Noelle Marie Javier, MD, left, with Roy Noy, MD, during Dr. Noy’s four-month observership at Mount Sinai to learn more about LGBTQI+ medicine and geriatrics.
The field of LGBTQ+ medicine has slowly been developing over the past decade, but a crucial intersection with a subspecialty has often been overlooked—geriatric medicine.
Throughout history, LGBTQI+ medicine has been underdeveloped and under-prioritized for several reasons, among them being that few people were historically willing to disclose and seek care as LGBTQI+ individuals, and that many members in the community lost their lives to the HIV/AIDS epidemic during the 1980s.
“There have been gaps in training at medical schools, residency, and fellowship training programs from the past until now,” says Noelle Marie Javier, MD, Associate Professor of Geriatrics and Palliative Medicine, and Medical Education, at the Icahn School of Medicine at Mount Sinai.
Across the majority of MD programs throughout the country, the average time devoted to training in LGBTQI+ medicine is about five hours in total across the four-year program, as cited in a 2011 JAMA paper. “That’s simply not enough,” says Dr. Javier.
These days, with increasing acceptance and awareness of diverse sexual orientations and gender identities in society, and modern advances in medicine, LGBTQI+ people are growing older and living longer—some with unique health concerns and disparities. These could include how older adults living with HIV are aging, or long-term effects of having received marginalized care or faced barriers to care. “Now, more than ever, we need to be prepared as physicians and allied health professionals to take care of them in a way that’s culturally humble, sensitive, and responsive,” Dr. Javier says.
The Brookdale Department of Geriatrics and Palliative Medicine at Mount Sinai is committed to providing inclusive and affirming care for older LGBTQI+ adults, which includes training and education for staff, students and trainees. Inspired by this work, the leadership at the Tel Aviv Sourasky Medical Center (Ichilov) reached out to the Mount Sinai LGBTQ+ Medicine Fellowship program to arrange a pilot program where a resident in geriatrics could gain knowledge and training through an observership for the care for older LGBTQI+ adults. During the fall of 2023, Roy Noy, MD, chief geriatrics resident at Ichilov, collaborated with Dr. Javier in expanding his geriatrics skills and developing a curriculum that he could use to train staff back in Tel Aviv.
Read more about Dr. Noy’s observership at Mount Sinai and the importance of focusing on geriatric LGBTQI+ medicine.
Dr. Noy is helping the Tel Aviv Sourasky Medical Center (Ichilov) set up an LGBTQI+ clinic for older adults. He spent four months at Mount Sinai observing various models of care in geriatrics and LGBTQI+ medicine.
How did this program come about?
Dr. Noy: We are trying to establish an LGBTQI+ service for older adults in our hospital at Tel Aviv. The head of the program, Roy Zucker, MD, was the inaugural fellow at the Mount Sinai LGBTQ+ Medicine Fellowship. He came up with the idea of trying to establish an observership for me to learn more from Mount Sinai about what is needed to start such a specialized service.
Dr. Javier: I was invited to be a plenary speaker at GLMA: Health Professionals Advancing LGBTQI+ Equality last year when Dr. Zucker and I first got acquainted. He wanted to set up a collaboration for one of his residents in the hopes of expanding his medical knowledge and clinical skills to take care of older LGBTQI+ adults.
What went into this observership?
Dr. Noy: The program had several parts to it.
- On the broader geriatrics side, I did a lot of observing with different doctors and other team members working in the Brookdale Department Geriatrics and Palliative Medicine, and I joined them on their daily rounds. I also got to join the departmental educational programs.
- For the LGBTQI+ medicine side, I observed Antonio Urbina, MD, Medical Director of Mount Sinai’s Institute for Advanced Medicine, in the HIV clinic. I got to train in Mount Sinai’s Center for Transgender Medicine and Surgery with Joshua Safer, MD, who is Executive Director of the Center. And I also got to shadow Angela Condo, MD, Assistant Professor of Geriatrics and Palliative Medicine, in the geriatrics clinic for people living with HIV.
- In addition, I was connected with people and organizations who play an important role in LGBTQI+ health, such as SAGE, an advocacy and services group for LGBTQI+ elders, and MJHS Hospice and Palliative Care.
- On the training side, I was connected to Mount Sinai’s Office for Diversity and Inclusion, to see what they are doing for new and current employees, how they are implenting sexual orientation and gender identity data gathering, and how the Health System connects with the LGBTQI+ community.
- There was also an academic side where I got to work with Dr. Javier on writing a chapter focused on affirming care, and we have an ongoing project concerning educational training programs.
Dr. Javier: The idea was to expose Dr. Noy to different models of care within the geriatric and palliative medicine landscapes—not just inpatient geriatrics and palliative care, but also neurology and memory care, outpatient clinics, urgent care, and chronic illnesses. By the time we were done with the observership, we had developed several deliverables, including submitting a chapter titled “Affirming Care for LGBTQ+ Patients” to Clinics in Geriatric Medicine that is currently in process for publication, and a scoping review research project titled “A Scoping Review Protocol of Educational Training Programs in Medical and Health-Related Professions Caring for Older LGBTQI+ Adults, November 2023 to Present.”
What were your takeaways?
Dr. Noy: Now that we’re starting our own LGBTQI+ older-adults service here in Tel Aviv, having been at Mount Sinai has helped us figure out what we need to focus on, as well as what are topics unique to us.
One big thing I learned is about communication in the way we address the community. It is important for everyone in the medical field, but it’s especially important in geriatrics because we do need to see the full picture of the person sitting in front of us and understand where they’re coming from. That involves knowing what are things that had been problematic, the history of what had been in the way of them getting treatment, and you can’t do that without good communication.
I also learned that connection with the community is important if we are going to be successful. The way community organizations work with health care in New York, I want us to be able to work as closely knit with them like that too.
Dr. Javier: I like mentoring people who want to be trained in LGBTQI+ medicine and health care. But just as I had helped Dr. Noy with his training, he had helped me too. Prior to this observership, I had several ideas in mind about developing a curriculum, but when Dr. Noy arrived and we started talking about what the program should look like, it helped to create more concrete ideas. I learned a lot from him in terms of what the community is like in Israel and what health services are available to them.
The amazing thing that came from this was: I want this same enriching experience for my fellows here in the department. We have 30-plus fellows in the department and are the largest ACGME-accredited fellowship program in geriatrics and palliative medicine in the country, but creating a LGBTQI+-focused curriculum had been on the back burner for quite some time. There is no formalized curriculum as of yet. This observership catalyzed the need to start working on this curriculum and make it a priority. In some serendipitous way, I got the outcome—a formalized program—before I got the template, and now I’m tracing our steps back of what we did and achieved in this pilot trial.
Why is it important that we focus on training physicians to care for LGBTQI+ older adults now?
Dr. Noy: Similar to the United States, in Israel, older LGBTQ+ people were less likely to identify as such than younger people. And we know that the LGBTQ+ population tend to face more barriers to accessing health care than the general population—this could include avoiding seeking treatment because of previous bad experiences, or even just from stigma.
As they age, the problems could accumulate, and they might end up needing more comprehensive treatment, when they could have preventive treatments earlier. There are general things like cancer, hypertension, or diabetes surveillance that could be done earlier, but there are also conditions more likely within the LGBTQI+ community, such as depression and mental health, that could get ignored.
Then there’s the fact that thanks to advances in medicine, we now have people with HIV living to old ages—even into their 80s and beyond. There’s still so much we don’t know about how they age, such as cognitive decline, frailty, effects of polypharmacy, and more. It’s not just about managing their medication, but also understanding their wellness as a whole. It’s important that we start integrating that training from medical school onwards. And also that we work with the community to show that we do exist—we’re here for everyone in the community.
Dr. Javier: When I was training as a fellow, I was not trained in LGBTQI+ medicine. Even today, that’s still not the case in many institutions. We need to change that and fast. The fellows in my department are knowledgeable enough to be able to take care of the needs of patients and be culturally responsive, but competencies around optimal LGBTQI+ medical care is not a requirement for them to graduate. The integration of LGBTQI+ care should be reflexive in geriatrics and palliative care curriculums across the country.
There continues to be a lot of disparities and inequities in care, especially for older LGBTQI+ adults and people of color. According to the 2015 U.S. Transgender Survey, 40 percent of respondents have attempted suicide in their lifetime. There are many other unique health concerns in the community, and if you did not ask about the sexual orientation and gender identity of a person, you can miss out on the big picture of why they’re seeking care in the first place while being clouded by our own biases and prejudices in helping them.
Read more about how Mount Sinai is empowering health care for LGBTQI+ communities