Perceived discrimination, health and wellbeing among middle-aged and older lesbian, gay and bisexual people: A prospective study
Perceived discrimination, health and wellbeing among middle-aged and older lesbian, gay and bisexual people: A prospective study
Sarah E. JacksonID 0 2
Ruth A. Hackett 0 2
Igor Grabovac 1 2
Lee Smith 2
Andrew Steptoe 0 2
0 Department of Behavioural Science and Health, University College London , London , United Kingdom
1 Department of Social and Preventive Medicine, Center for Public Health, Medical University of Vienna , Vienna , Austria , 3 Cambridge Centre for Sport and Exercise Sciences, Anglia Ruskin University , Cambridge , United Kingdom
2 Editor: Stephen D. Ginsberg, Nathan S Kline Institute , UNITED STATES
To examine cross-sectional and prospective associations between perceived discrimination
in daily life (based on a range of attributes), sexual orientation discrimination, and health and
wellbeing in middle-aged and older lesbian, gay and bisexual (LGB) people.
Data were from 304 LGB men and women aged 41?85 years participating in the English
Longitudinal Study of Ageing. Perceived discrimination in daily life was reported in 2010/11.
Participants could attribute their discrimination experience to characteristics including age,
sex, race, physical disability, and sexual orientation. Self-rated health, limiting long-standing
illness, depressive symptoms, quality of life, life satisfaction and loneliness were assessed
in 2010/11 and 2016/17. Analyses adjusted for age, sex, ethnicity, partnership status and
Perceived discrimination in daily life was reported by 144 (47.4%) participants.
Cross-sectionally, perceived discrimination in daily life was associated with increased odds of
depressive symptoms (OR = 2.30, 95% CI 1.02 to 5.21), loneliness (OR = 3.37, 95% CI 1.60 to
7.10) and lower quality of life (B = -3.31, 95% CI -5.49 to -1.12). Prospectively, perceived
discrimination in daily life was associated with increased odds of loneliness (OR = 3.12,
95% CI 1.08 to 8.99) and lower quality of life (B = -2.08, 95% CI -3.85 to -0.31) and life
satisfaction (B = -1.92, 95% CI -3.44 to -0.39) over six-year follow-up. Effect sizes were
consistently larger for participants who attributed experiences of discrimination to their sexual
orientation compared with those who attributed experiences of discrimination to other
reasons (e.g. age, sex, race).
study design, data collection and analysis, decision
to publish, or preparation of the manuscript.
Competing interests: The authors have declared
that no competing interests exist.
These results provide cross-sectional and prospective evidence of associations between
perceived discrimination in daily life and health and wellbeing outcomes in middle-aged and
older LGB adults in England.
Population ageing is a global phenomenon [
]. Older adults form a diverse group, with
heterogeneity in age, life stage (working or retired), health status, income and wealth, marital status,
and living arrangements [
]. They are also diverse in their sexual orientation, although little
research has focused on older lesbian, gay and bisexual (LGB) individuals. In the LGB
population, the age-related burden of poor health and wellbeing [
] may be compounded by
increased risks associated with their sexual orientation [
]. This study examines the impact of
perceived discrimination in daily life (based on a range of attributes) and sexual orientation
discrimination on the health and wellbeing of middle-aged and older LGB people in England.
Maintaining health and wellbeing in later life is a public health priority [
]. Ageing is
associated with increased risk of a wide range of mental and physical health complications .
Accumulating evidence indicates that individuals who identify as LGB experience poorer
health and wellbeing than their heterosexual counterparts [
]. Studies consistently report
increased prevalence of enduring psychological or emotional problems among LGB
individuals, including psychological distress, depression, anxiety disorders and substance abuse [
Notably, disparities related to psychological distress are most pronounced among those over
the age of 55 [
]. Deficits in physical health have also been documented, with LGB individuals
showing increased incidence of long-standing conditions that limit their daily activities (e.g.
musculoskeletal problems, arthritis, chronic fatigue syndrome) relative to heterosexuals [
and rating their general health as worse [
Discrimination has been identified as a potentially important influence on the health and
wellbeing of the LGB population [
]. A conceptual framework of ?minority stress? posits
that stigma, prejudice and discrimination create a hostile and stressful social environment that
has adverse consequences for health . This framework may apply to other characteristics
beyond sexual orientation, acknowledging that individuals may hold multiple marginalised
identities. A substantial body of literature has shown that LGB individuals are much more
likely than heterosexuals to experience discrimination related to their sexual orientation [
with many reporting that discrimination interferes with their ability to have a full and
productive life [
]. For some LGB people, experiences of individual discrimination occur in discrete
lifetime events (e.g. being fired from a job, being prevented from renting or buying a home)
and in day-to-day interactions with others who treat them poorly [
]. For others, experiences
are the result of institutional discrimination where laws and policies in the public domain
perpetuate inequalities (e.g. the prohibition of same-sex marriage), or where laws fail to protect
against discrimination based on sexual orientation [
]. In England, homosexuality was
considered a criminal offence until 1967 , so for many older people, much of their sexual
development happened under threat of imprisonment. Same-sex partnerships were not legally
recognised until the Civil Partnership Act was introduced in 2004 [
]. Older LGB adults in
England have therefore lived most of their lives in the context of prevalent institutional
2 / 15
The perception of discrimination can be based on multiple attributes such as age, sex, race
as well as sexual orientation. Discrimination based on a number of different attributes is
perceived to be widespread in Europe [
]. According to a survey of 27,718 individuals,
discrimination based on ethnicity was the most frequently reported type of discrimination (64%),
followed by sexual orientation (58%), being aged 55 years or older (42%) and gender (37%).
Those with multiple marginalised identities may experience even greater levels of
discrimination. Discrimination may be particularly harmful among older than younger LGB people
given the youth-masculinity culture that is prevalent in the LGBT community [
Meta-analytic evidence suggests that gender and ethnicity may influence experiences of victimisation
among LGB individuals [
An increasing body of work has examined experiences of discrimination in daily life as a
determinant of mental health and wellbeing. A 2009 pooled analysis of 110 studies found that
perceived discrimination (based on any attribution) was associated with poorer mental health
and wellbeing outcomes, including increased depressive symptoms and decreased life
satisfaction, quality of life and self-rated health [
]. However, the evidence on the impact of perceived
everyday discrimination on the health and wellbeing of LGB individuals is limited [
]. In a
study of LGB (n = 73) and heterosexual (n = 2,844) adults aged 25?74 years (LGB 77.5% <45
years, heterosexual 53.7% <45 years), LGB adults had more frequent experiences with
discrimination and 42% attributed this discrimination to their sexual orientation. Perceived
(nonattribute specific) discrimination was associated with higher prevalence of mental health
disorders, greater psychological distress and poorer self-rated mental health in the whole sample
]. In another survey of LGB and transgender (LGBT, n = 472, mean age 38.9 years) and
heterosexual (n = 7,412, mean age 40.0 years) adults, recent experience of a major incident of
discrimination attributed to any characteristic was associated with a range of indices of mental
health and lower utilisation of mental health care services [
]. Among the LGB and
transgender participants, just over half (51%) attributed the discrimination incident to their sexual
orientation. The existing evidence base lacks prospective data on the impact of discrimination in
daily life on health and wellbeing among LGB individuals. In addition, no studies to our
knowledge have investigated this (either cross-sectionally or prospectively) among older
adults. Furthermore, it is unclear whether the attribution of the discrimination to sexual
orientation in particular has an influence on the relationship between perceived discrimination and
health and wellbeing outcomes.
This study therefore aimed to examine associations between perceived discrimination in
daily life and health and wellbeing in a sample of middle-aged and older LGB people drawn
from a nationally-representative survey of middle-aged and older adults in England.
Specifically, we analysed cross-sectional and prospective associations between perceived
discrimination and self-rated health, limiting long-standing illness, depressive symptoms, life satisfaction,
quality of life and loneliness using data collected over a period of six years. These variables were
selected in order to provide a comprehensive picture of health and wellbeing, encompassing
general health, the presence of chronic conditions, positive and negative affect, global wellbeing,
and social wellbeing. We also assessed whether the pattern of results remained the same for
those who perceived discrimination but did not attribute it to their sexual orientation and those
who perceived discrimination on the basis of their sexual orientation.
Data were from the English Longitudinal Study of Ageing (ELSA), a longitudinal panel study
of middle-aged and older men and women living in households in England [
3 / 15
participants are drawn from households with one or more members 50 years or older
responding to the Health Survey for England (HSE). All household members 50 years or older plus
partners who are younger than 50 years or had joined the household since the HSE are invited
for interview. The study began in 2002, with data collected at two-year intervals via
computerassisted personal interview and self-completion questionnaires. The present analyses use data
from Wave 5 (2010/11; the only wave in which discrimination has been assessed) and Wave 8
(2016/17; the most recent wave for which data were available). Information on sexual
orientation was collected in Wave 6 (2012/13) and used to identify LGB participants for inclusion in
our sample. Of those who reported their sexual orientation (n = 6,939), 406 (5.9%) were
identified as LGB. We would expect sexual orientation to be a stable characteristic in this age group,
so would not expect it to differ between Waves 5 and 6. We restricted our sample to LGB
participants who completed the assessment of discrimination in Wave 5. This left a final sample
for analysis of 304 men and women for cross-sectional analyses, of whom 254 (83.6%)
provided follow-up data in Wave 8 and were therefore included in prospective analyses. Ethical
approval was obtained from the London Multi-Centre Research Ethics Committee. All
participants gave full informed written consent.
Sexual orientation. Sexual orientation was assessed with the question: ?Which statement
best describes your sexual desires over your lifetime? Please include being interested in sex,
fantasising about sex or wanting to have sex?. Response options were 1) entirely for women, 2)
mostly for women, but some desires for men, 3) equally for women and men, 4) mostly for
men, but some desires for women, 5) entirely for men, and 6) no sexual desires in lifetime. We
categorised participants with desires entirely for the opposite sex as heterosexual, entirely for
the same sex as gay and those endorsing response options 2, 3 or 4 as bisexual. We coded the
sexual orientation of those reporting no sexual desires as missing. No data were collected on
gender identity, so we were unable to include a group of gender non-conforming people. Due
to the low numbers of LGB participants in our sample, we analysed data using a binary sexual
orientation variable (heterosexual vs. LGB).
Perceived discrimination. Items on discrimination were based on measures used in other
]. Participants were asked about the frequency of five discriminatory
experiences: ?(1) you are treated with less respect or courtesy; (2) you receive poorer service than other
people in restaurants and stores; (3) people act as if they think you are not clever; (4) you are
threatened or harassed; (5) you receive poorer service or treatment than other people from
doctors or hospitals (almost every day/at least once a week/a few times a month/a few times a year/
less than once a year/never).? Because data were skewed, with most participants reporting
never experiencing discrimination, we dichotomised responses to indicate whether or not
participants had experienced discrimination in the past year (a few times or more a year vs. less
than once a year or never), with the exception of the fifth item which was dichotomised to
indicate whether or not respondents had ever experienced discrimination from doctors or
hospitals (never vs. all other options) [
A follow-up question asked participants who reported discrimination in any of the
situations to indicate the reason(s) they attributed to their experience from a list of options
including age, sex, race, physical disability, and sexual orientation. Participants could attribute more
than one reason to their experiences of discrimination.
Health and wellbeing. Depressive symptoms were assessed with an eight-item version of
the Center for Epidemiologic Studies Depression Scale (CES-D) [
]. Respondents were asked
to indicate if they had experienced depressive symptoms (e.g. restless sleep and being
4 / 15
unhappy) over the past month using a binary (yes/no) response. Total scores ranged from 0 to
8 with higher scores indicating more depressive symptoms. Data were dichotomised using an
established cut-off, with a score of 4 or higher indicating significant symptomatology [
Loneliness was measured using the three-item Revised UCLA Loneliness Scale [
Participants were asked to rate items including: ?How often do you feel you lack companionship??
(hardly ever or never = 1 to often = 3). Scores ranged from 3 to 9, with higher scores indicating
greater loneliness. They were dichotomised at 6 versus <6 to indicate high vs. low loneliness
Quality of life was assessed with the CASP-19 [
], a scale designed to measure quality of
life in older people. Items cover several domains of quality of life including control, autonomy,
self-realisation and pleasure. Respondents are asked how often each statement applies to them
(often = 0 to never = 3). Positively-worded items were reverse scored. A higher score indicates
higher quality of life (range: 0?57).
Life satisfaction was assessed with the Satisfaction With Life Scale [
], which asks
respondents to rate the extent to which they agree with five statements (e.g. ?In most ways my life is
close to my ideal?) on a scale from 0 (strongly disagree) to 6 (strongly agree). Responses were
summed to produce a total score (range: 0?30), with higher scores indicating greater life
Self-rated health was assessed using a single item: ?Would you say your health is. . . poor/
fair/good/very good/excellent?? We analysed the proportion of individuals rating their health as
fair/poor, as has been done in other investigations [
Limiting long-standing illness was assessed with two questions: (1) ?Do you have any
longstanding illness, disability, or infirmity? By long-standing I mean anything that has troubled you
over a period of time or that is likely to affect you over a period of time.? If they responded yes,
they were asked (2) ?Does this illness or disability limit your activities in any way?? Affirmation
of a long-standing illness and any form of limitation classified the participant as having a
limiting long-standing illness.
Covariates. We included information on age, sex, ethnicity (white vs. non-white),
partnership status (married/cohabiting vs. neither) and household non-pension wealth (a sensitive
indicator of socioeconomic status in this population [
Analyses were conducted using SPSS version 24. Data were weighted to correct for sampling
probabilities and for differential non-response and to calibrate back to the 2011 National
Census population distributions for age and sex.
In order to maximise the available sample for analysis, we imputed missing values for all
covariates. A multiple imputation model was run with age, sex, ethnicity, partnership status
and wealth entered as predictors. A total of 40 missing values were imputed for wealth and 1
missing value was imputed for ethnicity. Five imputed data sets were created, each was
analysed separately, and the results were combined to produce pooled estimates of effects;
allowing the analyses to account for uncertainty caused by estimating missing data. Pooled
estimates are reported throughout the paper.
Bivariate associations between perceived discrimination and covariates (assessed at
baseline) were tested using independent-samples t-tests for continuous variables and ?2 tests for
categorical variables. For our primary analyses, we examined differences in depressive
symptoms, loneliness, quality of life, life satisfaction, self-rated health and limiting long-standing
illness between those who reported perceived discrimination and those who did not, both
crosssectionally and prospectively over six-year follow-up. Categorical outcomes were analysed
5 / 15
using logistic regression and continuous outcomes were analysed using linear regression. We
ran two sets of models: the first was unadjusted, the second controlled for age, sex, ethnicity,
partnership status and wealth (covariates chosen a priori). For prospective analyses, the
adjusted models also controlled for baseline status/score on the outcome of interest. As there
were few differences in the pattern of results, we present the adjusted models and comment on
any differences between the unadjusted and adjusted models in the results section. However,
the full results of the unadjusted models are available to view in S1 Table. Results are presented
as unstandardized B and 95% confidence intervals (CI) for continuous outcomes and odds
ratios (ORs) and 95% CI for categorical outcomes.
As a secondary analysis, we repeated models using a three-level discrimination variable to
analyse differences in health and wellbeing outcomes between participants who did not
perceive discrimination, those who perceived discrimination but did not attribute it to their sexual
orientation, and those who perceived discrimination on the basis of their sexual orientation.
Categorical outcomes were analysed using logistic regression and continuous outcomes were
analysed using one-way independent analysis of variance with planned contrasts. In each
model, the group who did not report perceived discrimination was the reference category. As
in the primary analyses, all models controlled for socio-demographic covariates and the
prospective analyses also adjusted for baseline status/score on the outcome of interest.
The 304 middle-aged and older LGB adults in our sample included 103 men and 201 women,
ranging in age from 41 to 85 years. Perceived discrimination in daily life based on a range of
attributes was reported by 144 (47.4%) participants. Some 34.2% reported being treated with
less respect or courtesy, 23.7% reported receiving poorer treatment from doctors or hospitals,
19.4% reported people acting as if they were not clever, 15.9% reported receiving poorer
service in restaurants or stores, and 9.5% reported being threatened or harassed.
Characteristics of the groups who did and did not report perceived discrimination in daily
life are shown in Table 1. On average, participants who reported perceived discrimination in
daily life were significantly younger than those who did not (61.3 vs. 65.3 years, p<0.001), and
a higher proportion were non-white (7.4% vs. 0.7%, p = 0.003) and from the lowest quintile of
wealth (24.5% vs. 9.0%, p = 0.017). A slightly higher proportion of the group who perceived
discrimination in daily life than the group who did not was male, but this difference was not
statistically significant (44.6% vs. 34.3%, p = 0.093). There was no significant association
between perceived discrimination in daily life and partnership status (p = 0.854) or sexual
orientation (i.e. lesbian, gay or bisexual, p = 0.334).
Cross-sectionally, after adjustment for age, sex, ethnicity, partnership status and wealth,
participants who perceived discrimination in daily life had over 2 times higher odds of having
depressive symptoms above threshold (OR = 2.30, 95% CI 1.02 to 5.21, p = 0.046) and over 3
times higher odds of high loneliness (OR = 3.37, 95% CI 1.60 to 7.10, p = 0.001) relative to
those who did not perceive discrimination (Table 2). They also had significantly lower quality
of life (B = -3.31, 95% CI -5.49 to -1.12, p = 0.003). Odds of fair/poor self-rated health were
almost twice as high in the group who perceived discrimination in daily life as in the group
who did not but the difference did not reach statistical significance in the adjusted model
(OR = 1.95, 95% CI 0.91 to 4.19, p = 0.085; unadjusted OR = 2.14, 95% CI 1.19 to 3.86,
p = 0.011). Prevalence of limiting long-standing illness was also slightly higher, and mean life
satisfaction scores were slightly lower, in the group reporting perceived discrimination in daily
life, but differences were not statistically significant in the adjusted models (limiting
longstanding illness p = 0.211, life satisfaction p = 0.271).
6 / 15
Prospectively, after adjustment for covariates including baseline levels, participants who
perceived discrimination on the basis of any of the listed attributions had over 3 times higher
odds of high loneliness (OR = 3.12, 95% CI 1.08 to 8.99, p = 0.036) and significantly lower
mean quality of life (B = -2.08, 95% CI -3.85 to -0.31, p = 0.021) and life satisfaction (B = -1.92,
95% CI -3.44 to -0.39, p = 0.014) than those who did not (Table 2). There was no significant
association between perceived discrimination in daily life and self-rated health (p = 0.889),
limiting long-standing illness (p = 0.605) or depressive symptoms (p = 0.590).
Of the group who reported perceived discrimination (n = 144), 12.5% (n = 18) attributed
their experiences of discrimination to their sexual orientation. In stratified analyses, effect
sizes were consistently larger for the group who attributed experiences of perceived
discrimination to their sexual orientation than for those who did not (Table 3). In addition to the
significant associations identified in the primary analyses, these models revealed a significant
cross-sectional association with self-rated health in the group who attributed experiences of
discrimination to their sexual orientation (OR = 6.76, 95% CI 1.65 to 27.63, p = 0.008). The
cross-sectional association with depressive symptoms and the prospective association with
loneliness were only statistically significant for the group who attributed experiences of
discrimination to their sexual orientation. The cross-sectional association with quality of life and
the prospective association with life satisfaction were only statistically significant for the group
who did not attribute experiences of discrimination to their sexual orientation.
7 / 15
All figures are weighted for sampling probabilities and differential non-response and adjusted for age, sex, ethnicity, partnership status and wealth. Prospective figures
are additionally adjusted for baseline status/score.
SE = standard error, OR = odds ratio, CI = confidence interval, Ref = reference, Coeff = coefficient.
Possible scores on the quality of life scale range from 0?57, and on life satisfaction scale range from 0?30.
In this population-based sample of middle-aged and older LGB adults in England, perceived
discrimination in daily life (based on a range of attributes) was associated with significantly
poorer wellbeing. In cross-sectional analyses, participants who reported perceived
discrimination in daily life had increased odds of depressive symptoms and loneliness, and poorer quality
of life. Longitudinally, perceived discrimination in daily life was associated with increased
odds of loneliness, poorer quality of life, and lower life satisfaction over six years. These results
were independent of participants? age, sex, ethnicity, partnership status and socioeconomic
position. Effect sizes were consistently larger for participants who attributed experiences of
perceived discrimination to their sexual orientation compared with those who attributed
experiences of perceived discrimination to other reasons (e.g. age, sex and race).
Associations between perceived discrimination in daily life (based on a range of attributes)
and poorer wellbeing are in line with previous research in heterosexual older samples [
and younger LGB samples [
]. Consistent with evidence that LGB adults who
experience discrimination suffer poorer mental health [
], participants reporting perceived
discrimination in daily life in our sample had more than double the odds of depressive
symptoms above the threshold for clinical relevance in cross-sectional analyses. However, there was
8 / 15
9 / 15
are additionally adjusted for baseline status/score.
SE = standard error, OR = odds ratio, CI = confidence interval, Ref = reference, Coeff = coefficient.
Possible scores on the quality of life scale range from 0?57, and on life satisfaction scale range from 0?30.
no prospective association between perceived discrimination in daily life and depressive
symptoms over six-year follow-up. It is possible that the impact of ongoing discrimination across
the lifespan on mood had already become evident by the time of the baseline survey, limiting
scope for further deterioration over time, or that the instrument used to measure depressive
symptoms was not sensitive to change.
In contrast, we observed significant associations between perceived discrimination in daily
life and loneliness in both cross-sectional and prospective models. Middle-aged and older LGB
people who reported perceived discrimination (based on a range of attributes) had over three
times higher odds of being lonely cross-sectionally and over six-year follow-up. Previous
studies have shown that older LGB people tend to be more likely than older heterosexual people to
live alone, be childless, and grow old without a life partner or ?significant other? [
Civil Partnership Act legalised same-sex unions in 2004, and the Marriage (Same Sex Couples)
Act legalised same-sex marriage in 2013, when participants were on average in their 50s and
60s. The inability to form legal partnerships until later in life likely contributed to greater
loneliness and poorer wellbeing among older LGB people. Perceived discrimination (based on a
range of attributes) may exacerbate loneliness among older LGB people by making them feel
less accepted by society and causing them to avoid social situations where they anticipate they
may encounter discrimination [
]. Feelings of loneliness among older LGB people may be
exacerbated by the prominent youth culture in the LGBT community [
]. The LGBT
community is particularly tight-knit [
], and studies have found that LGB individuals who report a
greater feeling of belonging to a community of identity also possess an increased sense of social
and psychological wellbeing [
]. Older LGB people, who have likely spent much of their lives
feeling excluded from society, now live in a world where this side of their lives can be (to a
degree) freely expressed. However, with its strong emphasis on youth, they may find
themselves rejected by the LGBT community, worsening loneliness and depressive symptoms. Our
results also provide prospective evidence of associations between perceived discrimination and
lower quality of life and life satisfaction, suggestive of a potential causal role of discrimination
in the association between LGB sexual orientation and these experiences.
Interestingly, just one in eight of those who reported perceived discrimination attributed
these experiences to their sexual orientation. While this figure may seem surprisingly low,
particularly in comparison with the 42% of LGB adults in a previous survey in the USA of 25?74
year-olds (77.5% <45 years) reporting sexual orientation as the basis for experiences of
perceived discrimination [
], in the context of the older age of the sample it is understandable.
As an internal dimension of diversity, sexual orientation may be more difficult to recognise
than other frequently discriminated characteristics, such as race, age or disability [
example, a person might not necessarily reveal their sexual orientation during a medical
appointment, but they cannot hide their age. With older people rarely considered to be sexual
], sexual orientation, a key aspect of sexuality, may be even less likely to attract
discriminatory behaviour from others than it would in younger LGB individuals.
When we compared associations between perceived discrimination and health and
wellbeing outcomes in those who attributed experiences of perceived discrimination to their sexual
orientation with those who did not, we observed substantially larger effect sizes for the group
who reported perceived discrimination on the basis of their sexual orientation. Compared
with those who did not perceive discrimination, middle-aged and older LGB adults who
reported perceived discrimination on the basis of their sexual orientation had more than six
times higher odds of loneliness and more than nine times higher odds of depressive symptoms
in cross-sectional analyses; statistically significant differences despite the very small sample
size. The small size of this subgroup and the large confidence intervals mean that these results
should be interpreted cautiously. They also had more than six times higher odds of fair/poor
10 / 15
self-rated health; a significant difference that was not observed in the adjusted model when the
groups who did and did not attribute perceived discriminatory experiences to their sexual
orientation were combined. Prospectively, middle-aged and older LGB people who reported
perceived discrimination had significantly lower mean quality of life and had more than seven
times higher odds of being lonely. These results indicate that perception of discrimination on
the basis of sexual orientation was more strongly linked with health and wellbeing outcomes
than was discrimination attributed to other characteristics. It may be that group identity?in
this case, as a LGB person?has an important influence on the impact of perceived
discrimination on health and wellbeing. It is possible that perceived discrimination on the basis of this
core aspect of identity may have a more detrimental impact upon health and wellbeing than
other personal characteristics, such as age or sex.
These findings have important implications for the health and wellbeing of a substantial
proportion of the older population. The best available estimate of the size of the LGB
population in England is 2.5% (range 2.5% to 5.89%) [
]. Based on population estimates provided
by the Office for National Statistics [
], this equates to approximately 1.13 million LGB
adults in England, of whom around 253,000 (up to a maximum of 596,000 based on the upper
limit) are over the age of 65. With the number of older adults projected to continue to rise
substantially over coming years [
], the number of LGB individuals aged 65 looks set to
surpass 500,000 (up to a maximum of 1.2 million) by 2041. Initiatives tackling discrimination
against LGB people could help to mitigate the increased risk of poor health and wellbeing in
this rapidly expanding population group. These initiatives should recognise that individuals
might hold multiple marginal identities and as such the primary attribution for discrimination
in this group may not be solely based on their sexual orientation. Addressing stigma and
discrimination in healthcare settings may be particularly relevant to improving health outcomes
in middle aged and older LBG people. Previous literature has noted important differences
between LGB and heterosexuals in health insurance coverage, access to healthcare, and use of
preventive services [
], which may have a direct impact on health. In the present study one
in four participants reported receiving poorer treatment from doctors and hospitals.
Addressing the issue of LGB bias in medical training, where heterosexism and anti-LGB
discrimination occurs frequently , may help to promote a more equal health service for future
Strengths of this study include the prospective design and inclusion of a variety of validated
measures of health and wellbeing. The majority of previous studies investigating the health
impacts of other forms of discrimination have relied on cross-sectional designs and
convenience sampling [
]. Additionally, the questions on sexual orientation were drawn from a
questionnaire that was based on Britain?s National Survey of Sexual Attitudes and Lifestyles
(Natsal) and other studies where reliability and validity have been extensively assessed [
However, there were also several limitations. Previous studies have indicated reluctance of
LGB people to come out to researchers [
], so it is possible that LGB participants were more
likely than heterosexual participants to choose not to answer the questions on sexual
orientation used to identify the present study sample. There were no data available on whether
participants were ?out?. Those who are not out are often plagued by internalised homonegativity and
self-hatred, which may influence both the perception of discrimination and health and
wellbeing . In addition, the measure of sexual orientation asked about same-sex preference over
the life course, which may not necessarily equate to LGB identity. Although the sample was
drawn from a large, representative sample of middle-aged and older adults in England, the
prevalence of LGB sexual orientation was just 2.1% (in the same region as estimates from
]) so our sample was small, limiting statistical power to detect significant associations.
That we observed a number of statistically significant differences between LGB individuals
11 / 15
who did and did not report perceived discrimination (based on a range of attributes) despite
the small sample size attests to the strength of these associations. However, the stability of the
estimates relating to sexual orientation discrimination is likely to be low given the small sample
size. Replication in a larger sample is required to confirm these findings and provide more
reliable estimates of effect size. Perceived discrimination was determined by self-reports of past
experiences, introducing scope for bias. In addition, because reports of discrimination were
subjective, the results estimate the impact of believing that one has been a target of
discrimination as opposed to the impact of discrimination per se. The discrimination questions asked
about five situations, but there may be others that are relevant to LGB individuals that were
not assessed. Prospective analyses were restricted to participants who had data at six-year
follow-up. Attrition between data collection waves meant that there were no follow-up data
available for 50 of the participants included in the cross-sectional analyses. The analysed sample
was slightly younger and wealthier as compared with the total ELSA sample, so results may not
In conclusion, these results indicate that among middle-aged and older LGB adults in
England, perceived discrimination on the basis of any attribution is associated with deficits in
a range of measures of health and wellbeing. While significant progress has been made in
reducing institutional discrimination through legislation that offers greater equality to sexual
minorities and other protected groups, a substantial proportion of LGB people experience
discrimination in their everyday lives. The present findings underscore the need for further action
to address discrimination against sexual minorities on a societal level in order to address
demonstrated disparities in health and wellbeing between LGB and heterosexual people. Given
they are already at increased risk of age-associated health complications, older LGB people
may be particularly vulnerable to the detrimental impact of perceived discrimination in daily
life, particularly as they may hold multiple marginalised identities. Tackling ageism within the
LGBT community could further help to improve outcomes for this population group.
S1 Table. Unadjusted cross-sectional and prospective associations between perceived
discrimination and health and wellbeing outcomes.
Conceptualization: Sarah E. Jackson, Ruth A. Hackett.
Formal analysis: Sarah E. Jackson.
Funding acquisition: Sarah E. Jackson, Andrew Steptoe.
Investigation: Sarah E. Jackson.
Methodology: Sarah E. Jackson, Andrew Steptoe.
Supervision: Andrew Steptoe.
Writing ? original draft: Sarah E. Jackson.
Writing ? review & editing: Ruth A. Hackett, Igor Grabovac, Lee Smith, Andrew Steptoe.
12 / 15
13 / 15
14 / 15
1. Harper S. Economic and social implications of aging societies . Science. 2014 Oct 31 ; 346 ( 6209 ): 587 - 91 . https://doi.org/10.1126/science.1254405 PMID: 25359967
2. Office for National Statistics. Living longer-how our population is changing and why it matters [Internet]. 2018 [cited 2018 Jun 11 ]. Available from: https://www.ons.gov.uk/peoplepopulationand community/birthsdeathsandmarriages/ageing/articles/livinglongerhowourpopulationischanging andwhyitmatters/2018-08-13
3. Baltes PB , Smith J . New Frontiers in the Future of Aging: From Successful Aging of the Young Old to the Dilemmas of the Fourth Age . Gerontology. 2003 ; 49 ( 2 ): 123 - 35 . https://doi.org/10.1159/000067946 PMID: 12574672
4. Institute of Medicine (US) Committee on Lesbian, Gay, Bisexual, and Transgender Health Issues and Research Gaps and Opportunities . The Health of Lesbian , Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding [Internet] . Washington (DC): National Academies Press (US); 2011 [ cited 2018 Nov 5]. (The National Academies Collection: Reports funded by National Institutes of Health) . Available from: http://www.ncbi.nlm.nih.gov/books/NBK64806/
5. British Medical Association. Growing older in the UK [Internet]. 2016 [cited 2018 Oct 24 ]. Available from: https://www.bma.org.uk/collective-voice/policy-and -research/public-and-population-health/ healthy-ageing
6. Department of Health and Social Care . Wellbeing and health policy [Internet] . GOV.UK. 2014 [cited 2018 Oct 24 ]. Available from: https://www.gov.uk/government/publications/wellbeing-and -health-policy
7. Zeeman L , Sherriff N , Browne K , McGlynn N , Mirandola M , Gios L , et al. A review of lesbian, gay, bisexual, trans and intersex (LGBTI) health and healthcare inequalities . Eur J Public Health [Internet]. [cited 2018 Nov 7 ]; Available from: https://academic.oup.com/eurpub/advance-article/doi/10.1093/eurpub/ cky226/5151209 https://doi.org/10.1093/eurpub/ckv049 PMID: 25829506
8. King M , Semlyen J , Tai SS , Killaspy H , Osborn D , Popelyuk D , et al. A systematic review of mental disorder, suicide, and deliberate self harm in lesbian, gay and bisexual people . BMC Psychiatry . 2008 Aug 18 ; 8 ( 1 ): 70 .
9. Semlyen J , King M , Varney J , Hagger-Johnson G . Sexual orientation and symptoms of common mental disorder or low wellbeing: combined meta-analysis of 12 UK population health surveys . BMC Psychiatry . 2016 Mar 24 ; 16 : 67 . https://doi.org/10.1186/s12888-016-0767-z PMID: 27009565
10. Meads C , Kelly MP , Carmona C . Lesbian, gay and bisexual people's health in the UK: a theoretical critique and systematic review . Divers Equal Health Care [Internet] . 2012 [ cited 2018 Nov 7];9(1 ). Available from: http://diversityhealthcare.imedpub.com/abstract/lesbian -gay-and-bisexual-peoples-healthin-the-uk-a-theoretical-critique-and-systematic-review-1826 .html
11. Elliott MN , Kanouse DE , Burkhart Q , Abel GA , Lyratzopoulos G , Beckett MK , et al. Sexual minorities in England have poorer health and worse health care experiences: a national survey . J Gen Intern Med . 2015 Jan; 30 ( 1 ): 9 - 16 . https://doi.org/10.1007/s11606-014-2905-y PMID: 25190140
12. Meyer IH. Prejudice, Social Stress, and Mental Health in Lesbian, Gay, and Bisexual Populations: Conceptual Issues and Research Evidence. Psychol Bull . 2003 Sep; 129 ( 5 ): 674 - 97 . https://doi.org/10. 1037/ 0033 - 2909 . 129 .5.674 PMID: 12956539
13. Mays VM , Cochran SD . Mental Health Correlates of Perceived Discrimination Among Lesbian, Gay, and Bisexual Adults in the United States . Am J Public Health. 2001 Nov 1 ; 91 ( 11 ): 1869 - 76 . PMID: 11684618
14. Pascoe EA , Smart Richman L. Perceived discrimination and health: A meta-analytic review . Psychol Bull . 2009 ; 135 ( 4 ): 531 - 54 . https://doi.org/10.1037/a0016059 PMID: 19586161
15. Addis S , Davies M , Greene G , MacBride-Stewart S , Shepherd M. The health, social care and housing needs of lesbian, gay, bisexual and transgender older people: a review of the literature . Health Soc Care Community . 2009 Nov 1 ; 17 ( 6 ): 647 - 58 . https://doi.org/10.1111/j.1365- 2524 . 2009 . 00866 . x PMID : 19519872
16. Katz-Wise SL , Hyde JS . Victimization experiences of lesbian, gay, and bisexual individuals: a metaanalysis . J Sex Res . 2012 ; 49 ( 2-3 ): 142 - 67 . https://doi.org/10.1080/00224499. 2011 .637247 PMID: 22380586
17. Haas AP , Eliason M , Mays VM , Mathy RM , Cochran SD , D'Augelli AR , et al. Suicide and suicide risk in lesbian, gay, bisexual, and transgender populations: review and recommendations . J Homosex . 2011 ; 58 ( 1 ): 10 - 51 . https://doi.org/10.1080/00918369. 2011 .534038 PMID: 21213174
18. Sexual Offences Act 1967 [Internet]. [cited 2018 Nov 7 ]. Available from: https://www.legislation.gov.uk/ ukpga/1967/60
19. Civil Partnership Act 2004 [Internet]. [cited 2018 Nov 7 ]. Available from: http://www.legislation.gov.uk/ ukpga/2004/33/contents
20. European Union . Discrimination in the EU in 2015 . 2015 .
21. Sa ?nchez FJ , Greenberg ST , Liu WM , Vilain E . Reported Effects of Masculine Ideals on Gay Men. Psychol Men Masculinity . 2009 Jan; 10 ( 1 ): 73 - 87 .
22. Burgess D , Lee R , Tran A , Ryn M van. Effects of Perceived Discrimination on Mental Health and Mental Health Services Utilization Among Gay , Lesbian, Bisexual and Transgender Persons . J LGBT Health Res. 2007 Sep 1 ; 3 ( 4 ): 1 - 14 . PMID: 19042907
23. Steptoe A , Breeze E , Banks J , Nazroo J . Cohort profile: the English Longitudinal Study of Ageing. Int J Epidemiol . 2013 Dec; 42 ( 6 ): 1640 - 8 . https://doi.org/10.1093/ije/dys168 PMID: 23143611
24. Yuan ASV . Perceived Age Discrimination and Mental Health. Soc Forces . 2007 Sep 1 ; 86 ( 1 ): 291 - 311 .
25. Luo Y , Xu J , Granberg E , Wentworth WM . A Longitudinal Study of Social Status, Perceived Discrimination, and Physical and Emotional Health Among Older Adults . Res Aging . 2012 May 1 ; 34 ( 3 ): 275 - 301 .
26. Smith J , Ryan L , Sonnega A , Weir D , The HRS Psychosocial Working Group. Psychosocial and Lifestyle Questionnaire 2006 -2016. Ann Arbor, MI: Survey Research Center, Institute for Social Research; 2017 .
27. Rippon I , Kneale D , Oliveira C de, Demakakos P , Steptoe A . Perceived age discrimination in older adults . Age Ageing . 2014 May 1 ; 43 ( 3 ): 379 - 86 . https://doi.org/10.1093/ageing/aft146 PMID: 24077751
28. Radloff LS . The CES-D scale . Appl Psychol Meas . 1977 ; 1 ( 3 ): 385 - 401 .
29. Steffick DE. Documentation of affective functioning measures in the Health and Retirement Study . HRS Documentation Report DR-005 ; 2000 .
30. Russell DW. UCLA Loneliness Scale (Version 3): reliability, validity, and factor structure . J Pers Assess . 1996 Feb; 66 ( 1 ): 20 - 40 . https://doi.org/10.1207/s15327752jpa6601_2 PMID: 8576833
31. Steptoe A , Shankar A , Demakakos P , Wardle J . Social isolation, loneliness, and all-cause mortality in older men and women . Proc Natl Acad Sci U S A. 2013 Apr 9 ; 110 ( 15 ): 5797 - 801 . https://doi.org/10. 1073/pnas.1219686110 PMID: 23530191
32. Hyde M , Wiggins RD , Higgs P , Blane DB . A measure of quality of life in early old age: the theory, development and properties of a needs satisfaction model (CASP-19) . Aging Ment Health . 2003 ; 7 ( 3 ): 186 - 194 . https://doi.org/10.1080/1360786031000101157 PMID: 12775399
33. Diener E , Emmons RA , Larsen RJ , Griffin S. The satisfaction with life scale . J Assess . 1985 ; 49 ( 1 ): 71 - 75 .
34. Steptoe A , Jackson SE . The Life Skills of Older Americans: Association with Economic, Psychological, Social, and Health Outcomes . Sci Rep . 2018 Jul 5 ; 8 ( 1 ): 9669 . https://doi.org/10.1038/s41598-018- 27909-w PMID: 29977019
35. DeSalvo KB , Bloser N , Reynolds K , He J , Muntner P . Mortality prediction with a single general selfrated health question. A meta-analysis . J Gen Intern Med . 2006 Mar; 21 ( 3 ): 267 - 75 . https://doi.org/10. 1111/j.1525- 1497 . 2005 . 00291 . x PMID : 16336622
36. Banks J , Karlsen S , Oldfield Z. Socio-economic position . 2003 [cited 2014 Mar 4 ]; Available from: http:// discovery.ucl.ac.uk/15366/1/15366.pdf
37. Jackson SE , Hackett RA , Steptoe A . Age discrimination predicts impaired health and wellbeing: crosssectional and prospective findings from the English Longitudinal Study of Ageing . Lancet Public Health. 2019 ; 4 ( 4 ): E200 - 208 . https://doi.org/10.1016/S2468- 2667 ( 19 ) 30035 - 0 PMID: 30954145
38. D? ?az RM , Ayala G , Bein E , Henne J , Marin BV . The impact of homophobia, poverty, and racism on the mental health of gay and bisexual Latino men: findings from 3 US cities . Am J Public Health . 2001 Jun; 91 ( 6 ): 927 - 32 . PMID: 11392936
39. Shankle M. The handbook of lesbian, gay, bisexual, and transgender public health: A practitioner's guide to service . Routledge; 2013 .
40. Kertzner RM , Meyer IH , Frost DM , Stirratt MJ . Social and psychological well-being in lesbians, gay men, and bisexuals: the effects of race, gender, age, and sexual identity . Am J Orthopsychiatry . 2009 Oct; 79 ( 4 ): 500 - 10 . https://doi.org/10.1037/a0016848 PMID: 20099941
41. Nicholas CL . Gaydar: Eye-gaze as identity recognition among gay men and lesbians . Sex Cult . 2004 Mar 1 ; 8 ( 1 ): 60 - 86 .
42. Kessel B. Sexuality in the older person . Age Ageing . 2001 Mar 1 ; 30 ( 2 ): 121 - 4 . PMID: 11395341
43. Public Health England. Producing modelled estimates of the size of the LGB population of England: Final Report [Internet] . GOV.UK. 2017 [cited 2018 Nov 6 ]. Available from: https://www.gov.uk/ government/publications/producing -estimates-of-the-size-of-the-lgb-population-of-england
44. Office for National Statistics. Overview of the UK population: November 2018 [Internet]. 2018 [cited 2018 Jun 11 ]. Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/ populationandmigration/populationestimates/articles/overviewoftheukpopulation/november2018
45. Buchmueller T , Carpenter CS . Disparities in health insurance coverage, access, and outcomes for individuals in same-sex versus different-sex relationships, 2000 - 2007 . Am J Public Health . 2010 Mar; 100 ( 3 ): 489 - 95 . https://doi.org/10.2105/AJPH. 2009 .160804 PMID: 20075319
46. Heck JE , Sell RL , Gorin SS . Health care access among individuals involved in same-sex relationships . Am J Public Health . 2006 Jun; 96 ( 6 ): 1111 - 8 . https://doi.org/10.2105/AJPH. 2005 .062661 PMID: 16670230
47. Nama N , MacPherson P , Sampson M , McMillan HJ . Medical students' perception of lesbian, gay, bisexual, and transgender (LGBT) discrimination in their learning environment and their self-reported comfort level for caring for LGBT patients: a survey study . Med Educ Online . 2017 ; 22 ( 1 ): 1368850 - 1368850 . https://doi.org/10.1080/10872981. 2017 .1368850 PMID: 28853327
48. Mercer CH , Tanton C , Prah P , Erens B , Sonnenberg P , Clifton S , et al. Changes in sexual attitudes and lifestyles in Britain through the life course and over time: findings from the National Surveys of Sexual Attitudes and Lifestyles (Natsal) . The Lancet . 2013 Nov; 382 ( 9907 ): 1781 - 94 .
49. DeLamater J. Sexual expression in later life: a review and synthesis . J Sex Res . 2012 ; 49 ( 2-3 ): 125 - 41 . https://doi.org/10.1080/00224499. 2011 .603168 PMID: 22380585
50. Berg RC , Munthe-Kaas HM , Ross MW . Internalized Homonegativity: A Systematic Mapping Review of Empirical Research . J Homosex . 2016 Apr 2 ; 63 ( 4 ): 541 - 58 . https://doi.org/10.1080/00918369. 2015 . 1083788 PMID: 26436322
51. Geary RS , Tanton C , Erens B , Clifton S , Prah P , Wellings K , et al. Sexual identity, attraction and behaviour in Britain: The implications of using different dimensions of sexual orientation to estimate the size of sexual minority populations and inform public health interventions . PLoS ONE [Internet] . 2018 Jan 2 [cited 2018 Nov 13 ]; 13 ( 1 ). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5749676/