Tracking older LGBTQ+ people’s health: ‘I hear their voices and their stories’

Undeterred by US funding cuts, behavioural-health researcher Jason Flatt studies how dementia affects people from sexual and gender minorities

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This Nature Q&A series celebrates people who fight racism in science and who champion inclusion. It also highlights initiatives that could be applied to other scientific workplaces.

Early in Jason ‘Jace’ Flatt’s career as a dementia researcher, colleagues encouraged them to take advantage of their unique perspective and study the LGBTQ+ community. At the time, it made Flatt mad. “I want to study all people. Are you saying this because I’m gay?” they recall thinking. But in 2017, a project that involved interviewing older LGBTQ+ people in San Francisco, California, changed their mind. This older generation, Flatt says, fought for the rights that LGBTQ+ people enjoy today, and now they are facing health disparities as they age.

Flatt is a public-health researcher at the University of Nevada, Las Vegas. They study how Alzheimer’s and related dementias, as well as Parkinson’s disease, affect members of sexual and gender minority groups. Flatt prefers the more inclusive term LGBTQIA+, because their research covers a broad group of people including queer, two-spirit and intersex people. One of their studies showed that lesbian, gay and bisexual adults get diagnosed with Alzheimer’s disease at younger ages than do heterosexual people¹, even though these groups had higher levels of education, which is usually a protective factor. Flatt’s work has also shown that, starting in their mid-40s, lesbians, bisexual people, transgender people and those who select ‘other’ for their sexual orientation were more likely to report problems with thinking and memory². In 2020, Flatt published one of the first studies of physical and mental health in intersex adults³.

Flatt had hoped to extend their studies of dementia risk to older LGBTQIA+ military veterans this year, but US funding agencies have been cancelling research grants related to this community in response to US President Donald Trump’s executive orders. Flatt has had nearly US$5 million in federal grants across four projects cancelled because their work includes studies involving transgender people. The cancellation letters characterize such inclusion as “often unscientific”. Flatt calls this discriminatory, and notes that findings from the ageing LGBTQ+ population apply to everyone. For instance, Flatt’s work has highlighted the particular health risks to people who live alone.

As the US government moves to take away LGBTQ+ rights, they say: “Our community needs to come together to support one another right now.” Flatt tells Nature they are exploring legal action in response to the terminated grants.

What has been your biggest influence in focusing your research on older people?

My first job was in an assisted-living and skilled-nursing facility. Bingo started right at 9.00 a.m. I did singalongs, painted fingernails and booked entertainment. I was 17, in the closet and not really comfortable with being gay. The older adults didn’t bully me because I didn’t follow masculine stereotypes — I could just be myself.

During my graduate studies, my grandmother had Alzheimer’s disease, and she was really isolated at home. I saw her memory declining. That led to my PhD dissertation, a study about how interacting with people is good for your brain.

When did you realize you wanted to study public health in the LGBTQ+ community?

It was when I became a professor at the University of California, San Francisco. For my first study, I planned to interview 20 LGBTQIA+ people who were 60 years or older. I had planned to spend about an hour and a half with each one, learning about their life history, but also about their concerns regarding dementia.

Jace Flatt shares their research findings with a group of older LGBT+ people.Credit: Saul Bromberger

Many of them invited me into their homes, letting me hear their life stories and their challenges. This was in San Francisco. I was meeting pioneers: people who had fought for LGBTQ+ rights, who been through the AIDS epidemic in the 1980s and 1990s and lost their entire friend group.

It changed my life. Often when I’m doing this work, I hear their voices and their stories. These are my people, and I want to make sure they’re taken care of. They’re the reason I can be married to my husband, and they’re the reason that I can be out at my job and not worry.

How does discrimination play into the challenges faced by older LGBTQ+ people?

One of the important things for ageing well is financial security. Historically, there haven’t been protections for employment, housing and health-care access for this population. For many older LGBTQ+ people, who might not have been able to legally marry their partner, the assets they had built together were not protected once their partner had died.

The older groups that I work with grew up in a time when who they are was pathologized. Until 1987, US health-care standards defined being homosexual as either a mental-health disorder or a sexual-orientation disturbance.

And there’s still discrimination around health care. I’ve gone to the doctor about shoulder pain, and for some reason they asked about my sexual orientation. I shared that I was gay, and then they asked whether they could test me for sexually transmitted diseases (STDs). I asked: “Do STDs cause shoulder pain? Because I think I hurt something lifting.”

If you’re transgender, you might see a doctor about a cough, and they’ll want to examine your genitalia. Or you have a medical encounter in which you’re misgendered, and they’re using a name that you don’t use — and that brings up shame.

You go in and, because of who you are, they automatically blame you for the health problems that you’re facing. That has led to distrust of health-care providers. And that means that often, instead of LGBTQ+ people going to the doctor regularly, and having it noted if they have high blood pressure, it won’t be until they have a stroke that they actually show up for care.