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Correspondence should be addressed to Karen I. E-mail: fredrikk uw. Karen I. Bisexual older adults are a growing yet largely invisible, underserved, and understudied population. Utilizing the Health Equity Promotion Model, we examined hypothesized mechanisms ing for health disparities between bisexual older adults and lesbian and gay older adults. Bisexual older adults reported ificantly poorer health compared with lesbian and gay older adults.

Indirect effects involving sexual identity factors, social resources, and SES explained the association between bisexual identity and poorer health.

A potentially protective pathway was also identified wherein bisexuals had larger social networks after adjusting for other factors. Bisexual older adults face curious challenges and health risks relative to other older adults, likely because of the accumulation of socioeconomic and psychosocial disadvantages across the life course. Thus, it is important to disaggregate these groups to fully understand their experiences, strengths, and risk factors. At the same time, bisexual identities were largely invisible, including within lesbian and gay communities, limiting access to support and resources via those communities.

It is possible that the accumulation of social and economic disadvantage across the life course culminates in persistent or increasing health disparities for bisexuals as they reach older age. In the present study, we used an equity life course framework to investigate economic, psychological, and social risk and protective factors, with the goal of identifying modifiable seniors that contribute to health inequities in bisexual adults as they age.

This model highlights the heterogeneity and intersectionality of social positions that result in unique networks of interconnected health-promoting and adverse processes. As a result, it can shed light on experiences that are common across different subgroups of LGBT people, as well as mechanisms of risk and resilience that may be more likely to operate in a particular subgroup such as bisexual older adults.

The Health Equity Promotion Model is deed to move beyond simply identifying disparities toward ensuring LGBT people have the opportunity to reach their full health potential. Two processes that are unique to sexual minority populations and have been associated with health are internalized stigma and disclosure of sexual identity.

For : bisexual seniors

In studies with younger lesbian, gay, and bisexual LGB adults, internalized stigma i. Bisexual adults, compared with lesbians and gay men, have been found to have lower levels of family support and more negative pressure within their interpersonal relationships Jorm et al. Yet little is known about how these associations play out for older bisexuals, nor about how they may be influenced by age-related changes in the size and structure of social networks. Despite playing a prominent role in a wide variety of life domains, including mental and physical health across the life course, socioeconomic status SES and its components e.

For : bisexual seniors

To date, however, there is very limited information about potential differences in SES between bisexual older adults and lesbian and gay older adults. The few studies that have compared bisexual adults with lesbian and gay adults have found lower income levels Fredriksen-Goldsen et al. Although it is possible that resources available to older adults e. Each of the identified predictors—greater internalized stigma, lower identity disclosure, fewer social resources, and lower SES—has been associated with poorer psychological well-being and elevated psychological distress in sexual minority adults Kertzner et al.

Yet findings have been mixed regarding whether bisexual adults actually experience greater psychological distress compared with lesbians and gay men. While some studies have identified elevated levels of distress and mental health concerns for bisexual compared with lesbians and gay men e. The limited evidence available with bisexual older adults suggests that they may have poorer general mental health compared with lesbian and gay older adults Fredriksen-Goldsen et al. There is consistent evidence of physical health disparities between bisexual and other sexual minority adults.

Compared with lesbians, bisexual women more frequently report poor general health and health-related quality of life, limited activities due to health, and adverse health behaviors such as smoking and excessive drinking Fredriksen-Goldsen et al.

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Other studies have found poorer self-rated health for both bisexual women and bisexual men compared with lesbians and gay men Gorman et al. In one study of adults aged 50 and older, Fredriksen-Goldsen and colleagues Fredriksen-Goldsen, Kim et al. Based on the Health Equity Promotion Model and existing research, we tested three hypotheses in this study.

First, we hypothesized that bisexual older adults would have poorer health compared with lesbians and gay men of similar age Hypothesis 1. Next, we expected that bisexual older adults would show disadvantages in sexual identity factors lower level of identity disclosure and elevated internalized stigma and social resources less positive sense of LGBT community belonging, smaller social network size, and lower level of social support compared with lesbians and gay men of similar age and that these disadvantages would partially explain the association between bisexual identity and poorer health Hypothesis 2.

Finally, we hypothesized that bisexual older adults would show disadvantages in SES compared with lesbians and gay men of curious age and that this disadvantage would further explain the association between bisexual identity and poorer health Hypothesis 3both independently and by contributing to the disadvantages in Hypothesis 2.

The full hypothesized model is shown in Figure 1. Caring and Aging with Pride is the first federally funded and largest study to date of sexual and gender minority older adults. Inthrough community-based collaborations with 12 community agencies across the United States, 2, LGBT adults aged 50 years and older were surveyed. A complete description of the methods used in this study has been published see Fredriksen-Goldsen, Emlet et al.

This study selected those participants who identified as bisexual, lesbian, or gay, with a final sample of 2, The key domains assessed included sexual identity, other demographic and background characteristics, SES, sexual identity factors, social resources, and mental and physical health. Participants identifying as senior or other were not included in this analysis. Sexual identity factors measured in this study were internalized stigma and identity disclosure. Participants were asked to curious to what degree their sexual identity was known to 12 specific groups of people or individuals including family members, best friend, supervisor, neighbors, senior community, and primary physician.

We computed summary scores by taking the weighted average across items to accommodate nonexistence of certain relationships.

In other words, only items representing existing relationships were included in calculation of the summary scores. Social resources included three components: social support, social network size, and positive sense of community belonging. Social network size was calculated by summing the reported of people e.

We measured community belonging with two items, asking participants to indicate the extent of their positive feelings about belonging to LGBT communities.

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The average score ranging from 1 strongly disagree to 4 strongly agree was computed, with higher scores representing greater community belonging. Although occupation is often included as a component of SES, in this sample the majority were retired or not employed.

Household resources were assessed by asking participants to select their pre-tax household income level in Level of education was measured by asking participants to indicate the highest grade completed, ranging from 1 never attended school or only attended kindergarten to 6 4 years of college or more. Both of these variables were treated as continuous and used as observed indicators of a latent SES variable. The physical health subscale asks participants to rate their health during the past 4 weeks on four domains, including physical functioning, limitations due to physical problems, bodily pain, and general health.

The mental health subscale also includes four domains: vitality, social functioning, mental health, and role limitations due to emotional problems. These scores were used as observed indicators of a latent health variable. In preliminary analyses, we examined bivariate correlations and whether there were ificant differences between bisexual versus lesbian and gay older adults on demographic and background characteristics as well as the variables included in our hypothesized model.

Next, structural equation modeling SEM using full information maximum likelihood estimation with robust standard errors was conducted to test the hypothesized model with direct and indirect effects. We used a multistep model building approach to systematically examine our hypotheses: first, we computed a model with only the direct effect from bisexual identity to health; second, we added sexual identity factors and social resources as mediators; and finally, we added SES as an additional mediator to complete the hypothesized model Figure 1.

A series of systematic modifications consistent with the conceptual framework were implemented based on modification indices to produce the best-fitting final model Figure 2. Standardized coefficients for both latent and observed variables were reported to facilitate the interpretation of study. For exploratory purposes, we also stratified the sample and ran the model separately by gender. All statistical analyses were conducted in Mplus 7. Final fitted model.

Dashed lines indicate nonificant pathways.

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In the sample, participants identified as bisexual. On average, the sample was About Table 1 summarizes the demographic and background characteristics and descriptive statistics for the other key variables. Bisexual older adults reported poorer mental and physical health compared with lesbian and gay older adults. Notes: a All the standard deviations for continuous variables were calculated with bootstrapped replications. Table 2 presents the of bivariate correlations among the variables in the study. Moreover, although community belonging was not ificantly associated with education level, all the other correlations were ificant with moderate magnitudes, suggesting that SEM was an appropriate analytic approach.

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Notes: Factors 1 — 4 are binary and 5 — 14 are continuous. Correlation coefficients between a binary and a continuous variable are calculated with point-biserial correlation; correlation coefficients between two binary variables are calculated with tetrachoric correlation. The full fitted model is presented in Figure 2. Most of the hypothesized pathways were ificant, with two exceptions: There was no association between SES and community belonging, or between community belonging and health.

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Indirect effects, which address Hypotheses 2 and 3, are summarized in Table 3. One indirect effect involved only internalized stigma as an additional mediator: Bisexuals had higher internalized stigma, which predicted poorer health. Other indirect effects involved both identity disclosure and social resources as mediators e. Unexpectedly, a pair of protective social pathways involving social network size emerged i. Notes: All estimates are standardized. Only ificant indirect effects are included in effect total.

A large cluster of indirect pathways involving SES were also ificant, consistent with Hypothesis 3. Other effects also involved internalized stigma, identity disclosure, social resources, or a combination of these variables e. When we ran the model separately by gender, the findings for men were similar to the full sample all directions and ificances were identical. All other pathways for women were identical in direction and ificance to the full sample.

In this study, one of the first to examine health disparities in bisexual older adults compared with lesbian and gay older adults, we used the Health Equity Promotion Model, an intersectional life course framework, to identify multiple potential mechanisms that influence the aging process in this largely invisible population.