ABSTRACT

Programmatic vulnerability concerns access to and use of health resources, such as programs aimed at health prevention, care, and rehabilitation. For LGBTQIA+ older people, vulnerability issues are even more significant, since that group faces other social issues that reflect on the preparation of professionals to provide care in health services. The aim was to map the occurrence of programmatic vulnerability among LGBTQIA+ older people. This is a scoping review, guided by the JBI recommendations using the mnemonic P (LGBTQIA+ older people), C (vulnerability), and C (healthcare programs). The documents were analyzed qualitatively using the R Interface software, IRaMuTeQ. Two thematic categories were identified: The construction of comprehensive care: the role of health and social institutions in developing actions aimed at the needs of LGBTQIA+ older people; Programmatic vulnerability: gaps in care for older people belonging to sexual minorities. This study identified that situations of vulnerability are more evident in health services, long-term care institutions, and in care provided by health professionals, suffering from stigma and prejudice.

KEYWORDS
Disaster vulnerability; Aged; Sexual and gender minorities

Introduction

Human aging is a physiological process that brings about various changes, such as molecular, cellular, and behavioral damages, which have repercussions on the psychosocial context and the individual’s quality of life. In Brazil, the number of people aged 60 years or older reached 15.6% of the population in the year 2022, showing an increase of 56% compared to the year 2010. This led to an Aging Index of 80 (with 80 older people for every 100 children aged 0 to 14 years)¹1 Instituto brasileiro de Geografia e Estatística. Censo Demográfico 2022: população por idade e sexo. Brasília: IBGE; 2022..

Considering that aging is not a homogeneous process, since it depends on the physiological, psychological, and social aspects in which the individual is inserted, it is appropriate to point out that there are differences in the way people age. In this context, the LGBTQIA+ (Lesbian, Gay, Bisexual, Transgender, Queer, Intersex, Asexual and gender identities and sexual orientations that do not fit the cis-heteronormative pattern, but which are not highlighted before the symbol) older population stands out, which has been representing a significant quantitative increase compared to the general older population.

Studies show that by 2030 the number of gay, lesbian, bisexual and transgender older people in the United States of America (USA) will double. It is estimated that LGBTQIA+ adults represent around 3% to 4% of the general adult population in this country. However, ageing associated with the historical-cultural scenario of marginalization and discrimination increases vulnerability when it comes to LGBTQIA+ seniors, making them invisible in the context of US society²2 Fredriksen-Goldsen KI, Hoy-Ellis CP, Goldsen J, et al. Creating a vision for the future: key competencies and strategies for culturally competent practice with lesbian, gay, bisexual, and transgender (LGBT) older adults in the health and human services. J. Gerontol. Soc. Work. 2014 [acesso em 2023 out 5]; 57(2-4):80-107. Disponível em: https://doi.org/10.1080/01634372.2014.890690.
https://doi.org/10.1080/01634372.2014.89... .

Among other aspects, aging culminates in an increase in the vulnerability of older people, which can be reflected by the lack of conditions to react to some type of threat, danger or violence³3 Cipriani LM, Lopes BC, Acrani GO, et al. Social vulnerability of the older population using Primary Health Care in a municipality of Rio Grande do Sul. Semina Ciênc. Biol. Saúde. 2023 [acesso em 2023 out 20]; 44(1):3-14. Disponível em: https://pesquisa.bvsalud.org/gim/resource/fr/biblio-1511614.
https://pesquisa.bvsalud.org/gim/resourc... . This refers to the state in which individuals or specific groups have their capacity for self-determination reduced, and may have difficulties in protecting their own interests, as there are deficits in power, intelligence, education, resources, strengths, or other attributes⁴4 Barbosa KTF, Fernandes MGM. Elderly vulnerability: concept development. Rev. Bras. Enferm. 2020 [acesso em 2023 out 25]; 73(supl3):e20190897. Disponível em: https://doi.org/10.1590/0034-7167-2019-089.
https://doi.org/10.1590/0034-7167-2019-0... .

According to Ayres et al.⁵5 Ayres J, Calazans GJ, Saletti Filho HC, et al. Risco, vulnerabilidade e práticas de prevenção e promoção da saúde. In: Campos G, Minayo MCS, Akerman M, et al., organizadores. Tratado de Saúde Coletiva. São Paulo: Editora Fiocruz; 2006. p. 375-417., vulnerability can be seen under three categories: individual, social, and programmatic. This study will emphasize programmatic vulnerability which comprises the social resources needed to protect individuals from risks to their physical, psychological, and social well-being. It consists of a plan intended to provide subsidies to design strategies to improve care for the elderly, in line with the guidelines of the Unified Health System⁶6 Bolina AF, Rodrigues RAP, Tavares DMS, et al. Indices of social and programmatic vulnerability for older adults living at home. Enf. Global. 2022 [acesso em 2023 out 25]; 21(1):140-178. Disponível em: https://revistas.um.es/eglobal/article/view/477281.
https://revistas.um.es/eglobal/article/v... .

When taking this into account for LGBTQIA+ older people, vulnerability issues are even more significant, since, in addition to the aging process, this group faces other social issues that impact the preparedness of professionals in providing healthcare services.

The invisibility of older people’s sexuality coupled with the unique and specific challenges faced by the LGBTQIA+ population, raises discussions about the impact of healthcare services on maintaining active and healthy ageing. It is important to note that, in addition to professional care, programmatic vulnerability concerns access to and use of health resources, such as programs aimed at prevention, care and health rehabilitation⁶6 Bolina AF, Rodrigues RAP, Tavares DMS, et al. Indices of social and programmatic vulnerability for older adults living at home. Enf. Global. 2022 [acesso em 2023 out 25]; 21(1):140-178. Disponível em: https://revistas.um.es/eglobal/article/view/477281.
https://revistas.um.es/eglobal/article/v... .

The research which identified strategies to help access and develop culturally competent practice with LGBTQIA+ older people in health services, pointed to: the need for changes in personal and professional attitudes towards users’ sexual orientation, gender identity and age; understanding about the social and cultural context of LGBTQIA+ seniors; distinguishing similarities and differences within subgroups; using appropriate language to work with the mentioned public; understanding about the marginalization of seniors LGBTQIA+ in health programs and services; and understanding the need to improve access for LGBTQIA+ seniors and their families to social, aging and social health services²2 Fredriksen-Goldsen KI, Hoy-Ellis CP, Goldsen J, et al. Creating a vision for the future: key competencies and strategies for culturally competent practice with lesbian, gay, bisexual, and transgender (LGBT) older adults in the health and human services. J. Gerontol. Soc. Work. 2014 [acesso em 2023 out 5]; 57(2-4):80-107. Disponível em: https://doi.org/10.1080/01634372.2014.890690.
https://doi.org/10.1080/01634372.2014.89... .

Meanwhile – and considering that the aging process greatly influences the long-term of the older person’s health – issues related to the programmatic vulnerability of the seniors LGBTQIA+ deserve to be addressed in healthcare programs, since sexual orientation and gender identity are often neglected in the provision of services or in the training of professionals who work with such a public.

Therefore, the aim of the study was to map the occurrence of programmatic vulnerability among LGBTQIA+ older people.

Material and methods

This is a scoping review study, guided, pre-established, and structured by the recommendations of the Institute Reviewer’s Manual (JBI)⁷7 Peters MDJ, Godfrey C, McInerney P, et al. Chapter 11: Scoping Reviews (2020 version). In: Aromataris E, Munn Z, editores. JBI Manual for Evidence Synthesis. JBI; 2020. and the PRISMA-ScR for reviews⁸8 Tricco AC, Lillie E, Zarin W, et al. PRISMA Extension for Scoping Reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018; 169(7):467-473.. As recommended by the JBI, this review was developed using a protocol registered with the Open Science Framework (https://osf.io/e49m2), identification doi: https://doi.org/10.17605/OSF.IO/E49M2.

The guiding questions were determined through the mnemonic combination PCC, in which P (population) – LGBTQIA+ older people; C (concept) – vulnerability; and C (context) – health care programs, thus generating the following questions: what are the vulnerabilities related to healthcare programs for LGBTQIA+ older people? What is the perception of professionals and LGBTQIA+ older people about healthcare services?

After defining the mnemonic combination of the CCP and the guiding questions, the eligibility criteria were as follows: articles or documents addressing the vulnerability of LGBTQIA+ older people, available in full. There was no time or language restriction and those that were duplicated in more than one database were excluded.

The survey of studies in the literature was carried out independently by two researchers between October and November 2023. As recommended by the JBI, an initial screening was carried out in two databases, PubMed and Journals OVID Full Text, using the combinations: [(Idoso) AND (Minorias Sexuais e de Gênero) AND (Vulnerabilidade em saúde) AND (Health Services)] and [(Aged) AND (Sexual and Gender Minorities) AND (Health Vulnerability) AND (Health Services)]. To this end, the descriptors, titles, and abstracts of the articles were analyzed in order to develop the search strategies.

After the first search in the previously mentioned databases, a search strategy was developed to identify the available academic production. The following keywords were used in combination with Boolean operands AND & OR: [((Envelhecimento) OR (Idoso) OR (Adultos mais velhos) AND ((Má resultado de saúde) (Abuso de álcool) OR (Uso de substâncias) OR (Covid-19) OR (Determinantes de saúde) OR (Estresse psicológico) OR (Promoção à saúde) OR (Vacinação) OR (Consciência de classe) OR (Cuidado à saúde mental) OR (Estigma estrutural) OR (Depressão) OR (Suicídio) OR (Solidão) OR (Necessidades de saúde) OR (Disparidades de saúde) OR (Competências do cuidado em saúde) OR (Saúde e bem-estar) OR (Competência cultural)) AND ((Discriminação) OR (Minoria sexual) OR (LGBT saúde) OR (Identidade de gênero) OR (Orientação sexual) OR (Transgênero) OR (Gênero diversificado) OR (Atividade sexual) OR (Bisexual) OR (Gay) OR (Homem que fazem sexo com outro homem) OR (Comportamento sexual))].

The second search was carried out in the following databases: Medline via PubMed, Scopus (Elsevier), Web of Science (WOS), Latin American and Caribbean Health Sciences Literature (LILACS) and Scientific Electronic Library Online (SciELO). Evidence classified as gray literature was investigated in the Catalogue of Theses and Dissertations of the Coordination for the Improvement of Higher Education Personnel (CAPES). Finally, a reference list of the selected documents was made in order to identify new documents.

After the search, the data was grouped and exported to Rayyan, an online application developed by the Qatar Computing Research Institute, which allows articles to be organized and selected. It should be noted that studies identified in more than one database were only considered once according to the order of the analysis. In the case of articles that received differing assessments as to their relevance, a third reviewer was invited to analyze them and clarify any doubts.

Initially, 2,557 studies were identified; after reading the titles, 125 were selected because they suggested they were close to the subject under study. An exhaustive evaluation of the abstracts was then carried out, resulting in 35 articles which were read in full, and 18 studies which met the objectives of the review were then selected. All studies that did not meet the proposed objective were excluded, as were studies that were unavailable in full and duplicated in more than one database, as shown in figure 1.

Data was extracted using a structured tool developed by the reviewers which included information about the publication such as authors, title of the article, year of publication, country in which it was developed, journal, and type of study. In addition, evidences suggesting programmatic vulnerability and the implications for older people’s health were grouped together. Health vulnerability is observed in several facets, since it is considered a multidimensional construct. As such, the theoretical support chosen was the study by Ayres et al.⁵5 Ayres J, Calazans GJ, Saletti Filho HC, et al. Risco, vulnerabilidade e práticas de prevenção e promoção da saúde. In: Campos G, Minayo MCS, Akerman M, et al., organizadores. Tratado de Saúde Coletiva. São Paulo: Editora Fiocruz; 2006. p. 375-417., which seeks to understand vulnerability as a synthesis of the physical, social and programmatic dimensions, which are considered to be distinct but inseparable. The information was entered into a Microsoft Office Excel® spreadsheet, supporting the synthesis and description of the results in accordance with the aim of this study.

The data collected on programmatic vulnerability identified in the manuscripts selected in the sample was compiled in text corpus format and processed in IRaMuTeQ (Interface de R pour les Analyses Multidimensionnelles de Textes et de Questionnaires), version 0.7 alpha2⁹9 Camargo BV, Justo AM. IRAMUTEQ: a free software for analysis of textual data. Temas Psicol. 2013; 21(2):513-518., using similarity analysis and Descending Hierarchical Classification (DHC).

The CHD performs groupings within the textual corpus and makes it possible to form classes according to the association of words; these, in turn, are formed by Text Segments (TS) according to their vocabulary, forming cross matrices (X²) and determining the frequencies in which the occurrences are broken down⁹9 Camargo BV, Justo AM. IRAMUTEQ: a free software for analysis of textual data. Temas Psicol. 2013; 21(2):513-518.. The association of the word with the class was determined by p-value < 0.05 or x^2< 3.80.

The classes were critically analyzed according to the qualitative approach, supported by the thematic categorical analysis proposed by Bardin¹⁰10 Bardin L. Análise de conteúdo. São Paulo: Edição 70; 2011.^, which consists of the stages of pre-analysis, exploration of the material, and treatment of the evidence obtained, interpreting it. The categories that emerged follow the principle of mutual exclusion, completeness, representativeness, homogeneity, and relevance, according to the precepts of the technique¹⁰10 Bardin L. Análise de conteúdo. São Paulo: Edição 70; 2011..

Results

The sample consisted of 18 articles that met the eligibility criteria to address the guiding questions. Of these, the majority were written in 2014 (22.2%), developed in the USA (50%) and had a qualitative approach (50%) as shown in table 1 ¹¹11 Lampe NM, Barbee H, Tran NM, et al. Health disparities among Lesbian, Gay, Bisexual, Transgender, and Queer Older Adults: a structural competency approach. Int. J. Aging. Hum. Dev. 2023 [acesso em 2023 out 5]; 25:914150231171838. Disponível em: https://doi.org/10.1177/00914150231171838.
https://doi.org/10.1177/0091415023117183... ,¹²12 Roe L, Galvin M. Providing inclusive, person-centred care for LGBT+ older adults: A discussion on health and social care design and delivery. J. Nurs. Manag. 2021 [acesso em 2023 out 5]; 29(1):104-108. Disponível em: https://doi.org/10.1111/jonm.13178.
https://doi.org/10.1111/jonm.13178... ,¹³13 Adan M, Scribani M, Tallman N, et al. Worry and Wisdom: A qualitative study of transgender elders’ perspectives on aging. Transgend. Health. 2021 [acesso em 2023 out 5]; 6(6):332-342. Disponível em: https://doi.org/10.1089/trgh.2020.0098.
https://doi.org/10.1089/trgh.2020.0098... ,¹⁴14 Knochel KA, Flunker D. Long-Term care expectations and plans of transgender and nonbinary older adults. J. Appl. Gerontol. 2021 [acesso em 2023 out 5]; 40(11):1542-1550. Disponível em: https://doi.org/10.1177/0733464821992919.
https://doi.org/10.1177/0733464821992919... ,¹⁵15 Wirth M. Demand for Space: elderly transgender and gender nonconforming people, healthcare, and theological ethics. J. Relig. Health. 2021 [acesso em 2023 out 5]; 60(3):1713-1728. Disponível em: https://doi.org/10.1007/s10943-020-01101-9.
https://doi.org/10.1007/s10943-020-01101... ,¹⁶16 Waling A, Lyons A, Alba B, et al. Trans women’s perceptions of residential aged care in Australia. Br. J. Soc. Work. 2020 [acesso em 2023 out 5]; 50(5):1304-1323 Disponível em: https://doi.org/10.1093/bjsw/bcz122.
https://doi.org/10.1093/bjsw/bcz122... ,¹⁷17 Westwood S, Willis P, Fish J, et al. Older LGBT+ health inequalities in the UK: setting a research agenda. J. Epidemiol. Community Health. 2020 [acesso em 2023 out 5]; 74(5):408-411. Disponível em: https://doi.org/10.1136/jech-2019-213068.
https://doi.org/10.1136/jech-2019-213068... ,¹⁸18 Waling A, Lyons A, Alba B, et al. Experiences and perceptions of residential and home care services among older lesbian women and gay men in Australia. Health Soc. Care Community. 2019 [acesso em 2023 out 5]; 27(5):1251-1259. Disponível em: https://doi.org/10.1111/hsc.12760.
https://doi.org/10.1111/hsc.12760... ,¹⁹19 Kortes-Miller K, Boulé J, Wilson K, et al. Dying in Long-Term Care: Perspectives from Sexual and Gender Minority Older Adults about Their Fears and Hopes for End of Life. J. Soc. Work End Life Palliat Care. 2018 [acesso em 2023 out 5]; 14(2-3):209-224. Disponível em: https://doi.org/10.1080/15524256.2018.1487364.
https://doi.org/10.1080/15524256.2018.14... ,²⁰20 Smith RW, Altman JK, Meeks S, et al. Mental Health Care for LGBT Older Adults in Long-Term Care Settings: Competency, Training, and Barriers for Mental Health Providers. Clin. Gerontol. 2019 [acesso em 2023 out 5]; 42(2):198-203. Disponível em: https://doi.org/10.1080/07317115.2018.148519.
https://doi.org/10.1080/07317115.2018.14... ,²¹21 Sussman T, Brotman S, MacIntosh H, et al. Supporting Lesbian, Gay, Bisexual, & Transgender Inclusivity in Long-Term Care Homes: A Canadian Perspective. Can. J. Aging. 2018 [acesso em 2023 out 5]; 37(2):121-132. Disponível em: https://doi.org/10.1017/S071498081800007.
https://doi.org/10.1017/S071498081800007... ,²²22 Stinchcombe A, Smallbone J, Wilson K, et al. Healthcare and end-of-life needs of Lesbian, Gay, Bisexual, and Transgender (LGBT) older adults: a scoping review. Geriatrics (Basel). 2017 [acesso em 2023 out 5]; 2(1):13. Disponível em: https://doi.org/10.3390/geriatrics2010013.
https://doi.org/10.3390/geriatrics201001... ,²³23 Orel NA. Investigating the needs and concerns of lesbian, gay, bisexual, and transgender older adults: the use of qualitative and quantitative methodology. J. Homosex. 2014 [acesso em 2023 out 5]; 61(1):53-78. Disponível em: https://doi.org/10.1080/00918369.2013.835236.
https://doi.org/10.1080/00918369.2013.83... ,²⁴24 Foglia MB, Fredriksen-Goldsen KI. Health Disparities among LGBT Older Adults and the Role of Non-conscious Bias. Hastings Cent. Rep. 2014 [acesso em 2023 out 5]; 44(supl4):S40-4. Disponível em: https://doi.org/10.1002/hast.369.
https://doi.org/10.1002/hast.369... ,²⁵25 Sharek DB, McCann E, Sheerin F, et al. Older LGBT people’s experiences and concerns with healthcare professionals and services in Ireland. Int. J. Older People Nurs. 2015 [acesso em 2023 out 5]; 10(3):230-240. Disponível em: https://doi.org/10.1111/opn.12078.
https://doi.org/10.1111/opn.12078... ,²⁶26 Fredriksen-Goldsen KI, Kim HJ, Barkan SE, et al. Health disparities among lesbian, gay, and bisexual older adults: results from a population-based study. Am. J. Public Health. 2013 [acesso em 2023 out 5]; 103(10):1802-1809. Disponível em: https://doi.org/10.2105/AJPH.2012.301110.
https://doi.org/10.2105/AJPH.2012.301110... ,²⁷27 American Geriatrics Society Ethics Committee. American Geriatrics Society care of lesbian, gay, bisexual, and transgender older adults position statement: American Geriatrics Society Ethics Committee. J. Am. Geriatr. Soc. 2015 [acesso em 2023 out 5]; 63(3):423-426. Disponível em: https://doi.org/10.1111/jgs.1329.
https://doi.org/10.1111/jgs.1329... . It is worth noting that none of the studies were conducted in Brazil.

From the textual corpus, 135 ST emerged, with 111 being retained for CHD, equivalent to 82.22% retention; in addition, 4,958 occurrences were generated, of which 839 were active forms. The lexical content was organized into six classes as shown in the dendrogram below in figure 2.

After analyzing the excerpts, the following classes were defined: 1 - Access to health services; 2 - Stigmas and prejudices of health professionals; 3 - Role of long-term care institutions in caring for LGBTQIA+ older people; 4 - Impact of gender identity and sexual orientation on care; 5 - Programmatic vulnerability from the perspective of older people belonging to sexual minorities; and 6 - Care needs: specificities of LGBTQIA+ older people.

Figure 3 shows the diagram representing the classes with their respective words, frequency and x2, i.e. the visual representation of the terms indicating the linguistic similarities between them.

By organizing the dendrogram and visualizing the diagram, it can be seen that all the classes emerge from class 5, which is predominantly related to the social aspects of sexual orientation. Two subcorpora emerge from this class: subcorpus A, made up of classes 1, 2 and 6; and subcorpus B, made up of classes 3 and 4.

By considering the thematic content of the two respective textual subcorpora, it was possible to list two central thematic categories, namely: Category I (subcorpus A) - The construction of comprehensive care: the role of health and social institutions in developing actions aimed at the needs of LGBTQIA+ older people; Category II (subcorpus B) -Programmatic vulnerability: gaps in care for older people belonging to sexual minorities. The similarity analysis shown below by the maximum tree in figure 4 corroborates the definition of the thematic categories defined by the CHD.

Discussion

Category I (subcorpus A) - Building integral care: the role of health and social institutions in developing actions aimed at the needs of LGBTQIA+ older people

Category I emerged from classes 1 (access to health services), 2 (stigmas and prejudices of health professionals) and 6 (care needs: specificities of LGBTQIA+ older people). When looked at from the point of view of content, they go on to discuss the care that should be given to LGBTQIA+ older people and their social roles in order to meet their physical, psychological and social needs.

One of the gaps in care in terms of access to health services found in the study sample was the lack of specific services for the LGBTQIA+ older community¹²12 Roe L, Galvin M. Providing inclusive, person-centred care for LGBT+ older adults: A discussion on health and social care design and delivery. J. Nurs. Manag. 2021 [acesso em 2023 out 5]; 29(1):104-108. Disponível em: https://doi.org/10.1111/jonm.13178.
https://doi.org/10.1111/jonm.13178... ,¹⁴14 Knochel KA, Flunker D. Long-Term care expectations and plans of transgender and nonbinary older adults. J. Appl. Gerontol. 2021 [acesso em 2023 out 5]; 40(11):1542-1550. Disponível em: https://doi.org/10.1177/0733464821992919.
https://doi.org/10.1177/0733464821992919... ,¹⁶16 Waling A, Lyons A, Alba B, et al. Trans women’s perceptions of residential aged care in Australia. Br. J. Soc. Work. 2020 [acesso em 2023 out 5]; 50(5):1304-1323 Disponível em: https://doi.org/10.1093/bjsw/bcz122.
https://doi.org/10.1093/bjsw/bcz122... ,²¹21 Sussman T, Brotman S, MacIntosh H, et al. Supporting Lesbian, Gay, Bisexual, & Transgender Inclusivity in Long-Term Care Homes: A Canadian Perspective. Can. J. Aging. 2018 [acesso em 2023 out 5]; 37(2):121-132. Disponível em: https://doi.org/10.1017/S071498081800007.
https://doi.org/10.1017/S071498081800007... ,²⁵25 Sharek DB, McCann E, Sheerin F, et al. Older LGBT people’s experiences and concerns with healthcare professionals and services in Ireland. Int. J. Older People Nurs. 2015 [acesso em 2023 out 5]; 10(3):230-240. Disponível em: https://doi.org/10.1111/opn.12078.
https://doi.org/10.1111/opn.12078... . This lack permeated themes related to not being able to accept their sexual orientation and suffering some kind of discrimination²²22 Stinchcombe A, Smallbone J, Wilson K, et al. Healthcare and end-of-life needs of Lesbian, Gay, Bisexual, and Transgender (LGBT) older adults: a scoping review. Geriatrics (Basel). 2017 [acesso em 2023 out 5]; 2(1):13. Disponível em: https://doi.org/10.3390/geriatrics2010013.
https://doi.org/10.3390/geriatrics201001... or transphobia on the part of professionals¹¹11 Lampe NM, Barbee H, Tran NM, et al. Health disparities among Lesbian, Gay, Bisexual, Transgender, and Queer Older Adults: a structural competency approach. Int. J. Aging. Hum. Dev. 2023 [acesso em 2023 out 5]; 25:914150231171838. Disponível em: https://doi.org/10.1177/00914150231171838.
https://doi.org/10.1177/0091415023117183... ,²²22 Stinchcombe A, Smallbone J, Wilson K, et al. Healthcare and end-of-life needs of Lesbian, Gay, Bisexual, and Transgender (LGBT) older adults: a scoping review. Geriatrics (Basel). 2017 [acesso em 2023 out 5]; 2(1):13. Disponível em: https://doi.org/10.3390/geriatrics2010013.
https://doi.org/10.3390/geriatrics201001... ,²⁵25 Sharek DB, McCann E, Sheerin F, et al. Older LGBT people’s experiences and concerns with healthcare professionals and services in Ireland. Int. J. Older People Nurs. 2015 [acesso em 2023 out 5]; 10(3):230-240. Disponível em: https://doi.org/10.1111/opn.12078.
https://doi.org/10.1111/opn.12078... as well as not receiving the necessary care with regard to hormone replacement therapy¹⁴14 Knochel KA, Flunker D. Long-Term care expectations and plans of transgender and nonbinary older adults. J. Appl. Gerontol. 2021 [acesso em 2023 out 5]; 40(11):1542-1550. Disponível em: https://doi.org/10.1177/0733464821992919.
https://doi.org/10.1177/0733464821992919... ,¹⁶16 Waling A, Lyons A, Alba B, et al. Trans women’s perceptions of residential aged care in Australia. Br. J. Soc. Work. 2020 [acesso em 2023 out 5]; 50(5):1304-1323 Disponível em: https://doi.org/10.1093/bjsw/bcz122.
https://doi.org/10.1093/bjsw/bcz122... .

The challenges faced in general medical care for transgender people stem from various barriers, such as the fear of discrimination, shortage of specialists, financial concerns, among others. The presence of transphobia in health services contributes to lower demand for routine examinations, and refusal of certain treatments. Check-ups are essential for those receiving hormone therapy helping with the early detection of cancer. However, it is notoriously difficult to find professionals, such as gynecologists and psychiatrists capable of providing adequate care for this population¹⁵15 Wirth M. Demand for Space: elderly transgender and gender nonconforming people, healthcare, and theological ethics. J. Relig. Health. 2021 [acesso em 2023 out 5]; 60(3):1713-1728. Disponível em: https://doi.org/10.1007/s10943-020-01101-9.
https://doi.org/10.1007/s10943-020-01101... .

Long-term Institutions for Older People (ILPI) referred to entities, whether governmental or non-governmental, that have a residential character and are designed to collectively accommodate people aged 60 or over. Such institutions serve older people, whether or not they have family support, providing conditions that promote freedom, dignity and citizenship²⁸28 Brasil. Ministério da Saúde, Agência Nacional de Vigilância Sanitária. Instituições de Longa Permanência para Idosos (ILPIs). Gov.br. 2020 nov 19. [acesso em 2023 out 5]. Disponível em: https://www.gov.br/anvisa/pt-br/assuntos/servicosdesaude/saloes-tatuagens-creches/instituicoes=-de-longa-permanencia-para-idosos#:-:text-As%2 0ILPIs%20s%C3%A3o%2 0institui%C3%A7%C3%B5es%20governamentais,de%20liberdade%2C%20dignidade%20e%20cidadania.
https://www.gov.br/anvisa/pt-br/assuntos... .

Most of the manuscripts in the sample were not developed in Brazil, however, the premise of care for institutionalized older people that appear in the articles maintains the proposition of care for them. In Brazil, Resolution No. 502, of May 27, 2021, provides for the operation of residential ILPI, which must meet a group of basic premises, but that deserve to be emphasized: the promotion of a welcoming environment for the older people, the encouragement of activities to stimulate the autonomy of the seniors, and the guarantee of assistance free from discrimination or any type of violence²⁹29 Brasil. Ministério da Saúde, Agência Nacional de Vigilância Sanitária. Resolução de Diretoria Colegiada – RDC nº 502, de 27 de maio de 2021. Dispõe sobre o funcionamento de Instituição de Longa Permanência para Idosos, de caráter residencial. Diário Oficial da União. 31 Maio 2021. [acesso em 2023 nov 10]. Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/anvisa/2020/rdc0502_27_05_2021.pdf.
https://bvsms.saude.gov.br/bvs/saudelegi... .

The mistreatment mentioned in the research articles included actions discrediting the appropriate pronoun of choice and more severe situations of violence, such as physical, financial, and sexual abuse. Some older people participants in Shrek et al.²⁵25 Sharek DB, McCann E, Sheerin F, et al. Older LGBT people’s experiences and concerns with healthcare professionals and services in Ireland. Int. J. Older People Nurs. 2015 [acesso em 2023 out 5]; 10(3):230-240. Disponível em: https://doi.org/10.1111/opn.12078.
https://doi.org/10.1111/opn.12078... research reported preferring to conceal their sexual orientation because they felt trapped in a heterosexual world where their sexuality was sometimes disrespected.

The lack of inclusive public policies for the LGBTQIA+ community results in significant challenges for many older transgender people, who face substantial obstacles in preserving their mental health. This is due to frequent experiences of transphobia in public settings and a shortage of mental health professionals trained to meet the specific demands of this community. Health systems claim to be inclusive of the LGBTQIA+ community, but often face gaps in the effective implementation of these commitments¹¹11 Lampe NM, Barbee H, Tran NM, et al. Health disparities among Lesbian, Gay, Bisexual, Transgender, and Queer Older Adults: a structural competency approach. Int. J. Aging. Hum. Dev. 2023 [acesso em 2023 out 5]; 25:914150231171838. Disponível em: https://doi.org/10.1177/00914150231171838.
https://doi.org/10.1177/0091415023117183... .

Difficulties pointed out in working with LGBTQIA+ older people in ILPI include the lack of training in issues related to sexual and gender diversity, the lack of familiarity or availability of evidence-based treatments, residents’ hesitation to identify themselves as LGBTQIA+ and the presence of stigma¹¹11 Lampe NM, Barbee H, Tran NM, et al. Health disparities among Lesbian, Gay, Bisexual, Transgender, and Queer Older Adults: a structural competency approach. Int. J. Aging. Hum. Dev. 2023 [acesso em 2023 out 5]; 25:914150231171838. Disponível em: https://doi.org/10.1177/00914150231171838.
https://doi.org/10.1177/0091415023117183... .

Throughout history, transsexual women have had to establish safe spaces on their own due to extreme violence, hostility and discrimination in health services. This highlights the urgent need for trans-inclusive spaces, which are defined as welcoming services for transgender clients, creating hospitable and safe environments for interactions with staff and other residents. To offer such services, professionals need to receive comprehensive training and be well-informed about the specific health and care needs of the transsexual community²⁵25 Sharek DB, McCann E, Sheerin F, et al. Older LGBT people’s experiences and concerns with healthcare professionals and services in Ireland. Int. J. Older People Nurs. 2015 [acesso em 2023 out 5]; 10(3):230-240. Disponível em: https://doi.org/10.1111/opn.12078.
https://doi.org/10.1111/opn.12078... .

Training for professionals is crucial, especially when dealing with specific health conditions such as prostate or cervical cancer, which can become more complex in transsexual bodies due to frequent associations with cisgender perspectives of men and women. In addition, it is essential to carry out health screenings without perpetuating transphobia. Not only do services need to be trained in trans-inclusivity, but they also need to actively promote it so that community members are aware of the services available to them²⁵25 Sharek DB, McCann E, Sheerin F, et al. Older LGBT people’s experiences and concerns with healthcare professionals and services in Ireland. Int. J. Older People Nurs. 2015 [acesso em 2023 out 5]; 10(3):230-240. Disponível em: https://doi.org/10.1111/opn.12078.
https://doi.org/10.1111/opn.12078... .

Category II (subcorpus B) - Programmatic vulnerability: gaps in care for older people belonging to sexual minorities

Vulnerability is a multidimensional construct in which behavioral, sociocultural, economic, and political conditions interact with biological processes throughout life³⁰30 Barbosa KTF, Oliveira FMRL, Fernandes MDGM. Vulnerability of the elderly: a conceptual analysis. Rev. Bras. Enferm. 2019 [acesso em 2023 nov 10]; 72(supl2):337-344. Disponível em: https://doi.org/10.1590/0034-7167-2018-0728.
https://doi.org/10.1590/0034-7167-2018-0... . Thus, the articles analyzed highlight programmatic vulnerability, evidenced by situations in which there is a lack of access to health services or poor quality in the provision of service.

Studies have found that there are health services that refuse to provide healthcare or provide an inferior one to older people because of their sexual orientation or gender identity. Part of the LGBTQIA+ older population feels invisible as their individual needs are not taken into account, and this situation is considered a subtle form of prejudice³¹31 Willis P, Raithby M, Maegusuku-Hewett T, Miles P. ‘Everyday Advocates’ for inclusive care? perspectives on enhancing the provision of long-term care services for older Lesbian, Gay and Bisexual adults in wales. Br. J. Soc. Work. 2017 [acesso em 2023 nov 10]; 47:409-426. Disponível em: https://doi.org/10.1093/bjsw/bcv143.
https://doi.org/10.1093/bjsw/bcv143... . The discrimination faced by this group is at least twofold, since they are the target of aggression incited by homophobia and transphobia, as well as ageism.

Due to prejudice, some older people prefer not to reveal their sexual orientation or gender identity to the medical team, especially those aged 80 or over. It should be noted that non-disclosure can have adverse consequences for the health of LGBTQIA+ older people, such as delays in diagnosing illnesses, difficulties in accessing the necessary healthcare and refusal to disclose important information for therapeutic management, which may results in compromised clinical decision-making³²32 Portz JD, Retrum JH, Wright LA, et al. Assessing capacity for providing culturally competent services to LGBT older adults. J. Gerontol. Soc. Work. 2014 [acesso em 2023 nov 10]; 57(2-4):305-21. Disponível em: https://doi.org/10.1080/01634372.2013.857378.
https://doi.org/10.1080/01634372.2013.85... .

If, on the one hand, non-disclosure can have severe consequences for health, on the other, authors explain that if sexual orientation or gender identity are revealed to professionals, this can result in unconscious stereotypes that have a negative impact on providing care, making the patient feel uncomfortable or afraid. Negative behaviors such as asking to be excused from caring for an LGBTQIA+ older person due to personal beliefs, ignoring family and friends, or making derogatory jokes with other members of the team influence future decisions about using health services³³33 Knochel KA, Quam JK, Croghan CF. Are old Lesbian and Gay people well served?: understanding the perceptions, preparation, and experiences of aging services providers. J. Appl. Gerontol. 2011 [acesso em 2023 nov 10]; 30(3):370-389. Disponível em: https://doi.org/10.1177/0733464810369809.
https://doi.org/10.1177/0733464810369809... ,³⁴34 Buczak-Stec E, König HH, Hajek A. Planning to move into a nursing home in old age: does sexual orientation matter? Age Ageing. 2021 [acesso em 2023 nov 10]; 50(3):974-979. Disponível em: https://doi.org/10.1093/ageing/afaa185.
https://doi.org/10.1093/ageing/afaa185... .

With the process of human aging and the possibility of developing chronic non-communicable diseases, there is an indisputable need to promote disease prevention and screening actions, since most health practices are still based on curative interventions, with little emphasis on prevention and the specific needs of the older population. The state’s failure to provide equitable care results in a violation of the right to health, which is even more noticeable in the elderly population belonging to sexual minorities.

Gaps in care provision are even more present in transgender individuals, defined as a state “in which a person experiences dissonance between their gender identity and the gender they were assigned at birth”¹¹11 Lampe NM, Barbee H, Tran NM, et al. Health disparities among Lesbian, Gay, Bisexual, Transgender, and Queer Older Adults: a structural competency approach. Int. J. Aging. Hum. Dev. 2023 [acesso em 2023 out 5]; 25:914150231171838. Disponível em: https://doi.org/10.1177/00914150231171838.
https://doi.org/10.1177/0091415023117183... . Evidence shows institutional exclusion in medical sectors, where the reduced number of specialists in the field results in fear of discrimination and even refusal of medical treatment due to regular experiences of transphobia. The importance of promoting access for transgender older people to activities aimed at disease prevention is highlighted, given that monitoring by the health team is particularly important during hormone therapy and for early cancer detection, for example, when carrying out prostate cancer screening on transgender women³⁵35 Yarbrough E. Transgender Mental Health. Washington: American Psychiatric Association Publishing; 2018.,³⁶36 Selles BRS, Almeida PF, Ahmad AF, et al. Redes sociais de apoio às pessoas trans: ampliando a produção de cuidado. Saúde debate. 2023 [acesso em 2023 nov 18]; 46(esp6):148-61. Disponível em: https://www.saudeemdebate.org.br/sed/article/view/6910.
https://www.saudeemdebate.org.br/sed/art... .

In addition to health services, the articles show deficiencies in social support services, as in ILPI. Older people report episodes in which care was full of mistreatment and lack of affirmation of gender identity, such as being addressed by the wrong pronouns, not being able to dress according to their wishes, and even serious aggression, such as acts of physical, emotional and sexual abuse. Continuing and permanent education policies are associated with greater patient satisfaction, since there is a reduction in prejudice and stigma¹¹11 Lampe NM, Barbee H, Tran NM, et al. Health disparities among Lesbian, Gay, Bisexual, Transgender, and Queer Older Adults: a structural competency approach. Int. J. Aging. Hum. Dev. 2023 [acesso em 2023 out 5]; 25:914150231171838. Disponível em: https://doi.org/10.1177/00914150231171838.
https://doi.org/10.1177/0091415023117183... ,¹³13 Adan M, Scribani M, Tallman N, et al. Worry and Wisdom: A qualitative study of transgender elders’ perspectives on aging. Transgend. Health. 2021 [acesso em 2023 out 5]; 6(6):332-342. Disponível em: https://doi.org/10.1089/trgh.2020.0098.
https://doi.org/10.1089/trgh.2020.0098... .

One of the strategies for providing welcoming care is to change the way health and well-being are viewed, moving away from an exclusively biomedical model to a biopsychosocial one, in which health and well-being are viewed holistically according to the experience of each individual. Simple measures can encourage LGBTQIA+ older people to seek out more health services, such as creating safe spaces that accept sexual minorities, developing support materials such as posters that explicitly welcome them, providing caregiver support and connecting mainstream health services to LGBTQIA+ support organizations¹³13 Adan M, Scribani M, Tallman N, et al. Worry and Wisdom: A qualitative study of transgender elders’ perspectives on aging. Transgend. Health. 2021 [acesso em 2023 out 5]; 6(6):332-342. Disponível em: https://doi.org/10.1089/trgh.2020.0098.
https://doi.org/10.1089/trgh.2020.0098... ,²²22 Stinchcombe A, Smallbone J, Wilson K, et al. Healthcare and end-of-life needs of Lesbian, Gay, Bisexual, and Transgender (LGBT) older adults: a scoping review. Geriatrics (Basel). 2017 [acesso em 2023 out 5]; 2(1):13. Disponível em: https://doi.org/10.3390/geriatrics2010013.
https://doi.org/10.3390/geriatrics201001... . Creating safe spaces and building a bond with these older people can help minimize fear of discrimination and increase demand for health services.

Despite obvious efforts to uphold human rights, especially with regard to sexual and gender diversity, situations of violence and prejudice against people who deviate from the cis, heterosexual and binary standard are still perceptible. Although one of the specific objectives of the National Policy for the Integral Health of Lesbians, Gays, Bisexuals, Transvestites and Transsexuals is to provide health care for the older LGBTQIA+ population, there is still a need for legal provisions that can guarantee equal treatment for this population, regardless of sexual orientation or gender identity. Therefore, a political organization that allows representatives of LGBTQIA+ groups to participate in the construction and implementation of public policies is essential³⁷37 Brasil. Ministério da Saúde. Portaria nº 2.836, de 1 de dezembro de 2011. Aprova a Política Nacional de Saúde Integral de Lésbicas, Gays, Bissexuais, Travestis e Transexuais. Diário Oficial da União. 2 Dez 2011. [acesso em 2023 mar 17]. Disponível em: https://bvsms.saude.gov.br/bvs/saudelegis/gm/2011/prt2836_01_12_2011.html#:~:text=Institui%2C%20no%20%C3%A2mbito%20do%20Sistema,Nacional%20de%2 0Sa%C 3%BAde%2 0Integral%20LGB - T).&text=como%20sistema%20universal%2C%20integral%20e%20equitativo.
https://bvsms.saude.gov.br/bvs/saudelegi... .

Final considerations

This study identified that, from the perspective of the older people situations of vulnerability are more evident in the healthcare services, in the ILPI, and in the care provided by health professionals, suffering from stigma and prejudice. From the professionals’ point of view, this vulnerability entails differentiated care with proposed actions focused on the needs of this population.

Also, using the IRaMuTeQ tool, classes were generated using terms with some level of relation to the phenomenon of the study, including: barrier, lack, confront, elderly, transphobia, assumption, knowledge, recognition, question, concern, express, abuse, fear, care, mistreatment, exposure, isolation, discriminatory, mental, identity, service and risk. These terms form a lexical vocabulary of the programmatic vulnerability of LGBTQIA+ older people.

Finally, it was possible to observe that LGBTQIA+ older people have a significant degree of vulnerability and that, despite the implementation of public policies at the three levels of healthcare, there are still considerable gaps that affect the healthy ageing of this group.

References

Publication Dates

History