In 2011 the Institute of Medicine released a historic report documenting the health disparities faced by lesbian, gay, bisexual, and transgender (LGBT) individuals. This report was call to action for researchers, practitioners, and policy makers to address the burgeoning and often underserved health needs of the LGBT population. In the United States these health disparities coincide with an epidemiological shift: the aging of the American population. Due to increases in life expectancy and aging of the "baby boomer" generation, or those born between 1946 and 1964, approximately one third of the United States population will be 55 years or older by 2014.
While no direct population figures exists, extrapolations drawn from multiple sources suggests that within the population of older Americans, approximately 1.2 to 1.4 million will be older gay men, a figure more pronounced in urban areas such as New York City, where it is estimated that approximately 5 percent of gay men are 50 or older. A significant proportion of these older gay men, both nationally and in New York City, live with HIV, and as a group this generation of gay men, to whom I have previously referred as "the AIDS generation," have all been directly impacted by the epidemic.
Despite these critical population characteristics, we poorly understand the health care needs of aging Americans, who, by all indications, will live longer and will have very different expectations regarding their care than previous generations. And while we fail to truly understand the needs of an the overall aging American populace, we have even more limited information on the health disparities experienced by aging baby boomers who are gay, and only minuscule amounts of knowledge about those who are older, gay, and HIV-positive. Without such knowledge, we are not equipped to provide effective and meaningful health care to men of my generation.
The facts speak for themselves. Older gay men are more likely than heterosexual peers to have experienced a range of negative mental and physical health conditions throughout their lifetimes. Most notable of these is the AIDS epidemic, which has unduly impacted men of my generation. To date, gay men account for nearly 50 percent of AIDS-related deaths as well as HIV infections, despite representing only 2 percent of the U.S. population. Gay men also experience heightened levels of riskier health conditions such as substance abuse and other mental health disorders as compared with their heterosexual peers. Finally, many of this generation of gay men came of age at a time when homosexuality was considered a psychiatric illness. It was not until 1973 that the American Psychiatric Association declassified homosexuality as a mental disorder.
In effect, the confluence of these factors (homosexuality as a disease, the AIDS epidemic, and the socially imposed stigma of being gay) have unduly and negatively impacted the lives of older gay men, creating emotional and psychosocial stressors that undermine the well-being of men of my generation, a reality that extends into the lives of a new generation of gay men.
While recent advances in gay civil rights are a sign of progress, the fact remains that as a group we still remain under attack -- attacks that perpetuate the stress in our lives and compromise our health. Ecological studies indicate that gay men who live and love in states where gay civil rights are more advanced experience better health outcomes. The recent passage of marriage equality in the state of New York may, over time, impart such a benefit to future generations of gay men and may counter the venom of politicians such as Rick Santorum and the rest of the Republican presidential hopefuls. But those of us of advanced age cannot undo the years of victimization and stigmatization, both subtle and not-so-subtle, that we have experienced in our families, in our communities, in our workplaces, and in our nation. Therefore, it imperative that the delivery of health care to my generation of gay men -- the AIDS generation -- focus on the totality of our existence and consider our life experiences, including how the devastation of the AIDS crisis and a lifetime of bigotry have compromised and shaped our health.
Yet we have little data on the health of older gay men, or gay men in general. Because national, population-based studies do not incorporate questions assessing sexual orientation, and because studies focused on sexual behaviors among older adults include only small numbers of gay men, we lack nationally representative data on the risks, resilience, and needs, as well as the physical, mental, and neurocognitive health, of this population. In the absence of such knowledge, the delivery of service to an aging gay population will fail to be informed by science, and moreover, policies regarding health care and federal funding will continue to neglect our needs.
It is time that we attend to the health of aging gay men, and of all gay men. To achieve this goal, first, it is imperative that we develop and enact a research agenda that delineates the health risks, resiliencies, and needs of gay men across all ages. We must scientifically understand the multiple factors that compromise or enhance our health. This knowledge is critical in helping to develop effective service delivery systems, which recognize that the health of gay men is shaped in part by pathogens, to some extent by behaviors, and also by the social and structural stressors we experience as sexual minorities.
In effect, health care for gay men must attend to both individual-level behaviors and factors that shape our well-being and to the larger contextual matters that shape our lives. While we fight for our civil rights in this nation, including, but not limited to, the recognition of our love relationships, health care providers and policy makers must be prepared work with us to ameliorate the burdens we face due to the barrage of ongoing discrimination in our lives, which ultimately undermine our health. Said differently, a holistic approach to care is needed, with recognition that there are multiple micro (person-level) and macro (structural-level) factors that undermine our health and to which we must attend.
Such a multifactorial understanding of the HIV epidemic is evident in the enlightened AIDS policy developed by the Obama administration. Unfortunately, we waited 30 yeas for this national AIDS policy! We should not have to wait another 30 years to fully understand and address the multiple health needs of gay men.
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