Frailty over the rainbow: a cross-sectional study on LGBT+ adults over fifty

doi:10.21203/rs.3.rs-2485556/v1

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Frailty over the rainbow: a cross-sectional study on LGBT+ adults over fifty

https://doi.org/10.21203/rs.3.rs-2485556/v1

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Background

Frailty is associated with several adverse outcomes in older adults, including functional dependency, hospitalizations, and death. However, it has not been determined whether older LGBT + individuals are at a higher risk of frailty than the overall population. Therefore, we aimed to investigate the prevalence of frailty in older LGBT + adults, comparing them with heterosexual-cisgender individuals.

Methods

A cross-sectional study involving Brazilians aged 50 and over was performed. They were invited to answer an anonymous online-based survey between August 2019 and January 2020. The survey was widely distributed in neighborhood associations, day centers, non-governmental organizations, and social media. Participants were encouraged to forward information about the study to their contacts. Those who identified as homosexual, bisexual, pansexual, non-heterosexual, transgender, travesti, or non-binary were grouped as LGBT+; cisgender and heterosexual participants as non-LGBT+. Frailty was measured using the FRAIL scale, and participants were categorized as robust, prefrail, or frail. We used generalized ordered logistic models to examine the adjusted association between being LGBT + and frailty, according to age group and sex.

Results

We included 6,693 participants with a median age of 60 years. Overall, 1332 were LGBT+ (19.9%), and 5361, non-LGBT+ (80.1%). Pre-frailty or frailty was found in 656 (49%) LGBT + participants and 2,460 (46%) non-LGBT + participants (p = .03). In our multivariable analyses, we found that being LGBT + was independently associated with frailty in female participants aged ≥ 50 years (OR = 1.52, 95%CI = 1.08–2.13, p = .02) and in male participants aged ≥ 60 years (OR = 2.83, 95%CI = 1.41–5.69, p = .004). Non-cisgender participants were also more likely to be frail than cisgender participants (OR = 2.21, 95%CI = 1.42–3.42, p < .001).

Conclusion

Being LGBT + was independently associated with frailty in female adults over 50 and males over 60. More research in this area and inclusive government policies are needed to promote healthy aging and address the needs of the LGBT + population.

frailty

aging

minority health

sexual and gender minorities

Despite recent sociocultural advances, Lesbian, Gay, Bisexual, and Transgender (LGBT+) people are frequently stigmatized and marginalized as a group, even in healthcare settings. Furthermore, recent research has found that many LGBT + people feel discriminated against in healthcare institutions and often avoid disclosing their sexuality to providers.¹ As a result, there is a risk that LGBT + individuals might avoid seeking medical assistance because they fear discrimination and lack confidence in the system. Moreover, even if they overcame their fears and sought medical attention (e.g., in emergencies), evidence suggests that the LGBT + community has a higher risk of inadequate follow-up and adverse outcomes.^2,3

More recently, the concept of “minority stress” has also emerged. Its central premise is that minority groups, such as the LGBT + community, frequently face chronic stressors (e.g., non-acceptance, marginalization, internalized homophobia, victimization, and various types of violence) that directly impact their mental health.⁴ Consequently, it is unsurprising that LGBT + individuals would have distinctive health risks and complications compared to the heterosexual cisgender population.⁵ Numerous studies support this conclusion, reporting higher rates of depression, self-harm, suicide, addiction, obesity, hypertension, and diabetes in gay and bisexual patients.^6–8 These findings have prompted researchers to speculate that belonging to a sexual or gender minority may be associated with unhealthier aging processes and that models primarily focused on heterosexual aging are inadequate to understand the peculiarities of aging experiences in those with non-hegemonic sexual expressions.⁹

In recent years, aging research has increasingly focused on the concept of frailty and its impact on older adults.^10,11 Frailty is a measure of physiological reserve, and it is widely acknowledged that frail older adults are more vulnerable to adverse outcomes such as falls, hospital admissions, institutionalization and death.¹² The association between frailty and adverse outcomes makes the syndrome a vital issue for geriatric care. Moreover, it is an increasingly common condition, and it is estimated that in Brazil, as well as in Europe and the United States, frailty affects around 10% of the population over the age of 50 and 15% of those aged 65 or older.¹³

However, little is known about frailty in the older LGBT + population. Given that this group is more likely to suffer from depression and other chronic conditions, as well as being less inclined to seek medical assistance, it is reasonable to assume that they are also at a higher risk of frailty.^11,14 Previous studies conducted by us have shown a higher incidence of loneliness, fear of dying alone and fear of dying in pain in the LGBT + subjects when compared with the non-LGBT + ones.¹⁵ These studies also showed worse experiences when using health services and increased difficulty of access to these services for the LGBT + population.¹⁶ Therefore, we aimed to investigate the prevalence of frailty in older LGBT + adults and compare it with a corresponding heterosexual, cisgender sample.

Study design and population

We completed a cross-sectional survey with Brazilians aged 50 and over. The age cut-off was selected based on previous research investigating LGBT + health.^7,8 Participants were invited to complete an online survey created and managed using Research Electronic Data Capture (REDCap) resources.¹⁷ The study was promoted in medical associations, patient organizations, neighborhood associations, day centers, and non-governmental organizations. We also distributed the study’s web link on social networks such as Instagram, Facebook, WhatsApp, and YouTube and encouraged participants to forward the information to their social groups, using “snowball sampling” recruitment strategies.¹⁸

We included eligible candidates who consented to participate in the study and provided complete answers to our survey.

Data collection

Participants completed a thorough questionnaire detailing sociodemographic and clinical characteristics, healthcare service utilization, and previous discriminatory and victimization experiences.

Our main independent variables were gender (cisgender male, cisgender female, transgender male, transgender female, travesti, non-binary, other) and sexual orientation (heterosexual, homosexual, bisexual, pansexual, asexual, other). For analysis purposes, we created an additional variable grouping non-LGBT+ (cisgender male, cisgender female, heterosexual) versus LGBT + participants (transgender male, transgender female, travesti, non-binary, homosexual, bisexual, pansexual, other). Travesti is a transfeminine person who identifies with a travesti gender identity, that has been marginalized throughout history. It is a predominantly Brazilian identity construction, but also found in other Latin American and European countries.¹⁹

Our primary dependent variable was frailty status as defined by the FRAIL scale,²⁰ which assigns one point to each of the following five attributes: tiredness ("Do you feel fatigued?"); resistance ("Can you climb one flight of stairs?"); ambulation ("Can you walk one block?"); illness ("Do you have more than five illnesses?"); weight loss ("Have you lost more than 5% of your weight in the last six months?"). We classified participants with a score of zero as robust, those with one or two points were classified as prefrail, and those with three or more points as frail.^21,22

Statistical analysis

We described our data using central tendency and dispersion measures, counts and proportions. We compared LGBT + and non-LGBT + participants using contingency tables, chi-square tests, Fisher’s exact tests, Student’s t-tests, or Wilcoxon’s rank-sum tests as appropriate.

We examined generalized ordered logistic models to examine the adjusted association between belonging to an LGBT + group and frailty status and stratified our analyses according to sex (male, female) and age (< 60, ≥ 60). Since the LGBT + population is not affected uniformly by the same stressors, and past research suggests that transgender individuals experience poorer socioeconomic conditions and prejudice,^23,24 we also completed a sensitivity analysis modifying our primary independent variable to group transgender people, non-binary genders, and other genders as non-cisgenders. All models were adjusted for age, race/ethnicity, public healthcare system utilization, hypertension, diabetes, cancer, obstructive lung disease, asthma, coronary disease, heart failure, cerebrovascular disease, and chronic kidney disease. We reported adjusted odds ratios (OR) and 95% confidence intervals (95%CI) for each variable of interest.

Statistical analyses were performed using Stata SE 15 (Stata Corp, College Station, TX). All statistical tests were two-tailed, and an alpha error of up to 5% was accepted.

Ethical aspects

The study was approved by the University of Sao Paulo Medical School's Institutional Review Board. The online survey was open for six months and required eligible candidates to read, understand, and agree to an informed consent form to participate. The questionnaires were de-identified and anonymized.

A total of 7,164 candidates completed the consent form; 347 (5%) did not consent to participate, and 124 (2%) provided incomplete answers to our survey. Our final sample included 6,693 participants, 1,332 in the LGBT + group (20%) and 5,361 in the non-LGBT + group (80%). There were answers from all the country's macro-regions (Fig. 1), although with a noticeable predominance from the Southeast.

Overall, the median age was 60 years, 68% were female, and 79% were white (Table 1). Participants had high literacy levels, with 79% having completed university or postgraduate courses. LGBT + participants were younger, more frequently male, single, and used the public healthcare system more often. They were also more likely to live in a rental (18% vs. 10%, p < .001) and to earn less than the minimum wage (10% vs. 6%, p < .001). LGBT + participants were more likely to report not having anyone to assist them if they became bedridden (22% vs. 15%, p < .001).

Table 1

Sample characteristics according to LGBT + group.
	Total	Non-LGBT+	LGBT+	p-value
	N = 6,693	N = 5,361	N = 1,332
Frail status (FRAIL Scale)				.07
Robust	3577 (53%)	2901 (54%)	676 (51%)
Prefrail	2742 (41%)	2170 (40%)	572 (43%)
Frail	374 (6%)	290 (5%)	84 (6%)
Sex assigned at birth				< .001
Male	2,115 (32%)	1,343 (25%)	772 (58%)
Female	4,578 (68%)	4,018 (75%)	560 (42%)
Cisgender	6,444 (96%)	5,361 (100%)	1,083 (81%)	< .001
Age (years)				< .001
50–59	3257 (49%)	2387 (45%)	870 (65%)
60–69	2490 (37%)	2112 (39%)	378 (28%)
≥ 70	946 (14%)	862 (16%)	84 (6%)
Race/ethnicity				< .001
White	5272 (79%)	4298 (80%)	974 (73%)
Black	357 (5%)	301 (6%)	56 (4%)
Other	1064 (16%)	762 (14%)	302 (23%)
Literacy				.24
College or more	5272 (79%)	4235 (79%)	1037 (78%)
High school	1201 (18%)	944 (18%)	257 (19%)
Middle school or less	220 (3%)	182 (3%)	38 (3%)
Macro-region				< .001
Southeast	5,186 (77%)	4,241 (79%)	945 (71%)
Southern	458 (7%)	350 (7%)	108 (8%)
Central-West	247 (4%)	171 (3%)	76 (6%)
Northeast	739 (11%)	553 (10%)	186 (14%)
Northern	63 (1%)	46 (1%)	17 (1%)
Public healthcare system utilization	1117 (17%)	788 (15%)	329 (25%)	< .001
Polypharmacy	2113 (32%)	1680 (31%)	433 (33%)	.41
Two or more chronic conditions	1651 (25%)	1349 (25%)	302 (23%)	.06
Geriatric Depression Scale score	1 (0, 2)	1 (0, 2)	1 (0, 2)	< .001
Comorbidities
Hypertension	2483 (37%)	2009 (37%)	474 (36%)	.20
Diabetes mellitus	1028 (15%)	827 (15%)	201 (15%)	.76
Cancer	357 (5%)	288 (5%)	69 (5%)	.78
Coronary disease	225 (3%)	177 (3%)	48 (4%)	.58
Heart failure	201 (3%)	156 (3%)	45 (3%)	.37
Cerebrovascular disease	98 (1%)	69 (1%)	29 (2%)	.03
Chronic obstructive pulmonary disease	234 (3%)	185 (3%)	49 (4%)	.69
Asthma	420 (6%)	352 (7%)	68 (5%)	.05
Chronic kidney disease	87 (1%)	57 (1%)	30 (2%)	< .001

Data are presented as median (interquartile ranges) for continuous measures and counts (%) for categorical measures.

In the LGBT + group, 816 (61%) identified as cisgender homosexual, 199 (15%) as cisgender bisexual, and 68 (5%) as cisgender pansexual or other sexual orientations. There were 249 (19%) participants who identified as transgender or other genders (29 transgender women, 3 transgender men, 6 travestis, and 211 non-binary or other genders).

We found 374 (6%) frail participants in our sample, of whom 84 (6%) were in the LGBT + group and 290 (5%) were in the non-LGBT + group. LGBT + participants were more frequently prefrail or frail than non-LGBT + participants (49% vs. 46%, p = .02). Frailty was more common in LGBT + females than non-LGBT + females (9% vs. 6%, p = .03), in LGBT + males aged ≥ 60 years than non-LGBT + males of the same age (8% vs. 3%, p = .004), and in non-cisgender participants (11% vs. 5%, p < .001) (Fig. 2).

In our multivariable analyses, LGBT + was not independently associated with frailty in our overall sample (OR = 1.24, 95%CI = 0.95–1.63, p = .1). However, we found that being LGBT + was independently associated with frailty in female participants aged ≥ 50 years (OR = 1.52, 95%CI = 1.08–2.13, p = .02) and in male participants aged ≥ 60 years (OR = 2.83, 95%CI = 1.41–5.69, p = .004) (Table 2). Older age, using the public healthcare system, and several comorbidities were also associated with frailty in our sample.

Finally, in a multivariable sensitivity analysis, we found that the non-cisgender group was independently associated with frailty (OR = 2.21, 95%CI = 1.42 = 3.42, p < .001). The association was confirmed both among females (OR = 2.11, 95%CI = 1.23 = 3.63, p = .007) and males (OR = 2.75, 95%CI = 1.30 = 5.85, p = .008) (Table 2).

Table 2

Generalized ordered logistic models examining the association between LGBT + groups and frailty, according to sex and age.
	Prevalence	Unadjusted odds ratios (95%CI)	Adjusted* odds ratios (95%CI)	p-value
Overall
Age ≥ 50 years
Prefrailty or frailty vs. LGBT+	656/1332 (49%)	1.14 (1.01–1.29)	1.10 (0.97–1.25)	.14
Frailty vs. LGBT+	84/1332 (6%)	1.18 (0.92–1.51)	1.24 (0.95–1.63)	.11
Age = 50–59 years
Prefrailty or frailty vs. LGBT+	426/870 (49%)	1.12 (0.96–1.30)	1.04 (0.89–1.23)	.62
Frailty vs. LGBT+	42/870 (5%)	1.10 (0.76–1.59)	0.98 (0.66–1.44)	.92
Age ≥ 60 years
Prefrailty or frailty vs. LGBT+	230/462 (50%)	1.18 (0.97–1.44)	1.17 (0.96–1.44)	.13
Frailty vs. LGBT+	42/462 (9%)	1.51 (1.06–2.14)	1.56 (1.08–2.27)	.02
Sex assigned at birth = Female
Age ≥ 50 years
Prefrailty or frailty vs. LGBT+	320/560 (57%)	1.41 (1.18–1.69)	1.34 (1.12–1.62)	.002
Frailty vs. LGBT+	48/560 (9%)	1.44 (1.04–1.99)	1.52 (1.08–2.13)	.02
Age = 50–59 years
Prefrailty or frailty vs. LGBT+	194/340 (57%)	1.43 (1.13–1.80)	1.31 (1.03–1.67)	.03
Frailty vs. LGBT+	25/340 (7%)	1.59 (1.00-2.50)	1.45 (0.89–2.35)	.13
Age ≥ 60 years
Prefrailty or frailty vs. LGBT+	126/220 (57%)	1.41 (1.06–1.86)	1.34 (1.00-1.80)	.05
Frailty vs. LGBT+	23/220 (10%)	1.48 (0.93–2.35)	1.45 (0.88–2.37)	.14
Sex assigned at birth = Male
Age ≥ 50 years
Prefrailty or frailty vs. LGBT+	336/772 (44%)	1.26 (1.05–1.51)	1.21 (0.99–1.47)	.06
Frailty vs. LGBT+	36/772 (5%)	1.44 (0.92–2.26)	1.59 (0.94–2.69)	.08
Age = 50–59 years
Prefrailty or frailty vs. LGBT+	232/530 (44%)	1.23 (0.96–1.58)	1.15 (0.88–1.49)	.31
Frailty vs. LGBT+	17/530 (3%)	1.08 (0.54–2.20)	0.92 (0.42–1.98)	.82
Age ≥ 60 years
Prefrailty or frailty vs. LGBT+	104/242 (43%)	1.26 (0.94–1.68)	1.29 (0.95–1.76)	.10
Frailty vs. LGBT+	19/242 (8%)	2.37 (1.31–4.31)	2.83 (1.41–5.69)	.004
Sensitivity analysis
Age ≥ 50 years
Prefrailty or frailty vs. non-cisgender	143/249 (57%)	1.58 (1.22–2.03)	1.55 (1.19–2.02)	.001
Frailty vs. non-cisgender	27/249 (11%)	2.14 (1.41–3.23)	2.21 (1.42–3.42)	< .001
Age = 50–59 years
Prefrailty or frailty vs. non-cisgender	76/134 (57%)	1.51 (1.06–2.13)	1.48 (1.03–2.12)	.03
Frailty vs. non-cisgender	9/134 (6%)	1.56 (0.76–3.13)	1.43 (0.69–2.96)	.33
Age ≥ 60 years
Prefrailty or frailty vs. non-cisgender	67/115 (58%)	1.65 (1.13–2.41)	1.62 (1.09–2.41)	.02
Frailty vs. non-cisgender	18/115 (16%)	2.76 (1.64–4.66)	3.04 (1.74–5.33)	< .001

95%CI = 95% confidence interval; LGBT + = Lesbian, Gay, Bisexual, and Transgender; non-cisgender = transgender, non-binary, and other non-conforming genders.

All models were adjusted for age, race/ethnicity, public healthcare utilization, and comorbidities (hypertension, diabetes, cancer, coronary disease, heart failure, chronic obstructive pulmonary disease, asthma, cerebrovascular disease, and chronic kidney disease). Sensitivity analyses also adjusted for sex.

In a large cross-sectional survey, including over six thousand participants, we found that LGBT + females aged ≥ 50 and LGBT + males aged ≥ 60 years were more likely to be frail than their non-LGBT + counterparts. Likewise, participants who identified as transgender or other nonconforming genders were more likely to be frail than cisgender participants.

The prevalence of frailty in our study varied from 3% in male non-LGBT + participants aged 50–59 years to over 10% in female LGBT + participants aged ≥ 60 years. Our results indicate a lower prevalence than those found in other studies, but factors such as demographics, frailty definitions, and assessment measures often affect findings in this field.²⁵ The ELSI-Brazil study, a populational cohort including more than eight thousand participants, reported that frailty occurred in 9% of those aged ≥ 50 years, 14% of those aged ≥ 60 years, and 16% of those aged ≥ 65 years.¹³ However, frailty was assessed using the Fried phenotypic criteria, and they had a higher prevalence of multiple chronic conditions in their sample. We preferred to use the FRAIL scale, which can be self-rated and has been validated against the Fried criteria in Brazil,²⁰ and observed that only one in four of our participants reported two or more chronic conditions.

Moreover, although the ELSI-Brazil Study verified that factors such as low schooling, residence without a partner, poor self-rated health, having two or more chronic conditions, and limitation to perform activities of daily living were associated with a higher prevalence of frailty, they did not investigate its association with gender identity or sexual orientation. Indeed, there is a scarcity of evidence on frailty in the context of LGBT + health. Baseline data from the Multicenter AIDS Cohort Study found in a sample of 1,048 sexual minority men that 10% of them were frail and that negative self-perceptions of aging were associated with frailty transitions.²⁶ But 48% of that cohort was HIV+, and the study did not include a diversity of genders and sexual orientations. Another large cross-sectional study investigating successful aging among LGBT + older adults surveyed 2,560 LGBT + adults aged ≥ 50 years and reported that physical and mental health quality of life was negatively associated with discrimination and chronic conditions.²⁷ Nonetheless, they did not provide results regarding frailty nor comparisons with non-LGBT adults.

Our research makes a significant contribution to understanding health-related difficulties associated with being a member of a gender or sexual minority. In particular, the independent association between being LGBT + and frailty indicates that this population may be experiencing inferior aging processes. Frailty is a complex and developing construct, possibly influenced by individual, social, and programmatic factors. Our findings might be partially explained by the fact that conditions like depression, obesity, and addiction are more common in the LGBT + population.⁸ Furthermore, evidence suggests that LGBT + persons have less access to healthcare services, which may contribute to lower adherence to health promotion measures, including physical exercise and healthy eating habits.^28,29 Our results appear to confirm these trends since LGBT + participants were more reliant on public healthcare, had lower income, lived in rentals more frequently, and had lower social support.

Another possible explanation for the greater vulnerability to frailty in the LGBT + group could be related to the “minority stress” theory.⁴ This theoretical model suggests that the accumulation of discrimination and stigmas experienced by the LGBT + population, including fear of rejection and internalized homophobia, among others, could make this population more vulnerable to mental illness. Although minority stress was initially thought of in relation to mental health issues, there is evidence its effects also apply to physical health.³⁰ Transgender and other nonconforming genders likely have additional unstudied characteristics that lead to frailty, and compared with lesbians, gays, and bisexuals, they have considerably worse physical health, disability, depressive symptoms, and stress.³¹

Our study had limitations. First, it was a cross-sectional study, and causal relations between gender, sexual orientation, and frailty could not be established. Second, Second, our sample was subject to possible biases intrinsic to snowball sampling strategies and the use of social networks to encourage participation. These include literacy and socioeconomic levels that were above the average Brazilian indicators. Third, using an online questionnaire may also have impacted the engagement of older contributor age groups. Fourth, gender identity, sexual orientation, healthy aging, and frailty are complex concepts, and there are likely relevant confounders we did not explore in their associations.

Conversely, there are also important strengths in our work. We included a considerable number of participants, both non-LGBT + and LGBT + and examined numerous aspects of our respondents' health. Another essential element of our survey was the anonymity of the participants, which enhanced the likelihood of receiving accurate answers concerning subjects that are generally considered taboo. Furthermore, we had a high percentage of complete responses and minimum exclusions for missing data, which asserts the quality of the data. Finally, this groundbreaking quantitative study on frailty, gender, and sexual minorities highlights the importance of more research dedicated to aging LGBT + adults.

In summary, in our study, being LGBT + was independently associated with a higher prevalence of frailty. The LGBT + community is frequently the victim of hetero-cis-normative society's intolerance and violence, whether physical or psychological. We hypothesize that such life events may result in social isolation and physical illness, including frailty. Since frailty represents an additional burden and risk factor for adverse outcomes, it is critical to further investigate its effects on LGBT + older adults and consider healthy aging interventions specifically tailored to this population.

OR - Odds ratios

LGBT - Lesbian, Gay, Bisexual, and Transgender

RedCap - Research Electronic Data Capture

Acknowledgements

The authors declare no conflicts of interest or competing financial interests.

We appreciate the help of everyone who helped spread the online survey, notably the non-governmental organization EternamenteSOU.

Authors’ contributions

LRM, MRFC, TJAS, and WJF contributed to the conception and design of the work. LRM, MRFC, and TJAS performed the acquisition, analysis, and interpretation of data. LRM, MRFC, TJAS, and WJF contributed to drafting and revising the manuscript. All authors approved the final version before submission.

Funding

This work was supported by USP (Universidade de Sao Paulo), Brazil. However, it had no funding or sponsorship.

Availability of data and materials

All data are available upon request. Requests can be sent to the corresponding author Leonardo Rabelo de Melo.

Declarations Ethics approval and consent to participate

Consent for publication

Not applicable.

Competing interests

None to declare.

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No competing interests reported.

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Frailty over the rainbow: a cross-sectional study on LGBT+ adults over fifty

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Abstract

Background

Methods

Results

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Introduction

Methods

Study design and population

Data collection

Statistical analysis

Ethical aspects

Results

Discussion

Conclusions

List of abbreviations

Declarations

References

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