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Taking LGBTQ+ Health to Heart: An Interview with Dr. Carl Streed, Jr., on LGBTQ+ Older Adults, Heart Health & Frailty

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Tony L. Teano, MLA

Tony L. Teano, MLA

Communications Specialist
Johns Hopkins University School of Medicine

Hands forming a heart shape with a rainbow flag in the view at the beachFor “Pride Month,” we wanted to focus on Lesbian, Gay, Bisexual, Transgender, and Queer+ older adults’ heart health as a possible risk consideration for frailty.

There is increasing recognition of a multitude of health inequities that exist across many areas of wellness for LGBTQ+ people throughout the lifespan. In addition to age-related changes in cardiovascular risk, older LGBTQ+ adults are at high risk for poor heart health outcomes related to LGBTQ+ specific life stressors and psychosocial, behavioral, and physiologic factors. Further considerations include increased prevalence of diabetes, tobacco abuse, and the use of hormonal therapies in transgender individuals.

Stemming from their lived experiences, or perceived and actual discrimination from present day physicians, many LGBTQ+ older adults mistrust health care providers; consequently, delaying doctor visits may lead to an LGBTQ+ patient being diagnosed when they present with overt clinical disease rather than an early disease stage, where institution of preventative measures may impact patient care.

Last June, the New York Times ran a story titled, “Why L.G.B.T.Q. Adults Are More Vulnerable to Heart Disease” that interviewed several high-profile cardiology researchers and experts on LGBTQ+ health. Among them were Dr. Erin Michos, a current cardiologist at Johns Hopkins Medicine who is also affiliated with the American Heart Association, and Dr. Carl Streed, Jr., who attended medical school at Johns Hopkins University and completed his internal medicine residency at the Johns Hopkins Bayview Medical Center. Dr. Carl Streed, Jr., is now an Assistant Professor at Boston University Chobanian and Avedisian School of Medicine and the Research Lead for the GenderCare Center at Boston Medical Center.

Dr. Carl Streed, Jr., is an Assistant Professor at Boston University Chobanian and Avedisian School of Medicine and the Research Lead for the GenderCare Center at Boston Medical Center.

Dr. Carl Streed, Jr.

For this blog, Dr. Streed kindly answered a few questions on this topic, keeping in mind the context of frailty research.

Tony Teano: With regard to function, how may poor coronary/vascular health lead to frailty?

Dr. Streed: Poor heart health limits the ability to engage in physical activity that reduces the likelihood of frailty. It also limits additional activities, such as community engagement, that are protective against frailty. 

Tony Teano: Within the LGBTQ+ community, are some sexual minorities and gender diverse/expansive people more at risk than others?

Dr. Streed: LGBTQ+ communities are not homogenous and so have significant variation in risk factors for CVD and outcomes. Additionally, persons with multiple marginalized identities can face significant disparities in CVD risk and outcomes (e.g., Black cisgender lesbians, Black transgender women, etc.). There are unique minority stressors that lead to differences in coping mechanisms as well as physiologic changes in response to stress. 

Tony Teano: What are the top few things physicians can do to better evaluate LGBTQ heart health?

Dr. Streed: Improved Sexual Orientation and Gender Identity (SOGI) data collection could help. Also, improved training of clinicians and improved screening of stressors unique to LGBTQ+ persons may make a difference. 

Tony Teano: What interventional steps might LGBTQ+ older adults consider taking above and beyond those for the general population?

Dr. Streed: I would advise to get connected to community, especially through LGBTQ+ community centers. Engagement in any physical activity, especially that which improves daily function can also help, as can getting connected to cessation programs tailored for LGBTQ+ persons if you are still smoking.

Many thanks to Dr. Streed for taking the time to answer these questions. For more information on these matters, please see the following related research and news:

Right now, there is not an abundance of frailty research on LGBTQ+ older adults. However, Johns Hopkins investigators are making strides to contribute to our understanding of aging research among marginalized populations. For example, the JHU Diversity Leadership Council funded a crowd-sourced grant that Frailty Science team member Brian Buta, MHS, pitched earlier this year (about which you may find a related blog here).  Over the spring term, this Diversity Innovation Grant (DIG) helped train 20 research coordinators, scientists, and staff to be more culturally competent at recruiting diverse older study participants. “This is a first step towards improving diversity in aging research at Johns Hopkins, and staff from the Schools of Medicine, Nursing, and Public Health participated in it” said Mr. Buta, adding that the training “covered historical and societal barriers to participating in research among racial/ethnic and sexual and gender minorities. Being aware of such barriers and understanding the importance of treating potential research candidates from these communities with dignity and respect, especially during the recruitment stage, is critical to achieve diverse representation in our research studies, and ultimately, to meet the health needs of those who are most vulnerable.”

The Center on Aging & Health (COAH)’s DIG training builds upon another DIG training from the JHULesbian couple at the beach with Rainbow Flag Division of Geriatric Medicine and Gerontology’s Mosaic Initiative collaboration with Medicine for the Greater Good, “Geriatricians Engaged and Ready for LGBTQ+ Aging, Health & Wellness” (“GEARed”—about which you may learn more here). GEARed trained 18 geriatric faculty and staff in 2022, and the team continues to hold quarterly meetings, and updates are reported at faculty meetings. Also, this year, the JHM Office of Diversity, Inclusion & Health Equity relaunched their “Proud Partner” training—an interactive LGBTQ+ allyship educational offering to improve the ability to interact with and support our LGBTQ+ patients, learners, and co-workers—available to Johns Hopkins faculty and staff through MyLearning in the JHU portal. Moreover, JHU/JHM is taking an active role in transforming LGBTQ+ heath care.

Finally, you may be interested in past COAH & Frailty Science blogs on LGBTQ+ older adults:

Many thanks to Dr. Monica Mukherjee with the Johns Hopkins University Division of Cardiology for providing editorial input for this blog.

Frailty in LGBTQ+ Adults: notes from a conversation with Dr. Karen Fredriksen-Goldsen

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Tony L. Teano, MLA

Tony L. Teano, MLA

Communications Specialist
Johns Hopkins University School of Medicine

Older adult male holding rainbow flagRecently, I asked Dr. Karen Fredriksen-Goldsen, Professor at the University of Washington School of Social Work and Director of the Goldsen Institute, to share her thoughts about frailty in older LGBTQ+ adults. Dr. Fredriksen-Goldsen is a pioneer in research on LGBTQ+ aging.  She led the nation’s first federally-funded longitudinal study of the health and wellbeing of LGBTQ+ people over the age of 50, “Aging with Pride: National Health, Aging, and Sexuality/Gender Study.” When I brought up the topic of frailty-specific insights in this population, Dr. Fredriksen-Goldsen noted that frailty was a significant problem for LGBTQ+ older adults: 

 

“[Frailty] is an area that really warrants more research and understanding in terms of incidence and prevalence [among LGBTQ+ older adults].”

“We do see higher rates of frailty; I know it is different than disability, but we find disabilities as early as the age of 18 [among lesbian and bisexual women]—that creates vulnerability for frailty.”

 

Research on aging is not the same as a specific attention to frailty, a state of heightened vulnerability to stressors, where studies among LGBTQ+ older adults lag despite a growing body of evidence that the risk factors for frailty are increased in this population. For example,  LGBTQ+ older adults are at increased risks for accelerated aging syndromes and poor health outcomes compared to peers in the general population (Fredriksen-Goldsen et al., 2013; Karen I. Fredriksen-Goldsen, 2017). Trajectories associated with physical and cognitive decline in LGBTQ+ adults are consistent with the consensus on frailty definitions (e.g., Morely et al., 2013), allowing for current frailty research methodologies to be directly employed in future studies in Frailty Science.  Dr. Fredriksen-Goldsen noted that research on LGBTQ+ older adults needs to measure all the factors that mediate frailty in the general population in order to be able to understand the origins of the differences. “[The concept of frailty is] why we have added physical activity [to our research metrics].”

A potentially hidden minority, well-known social determinants of health that can be specific to this this population also contribute to vulnerability (Fredriksen-Goldsen et al., 2011; Fredriksen-Goldsen and Muraco, 2010; see also Healthy People 2020 report on LGBT Health and the AARP’s “Dignity 2022: The Experience of LGBTQ Older Adults”). Dr. Fredriksen-Goldsen observed that much of the general population-based data “doesn’t have good measures” to gather LGBTQ+ status. Even when attempted in surveys assessing same-sex married couples, “research limitations exist,” in this case leaving out data on those who are not married.  Some approaches are not well-informed by the community.

For additional insight, I asked Dr. Jason Flatt, Assistant Professor in the Social and Behavioral Health Program at the University of Nevada-Las Vegas School of Public Health, about the dearth of frailty-specific information on LGBTQ+ elders and he noted: “I haven’t seen much in frailty and LGBTQ broadly, but I think if we look at frailty studies in non-LGBTQ+ we would see disparities for subgroups. Transgender and Bisexual older adults stand out for me.” He encouraged researchers to try and identify such subgroups, suggesting:  “I think you could take indicators from the Behavioral Risk Factor Surveillance System or the National Health Interview Survey.” 

Interestingly, studying frailty in the LGBTQ+ community may also provide insight into mechanism by which to avoid frailty and preserve resilience. Specific generations within the LGBTQ+ older adult cohort are more resilient and aging better than others (Karen I. Fredriksen-Goldsen, 2017; “Lessons on Resilience from LGBTQ+ Elders.”).  Interventions are in early days for frailty in general (explore our interventions page for more information); and with the added health challenges and counter-balancing community resources (Fredriksen-Goldsen and Muraco, 2010) that can affect the health-span trajectories of LGBTQ+ older adults, ensuring that the frailty research field includes this aspect of diversity will be of value to all.

I posed these frailty-related questions to Dr. Fredricksen-Goldsen in the Q&A after her webinar “Emerging from the Margins: LGBTQ+ Health and Aging” presented to the public by the Center for Aging Population Sciences, University of Texas at Austin, on March 30, 2022. In this talk, Dr. Fredriksen-Goldsen reviewed results on the health, aging, and well-being of LGBTQ+ older adults from “Aging with Pride”–a longitudinal study of 2,450 demographically diverse LGBTQ+ older adults from 2003 to 2010 at 18 partner centers across the nation. Here is a few key take-away points from her talk:

  • Currently, there is approximately 2.7 million LGBTQ+ older adults in the United States; this number is expected to increase to 20 million by 2060.
  • 9 out of 12 Lesbians, Gay men, and Bisexuals had higher rates of a disabling, chronic condition, including stroke, heart attack, and weakened immune system than heterosexuals.
  • Overall, 41% have a disability.
  • Lesbian and Bisexual older women had higher rates of disability, cardiovascular conditions, and physical limitations than Gay and Bisexual older men.
  • Gay and Bisexual older men had greater risk for overall poor health and for living alone compared to Lesbian and Bisexual older women.
  • Lesbian, Gay, and Bisexual older adults have higher rates of disability and mental distress than heterosexual older adults.
  •  Lesbian and Bisexual older women have higher rates of cardiovascular disease and obesity than heterosexual older women.
  • Gay and Bisexual older men are more likely to experience poor physical health and to live alone than heterosexual older men.
  • Transgender older adults have higher rates of disability, depression, and loneliness than non-transgender older adults.
  • Overall, most LGBTQ+ individuals are aging well.

I deeply thank Dr. Fredriksen-Goldsen for entertaining my questions about frailty following this talk, and for sharing her wise insights. The statistics above can be found in fact sheets and other reports online at: www.GoldsenInstiute.org.

Finally, in honor of pride month, we also hope that clinicians working with older adults will consider renewing their engagement with cultural humility vis-a-vis care for their LGBTQ+ older adults, and revisit training in this space. This year, as a first step toward this purpose, Johns Hopkins Medicine’s Division of Geriatric Medicine and Gerontology’s Mosaic Initiative partnered with Medicine for the Greater Good in a project called “Geriatricians Engaged and Ready (“GEARed’) for LGBTQ+ Aging, Health, & Wellness,” which has been training a core of 17 clinicians and one staff member on LGBTQ+ older adult healthcare through free CME courses offered by the Fenway Institute’s National LGBTQIA+ Health Education Center. In addition, GEARed providers received enamel pins, badge reels, and stickers for their clipboards with a logo incorporating the recently updated rainbow pride and Transgender flag colors encircling the statement “You are safe with me.” The hope is that such easily recognizable symbols will help to facilitate both patient interactions and new conversations about LGBTQ+ older adult health among colleagues. GEARed providers can thus become better partners in care to achieve better health outcomes across the institution. Anyone wishing to explore implementing such a program in their practice can contact me.

For more resources on LGBTQ+ Elders and their health needs, see this related blog: Top 10 Recommended Resources About LGBTQ+ Aging & Older Adults

New AI/Technology & Aging Research Collaboratory: Pilot Proposals Due Feb. 18

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Jeremy Walston, MD

Jeremy Walston, MD

Raymond and Anna Lublin Professor of Geriatric Medicine
Johns Hopkins University School of Medicine
Co-Director, Johns Hopkins Older Americans Independence Center

The recently funded Johns Hopkins Artificial Intelligence and Technology Collaboratory for Aging Research (JH AITC; website) seeks to improve the health and well-being of older adults through novel uses of artificial intelligence and new technologies.  Combatting frailty and its outcomes are important aims of this Collaboratory.   

The JH AITC is funded by a $20M federal grant from the National Institute on Aging (P30AG073105).  It is one of three centers at leading research institutions participating in this innovative Collaboratory: the other two are at the University of Massachusetts and the University of Pennsylvania. 

The scientific vision of the JH AITC is led by experts from the Johns Hopkins University schools of Medicine, Nursing, the Whiting School of Engineering, and the Carey Business School.  Stakeholders, including older Americans and caregivers, technology developers and innovators, and industry partners, will also play a key role in informing the development of novel and adaptive technologies to improve the health and independence of millions of older Americans.  To propel these efforts, the JH AITC is now offering a call for pilot proposals, including those that are relevant to frailty and resiliency in older adults.   The Requests for Proposals can be found here:

The JH AITC’s tagline provides a concise summary of their role and mission: “Engineering Innovations to Change Aging.”  You can learn more background about this transdisciplinary effort at Johns Hopkins University here.