Aging with Pride: A Longitudinal Investigation of Multidimensional Quality of Life Among Sexual and Gender Diverse Midlife and Older Adults

Background and Purpose: Sexually and gender diverse (SGD) midlife and older adults have aged within contexts of structural stigma, discrimination, and violence. Evidence on quality of life (QOL) in SGD populations is largely cross-sectional and often focuses on single outcomes. Guided by the Health Equity Promotion Model and using longitudinal data, we investigated linear changes in physical, psychological, social, and environmental QOL and identified modifiable factors associated with QOL, including gender-related heterogeneity.

Methods: Data were from five biennial waves (2014–2022) of Aging with Pride: National Health, Aging, and Sexuality/Gender Study, a national cohort of SGD adults aged 50+. QOL was measured with the WHOQOL-BREF (0–100) across four domains. Mixed-effects models with random slopes for time estimated linear change and tested predictors spanning socioeconomic position and other background factors, bias experiences (lifetime discrimination/violence, day-to-day discrimination, microaggressions), identity processes (affirmation, stigma, explicit outness), social resources (participation, network size, LGBTQ+ community engagement), behavioral risks (sleep problems, insufficient food intake, physical inactivity, suicidal ideation), and healthcare access. Interaction models tested differences in those associations by gender.

Results: All four QOL domains declined linearly from 2014 to 2022. The rate of decline in physical and environmental QOL was more pronounced among older participants. Socioeconomic disadvantage (lower income and education) was consistently associated with lower QOL across domains. Discrimination-related stressors showed the most persistent associations with non-physical domains: day-to-day discrimination remained associated with lower psychological QOL; lifetime and day-to-day discrimination remained associated with lower social QOL; and lifetime discrimination, lifetime violence, and day-to-day discrimination remained associated with lower environmental QOL in fully adjusted models. Health-promoting factors, including social participation, larger networks, LGBTQ+ community engagement, identity affirmation, and better healthcare access, were positively associated with psychological and social QOL; social participation, network size, identity affirmation, and healthcare access were also positively associated with environmental QOL. Restless sleep, insufficient food intake, physical inactivity, and suicidal ideation were associated with lower QOL. Interactions indicated distinct vulnerabilities: lifetime violence was linked to poorer psychological and environmental QOL among men but not women, and network size benefited environmental QOL only among men. Among transgender and gender diverse adults, day-to-day discrimination was associated with lower physical QOL, identity stigma with lower psychological QOL, and explicit outness with lower environmental QOL.

Conclusions and Implications: Multidimensional QOL among SGD midlife and older adults declined from 2014 to 2022. Findings identify modifiable targets: affirming and accessible healthcare; strengthening identity affirmation, social participation, and community engagement; addressing sleep and food insecurity and improving healthcare access; and reducing discrimination and violence. These results underscore the critical need to tailor policies and interventions by gender and gender identity to support equitable, healthy aging across diverse SGD populations.