 LGBTQ plus aging in Canada. What can we learn from the CLSA? I'd like to introduce Dr. Arne Stinchcom and Dr. Kimberly Wilson. Dr. Wilson will actually be presenting first. She's an assistant professor in adult development and aging in the Department of Family Relations and Applied Nutrition at the University of Guelph. As a social gerontologist, her program of research is broadly focused on health and well-being for aging individuals and aging populations. Her current research is focused on understanding and accounting for diverse experiences of aging with a particular focus on LGBTQ plus older adults. And then after Dr. Wilson will be Dr. Arne Stinchcom who is an assistant professor in the Master of Applied Gerontology program at Brock. He maintains expertise in psychosocial aspects of health, aging and older adulthood. He has a particular focus on inclusion and diversity with older adult populations. And his research seeks to promote health and well-being among older LGBTQ plus populations. So, I think we will get started now and turn it over to Dr. Wilson. If I can... Great, thank you so much, Jennifer. I think you're good to go. Okay, thank you. All right, so I just wanna start by saying thank you to the folks at CLSA for this invitation and for the opportunity to present some of our research. And I also understand that we have a great group on the line today, but I wanna thank all of you for taking some time out of your day to join us. Today Arne and I will be sharing some of the work that we've been doing over the last few years focused on LGBTQ plus aging. And that is the experiences of lesbian, gay, bisexual, transgender and queer people. And before we begin, I just wanna acknowledge that the work we're presenting today was funded by the Canadian Institute of Health Research and we're grateful for their support. In the next 40 minutes or so, we plan to share with you some of the background information that led us into this work. And then I'll be turning it over to Arne who will share with you some of the information about the CLSA. And then walk you through some of our findings related to the participants from the CLSA who are lesbian, gay or bisexual, including highlighting some of the health disparities, their caregiver status and roles, mental health. And then we'll end with some considerations of the data and opportunities for future work in this area. And as Jennifer mentioned, we wanna make sure that we leave lots of time for questions so please be able to put them into the chat as we go along. So much of what we know about LGBTQ plus aging comes from research out of the United States and other international jurisdictions. Their work has shown that there are higher rates of mental illness and chronic disease among LGBTQ plus people. And we also know that LGBTQ plus people, older adults have historical experiences as of discrimination and they carry those with those today and continue to have some in their aging experiences. These minority stress experiences adversely affect the health and wellbeing of lesbian, gay, bisexual, transgender and queer community. Series of human development emphasize historical experiences in context and LGBTQ plus older people have experienced social historical context that are unique from their heterosexual peers but also from younger LGBTQ plus cohorts. For our purposes, it's important to note there are some shared similarities across jurisdictions such as the removal of homosexuality from the DSM in 1973, but there are some important unique considerations for our context. So in 1969, Canada decriminalized homosexuality in 2005, the marriage act made same-sex marriage legal. And it wasn't until 2017 that Bill C-16 added gender identity and gender expression to the Canadian Human Rights Act. So it's important to note that there are some unique pieces here in Canada that are relevant for us. We also know that these are individuals and communities who have enormous strengths and have demonstrated resiliency. One great example is for the age crisis, the networks that were created, the care networks that were created as well as the advocacy work through the LGBTQ plus community. We also know that Canada's population is aging and is becoming increasingly diverse. And so it makes it very important to have an LGBTQ plus older adult within our context. As noted earlier, when we look at the health and wellbeing of sexual and gender minorities, we see poor health outcomes relative to their majority peers. So why this case? Well, we can look to Dr. Elon Meyer's pioneering work from UCLA to suggest that health disparities among LGBTQ plus people relate to minority stressors like stigma, discrimination, real or perceived threats. And this requires increased vigilance, concealment of one's identity, and internalization of negative societal perceptions. The minority drug model informs much of our work. So in addition to the research from our colleagues in other countries, we've been working together as a team for several years to look at the Canadian experience. Our first project started initially with the funding from the Law Commission of Ontario, where we asked the question, what are the unique needs of LGBTQ plus older adults at the end of their lives? In this area was focused on end of life and through focus groups with LGBTQ plus older adults from across Ontario, we learned that they have unique health and psychosocial needs. And their end of life concerns were related to inclusion, relationships, maintaining identity, and most importantly staying out of the closet. They identified fears of formal care systems, which included social isolation, decreased independence, and increased vulnerability to stigma. As a result of that, we were inspired to go to care providers to ask them about their experiences serving and caring for LGBTQ plus older adults. And what we found is that many of the care providers that are currently working in the system lacked training to provide culturally sensitive care for LGBTQ plus older adults. So with these unique social historical contacts in Canada, plus what we know around experiences of biphobia and homophobia, along with our research that showed that folks have fears related to personal information with the care system, it felt increasingly important that we look at the health of LGBTQ plus older adults. And the CLSA as Aaron will talk you through is a unique platform for much to examine trajectories of health in relation to age, sex and gender, sexual orientation, and sexual determinants. So from here I'm gonna pass it over to Aaron who will walk you through then the CLSA data and what we were able to do within this study. Great, so thanks so much, Kim and Jennifer and hello everyone on the line. So I'll be sharing some of the analyses that we've been working on over the last few years on LGBT aging in Canada. But before we get there, for those of you who may not know what exactly is the CLSA? Well, the Canadian Longitudinal Study on Aging or the CLSA is the largest, most comprehensive research platform and infrastructure available for aging research with longitudinal data that will span 20 years from over 50,000 Canadians who at the age of, or who at baseline were 45 years of age older. So the CLSA will collect data from participants every three years for 20 years. It collects a wealth of data, psychosocial survey data and physical assessments. And for the first time, the CLSA offers population level data on the bio-psycho-social aspects of aging as a sexual minority in Canada. So there are two cohorts within the CLSA. So on the left here we can see the tracking cohorts and on the right we can see the comprehensive cohort. The tracking cohort is made up of about over 20,000 folks who complete telephone interviews every three years. And the comprehensive cohort are just a bit over 30,000 participants who in addition to completing interviews also complete physical assessments where they go into a data collection site. So just to give you an idea of where the data are collected, the tracking cohort participants can be almost anywhere in Canada. So we haven't quite reached the territories yet. And then the comprehensive cohort, those are those big red dots that you see on your screen. So there are 11 data collection sites across Canada. So at baseline, this is a community sample, but the intention is to follow participants as some of them transition into more formal types of care. As I mentioned, the CLSA collects a wealth of data. So physical and cognitive measurements, health information, psychosocial variables, which we'll be focusing on today as well as some lifestyle and sociodemographic variables. So in terms of what data are available, right now baseline and first follow-up data are available for analysis. So data from over 51,000 participants who again at baseline were 45 to 85 years old. And I'd encourage individuals who are interested to check out the CLSA website for more information. In 2018, the Public Health Agency of Canada and Employment Social Development Canada commissioned a report to look at some of these baseline data within the CLSA with a focus on health and aging. So there are 12 chapters as part of this report ranging from mental health to transportation. And Kim and I contributed a chapter on LGB aging, which we'll talk a little bit about. For those of you who are educators, I find that in my own teaching, the report is an exceptional teaching resource. So if this is relevant to your work and I speculate that it might be, please do check it out. So what were the participants asked about sex and sexual orientation at baseline? So in terms of sexual orientation, participants were asked whether they are heterosexual, that is sexual relations with people of the opposite sex, homosexual, that is lesbian or gay, bisexual, that is sexual relations with people of both sexes. And in terms of sex, they were asked whether they are male or female. And with this particular question, we can't ascertain whether participants are responding based on their sex assigned at birth or their gender identity. So in our own research, we refer to this variable as sex slash gender and we refer to participants as women and men. So in terms of some of the characteristics of lesbian, gay and bisexual participants in the CLSA, just about 2%, so just over a thousand folks self-identified as LGB within the CLSA at baseline. Relative to heterosexual participants, sexual minority participants were younger and they reported higher levels of education. We did note some differences in terms of total household income such that gained by sexual men have lower total household income in comparison to heterosexual peers of the same sex. And they were less likely to be retired as well. LGB participants in the sample were more likely to reside in urban environments and they were less likely to own their own homes. They were less likely to be married and more likely to report being single, having never married or lived with a partner. Importantly, LGB participants were more likely to report being lonely at least some of the time in comparison to heterosexual peers. And they were also more likely to be living alone. We looked at scores on a measure of social support which is a composite measure of social support called the MLS Social Support Survey. And what we found is that gained by sexual men had the lowest levels of social support, whereas lesbian and bisexual women had the highest levels of social support in the sample. We also noted that LGB participants were really active in their communities. Yet they also reported the desire to participate more in their communities in social, recreational and group activities. And through focus groups that Kim and I have conducted with LGBTQ older adults from across Canada, we've heard that loneliness is a major concern. And this was coupled with an interest in innovative approaches to things like aging in place and housing and communal housing, which may be some of the solutions to address social isolation. So again, here we see the vast majority of LGB participants, men and women, are participating within their communities at least once a week. But that said, they do want the opportunity to participate more. And again, through some focus groups, we've heard that there is a desire to participate more socially in community through volunteer work, maybe with LGBTQ youth, but that they may experience some barriers to such participation. In terms of self-perceived health, the CLSA uses three questions to assess self-reported health. So participants are asked to describe their physical health, their mental health and their healthy aging. And here we can see that LGB participants, most of them are saying that their health is either very good or excellent. And this is in spite of many of them having at least one chronic disease and a higher lifetime prevalence of mental illness. So I think this highlights resilience within this particular population. The data that I've shown you so far are highly descriptive. And we wanted to model some of the data which would allow us to control for relevant covariates. So given that this is the first time that we have data on sexual orientation within a national population health survey that is representative, we wanted to confirm some of the international data that are showing health disparities among sexual minority communities that are aging in Canada. Again, much of the data that we have is from the United States of America. So going forward, we pooled the tracking and comprehensive cohorts. And we looked at self-reported lifetime diagnosis of chronic disease and mental illness. So these are questions like, has a doctor ever told you that you have asthma? For example, we first performed crude logistic regression and then we adjusted for some known covariates. So things like age, income, education in province and all of our analyses were stratified by sex and gender. So here we see some of the results for women. After adjustment, we see an increased odds of asthma, mood disorders, being a former smoker and heavy drinking. And again, this is consistent with the minority stress framework in aligns with some of the international estimates that show higher rates of chronic disease after adjustment among sexual minority women. And when we look at the results for men, we see a very similar pattern of results. Again, bisexual men had a 1.9 greater odds of reporting a mood disorder in comparison to heterosexual men after adjustment. Again, asthma came out as significant cancer, being a current smoker. And interestingly, seeing a psychologist within the last 12 months came out as significant. So this was important because again, we were replicating some of the international estimates. Some of this work is published in the Canadian Journal of Public Health and a follow-up analysis showing higher prevalence of migraine headache among gay and bisexual men was published in the Journal of Headache. And I just wanna mention the hard work of Nicole Hammond who's a PhD student in epidemiology at the University of Ottawa who's worked substantially on these analyses. So we know that minority stress is associated with health disparities among sexual minority communities, but other research highlights minority stress as contributing to the development of coping resources throughout the lifespan. We know that for members of these communities, families of choice or fictitious kin are really important to them. We know that social support networks are diverse and linked to health among members of these communities. So as a next step, we wanted to look at social network size. We wanted to look at the provision of informal care and the relationship to the care recipient. I'm a pet owner and I also wanted to know about pet ownership within these communities. So all of these analyses are adjusted for relevant covariates as appropriate. And the provision of care, so caregiving was captured by asking participants if they provided support in the last 12 months and if they did, who that person was. So the results showed that lesbian and bisexual women as well as gay and bisexual men had fewer children in comparison to their heterosexual peers. And this is important because when we start to think about informal caregiving, we know that children are often built in caregivers within our families, within our society. Lesbian and bisexual women had higher rates of pet ownership and this is a finding consistent with some of the qualitative literature showing that companion animals are an important source of strength and support for LGBTQ older adults. We saw lots of caregiving. So 49% of lesbian and bisexual women were providing care, which is very similar to heterosexual women, but we saw higher rates of caregiving among gay and bisexual men relative to heterosexual men. We saw that in terms of the recipient of the care that it was likely to be a friend or an older parent. In terms of the types of care provided, LGBT participants were more active in providing transportation, assistance with activities and meal preparation. I think some of these findings help us think differently about care and care networks. We often talk about the gendered nature of care and perhaps we should also be thinking about sexual orientation when we think about support services for caregivers. Some of these analyses are published in the International Journal of Human Development and I wanna acknowledge the work of Miriam Ismail who recently completed her degree or her master's degree rather in counseling. So next we wanted to look at contemporary experiences of mental illness. So just to remind you that previously we were looking at lifetime prevalence. Now we wanted to know about participants' contemporary experiences with mental illness. So we looked at psychological distress and depression within the last four weeks. We also looked at social support. So here we looked at the Center for Epidemiological Studies, Depression Scale, the CESD-10 and the Kessler Psychological Distress Scale K-10. And again, we looked at the MOS Social Support Survey. And again, adjusted for relevant covariates as appropriate. So we see that gay and bisexual men had an increased odds of screening positive for depression as well as psychological distress. And again, this is contemporary mental illness, not lifetime prevalence. We also saw low levels of perceived social support, especially among gay and bisexual men. High levels of perceived social support among lesbian and bisexual women. Again, we saw high levels of lowliness among gay and bisexual men. And I think some of these results really highlight opportunities for supporting aging LGBT people. And I'm gonna hand it back over to Kim who's gonna speak some more about some of the implications of this work. Great. Thanks, Aaron. So in terms of implications, I think that hopefully you've seen through some of the findings that are presented. I think there's a lot of opportunity for us, but first we just wanna talk a little bit about some of the considerations of the data that we need to keep in mind when interpreting. So as I mentioned earlier on, 72% of the participants who are lesbian, gay and bisexual were less than age 65. So at baseline which these analyses are presenting from, we're largely capturing a midlife experience of participants. So we'll be interested to see how these continue to evolve and change as we have the opportunity to follow folks over time. I see already that there's a question about this. So I want to address it here in terms of one of the considerations. Gender identity was not at baseline. So what we were presenting today was only related to sexual orientation and folks who were identified as lesbian, gay or bisexual. So at this moment, although in our title, we're advertising what can we learn about LGBTQ plus aging. At this moment, we are not able to analyze any other identities within the LGBTQ plus community beyond lesbian, gay and bisexual. Also, as Arne mentioned in terms of the sampling frame up for the CLFSA, at this moment, we have noted that included in this for Northern, rural and remote older LGBT individuals who are likely underrepresented because the territories are not captured within the sample. But with that in mind, I think there are some really interesting implications for us moving forward. So I think we hope that we're building the case here that we need to consider sexual orientation as a determinant of health within an Asian population. And in some of the lists of social determinants of health, it doesn't always come up. And I think we're seeing here that it really does potentially have an impact on folks aging experiences. I think too, there's an opportunity for us to be thinking about strengths-based approaches and how we are developing our future policy, practice and clinical work that draws on the strengths of the LGBTQ plus individuals and communities. Here too, I think that this data, these data and some of the future work that will come out of the CLFSA gives us an opportunity to think about inclusive and equitable program and policy responses. And I think here, one of the great examples, as Arne mentioned, is for example, when it comes to caregiving. So much of the literature around caregiving and gerontology talks about the gendered experience. And therefore, a lot of our support groups or programs or policies think about that gendered experience and perhaps we need to also consider creating spaces that are open and supportive of those who are lesbian, gay and bisexual older adults who are in caregiving roles, who may not be captured when we take that sort of majority lens in our planning. So we are excited about the opportunity to look at aging trajectories in the future and also to think about how these social historical contexts as they continue to evolve, shape the aging experience of the current cohort of older adults and those were coming up behind them. So we wanted to leave a lot of time for questions and engagement because we know this is, you know, as Arne mentioned, this is the first time we've had the type of data here in Canada. So we, I can see that there's some questions coming in already. So I think we'll turn it over to Jennifer then who can maybe facilitate the question in a later period. Okay, so thank you very much for the excellent presentation. I think, I know I learned a lot. So I'm guessing others learned a lot as well. Of course it always raises questions about the data as well as the outcomes and now we'll be able to have a chance to discuss those. Just a reminder that muting will remain on but you can enter your questions into the chat box within the bottom corner of the WebEx window. So hopefully you've all figured that out. So I'll start with the first. So you did, I think Kim, you were monitoring the questions as you went. So that's great. Maybe following up with the one question where it says where are trans folks? I think there was also a question about two-spirited and how any indigenous populations that may have been captured may have not identified as gay or lesbian because they may identify as two-spirited. I'm gonna hope you could just explain and talk to why that was not represented in your work. You hear me? Hello? Can everyone hear me? Yes. I think you're good. Thank you. Yeah, that's a great question. So again, the LGBT participants within the CLS, they made up about 2% of participants. So whenever we're doing data analysis, we kind of have to make some decisions about how we're gonna slice and dice the data. So we've had other comments before about separating out bisexual participants, which I think is a similarly important approach, but absolutely the examination of ethnic diversity within the LGBT sample is a priority for us. It's just with these initial descriptive statistics, it was a priority for us to to maintain as much data as we could. We didn't wanna break down the data into really small cell sizes, which would impact our statistical power, but I absolutely take your point. Great. So now I'll go to the top of the question since I already started asking them out of order. So the first question related to the strategies to address the isolation and loneliness that was addressed and whether you can talk to some strategies that you know of or have come across in relation to that. Yeah, and I'm happy to take a stab at this one. Can you help me just to make sure? Okay. Yes, I can. Okay, so that's a great question, and thank you for raising it. I think through the literature that we've been looking at and some of the other research we've been doing, we've been thinking quite a bit about this. So I think the first thing I wanna say is how important it is to create safe spaces for people to be engaging with one another so that social isolation and loneliness may be part of the fact that folks are not sure if the different community groups or opportunities to engage in activities in their community are safe and inclusive spaces. And I think what we've learned and heard is that within LGBTQ plus communities and groups, older adults sometimes feel excluded, and then within aging, the LGBTQ plus folks also feel like they're not represented. So in some ways they fall in between for the fact that the two different communities where there might be specific programming or activities around reducing loneliness or social isolation. And so having that lens to think about do we need particular targeted events for the LGBTQ plus folks in our community or give it ways to ensure that we're showing the activities and events we have in our communities are inclusive and open to all are really important. And there's been some really great work happening in Canada around reducing social isolation. So I think coming out of the 2015 Pankany New Horizons project, for example, there's work out of Hamilton around the seniors isolation impact plan and work out of BC where they were bringing together resources around social isolation as well. So there's some really great work out there around reducing social isolation. And then I think it's important that we put on that sort of LGBTQ plus lens to ensure that it's working for all older adults. And if you're interested in thinking about how to do that, ESDC also put out a toolkit recently, specifically looking at social isolation and LGBTQ plus communities. And within their tool kit, they have sort of suggestions for how to create inclusive ideas exchange events for LGBTQ plus seniors. And I think within that sort of safety around spaces is really important. And when I think about some of the work out of the States, there's been a strong focus on intergenerational work. So congregate meals, for example, between LGBTQ plus youth and LGBTQ older adults. But I think where possible the strategies should come from the community as well. So working with existing, you know, Asian pride groups to think about asking them what they perceive will work best and then we're working with them to reach out to those who may be particularly socially isolated or lonely. Great, thanks for that response. Hopefully that gave, I think it was Shanika or Shanika, some good input. The next question was, we've already answered part of it. The first part of it was, what are the relevant covariance for these findings? And then of course, you've already responded to the second part of that question. So which are the relevant covariance for these findings? Yeah, so in the report, we did find differences in age, obviously, in household income, in education. And we suspect that there are some regional differences as well. So in our analysis, we controlled for age, income, education in province. And again, thanks to Janine, who raised the question related to spirited. And I think that's been addressed. Going down and then of course, Alexander also commented. Thank you, I agree on the importance of breaking the data down based on race and ethnicity. This is something actually from a CLSA perspective we are aware of and hoping to provide researchers with some support in doing that down the road. And then so next we have the question, what is the minority stress model that was mentioned? Can we get an explanation of it? So maybe, I don't know if you can put that slide back up and maybe give a bit more explanation on that. All right, I'm just pulling the slide out if you wanna speak to it, if that's helpful. Sure, so this is some work that's come out of UCLA by Dr. Elan Meyer. So we do these health disparities across the lifespan amongst LGBTQ people, or LGBTQ people rather. And we attribute these disparities to stress experiences associated with their marginalized identity. So things like stigma and discrimination and real or perceived threats that they endure. And when we think about it within the aging context, we can think about the accumulation of all of these negative experiences related to their marginalized identity, which might result in increased vigilance. It could individuals could conceal their identity so hide their LGBTQ identity and maybe even internalize these negative societal perceptions. So this relates to things like coping behaviors, relationships with others, and ultimately has been linked to these increased risk of chronic disease. Hopefully that gives you a bit more context for the minority stress model. The next question is to try to address loneliness, and as specifically as service providers, did the research indicate how best to engage LGBTQ plus population? And if not, perhaps address through the research if you can maybe speak to any best practices or evidence that you're hearing. I think if I'm sort of, I'm also just sort of scrolling through the chat here. I think that this question came from Jane who I think sort of felt that maybe that was answered in the previous response, but asking for more information around the toolkit. So I can indeed put a link into the toolkit, but I'll just say it again, it comes from Employment and Social Development Canada. And the title is social isolation of seniors, a focus on LGBTQ plus seniors in Canada. And again, through there they have within part two, they have a toolkit and examples of inclusive ideas exchange events for LGBTQ plus seniors. Right, and maybe I don't know if one of our team members can find that in the background and potentially post a link to it. And if not, hopefully you've got the information to find it. Okay, so next question. From previous research and perhaps not the CLSA, what are the differences or similarities for either barriers or facilitators to research participation in the older adult LGBTQ plus community? And knowing this, do you have any advice on how researchers can address this and be more inclusive? Aaron, I'll take the first stab at this and then feel free to jump in, is that okay? Yep. So hi, Laura, thanks for your question. So I think that in our work with the sort of the program of Reducted Development Area, we've learned a lot about this and we have been educated a lot by the folks who have participated in our focus groups, for example. And I think we need to think about that social historical contact. So there are many folks in the older population who have been engaged in research throughout their lifetimes and the research has not always done perhaps the most ethical way or with always sort of the best intentions, particularly folks in the LGBTQ plus community. So there's a documentary called Fruit Machine which sort of outlines how historically researchers have not done a very good job working with LGBTQ older adults who are now older and we're asking to participate in research. So I think it's really important that we think about again building credibility and building trusting relationships with communities who we may ask to support our research. So we have found that partnering with community organizations and spending time to build that trust in relationship is really important. And as part of that, ensuring that we are reporting back to the communities that we're partnering with so that they know how we are using their stories and experiences again with our goal of promoting more equitable aging experiences but making sure that we really walk the talk that we are telling them we're going to do. And similar I think to some research philosophies of working with folks who have been marginalized in the past, we've adopted sort of a co-researcher approach so we're trying to sort of embody that nothing about us without us. So particularly for qualitative research where we're asking people to come in and share their stories and aging experiences with us, we are partnering with older adults from LGBTQ plus community who are helping us to design the research and make sure that it is conducted in a way that is inclusive and safe and respectful. And so we're sort of partnering that approach with then the opportunities we have for these large data sets available to us through the CLSA. And just Laura, the name of the documentary is called The Fruit Machine. And again, it is available on TVO. So if you're in Canada, you would have access to watch it on their website at no cost. So if that answers that question. Did Arne want to add to it? That was a great response, Kim. And I'll just add that with respect to the CLSA, some of the fighting against these negative experiences that members of these communities have had with researchers has been, in my case, bringing some of the findings from the CLSA and presenting to local groups who are really excited to hear about the work and also have some really great critiques and commentary about how to do the work going forward. So that's been really, really fun. Thanks for those responses. The next question is actually a question I also had. So thank you, Dean, for articulating it. Is there a breakdown of feelings of isolation and loneliness across the age cohorts? Ageism was more prevalent earlier in the LGBTQ plus community and especially amongst gay men. That's a really good question. And in some ways, it kind of relates to this idea of how do we, ahead of time, decide about how we want to slice and dice the data. It would be great if we had a really large sample of LGBT participants. We only have 1,000 folks, which for some analysis is great. But in terms of looking at cohort differences, we are somewhat limited. So I would suggest that we would have to include both men and women, LGBT participants in that analysis and probably look at some large age cohort groups. But certainly we could do that. We haven't yet done it. And I agree. I suspect that there are likely some cohort differences there. I also just wanted to note that Sarah Yusuf, who works at our Statistical Analysis Center in Montreal, which is part of the CLSA, posted that the follow-up one wave of CLSA data does include a questionnaire on gender identity. The response options do include identification of trans and the possibility of specifying other gender identities in open text. So as we move forward in the CLSA, that was something that was identified. And in the follow-up one data collection and all subsequent, that question is going to be asked. And I believe the toolkit will be shared or at least the information was identified. And so we'll go on to a question from Wook Yang. How did you go about dealing with the huge difference in number of respondents in each group, heterosexual versus sexual minority population during your analyses? Not for a descriptive, but for the regressions, but for regressions, for example. So if you could speak to that. Yeah, that's a great question. And quite honestly, that work was performed two years ago now. So it's not as fresh as it probably should be. I could go back to our paper and get back to you on that one, absolutely. So we'll go to Baram, who asks, has there been any efforts to link the CLSA data for the LGB population with different healthcare registries to better understand their healthcare utilization patterns and or outcome? Maybe I'll let one of the presenters answer that and then I'll give my response on behalf of CLSA. So that's a great question. And I would love to do that. So we have, in our data request, we have requested some of the linked data. We're still getting our first follow-up data screened and cleaned, but that is some of our intention to use some of that linked data. And I'm looking forward to hearing what the CLSA response is about that. Yeah, so just the quick answer is that the CLSA has had a focus on creating linked data for the past, well, several years. It's not an easy process and we've been working with various provincial and national registries to obtain vital status data that we can use to enhance our database. We've linked environmental data into the CLSA, but we're also in the process outside of some small pilot studies where we've been trying to work out the processes, still trying to really link provincial health registries with CLSA data. So it's a work in progress and we do anticipate it's going to happen, but for now linking it with its actions, all that data is not available right now. So that's the kind of short but long answer. So maybe I'll go on to the next question. There's a few more here and we do have about 10 minutes left. So how are the specific histories of those socio-historical issues mentioned incorporated into the research? For example, the specific colonial history of anti-Sodomy laws and their repeal. So I'm happy to take a first answer at this and then of course, Aaron Jumpin. So thank you for that question. We always make an effort to always bring in that social-historical context in any of the work that we're doing. And in particular, we've heard from some of the older adults that we've worked with how important this is because some feel that that sort of social-historical context is getting lost with the younger generations who are sort of their unique history. And so we mentioned and it's up on the slide here that a lot of our work is informed by the minority stress model. We also look to the health equity promotion model that Karen Fredrickson-Goldson who's the leader in this area out of the United States. We've referenced her several times throughout this, has developed this model that embeds both the minority stress model but also a life course approach that in particular looks at those social-historical context. So we particularly in our analyses and discussion and thinking about future work, we always go back to that unique social-historical context. And this is, I think, a place where some of our other research where we are working directly with older adults and hearing their life histories and stories and experiences, we try to bring back their narratives into all of our interpretation of what we're doing to really contextualize it in those individual lived experiences. Which is why it's been nice to have the opportunity to look at the CLSA data and then marry that with some of the qualitative work that we've been doing where folks are talking about how those early experiences continue to shape their aging experiences. I'll just add that it would be great if the CLSA included a measure of historical experiences with discrimination. At this time it doesn't, but perhaps in future ways that could be included. Well, you never know. Thanks for those responses. So we do have a, just wanted to mention, we do have a few more minutes. So if you do have any questions, please feel free to post them and we'll go to as close to one o'clock as possible. But for now we will answer another question by Janika. You mentioned the health disparities, which you're also just talking about. Can you comment on the barriers to accessing healthcare or achieving health equity for this population? Waiting to see who's gonna take that first. Do you want me to go first or do you want to answer? I can go. So I mean, that could be a presentation in and of itself. I think some of the things that we're hearing are around affirming care for LGBTQ older adults. We know that there's a lot of fear and individuals within these communities may not seek out medical treatment for fear of discrimination within the healthcare system. So affirming healthcare, I think, is a major step towards reducing some of these disparities. Kim? Yeah, and I think to the affirming care and then also in particular, I think there's two ways for us to think about this. We need to start now with the current cohort of older adults, but we also need to think about that lifelong approach. And when we use sexual orientation and gender identity as social determinants of health, and if we start thinking about that from the beginning, hopefully it will sort of make some differences in terms of that health equity lens that we'll be putting on every time we're looking at access to services. So there's a lot of work to do with our current cohort of midlife and older adults, but also to think about that lifelong approach. And if we embed more explicitly sexual orientation and gender identity as social determinants, I think that will help us in terms of health equity for future generations as well. Maybe I'll just add that I think part of addressing health equity involves these data collection initiatives, right, and we're just starting to collect data on sexual orientation among older adults. And now with the first follow-up wave of CLSA, now we have gender identity. So I think this is a great start and now it's about sort of addressing some of those differences that we do see. Yeah, just a quick follow-up to that. I'm wondering if, are there other longitudinal studies that you're aware of internationally that have collected this data or I thought you mentioned that this is the first of its kind in Canada, but I'm wondering if there are others internationally that you could have pulled from? Certainly there are a lot of data sets in the United States that do collect these data. And a very large study, and I'll just do a quick shout-out, is to Karen Fredrickson-Goldson, who has done a very large longitudinal study called the Aging with Pride Survey. So that's specific to LGBTQ aging. And she's done a lot of really great work. What's interesting to see from a population health perspective is that what we're seeing in the United States is very similar to what we see in Canada. And I think as Canadians, we tend to think of ourselves as quite distinct from our neighbors to the South. So we still have a lot of work ahead of us. So another question that I think relates to the finding about accessing psychologists. The question is based on the fact that psychologists are frequently consulted. I believe it was specifically amongst gay men, was one of your findings. Should we promote LGBTQ-plus psychology in our training programs? And should we find ways to facilitate access to psychological services? So do you have any comments on that? This question may have just come to me privately. I'm not sure if it's visual to everyone. I mean, I'll just say, and then I'll look for it but I think we should be doing a better job with all of our training programs to be embedding in culturally competent and cultural humility into our training for health and social professionals and psychology, social work, psychiatry, ensuring that we really are sort of training to be able to be inclusive and culturally competent. And I think that piece around access is really important. So I know with our current context in how folks are able to access psychological supports if they are community welling and if it's a psychologist in the community, it's not necessarily covered through their provincial health insurance plan. So I think that is some evidence that perhaps is a nice advocacy tool part of the Canadian Psychological Association has been advocating for a long time that their work should be included within insured health plans. And so again, I think that's another sort of supportive piece of evidence around the success of their work with particularly with gay men and gay older adults but I'll let you chime in. Yeah, I would just add that part of what I said earlier in terms of addressing health equity was to provide affirming care. And what we're seeing is that healthcare providers aren't getting this training within their regular training. And I just want to shout out to Kim who is leading a short partnership development as PI looking at how do we embed issues of LGBTQ aging into curricula within Ontario so that the next generation of professionals is equipped to work with members of these communities, provide affirming care and reduce some of these health inequalities. I'd really like to thank Arne and Kim for a great webinar with lots of information about your new evidence from the CLSA that you've managed to ascertain from the CLSA data. I think definitely it will have definitely going to be useful and will lead to some hopefully some change in the long term, especially as you are able to start complementing it with other qualitative research and again bringing the quantitative and qualitative research together to perhaps even develop some strategies that are informed by this work that would be fantastic. So we really appreciate your participation in this. I'd also just like to, so now I'm just gonna do a few reminders and plugs before people do start to pop off. Just a reminder the survey poll was prompted up on the top of your screen. If you have any questions or comments that we can help with, please also feel free to write us in the chat box and we can help at that point too. The next CLSA data access request for any researchers that are interested in pursuing your own research related to this topic or other topics is February 12th. You can visit the CLSA website under data access to review the available data as well as further information and details about the application process. And remember CLSA promotes the webinar series using the hashtag CLSA webinar and we invite you to follow us on Twitter at CLSA underscore ELCV. The next webinar will be focused on mobility and fall risk assessment. That will be on November 28th and then the final webinar of 2019 will be, will include a focus on stroke and osteoarthritis. And that'll be on December 16th. The final thing I just want to mention before we sign off is that graduate students and postdoctoral fellows with an interest in longitudinal studies on aging are encouraged to save the date for what's called SPA 2020. This innovative five day training program will take place next June at Hawkely Valley Resort in southwestern Ontario. More details will be available in January 2020 when the program launches on CIHR's research net. So this will be required an application for graduate students and postdoctoral fellows but it will be proved to be a very exciting and thoughtful learning event. I think that's it. So please go to CLSA website to register for our future webinar series and join us for these webinars. And thank you again to our presenters as well as all of you for joining us today.