appraisal checklist for qualitative research [33]. This is considered the appropriate approach given that the intention is to examine experiences and meaning versus descriptive mapping, as outlined in a scoping review [34]. This review considers studies that focus on qualitative data including, but not limited to, designs such as phenomenology, grounded theory, ethnography, narrative inquiry, action research and feminist research. The review also includes any other qualitative data reported in mixed-methods studies where information focusing on LGBTQ+ personal healthcare experiences has been collected. Published articles written in English, from inception up to the end of 2025, were included.

5. Inclusion Criteria

The studies reviewed included participants who are LGBTQ+ individuals, aged 60+ who identify as part of the lesbian, gay, bisexual, transgender, or queer community, or individuals who do not identify as being heterosexual and/or cisgender (e.g., men who have sex with men/MSM, women who have sex with women/WSW, etc.), who have accessed the healthcare system. While 60 + is generally utilized as an operational definition for aging in the literature [1], a younger age threshold (e.g., 45–50+) has been utilized by many researchers in relation to the LGBTQ+ community. This acknowledges the reality of many LGBTQ+ individuals who experience health and social disparities related to minority stress and discrimination [35]. While we acknowledge and support this approach, we decided not to use a younger age range in this review because this may increase heterogeneity of the sample and not capture the full richness of later life experiences in relation to healthcare such as long-term care, chronic illness, and end-of-life care. We acknowledge why some researchers choose to lower the age range as this may reflect the effects of stigma and minority stress, as well as illnesses such as HIV/AIDS which can result in accelerated aging. However, we chose 60+ to ensure that we did not broaden the scope beyond what our question intended. We therefore drew on the narratives of participants 60 years of age and over to ensure we captured a more nuanced understanding of healthcare experiences in later life. This is consistent with two recently published reviews [29,30].

6. Phenomena of Interest

This systematic review included qualitative studies that explored the experiences of LGBTQ+ older adults in healthcare. We utilized the Beryl Institute’s definition of healthcare experiences as the phenomenon of interest. They define healthcare experiences as “the sum of all interactions, shaped by an organization’s culture that influence patient perceptions, across the continuum of care” [36] (para. 3). The objective of the review was to explore the experiences of LGBTQ+ older adults in healthcare. This includes all aspects of healthcare ranging from interactions with health professionals from a preventative, curative, rehabilitative, long term, community, and palliative perspective.

7. Types of Studies

For this review, the qualitative data that was collected and analyzed includes, but is not limited to, designs such as phenomenology, ethnography, personal narratives, and action research. The review also considered any other qualitative data reported in quantitative studies, where information focusing on personal LGBTQ+ healthcare experiences has been collected. Published articles written in English up to 2025 were included.

8. Search Strategy

The search strategy, devised in 2023, aimed to find published studies limited to the English language. An initial search of PROSPERO, MEDLINE, the Cochrane Database of Systematic Reviews, and the JBI Database of Systematic Reviews and Implementation Reports was conducted. This was followed by analysis of the text words contained in the title and abstract and of the index terms used to describe the article. A search using all identified index terms and keywords was then undertaken across all included databases.

9. The Databases Searched Included the Following:

• CINAHL;
• Pubmed;
• PsycInfo;
• Ageline;
• ASSIA (Applied Social Sciences Index & Abstracts);
• Social services abstracts;
• Social work abstracts;
• Sociological abstracts;
• SocINDEX with full text.

Article reference lists were checked and cross-referenced with the search findings.

10. Study Selection

Following the search, all identified citations were collated and uploaded into Covidence (Veritas Health Innovation, Melbourne, Australia), and duplicates were removed. Titles and abstracts were screened by two independent reviewers for assessment against the inclusion criteria for the review. Potentially relevant studies were retrieved in full, and their citation details were imported into JBI SUMARI. The full texts of selected citations were assessed in detail against the inclusion criteria by two independent reviewers. Reasons for exclusion of full-text studies that did not meet the inclusion criteria were recorded and reported in the systematic review. Any disagreements that arose between the reviewers at each stage of the study selection process were resolved through discussion, or with a third reviewer. The results of the search are presented in a Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) flow diagram—Figure 1 [37]. The PRISMA checklist (Table S1) and the PRISMA abstract checklist (Table S2) are presented in the Supplementary Material.

Figure 1. PRISMA flow diagram.

11. Assessment of Methodological Quality

Studies that met the inclusion criteria were critically appraised by two independent reviewers for methodological quality using the standard JBI Critical Appraisal Checklist for Qualitative Research. Any potential conflicts between the two independent reviewers were addressed through discussion or with the perspective of a third reviewer until consensus was reached. All studies, regardless of the results of their methodological quality, underwent data extraction and synthesis wherever possible.

12. Data Extraction and Synthesis

Data were extracted from studies included in the review by two independent reviewers using the standardized JBI data extraction tool. The data extracted included information about the population, context, geographical location, study methods, and the phenomena of interest relevant to the objective of the study review. In terms of data synthesis, qualitative research findings were pooled using JBI SUMMARI with the meta-aggregation approach.

13. Review of Findings

Figure 1 presents the PRISMA flow diagram of identifying articles for the systematic review that met our inclusion criteria. A total of 3755 studies were initially gathered from literature searches, with 648 duplicates removed. Then, a total of 3116 studies were screened based on their titles and abstracts that determined their eligibility. Two thousand, eight hundred and forty-seven studies were excluded after screening, with 269 studies assessed in full text for eligibility. In this analysis, 249 studies were excluded for reasons such as incorrect population, incorrect purpose, incorrect study design, incorrect setting, book reviews, or because the article was repeated. Finally, 20 studies discussing LGBTQ+ older adults’ healthcare experiences, published between 2000 and 2024, met the inclusion criteria for the systematic review. As a result of analyzing these 20 eligible studies, four themes were identified, including (1) stigma and barriers to accepting and affirming identities, (2) lack of knowledge and services regarding LGBTQ+ healthcare for aging individuals, (3) the importance of connection and community among LGBTQ+ older adults, and (4) improving care for LGBTQ+ older adults. While each of these themes will be thoroughly discussed, it is important to note that the discourse in the literature contains many differing views from study participants. The aging LGBTQ+ population encompasses a variety of multifaceted, complex identities and perspectives; therefore, each theme reflects the most frequently occurring patterns found in the studies eligible for this review.

14. Stigma and Barriers to Accepting and Affirming Identities

Within the literature reviewed, LGBTQ+ older adults shared a recurring sentiment, emphasizing how stigma shaped their experiences in healthcare. Participants across studies placed emphasis on the importance of being able to maintain all aspects of their identity, including their sexual orientation and gender identity. While findings of stigma and discrimination were relatively consistent across studies, there is a noticeable shift in focus over time in relation to how the results were interpreted. Earlier studies focused largely on interpersonal discrimination e.g., [22,38,39,40], with recommendations for education and improved interpersonal communication. These studies highlighted perceived barriers to care preventing older adults in the LGBTQ+ community from feeling safe to disclose their sexual orientation/identities in healthcare and long-term living settings. They note the role of historical discrimination that produced stigma and fear of disclosure, often resulting in individuals not coming out to family and healthcare providers [39,41]. Recent studies were more likely to situate the experiences within the broader systems, conceptualizing stigma as a product of heteronormative and cisnormative policies and practices that are embedded in organizational cultures within healthcare and educational institutions e.g., [42,43,44,45]. While the patients’ experiences remain a focus, and there is acknowledgement that individual behavior is still important, this approach exposes the underlying mechanisms that sustain systems that continue to marginalize the LGBTQ+ older adult population. These authors highlighted the impact of historical discrimination but also discussed the notion of anticipated stigma as one that is embedded within in broader heteronormative/cisnormative structural contexts out of which policies and specific interactions arise. For example, Candrian et al. [42] noted how identity hiding, due to historical discrimination, for older lesbian participants impacted their perceptions today. Participants in this study talked about the impact of discrimination as a consequence of coming out to their family and social circles, as well as in previous employment. As one participant stated,

No, you couldn’t be out, no not at all. Truth be known, I got fired from the job because somebody in the hospital picked up on the fact that I was lesbian and I was talking to another lesbian, and we had lunch together and everything, and I ended up losing my job after 10 years [42] (p. 599).

In another study by Siverskog [46], a participant stated “It has been a threat level that someone would find out that I was interested in wearing women’s clothes. I felt I would be completely estranged and left out if I did that” (pp. 386–406).

While anticipated discrimination in healthcare was a common theme throughout the studies reviewed, actual experiences of discrimination were highlighted by many authors [39,47,48]. In a study by Rosati et al. [49], for example, a 70-year-old gay male participant stated, “I was looking for a psychoanalyst […] at the 3rd session he mistreated me by telling me: “I deal with real problems and you don’t have any problem! Don’t waste my time… even with the homosexual aspects of your person” (p. 69). Another participant in a study by Clover [50], describing an interaction with his physician, stated “I went there and I was there as a gay person. He couldn’t get near me! He couldn’t get near me! The way he was, his body language… he wouldn’t touch me. I haven’t been there since” (p. 46).

Not all experiences were perceived as negative, however, as some participants highlighted the positive aspects of identity affirmation. In a study by Sharek et al. [51], for example, a number of participants stated that attitudes and experiences with healthcare providers were becoming more positive. One participant, a 66-year-old gay male, stated, “I’ve been seeing the consultant every 6 weeks since I had [names medical condition] and [names partner] comes in with me and she accepts that completely. That’s not a problem. He’s my partner and that’s that. No problem.”(p. 234). Another participant in a study by Williams et al. [5] stated, “Actually, my partner went with me and for the first time in my life said this is my partner and the doctor didn’t even bat her eyes” (p. 226). While this is encouraging, concerns still arose regarding trans care. A trans participant in a study by Mackenzie Jones and Willis [52] stated,

They [the staff] are very aware of gay and lesbian issues and very respectful about that but at times also willfully ignorant of trans issues […] like how to use the right pronouns or respect their name when it is different from what their legal name is, stuff like that, really basic stuff (p. 55).

15. Lack of Knowledge and Services Regarding LGBTQ+ Healthcare for Aging Individuals

Even with great advances for LGBTQ+ rights in social and political spheres, there is still a significant gap between what this population of older adults needs in healthcare and what is available to them [49]. Participants across studies voiced concerns regarding healthcare providers’ lack of knowledge and preparedness in providing care that was informed and affirmative [41,51,52]. A number of earlier studies highlighted participant concerns regarding interactions with healthcare providers that lacked insight and sensitivity, where they felt stigmatized due to underlying assumptions about the participant’s sexuality that reflected heteronormative beliefs. For example, a participant from one study noted “It was really horrible and… it was very badly handled and she made me feel really sort of dirty, as if [I was] doing some sort of peculiar thing that nobody else does” [39] (p. 194). This lack of knowledge was also noted by participants from the trans community. For example, Siverskog [46], in a study that explored transgender aging, noted situations where participants had to educate physicians and other health professionals. One participant talked about how she had to bring information materials to the doctor. The study also demonstrated how the participants repeatedly had to explain themselves, educating and addressing common misconceptions related to what being transgender means. This is also illustrated by a trans participant in a later study by Willis et al. [48], who, after seeking support and informing her physician that she felt like a woman her entire life, stated “And the first thing she said is “what do I know about that, then?” (p. 1235). Such knowledge gaps have been consistently reported in the literature with participants feeling invisible, stigmatized, and responsible for teaching the health professionals.

There is, however, a notable distinction in relation to the interpretation of these findings across studies. Earlier studies focus on the impact of the interactions in relation to the knowledge gap [22,38,50]. The recent literature emphasizes the lack of educational preparation and infrastructure within healthcare systems to accommodate for LGBTQ+ older adults’ healthcare, rendering this population invisible within the larger heteronormative system [5,43,53]. For example, a participant in a study by Williams et al. [5] stated, “I visited a number of rehabilitative retirement homes and long-term care facilities and I (sigh) see only invisibility on the part of LGBT people and… I don’t want to be relegated to invisibility in old age” (p. 229). While part of this may be attributed to stigma, as noted above, the lack of knowledge on the part of healthcare professionals has been consistently noted throughout the studies reviewed. For example, a participant in a study by Sharek et al. [51] stated that “if the health service is not homophobic, I would think a very large percentage of the workers are not particularly well-informed or intuitive about gay ageing people’s rights” (p. 236). According to Williams et al. [5], providers must consider the concerns at a macro level with a focus on nondiscriminatory policy development, enhancing standards in care facilities, and focusing on services designed for LGBTQ+ older adults. In addressing this need, Lappan et al. [43], who explored the healthcare experiences of racially diverse lesbian and bisexual older women, built on these recommendations, stating that their participants voiced the need for healthcare systems to address inequities and disparities with a focus on education and collaboration. As one of their participants noted, “I think people in the medical industry are gonna have to start being sensitive to the changing demographics… and I think those diverse needs start back at medical school or nursing school or social work to start dealing with this community” (p. 841).

The literature also presents a consistent lack of outreach and healthcare services for this population, such as support groups and programs that recognize the intersectionality of needs that patients in this community may have [5,38]. Participants throughout several studies discussed the need for either LGBTQ+ exclusive care or LGBTQ+ friendly care. For example, Stein et al. [40] highlighted the need for gay-friendly services where staff did not assume heterosexuality, providing care that was respectful, while upholding the dignity of the person and their lived reality. Participants in this study were positive about gay-friendly and gay-specific care, suggesting that even within mainstream long-term care, consideration should be given to “a separate floor for gay residents because they said they would feel safer” (p. 431). More recent studies have also described limited access to affirming care in various contexts, including a lack of LGBTQ+ friendly/exclusive long-term care facilities [43,52,54].

16. The Importance of Connection and Community Among LGBTQ+ Older Adults

The literature has shown that feeling a strong sense of belonging and camaraderie among LGBTQ+ older adults significantly increases quality of life and provides positive mental and social health benefits [55]. Unfortunately, LGBTQ+ older adults are at a higher risk of having less social support, and there are few long-term living centers that provide formal avenues for LGBTQ+ older adults to interact with each other [56]. Encouraging this sense of connection to other individuals who identify as LGBTQ+ helps members of the community feel supported and less isolated, as noted in several studies reviewed here.

The importance of close connections and “chosen families” in reducing loneliness and fostering identity affirmation was supported in the literature [22,38,46,50]. Consistent with the noted evolution of the literature, Grigorovich [57] broadened this sense of community to include healthcare relationships and inclusive care environments. Grigorovich, in this study exploring older lesbian and bisexual women’s access to publicly funded homecare, highlighted the importance of access to social support networks. The study reported that relationships with biological families were often strained because of families’ homophobic attitudes and behaviors toward participants and their partners. Overall, the analysis indicated that the 16 participants experienced barriers to care. Several participants identified that they had some support of friends and family members. However, they did not feel they could rely on them for everyday care. For example, one participant in this study stated, “most of my friends that are alive are in their 60s, 70s and 80s…why would I burden them?” [57] (p. 776).

In addition to feeling more connected, creating a community for older adults who identify as part of the LGBTQ+ community helps affirm identities, while making individuals feel safer, more welcomed, and resilient [40,55].

There is consensus in the literature relating to the connection members have with each other within the community and with the healthcare system. The literature also highlights some inequities such as rural isolation, limitations in caregiving responsibilities, and increased risk of isolation [45,46]. Mackenzie-Jones and Willis [52] conducted a study exploring trans peoples’ experiences, concerns, and suggestions regarding how agencies providing elder care can better meet their expectations. Their research highlights the importance of active engagement in community and community support networks. Many of their participants discussed the importance of broader social networks that acted as substitutes for families or built upon existing family relationships. These relationships served as supportive structures that enhanced their daily lives. They also discussed the importance of programs and policies that were intentionally designed to support LGBTQ+ socialization and peer support, such as gay-only units within long-term care settings, a focus on bereavement support, and end-of-life care. This was consistent with the recent literature that emphasizes the role of health systems in producing and sustaining knowledge gaps and not engaging with the community to develop and implement programs and policies to improve equitable access to affirming care [5,49,53].

17. Improving Care for LGBTQ+ Older Adults

As with the other themes arising from this review, the call for improved care for LGBTQ+ older adults was consistent across the reviewed studies. However, they do differ somewhat in their prioritization of structural versus interpersonal interventions. The early reviewed studies [22,38,39,50] recognized the need for improving care but tended to focus recommendations on the promotion of enhancing respectful communication and recognition of chosen families or partners on a more individual or service-based level rather than broader structural/institutional solutions. As previously noted, while many participants recalled healthcare providers’ lack of knowledge and competency regarding LGBTQ+ health issues due to a lack of training at all levels, solutions often focused on improving training without necessarily addressing broader institutional policies or organizational structures. For example, in a mixed-methods study by Sharek et al. [51] results demonstrated an overall concern related to the preparedness of healthcare providers. As one participant stated, “one of the big issues is they (practitioners) don’t know the issues, can’t deal with them, have never been trained to deal with them… so there is a massive gap” (p. 236). While participants in Sharek’s study did not feel overall that their providers were homophobic, other studies have found that participants’ perceptions of healthcare settings suggested they did not anticipate a welcoming environment that allowed them to feel safe and able to disclose their identities [38,42,46]. Waling et al. [54], in a study of 10 older trans women’s perception of care, found there was a belief for some that residential older adult care was poor even for cisgender people; thus, participants anticipated an added fear around transphobic care that would complicate this further. As one participant stated,

“I have doubts how just good aged care for transgender people is going to be. Because transgender is such a new, well it’s not new, but it’s suddenly become such a new item everybody’s talking about, and that’s all that’s really happening at the moment is just talk. No real action” (p. 1312).

These concerns were also seen by many older adults planning for future healthcare directives. Older adults who identify as LGBTQ+ may have an even more complex experience during these difficult transitions, as many LGBTQ+ older adults are at high risk for poorer quality of care [58]. While participants in the reviewed studies outlined their fears related to future healthcare needs, including long-term care and community supportive care, participants in the study by Valenti et al. [44,59] highlighted the need for more explicit discussions with healthcare providers regarding advanced care planning. They noted they experienced incomplete care often informed by heteronormative systems of care. Findings in this study, along with other studies reviewed, suggest that heteronormative practices in healthcare resulted in a lack of advance care planning and palliative care discussions, ultimately impacting the preparedness of the participants for this stage [42,55].

As noted by authors in the reviewed studies, improvements in healthcare for LGBTQ+ adults require care and support beyond the individual level and should also include organizational, educational, and policy considerations. Affirming care should depend on organizational commitment through inclusive policies, leadership support and health professional education [44,53,55,58,59]. Recent studies have elicited recommendations for more comprehensive environmental, cultural and systems-based solutions utilizing a trauma-informed and intersectional lens considering histories of discrimination, sexuality, socioeconomic status and geographic location [42,43,45]. Waling et al. [45] referred to this as an “ambitious whole of organisation” change process that embeds within the organisation a commitment to address disadvantage and celebrate diversity” (p. 1318). These structural approaches support affirming policies and practices such as inclusive intake forms, relevant symbols, and respectful communication that is not rushed [44,49]. Valenti et al. [59] noted that for advanced care planning, incomplete information based on a lack of inclusion equals incomplete care. As one participant noted, “While she was in the hospital, the hard part was they were talking about putting her in long term palliative care. And I didn’t understand. They glossed over it” (p. 381). A description of the of the qualitative research articles that met the review criteria is included below in Table 1.

Table 1. Description of the qualitative research articles that met review criteria. * Five studies have more than one publication.

Author (Year)	Aim/Purpose (as Outlined in Articles) *	Sample Size/Participant Characteristics	Country/Region of Study	Key Findings/Themes Reported
(1) Burton et al. (2020)	To increase understanding of the experiences and needs of older LGBT adults when accessing care	n = 10 Inclusion criteria: 65 years or older and self-identified as LGBTQ 5 identifying as female, 5 identifying as male; 5 identifying as gay, 5 with no clarification of sexual orientation	USA	Theme 1: Outness: code families include Sexuality and Open to Disclose Theme 2: Social Climate: things are different now—code family is discrimination Theme 3: Additional Resources: code families include Planning Ahead and Life Changes
(2) Butler (2017)	To respond to the question of whether the phenomenon of nearly all home care workers being women mitigates potential tensions for older lesbians using home care services	20 older lesbian women who had used homecare and 6 informal caregiving partners Inclusion criteria: identifying as a lesbian; being 65 or older; having received homecare services within the preceding 10 years 100% of primary participants were White; age range of 66–86	USA	Theme 1: Level of Disclosure Subtheme: “Did not Spell Out” Subtheme: “No idea I’m a Lesbian” Subtheme: “Disclosure up Front” Theme 2: Experiences of Homophobia Subtheme: Comfort Subtheme: Tolerance Subtheme: Homophobic Reactions Theme 3: Evaluation of Care Subtheme: Good Care Subtheme: Dissatisfaction with Care Theme 4: Visions of Ideal Long-Term Services and Supports Subtheme: Financing Subtheme: Lesbian-specific or Not
(3) Butler (2018)	To examine the formal and informal caregiving experiences of lesbians 65 and older who had utilized home care services due to acute illness or chronic disabilities	20 older lesbian women who had used homecare and 6 informal caregiving partners Inclusion criteria: identifying as a lesbian; being 65 or older; having received home care services with the preceding 10 years 100% of primary participants were White; age range of 66–86	USA	Informal Care Network: Subtheme: Care Provided by Partner Subtheme: Isolation vs. Community of Friends and/or Family Relationships with Home Care Workers: Subtheme: Good Connection Subtheme: Friends Outside the Job Lesbian Aging: Subtheme: “Does it make a difference?” Subtheme: Negative and Positive Effects of Being Lesbian on Aging
(4) Candrian & Hinrichs (2021)	To present a paper that uses one case study to frame a broader discussion about end-of-life care for LGBT older adults	Drawing on insight from a sample of 31 in depth interviews with older LGBT adults to understand the health needs and experiences of older lesbians in the Rocky Mountain Region, this paper focuses on one participant’s story Mid-60s	Rocky Mountain Region, USA	Esther’s story demonstrates the current tensions around collecting sexual orientation and gender identity data in settings where provider and behavior practices are not always competent or affirming. Her story highlights the trauma and avoidable suffering created when patients’ essential identity and relationships are ignored at the end of life and the ways LGBT older adults are at risk for inequitable end-of-life care and bereavement. Systemic practices that render LGBT patients and caregivers invisible, such as not collecting sexual orientation and gender identity data and not supporting provider communication competency and humility training, present a challenge to ensuring just and equitable end-of-life care for LGBT older adults.
(5) Candrian & Cloyes (2021)	To present a paper that uses one case study to frame a broader discussion about end-of-life care for LGBT older adults	Drawing on insight from a sample of 31 in depth interviews with older LGBT adults to understand the health needs and experiences of older lesbians in the Rocky Mountain Region, this paper focuses on another participant’s story	Rocky Mountain Region, USA	Sandra’s story highlights the struggles for LGBT older adults in relation to end-of-life care for their partners. The story illustrates the tension Sandra experienced with being out while her partner Cathy was palliative and experiencing homophobia from nursing staff. Both Sandra and Cathy felt they must hide their relationship in order to receive empathetic care. This provides insight into the impact of collecting SOGI data when caregivers are not prepared to provide inclusive and affirming care.
(6) Candrian et al. (2022)	To amplify the voices of older lesbians so that their experiences can have direct implications for improving the human and clinical services that serve them	n = 31 Participants included older lesbians aged 56–84 in the Rocky Mountain Region Race: 28—White 2—African American/Black 1—More than one race Ethnicity: 29—Non-Hispanic 2—Hispanic or Latino	Rocky Mountain Region, USA	Six themes were identified Theme 1: The emergence of a vocabulary to make sense of who you are Theme 2: Culture of identity-hiding and the consequences of “coming out” Theme 3: Lack of recognition and discrimination in healthcare Theme 4: Channeling passion, anger and fear into action Theme 5: Concerns about aging as lesbian Theme 6: Identified health needs and priorities
(7) Clover (2006)	To explore the experiences of older gay men in relation to health, what gaps exist in health and social care services, and how primary care services could better meet the needs or concerns of older gay men	n = 10 Inclusion criteria: sixty years of age or over; living within the Greater London area; a range of relationship statuses, borough of residence, incomes, and length of time they had been “out” as gay men Aged 60–75 3 born outside of UK The recruitment strategy did not reach men from non-English backgrounds or Black/ethnic minority men	Greater London, UK	Analysis of the interviews revealed that older gay men may view health services with caution, having experiences of, or expectations of, discrimination or poorer quality care or treatment. Older gay men may not disclose their sexuality to health providers and may find some needs unmet, particularly around areas of partner and other social relationships. Theme 1: Growing older Theme 2: Experiences of health and social services Theme 3: Talking openly about sexuality
(8) Elder (2016)	To enrich the understanding of transgender and gender nonconforming (TGNC) older individuals’ subjective experiences in psychotherapy throughout their lifespans; to offer perspectives that are often overlooked due to TGNC marginalization; and to improve the quality of psychotherapeutic care for gender-diverse people	n = 10 TGNC individuals living in the San Francisco Bay Area between 60 and 83 years of age who had at least one significant psychotherapeutic experience as determined by the participants, regardless of their gender identity at the time of treatment Inclusion criteria: transgender, transsexual, cross-dresser, intersex, or gender nonconforming Gender: 4 females, 1 transgender woman; 1 male-to-female and back, 1 trans man, 3 males Race: 1 Black, 1 Chinese, 8 White Sexual Orientation: 1 asexual, 1 gay, 2 lesbian, 2 bisexual, 1 attracted to men, 2 heterosexual, 1 straight	San Francisco Bay, USA	10 themes were identified and organized into 3 categories Category 1: Experiences in Therapy Theme 1: Transaffirmative and healing experiences in therapy Theme 2: Negative or transphobic experiences in therapy Theme 3: Positive changes in the way therapy is conducted Category 2: Life Experiences Theme 4: Transition and transition issues Theme 5: Older TGNC issues Theme 6: Family of origin Theme 7: Discrimination, harassment, and abuse Theme 8: Resiliency, community activism, education, and celebration Category 3: Recommendations Theme 9: Recommendations to TGNC individuals seeking therapy Theme 10: Recommendations to providers
(9) Grigorovich (2015a)	To present an analysis of older lesbian and bisexual women’s perspectives on accessing healthcare services and the barriers they faced in securing needed care	n= 16 Inclusion criteria: women aged 55 or older; self-identified as lesbian or bisexual (or a related term); have lived in Ontario while receiving home care, and have attempted to access and/or receive these services in the last five years Aged 55–72 Sexual Orientation: 7 lesbian, 2 lesbian/queer, 1 lesbian/queer/dyke, 1 bisexual, 4 gay, 1 woman loving woman Race/Ethnicity: 12 white/European, 1 of color, 3 Aboriginal	Ontario, Canada	The findings are drawn from the thematic analysis of participant’s experiences of access and are presented in the form of six interrelated themes Theme 1: Initiating Access to HCS Theme 2: Point of Access Theme 3: Type of Care Theme 4: Assessment of Need Theme 5: Knowing How Theme 6:Access to Other Social Supports
(10) Grigorovich (2015b)	To explore older lesbians’ and bisexual women’s experiences with publicly funded home care services in Ontario, Canada; to investigate the impact of neoliberal home care reforms and existing care policies on this population’s experiences of accessing care		Ontario, Canada	Four major themes emerged from the interviews Theme 1: Deciding to Come Out Theme 2: Negative Reactions to Disclosure Theme 3: Supportive Reactions and Gratitude Theme 4: Maintaining Vigilance
(11) Hughes (2007)	To explore older lesbian and gay people’s experiences accessing health and aged-care services, including the impact of past experiences of discrimination and homophobia	9 men and 5 women (n = 14) self-identifying as gay or lesbian, 58–72 years of age, in the Blue Mountains of Australia; 2 people had migrated to Australia from Northern European countries and 1 was part-Aboriginal	Blue Mountains of Australia	Theme 1: Sexual Identities Theme 2: Disclosing Identities to Service Providers Theme 3: Discrimination in Accessing Services Theme 4: Local Experiences Theme 5: Hopes and Expectations for Service Delivery
(12) Hughes (2008)	The research aimed to (1) gain insight into older gay and lesbian people’s experiences with health and aged care services; (2) explore older gay and lesbian people’s preferences for how their sexual identity is acknowledged in contacts with health and aged care organizations; and (3) examine the preferences of older gay men and lesbians in future health and aged care services	9 men and 5 women (n = 14) self-identifying as gay or lesbian. 59–72 years of age, in the Blue Mountains of Australia; 2 people had migrated to Australia from Northern European countries and 1 was part Aboriginal	Blue Mountains of Australia	In examining the ways participants narrated the concepts of identity and community, five overlapping dimensions of community were identified, relating to different aspects of private and public identities and including but not limited to sexual identity: 1: Attachment to imagined lesbian and gay communities 2: Experiences within local environments and neighborhoods 3: Experiences accessing local mainstream organizations and services 4: Direct involvement in gay and/or lesbian groups and organizations 5: Experiences within friendship networks
(13) Lappan et al. (2024)	To explore the experiences and recommendations of lesbian and bisexual older women and their chosen partners in the Deep South	n = 18 Inclusion Criteria: Lesbian and bisexual; lived in the Deep South; identified as women; identified as either African American/Black or White; and at least 50 years of age Race: 10 White women, 7 Black women Sexual Orientation: 16 lesbian, 1 bisexual	Deep South of Alabama and Georgia, USA	The thematic analysis of 18 participants’ responses revealed 7 recurring themes and 3 sub-themes Theme 1: Importance of inclusivity, starting at initial interaction Theme 2: Being willing to collaborate with patient Theme 3: Physician and caregiver being able to spend more time with the patient Theme 4: Effective communication in healthcare Subtheme: Thorough explanation of the medical process Subtheme: Speak to everyone in the room Subtheme: Patient and accessible communication Theme 5: Treat each person equitably Theme 6: Emphasize good bedside manner and self-awareness at the training level Theme 7: Bridge the gap of disparities
(14) LaVaccare et al. (2018)	To understand the complex healthcare experiences of women identifying as lesbian or bisexual, who are also women of color, veterans, and/or 65 years of age and older	n = 35 Inclusion criteria: age 25 or older; Los Angeles County resident; self-identification as a lesbian or bisexual woman; and as an African American, Latina, Asian-Pacific Islander, and/or a veteran For the age 65 years and older group, participants were eligible regardless of their veteran status or race/ethnicity Race: 5 African American, 7 Asian-Pacific Islander, 7 Latina 3 Veterans Sexual Orientation: 80% Lesbian, 20% Bisexual	Los Angeles, USA	Theme 1: Disclosure of sexual orientation to healthcare providers Subtheme: Patient-provider relationships Theme 2: Provider training and certification in LGBTQ health Theme 3: Healthcare environment Theme 4: Impact of race and ethnicity Theme 5: Legal protection Subtheme: End-of-life planning
(15) Mackenzie-Jones & Willis (2016)	To canvas the concerns, priorities, and expectations for future care in later life for trans elders, and to articulate a vision of trans-positive care for social care services	n = 9 trans people across a range of age spectrums living in the USA, Canada, and Europe	USA, Canada, Europe	Six core themes are reported in this paper Theme 1: The relationship between health and social care Theme 2: The importance of networks and community Theme 3: The need to provide culturally competent services Theme 4: The concerns regarding discrimination and abuse Theme 5: The expectations of an aged activist generation Theme 6: The aspirations of future care provision
(16) Platzer & James (2000)	To report on the findings of part of an interview study of lesbian and gay men’s experiences of nursing care which was conducted to develop nursing guidance for members of the Royal College of Nursing	The analysis is based on focus-group discussions and in-depth individual interviews with 35 lesbians aged 16–74 years	UK	Theme 1: Concern that disclosure would lead to feelings of vulnerability and powerlessness Theme 2: Heterosexism makes disclosure difficult and affects the accuracy of treatment and diagnosis; this in turn restricts access to appropriate care, advice, and support Theme 3: Homophobic reactions to disclosure, including physical, verbal, non-verbal, and sexual abuse Theme 4: Ignorance among professionals about the health needs, lives, and concerns of lesbian women
(17) Rosati et al. (2021)	To explore perceptions and experiences related to healthcare utilization in a group of Italian sexual minority older adults, to understand the unique challenges faced by this population when accessing healthcare services	n = 23 Inclusion criteria: self-identifying as a sexual minority person and being at least 60 years old Gender Identity/Sexual Orientation: 11 woman/lesbian, 12 man/gay	Italy	Three interconnected themes were identified Theme 1: The relevance of clinician and patients’ identities in determining confidence and satisfaction Theme 2: Expectations and experiences of discrimination Theme 3: The need for specific competencies on sexual minority concerns
(18) Sharek et al. (2014)	The aim of this paper, which is part of a larger study, is to detail older LGBT persons’ usage, experiences and concerns with accessing healthcare services, disclosing their LBGT identity to healthcare professionals, preferences for care and their suggestions for improvement in services, including nursing services	144 respondents completed the 84-item questionnaire and 36 participants participated in in-depth interviews Inclusion criteria: Over 55 years of age; living in the Republic of Ireland; and identify as LGBT Gender: 115 male, 50 female, 12 transgender Sexual Orientation: 109 gay, 41 lesbian, 14 bisexual, 9 no term, 3 heterosexual, 3 other	Ireland	This study reported several themes Theme 1: Experiences of healthcare provision and interaction with professionals including nurses Theme 2: Concerns about coming out to healthcare providers Theme 3: Concerns about nurses and other healthcare practitioners’ knowledge base Theme 4: Concerns about accessing residential care Theme 5: Recommendations for staff and service development
(19) Silverskog (2014)	To utilize a biographical approach to explore how earlier life experiences matter in later life, and how age and (nonconforming) gender identities can be understood in relation to one another	n = 6 adults between 62 and 78 years old from Sweden who are, or during their life have previously been, trans identified	Sweden	The analysis focuses on three themes Theme 1: Intersections of age and gender during the life course Theme 2: Lack of knowledge of transgender issues Theme 3: How previous experiences of accessing care and social services matter in later life
(20) Smith & Wright (2021)	To examine older (over 60 years) LGBTQI+ people’s perceptions and experiences of using formal home care services in the community and to answer the following three research questions: What are the experiences or perceptions of older (over 60 years) LGBTQI+ people in using formal home care services? What impact (if any) do these experiences have on the physical and mental health of those utilizing home care services? What are the barriers and facilitators to accessing these services?	This systematic review included seven studies involving 169 participants in total. Studies were included if they investigated the formal home care experiences of LGBTQI+ people aged over 60. The majority of participants were lesbian women or gay men, with five bisexual people. One participant also self-identified as transgender. Ages ranged from 39 to 86 with the average and median ages of participants above 60 years old for all studies.	Various: Systematic Review	Three overarching themes were developed from the narrative synthesis Theme 1: Experiences and perceptions of older LGBTQI+ people receiving home care services Theme 2: Impact of home care services on the physical and mental health of LGBTQI+ people Theme 3: Barriers and facilitators for older LGBTQI+ people in accessing home care services
(21) Stein et al. (2010)	This exploratory inquiry aims to better understand the health and psychosocial experiences of lesbian and gay older adults living in long-term care and those living in the community contemplating the possibility of a future move to long-term care	n = 16 Two focus groups were conducted with lesbian and gay older adults in a community-based organization for LGBT older adults in New York City (SAGE) and a residential long-term care facility in northern New Jersey. Fourteen participants were White and two were African American. In the SAGE group, ages ranged from 60 to 84; eight men and four women. In the long-term care facility, ages ranged from 65 to 75; all men.	New York, USA	When asked about their psychosocial challenges and concerns as a gay or lesbian older adults, the following themes were articulated: Theme 1: Fear of being rejected or neglected by healthcare providers, particularly person care aides Theme 2: Fear of not being accepted and respected by other residents Theme 3: Fear of having to go back into the closet if placed in a mainstream long term care facility Theme 4: The preference of gay-friendly residential options if needed for long term and end of life care Theme 5: Fear of being neglected or abused by healthcare providers because of being gay Theme 6: Fear of being maltreated or ostracized by roommates/other residents because of being gay Theme 7: Greater anxiety about healthcare aides who assist with daily life activities Theme 8: Feel alone because could not talk about their lives, partners, and grief after loss of their partners
(22) Valenti et al. (2021)	To explore experiences of bereaved LGB older women to understand perspectives regarding advance care planning communication between clinicians, patients, and dyads	n = 16 lesbian, gay, or bisexual women age 60 years or older from across the United States who had lost a spouse/partner within the past 5 years Sexual Orientation: 15 lesbian, 1 bisexual Aged 60–85	USA	Four main themes emerged from the transcripts Theme 1: LGBT+ older women experience unclear advance care planning communication and end of life care support from clinicians Theme 2: LGBT+ older women often avoid care planning discussions with spouse or partners Theme 3: LGBT+ older women lack knowledge about palliative or end-of-life care Theme 4: LGBT+ older women have more positive experiences when there is consistent communication with spouse or partner and clinicians during a spouse/partner’s illness and end of life
(23) Valenti et al. (2022)	To examine the end-of-life experiences, communications, and grief support during and after their loved one’s death of older lesbian, gay, and bisexual women ages 60–85 who have lost a spouse or partner	n = 16 Inclusion criteria: self-identified as a woman; were 60 years of age or older; had been in a same-sex relationship with a spouse or partner who had died; were able to communicate in English Sexual Orientation: 12 lesbian, 3 lesbian/gay, 1 bisexual Race: All non-Hispanic White Aged 60–85	USA	Two important themes were found from the analysis of the data Theme 1: Gathering the women Subtheme: Speaking a different language Subtheme: Forming a community of lesbians Subtheme: Manifesting good death Theme 2: Compassionate Care Subtheme: Safe supportive spaces Subtheme: Relationship building
(24) Waling et al. (2020)	To explore older Australian trans women’s perceptions of residential care and the rationale behind their current and future decision-making processes with regard to aging and future care	n = 10 older Australians who were identified as trans women aged 60 and older. Participants were residing in a mixture of rural, regional, and urban/suburban areas. Aged 60–75 Sexual Identity: 1 straight, 3 lesbian, 1 asexual, 1 queer, 1 pansexual, 1 other/unsure, 1 did not disclose	Australia	Three major themes emerged from the analysis Theme 1: Concerns related to being trans Theme 2: Avoidance of, and alternative strategies to, using residential care services Theme 3: Specific wants and needs relating to residential care service provision
(25) Williams et al. (2022)	To examine the experiences of LGBT+ older adults in rural south central Appalachia with health, mental health, social, and long-term care services as well as their perceptions of future formal service needs	n= 11 Inclusion criteria: being age 60 or older; residing full-time within rural south central Appalachia; identifying as lesbian, gay, bisexual, and/or transgender Sexual Orientation: All lesbian or gay Gender: 10 cisgender, 1 transgender Race: All Caucasian	Rural South Centre Appalachia, USA	Category 1: Concerns or obstacles with formal services Related themes: No specific concerns Concerns directly or indirectly related to LGBT+ identity Either self or partner had medical issues requiring driving away from area for specialized care Concerns about ability to pay for services Category 2: Being out with service providers Related themes: Out Subtheme: Self-disclosure to service providers described as a positive experience Less Out Subtheme: Self-disclosure had not occurred with service providers but identified no barriers to self-disclosure Subtheme: Distrustful of self-disclosure to service providers based on past experience Category 3: Concerns about planning for future needs Related themes: Concerns about long-term care settings or services Need to leave area Transportation Health issues Aging in place Category 4: Recommendations for service providers and the community Related themes: Need for provider education about LGBT+ older adult needs LGBT+ inclusive long term care facilities Accessible and LGBT+ inclusive community housing options LGBT+ friendly literature provided by formal service providers
(26) Willis (2020)	To examine supportive and obstructive points of interaction with healthcare professionals and to identify key learning messages for improving trans-related healthcare from the perspectives of trans-identifying adults in later life	n = 19 Inclusion criteria: identifying as trans or gender nonconforming; residing in Wales; 50+ years of age Race/Ethnicity 20 White—born in UK, 2 White—born outside UK Gender Identity: 15 trans women, 4 trans men	Wales, UK	Three core themes were reported Theme 1: General practitioners as inconsistent allies Subtheme: Trans patients as reluctant educators Subtheme: Supportive and affirming responses Theme 2: Discriminatory and negative responses from healthcare professionals and services Theme 3: Uncertainty and delay in the healthcare system Subtheme: Delays and difficulties at the local level Subtheme: Challenges and pressures when accessing gender identity clinics

The articles aligning with each theme are outlined in Table 2.

Table 2. Themes per included study.

Publication	1. Stigma & Barriers to Identity	2. Lack of Knowledge/Services	3. Connection & Community	4. Improving Care
Burton et al. (2020)	✓	✓	✓	✓
Butler (2017)	✓	✓	✓	✓
Butler (2018)	✓	✓	✓	✓
Candrian & Hinrichs (2021)	✓			✓
Candrian & Cloyes (2021)	✓	✓	✓	✓
Candrian et al. (2022)	✓	✓	✓	✓
Clover (2006)	✓	✓		✓
Elder (2016)	✓	✓	✓	✓
Grigorovich (2015a)	✓	✓		✓
Grigorovich (2015b)	✓	✓		✓
Hughes (2007)	✓	✓	✓	✓
Hughes (2008)	✓	✓	✓	✓
Lappan et al. (2024)	✓	✓	✓	✓
LaVaccare et al. (2018)	✓	✓		✓
Mackenzie-Jones & Willis (2016)	✓	✓	✓	✓
Platzer & James (2000)	✓	✓		✓
Rosati et al. (2021)	✓	✓		✓
Sharek et al. (2014)	✓	✓	✓	✓
Silverskog (2014)	✓	✓	✓	✓
Smith & Wright (2021)	✓	✓		✓
Stein et al. (2010)	✓	✓	✓	✓
Valenti et al. (2021)	✓	✓	✓	✓
Valenti et al. (2022)	✓	✓	✓	✓
Waling et al. (2020)	✓	✓	✓	✓
Williams et al. (2022)	✓	✓	✓	✓
Willis (2020)	✓	✓		✓

18. Discussion

The findings from this systematic review provide important insights into the ways in which LGBTQ+ older adults consider how their sexual orientation/identity interacts with their healthcare experiences. The themes focus on the importance of the LGBTQ+ community maintaining their sense of identity and having that identity affirmed and supported by their environment. While this remains one of the most crucial aspects of care for older adults who identify as LGBTQ+, there are many barriers that prevent individuals from feeling safe and sharing their identity in healthcare settings [60]. Historical discrimination has contributed to a complex relationship between the LGBTQ+ community and healthcare institutions, leaving many LGBTQ+ older adults feeling fearful of discrimination and distrusting of healthcare providers [10,49]. It is this fear that creates a culture of identity hiding, where LGBTQ+ older adults felt it was a safer option to purposefully deny or simply not disclose their sexual or gender identity [55]. Many who have done so state they believed their healthcare treatment would be affected if they disclosed this part of their identity and that they would receive lower quality care [51,55]. Notable instances of discrimination faced by LGBTQ+ older adults in long-term care environments include refusal of admission, refusal of basic care, harassment from staff, restriction of visitors, denial of treatment, lack of acknowledgement of the medical power of attorney of the spouse, and even abuse [47].

In the mental health context, transgender individuals reported disclosing their identity would dilute their therapy as some therapists would focus on “curing” their sexual or gender diversity [61]. This fear of discrimination, combined with heteronormativity, or the assumption that someone is straight, results in a belief that they must hide their sexual or gender identities, even though many older adults emphasized the importance of feeling accepted for who they are [17,62]. LGBTQ+ older adults felt the constant need to guard against potential homophobia so that even subtle disapproval or indifference, while not explicitly derogatory, is stressful and isolating [57]. While there has been progress related to affirmation and inclusion [56], there remains a lack of understanding related to LGBTQ+ older adults [15,63].

Participants in the studies reviewed had experienced healthcare providers violating their rights and their partner being treated as a friend instead of a romantic partner, which led to partners being excluded from important conversations [5]. This injustice occurs not only in hospital and clinic settings, but also in homecare and long-term care. Heteronormative attitudes, poor LGBTQ+ awareness, and homophobia are prevalent in homecare staff workers and residents, which further leads to inequality and concealment of sexual and gender identities [17]. In long-term care centers, the literature reports a lack of inclusivity and protection for older adults who identify as LGBTQ+, as well as sexuality-based discrimination and poor-quality care [64,65]. Likewise, many LGBTQ+ older adults have experienced healthcare providers dismissing their romantic partners and spouses when they are ill or receiving palliative care. Then, after their passing, their spouse is treated as a “friend” and not given adequate support for their grief [53]. This continues to ignite an internal conflict for members of the community, who wish to be “out” to healthcare providers, but also feel they need to hide their identity to avoid discrimination. This struggle contributes to a lower quality of social and mental health, especially when past traumas and microaggressions are added to the equation [66].

A major concern highlighted in the studies reviewed is the lack of knowledge and formal education on LGBTQ+ older adults’ needs. Participants in the studies noted deficits in healthcare knowledge and the lack of specialized resources. They were uncertain whether staff in residential care services have been educated about the experiences and needs of individuals in the LGBTQ+ community [43,45,47,57,67,68]. This is supported by the literature, which states that the needs of the LGBTQ+ community are often ignored or misunderstood [62,69]. This disparity results in a lack of personalized LGBTQ+ care and necessary measures such as trauma-informed care approaches [66]. To compensate for the lack of knowledge, many transgender patients have described being “reluctant educators” to providers to get the care that they need. This is an additional burden for LGBTQ+ older adults that is not placed on older adults who are heterosexual [46,48]. Similarly, some older gay and lesbian adults expressed stress caused by having to explain their situation and educate healthcare providers about their lifestyles [38]. These shortcomings in healthcare systems deepen a growing disconnect between providers and LGBTQ+ patients which further impairs their healthcare experience [5].

When LGBTQ+ older adults are treated by providers who are knowledgeable, competent, and work to affirm their identity, there is a positive correlation with future interactions, increased utilization of services, a feeling of safety in healthcare settings, and overall satisfaction with care [49]. This is consistent with findings of studies with LGBTQ+ across age groups [70]. There are several strategies highlighted by the participants in the studies reviewed to address these concerns, including more training and the creation of inclusive environments that openly supports sexual and gender-diverse people [22,38,41]. For example, some older lesbian and bisexual women recommend healthcare providers offer extended appointment times for building rapport and developing a deeper understanding of their needs, specifically emotional and psychological needs [43]. Display of gay-friendly images and targeted health promotion information in the healthcare environment was also noted to promote inclusivity [38,41,50]. This is consistent with other literature that noted that when staff members explicitly state their support for LGBTQ+ older adults, it creates an environment that ensures older adults feel safe and respected [62]. To feel safe to disclose their identities, the literature emphasizes the importance of sensitivity training for healthcare professionals and how crucial it is for LGBTQ+ to have a sense of belonging and connection among their members as they age in order to embrace this part of their identity and feel accepted [71].

As previously noted, the need for a sense of community for LGBTQ+ older adults is credible and complex. It is well documented that LGBTQ+ older adults are less likely to have children, which decreases the amount of social support they have available to them as they age [12,56]. In long-term care settings, it is vital to create an environment of belonging and camaraderie, which many LGBTQ+ older adults find in communities with other LGBTQ+ members [71]. As identified in our review and supported in other literature, many LGBTQ+ older adults find comfort and a strong sense of connectedness to each other through shared or similar histories, which contributes to older adults feeling seen, supported, and more at ease [52,55]. There is also a need for informal and formal support groups for LGBTQ+ older adults [55] and programs that consider intersectionality in the aging LGBTQ+ population, as many significant factors are often overlooked [71]. Studies also show that when LGBTQ+ individuals feel that they have a community, it also acts to affirm their identity and improve resiliency and overall well-being [71,72].

This affirmation has also been found to be important when planning for end-of-life care [73]. Overall, the literature states that older adults who identify as LGBTQ+ have many obstacles they must face when planning for advanced healthcare directives, which can be mitigated through designing healthcare settings such as homecare, long-term care, and hospices with this unique population and their needs in mind [74]. It is also integral that relationships are valued and that spouses of LGBTQ+ older adults are treated with dignity and respect, and that when considering end of life, grieving family members have a support system within the LGBTQ+ community after the death of their loved one [44].

While the issues highlighted in this review arise from individual experiences, it is evident from the literature that structural inequities within and across various healthcare systems are implicated in the delivery of care that is not inclusive or affirming, along with associated negative health outcomes [75]. While each of the themes highlighted speaks to how care was delivered and received, often through individual interactions, it is important to acknowledge that each of these interactions were shaped by structural elements of healthcare systems that vary in terms of legislation, governance, funding, professional education, as well as organizational and societal contexts. These structural inequities are ultimately linked to structural stigma [76], suggesting that the experiences highlighted within the findings of this review are greatly influenced by the complex set of systems within which the care is experienced. Structural stigma has been defined as “societal-level conditions, cultural norms, and institutional policies that constrain the opportunities, resources, and well-being of the stigmatized” ([77], p. 742). According to Hatzenbuehler et al. [77], structural stigma is associated with fear of engaging with health systems and negative mental and physical health outcomes for people within the LGBTQ+ community. This is quite evident in the literature reviewed, not only in instances where health professionals have provided personal care that is non-inclusive and stigmatizing, but also in care that is clearly being shaped a system developed within a heteronormative design. Such design privileges heterosexual individuals and families, often to the exclusion of the LGBTQ+ population in institutional policies, regulation and legal recognition [7,78]. This often renders those from the LGBTQ+ population invisible within the healthcare system [79]. This was clearly evident for participants in the studies reviewed, who highlighted the health professional knowledge gap and the lack of attention to inclusive and affirming spaces. Such systemic exclusions fail to acknowledge how ageism, heterosexism, genderism, racism and other forms of marginalization impact the experiences of LGBTQ+ older adults.

The existing research on structural inequities points to the historical and ongoing invisibility of the LGBTQ+ community within health and social systems. This research, however, has predominantly emerged from Western, higher-income countries where policies and legislation have evolved to incorporate greater recognition and legal protections for the LGBTQ+ community. Our conclusions and recommendations are based upon findings that reflect this reality. Unfortunately, in areas with discriminatory laws and policies, where identities remain marginalized or even criminalized, the voices of these LGBTQ+ individuals may be silenced and structural stigma may be even more dangerous and damaging.

19. Limitations of This Review

Although measures were taken to ensure accurate and relevant analysis and findings, there are a few limitations that must be addressed. While the review highlighted themes in the literature that was analyzed, the inclusion criteria only allowed for literature published in English, which may have excluded other healthcare experiences from LGBTQ+ older adults as well as limiting global representativeness. As previously noted, the current literature related to the healthcare experiences of LGBTQ+ older adults has largely emerged from Western countries where LGBTQ+ rights movements and legal reform have been active for a number of years. This reflects the global variation in the level of rights recognition and protections for LGBTQ+ individuals. Thus, the voices of those individuals who are marginalized and even criminalized are often predominantly absent from the literature, therefore limiting our understanding of experiences of discrimination and marginalization at a global level. Additionally, while healthcare experiences were analyzed in depth and grouped into themes for discussion, there were a multitude of opposing and intricate experiences shared in previous studies, some of which were not highlighted within the scope of this review. Also, there may have been some disparity in healthcare systems across different countries that were included in this study. Of the literature that was extracted, not all published works included a variety of participants that reflected individuals of all races, socioeconomic status, gender identities, nationalities, and other lifestyle and societal factors. It is likely that not all relevant experiences and intersectionalities were included in this systematic review. Lastly, limiting the age to participants to 60+ could exclude experiences of those who experience age-related issues at a younger age due to the discrimination and minority stress experienced buy this community.

20. Suggestions for Future Research and Practice

To further the research related to LGBTQ+ older adults’ healthcare experiences, new studies must be conducted with consideration to the complexity and diversity within the LGBTQ+ community, including those with disabilities, low socioeconomic status, people of color, and Indigenous peoples. While systemic restraints exist, research is needed in areas of the globe where laws and policies remain anti-LGBTQ+ to explore the experiences of those whose identities continue to be marginalized or criminalized. By gathering these experiences and adding to the pre-existing literature regarding LGBTQ+ experiences in healthcare using an intersectional lens, research will provide more opportunities to hear the voices of individuals who may not be well represented in current studies. Additionally, many studies introduce the concept of creating exclusive LGBTQ+ services or healthcare settings; however, not many studies exist that explore these services, particularly for older adults. For future research, it would be valuable to focus on creating and analyzing the impact of these environments to determine the potential positive effects of these centers. Additionally, it is important to focus on the efficacy of interventions that already exist for older adults who identify as LGBTQ+, as many studies have demonstrated that not all older adults have access to or knowledge of safe spaces that were available to them. This research should also utilize a structural focus, considering the broader systems that not only produce marginalizing and non-affirming practitioners but the very policies and environments which inform their care.

The findings of this research should be appraised and synthesized to inform practice. Based upon the research reviewed, we recommend an LGBTQ+ friendly focus through all policies and program development within given healthcare systems. This would ensure that the physical, spiritual and psychosocial needs of LGBTQ+ older adults are taken into consideration at all levels of program planning and development. This should be done in partnership with the community members with a focus on collaboration and intersectoral cooperation.

21. Conclusions

In this review, we discussed the importance of having one’s identity supported by healthcare providers, while also addressing the barriers, stigma and deficits in services that prevent LGBTQ+ older adults from receiving quality care. We noted that throughout history, LGBTQ+ individuals have faced many challenges in society, especially in relation to healthcare institutions. As people within the LGBTQ+ community age, healthcare systems must focus on the intersectionality of needs and barriers that must be addressed to provide the best possible care. To help alleviate the burden that is unfairly placed on this population, we must advocate for more formal and informal spaces that explicitly welcome and affirm LGBTQ+ identities and work to ensure that pre-existing programs are accessible to LGBTQ+ populations. While the literature demonstrates that this population is resilient and thrives on community connection, there is a need for recognition of the impact of heteronormative systems on healthcare delivery. The voices of the participants across studies in this review speak to the need for a shift beyond the focus of individual training and education to an examination of systems and a focus on structural stigma. By analyzing the literature on LGBTQ+ older adults’ experiences with healthcare services, this review highlights these vital areas for improvement and offers recommendations to ensure a more positive healthcare experience for LGBTQ+ older adults.