Challenges and Opportunities for Equitable Aging for LGBTQ+ Older Adults in Rural Communities: A Community-Engaged Focus Group Study

Abstract

Research on LGBTQ+ rural aging is sparse—thus limiting understanding on how best to support this population. Building on equitable aging theory, this community-engaged qualitative study incorporated data from 4 focus groups with 31 LGBTQ+ older adults in rural communities in California to examine challenges, thriving and surviving strategies, and recommendations for policy and practice. Data analysis identified six interrelated domains reflecting challenges and strengths regarding health, housing, technology, transportation, caregiving, and community for LGBTQ+ older adults in rural communities. We identified three themes to illustrate how these domains intersected across levels (micro, mezzo, macro) to explain equitable aging for LGBTQ+ older adults in rural communities: fractured culturally responsive health care and family fortifications, social connections and space, and affordable and accessible housing. Findings around health, housing, technology, transportation, caregiving, and community were interwoven throughout these themes and provide a blueprint for policymakers and practitioners to better support this population.

Introduction

Lesbian, gay, bisexual, transgender, and queer (LGBTQ+) older adults in rural communities represent an understudied population that remains mostly invisible in gerontological research. This invisibility reflects a microcosm of larger disparities that LGBTQ+ older adults experience (e.g., Rowan et al., 2022; Telazzi & Colombo, 2024). Understanding intersections of rurality and LGBTQ+ aging could help identify and implement multilevel solutions for culturally responsive services, programs, and support, particularly in rural areas where resources may be limited (Barringer & Savage, 2023; Easpaig et al., 2022). Emerging literature on equitable aging provides a helpful framework for examining LGBTQ+ aging in rural communities. This community-engaged study reports findings from 4 focus groups with 31 LGBTQ+ older adults in rural communities about how challenges and strengths they experience shape opportunities for equitable aging. Study findings provide guidance for practitioners and policymakers on ways to further support this population across the life course.

This article begins with an overview of LGBTQ+ aging before describing LGBTQ+ rural aging. It then introduces equitable aging to theoretically ground and explain the findings, which builds on ecological frameworks and centers power across multiple levels (micro, mezzo, macro). Findings are organized around three themes that cut across six domains (health, housing, technology, transportation, caregiving, and community) and levels to explain challenges and opportunities for equitable aging for LGBTQ+ older adults in rural communities.

Literature Review

LGBTQ+ Aging

A growing literature has emerged around LGBTQ+ aging. Studies have found that LGBTQ+ older adults experience more health disparities compared to cisgender (non-transgender) and heterosexual older adults (Rowan et al., 2022; Telazzi & Colombo, 2024). Some LGBTQ+ older adults may experience greater disparities, barriers, and stigma, including people living with HIV (Marshall & Cahill, 2022), older immigrants and racial minorities (Chen et al., 2022), and transgender older adults (Fabbre & Gaveras, 2020; Pharr, 2021) that may be related to inequities in macro-level systems, institutions, and structures (Lampe et al., 2023; Srithumsuk et al., 2024), policies (Nelson et al., 2023; Perone, 2020), financial barriers or access to income (Bouton et al., 2023; Czaja et al., 2015), social networks (Erosheva et al., 2015), and internalized stigma (Hoy-Ellis et al., 2017). LGBTQ+ older adults also report strengths that can help buffer some of these challenges. LGBTQ+ older adults have a long history of resistance (Li et al., 2023; Perone, 2024), resilience (Fredriksen-Goldsen et al., 2024; Perone, Glover Reed, & Gant, 2025) and strong social networks and community supports (Perone, Zhou, Reed, et al., 2025; Toze et al., 2023), including across age cohorts and historical generations (Perone, Toman, et al., 2025).

LGBTQ+ Rural Aging and Social Networks

Less research has examined experiences, needs, and supports among LGBTQ+ older adults in rural communities. More research is needed, particularly since emerging research has identified findings that suggest that unique and targeted approaches are needed for this population (e.g., Guest et al., 2023; McKay et al., 2024). While scholarship on LGBTQ+ older adults in rural communities is small, much of it focuses on social networks (e.g., Dakin et al., 2020; Guest et al., 2023; McKay et al., 2024) and has pointed to mixed outcomes. While broader research on rural aging emphasizes the importance of family for social connection (Hussain et al., 2023), LGBTQ+ older adults in rural communities may rely on other sources, including families of choice. For example, a national longitudinal survey of 1,256 LGBTQ+ adults aged 50-76 found that those in rural communities had less support for their LGBTQ+ identity from family members and friends than those from urban communities (McKay et al., 2024). Social networks of rural LGBTQ+ older adults included fewer LGBTQ+ people (McKay et al., 2024). A study of LGBTQ+ older adults in rural Kentucky, West Virginia, and Tennessee found that social networks were based on availability (versus homogeneity) (Guest et al., 2023) and suggests that rural LGBTQ+ networks may be less homogenous than non-rural LGBTQ+ networks or rural networks for cisgender and heterosexual older adults. In this study, the needs for aging supports surpassed the needs for LGBTQ+ community, in many instances, and participants often developed support networks that required them to conceal their sexual identity (Guest et al., 2023). Other literature has underscored the importance of urban-based resources and networks for supporting LGBTQ+ older adults in rural communities (e.g., Butler, 2017) that could be helpful (as possibly the only resources for some) yet not narrowly tailored to meet specific needs of those in rural communities. Relying on urban resources or having to conceal one’s identity pose challenges for LGBTQ+ rural aging.

In contrast, another study of 11 LGBTQ+ older adults in Southern Appalachia found that many (not all) had rich informal social support networks that helped mitigate experiences of homophobia and transphobia (Dakin et al., 2020). That same study of LGBTQ+ older adults in southern Appalachia also found that religion and spirituality evoked negative past experiences of pain and harm while also providing current sources of strength, meaning, and support for some (Dakin et al., 2022). Religion is an important facilitator for social connections among older adults, generally (Hussain et al., 2023), but as noted above can create mixed outcomes for LGBTQ+ older adults. It is possible that LGBTQ+ older adults in rural communities may experience both social disconnection from diverse sources that make some feel compelled to hide their sexual or gender identity for safety reasons, while also experiencing rich support networks in other contexts, but more research is needed.

LGBTQ+ Rural Aging and Services and Programs

Research on LGBTQ+ older adults in rural communities has also found challenges in accessing formal services (Williams et al., 2022), including healthcare (Rosenkrantz et al., 2017) and that they are nearly twice as likely to report that they cannot find an LGBTQ+ affirming health care provider and have emphasized the importance of LGBTQ+ affirming care (McKay et al., 2024). In a qualitative study of 20 LGB older adults, participants also described transportation difficulties, lack of care choices, affordability of care, and lack of connection and belonging that presents barriers to aging-in-place (King & Dabelko-Schoeny, 2009). Community programs centered around LGBTQ+ identities in rural communities have also provided important sources of support, including a doula program to provide social support for LGBTQ+ older adults with serious illness in rural Massachusetts (LeBlanc et al., 2025). This small but provocative literature on LGBTQ+ rural aging suggests mixed outcomes about challenges, supports, and possible interventions that merit further research. It also underscores, however, that LGBTQ+ older adults in rural communities remain invisible in many ways, in part because their numbers are often small and hard to sample, but also because of the complexities of challenges and supports that exist at multiple levels for this population. We next turn to the concept of equitable aging to help untangle these complexities.

Equitable Aging

The experiences of LGBTQ+ aging align well with emerging theoretical and conceptual frameworks on equitable aging, which build on an established body of literature on ecological frameworks (e.g., Gendron et al., 2024) and healthy aging and ageing well (e.g., Waddell et al., 2025). Healthy aging emphasizes older adults’ healthy lifestyles and the importance of maintaining physical health and functionality while aging (Michel & Sadana, 2017; Zamudio-Rodríguez et al., 2021). Its novelty was its departure from a pure medical model, which had previously dominated research on aging. Scholarship on healthy aging grew in the 1990s after the World Health Organization presented healthy aging as a concept for building policy that addresses inequities in aging and treats aging not as a disease but instead promotes positive health (Hermanova, 1995; WHO, 1990). While most scholarship on healthy aging foregrounds a strengths-based approach for positive health, healthy aging also implicitly incorporates the need for research on how inequities shape (or pose barriers to) positive health across the life course (e.g., Bethune, 2025). Equitable aging, thus, builds on these foundations of healthy aging while foregrounding the need to examine equity to better reach the goal of healthy aging.

Equity comprises varying definitions, depending on one’s disciplinary orientation, cultural perspective, and context. In law, equity generally refers to fairness, usually under a set of agreed-upon principles or rules that aim to promote fairness when following the law would produce an unjust result (Blackhawk, 2020; Nadler, 2021). In education, equity generally invokes questions about social justice that examine how to provide every student opportunities to reach their full potential (Appels et al., 2023). Health equity tends to emphasize fair and just opportunities for everyone to achieve positive health (Braveman et al., 2018). Research on aging often examines how interactions, processes, systems, and structures shape one’s experiences throughout the life course. Like other disciplines, equitable aging also involves concepts of fairness and justice (Perone, Urrutia-Pujana, et al., 2025). While these concepts are still somewhat elusive and dependent on how one defines “fair” and “just,” existing research on aging suggests that they matter in interactions, processes, systems, and structures across the life course–especially for people to maintain positive health throughout their life. Building on ecological frameworks, a new conceptual framework on equitable aging in health situates aging within broader social and political contexts across multiple levels (micro, mezzo, macro) that underscore the importance of locating an individual within interactions among other individuals (micro), organizations and agencies (mezzo), and larger institutions of power (macro) (Perone, Urrutia-Pujana, et al., 2025). Scholars have used this framework to examine how intersecting systems and levels shape health-related supports for transgender older adults (Perone, Zhou, Coldon, et al., 2025). Equitable aging, thus, underscores from a multilevel lens the importance of fair and just opportunities for people to age across the life course. Fairness and justice are not monolithic concepts, however, and a subsequent article from this project is examining how LGBTQ+ older adults, including those in rural communities, conceptualize fairness and justice. This article is narrowly focused on the experiences of LGBTQ+ older adults in rural communities and asks the following research questions, which were collaboratively identified with community partners through this community-engaged research design:

(1) How do challenges experienced by LGBTQ+ older adults in rural communities shape opportunities for equitable aging?

(2) How do strengths experienced by LGBTQ+ older adults in rural communities shape opportunities for equitable aging?

Methods

Research Design

This qualitative study of LGBTQ+ older adults in rural communities employs a community-engaged focus group design guided by collaboration with five community partners in rural California. Data includes four focus groups and 31 LGBTQ+ older adults that examines challenges, strengths, and solutions regarding rural LGBTQ+ aging. Of the 31 participants, 25 participants identified solely as white, 3 participants identified as multiracial/biracial, including Native American, Hispanic, and/or Asian, 2 participants identified as Black, and 1 participant identified as Hispanic. Participants predominantly identified as “woman” with 4 participants identifying as “man” and 4 participants identifying as genderqueer, non-binary, and/or transgender. Participants’ age ranged from 45 to 85. Nearly two-thirds of the participants (n = 20) had household incomes under $50,000. See Table 1 for more demographic information of the participants.

Table 1.

Participant Sample Description (n = 31)

Pseudonym	Age	Race	Gender	Sexual orientation	Household income
Miss sunshine	69	White	Woman	Lesbian	$70,001–$80,000
Lois lane	75	White	Woman	Lesbian	$70,001–$80,000
Ann	74	White	Woman	Lesbian	$30,001–$40,000
Helen	73	White	Woman	Bisexual, lesbian	$110,001–$120,000
Louise	73	White	Woman	Pansexual	$20,001–30,000
Marie	80	White	Cisgender woman	Lesbian	$20,001–$30,000
Ellie	72	White	Woman	Lesbian, queer, same-gender loving	$10,001–$20,000
Carolyn	77	White	Cisgender woman, genderqueer, woman	Lesbian, queer, same-gender loving	$50,001–$60,000
Pinck	76	White	Woman	Gay, lesbian, queer, same-gender loving, two-spirit	$50,001–$60,000
Peachy	75	White	Cisgender woman	Lesbian	$70,001–$80,000
Halley	64	Asian, white	Cisgender woman	Pansexual	$20,001–$30,000
Sophia	64	White	Non-binary, transgender woman	Pansexual	$120,001–$130,000
Lola	63	White	Woman	Lesbian, queer	$50,001–$60,000
Bea	79	White	Man	Gay, queer	$20,001–$30,000
Raven	54	White	Non-binary	Lesbian	$20,001–$30,000
Ruthie	76	White	Woman	Lesbian	$70,001–$80,000
Wolfer	52	White	Transgender man	Pansexual, queer	$80,001–$90,000
Patty	77	White	Woman	Bisexual	$70,001–$80,000
Candy	45	White	Woman	Bisexual	$20,001–$30,000
Kilo	58	Hispanic	Woman	Lesbian	$10,001–$20,000
Oreo	60.5	Native American, white	Woman	None	$1–$10,000
Jackie	61	Native American, Hispanic, white	Woman	Lesbian	$0
Charlie	71	White	Man	Bisexual	$20,001–$30,000
Charlotte	69	White	Woman	Lesbian, same-gender loving	$30,001–$40,000
Toby	68	White	Woman	Gay, lesbian, same-gender loving	$20,001–$30,000
Jeff	77	White	Man	Gay	$1–$10,000
Hera	76	White	Woman	Lesbian, same-gender loving	$10,001–$20,000
Buck	85	White	Woman	Gay	$20,001–$30,000
Nate	67	White	Man	Gay, same-gender loving	$30,001–$40,000
Little bit	65	Black	Woman	Lesbian	$1–$10,000
JJ	69	Black	Woman	Lesbian	$40,001–$50,000

This subproject on rural LGBTQ+ aging was conducted within a larger qualitative study of LGBTQ+ aging with 23 focus groups of LGBTQ+ older adults in California (n = 208) in collaboration with 18 community organizations across the state. Community partners collaborated on research design, protocol refinement, recruitment, data collection, and dissemination. Participants also completed a demographic survey. Focus groups are particularly beneficial for exploring complex phenomena and needs among underrepresented communities (Perone, Toman, et al., 2025; Redden et al., 2021) and when participants have something in common and share a stake in the issue being discussed (Barbour & Morgan, 2017). Focus groups allow participants to bounce off ideas, diversify opinions, and flesh out issues more comprehensively (Prasad et al., 2022). This study was approved by the University of California, Berkeley Institutional Review Board.

Sampling Strategy

We applied a purposive sampling strategy and collaborated with community partners in recruiting participants in rural communities. Community partners’ involvement brought insight, experience, and knowledge of local rural communities and trust with LGBTQ+ older adults, which can strengthen research rigor with underrepresented communities whose voices are often excluded (e.g., Abreu et al., 2022; Hwahng et al., 2021; McKay et al., 2024; Pipkin & Clarke, 2024). Community partners received $1,250 for recruitment, meals, space, and other related expenses. From the larger project with 18 community partners, we identified 5 community partners in rural communities who helped us conduct purposive sampling to conduct 4 focus groups.

Focus group participants were eligible if they (1) were over 50 years old, (2) lived in California, and (3) identified as LGBTQ+. During the study and in consultation with community partners, we subsequently lowered the age of eligibility to 45, particularly given the realities of how discrimination and trauma can create inequities in aging and accelerate aging for minoritized communities (e.g., Pereira & Banerjee, 2021; Perone, Zhou, Coldon, et al., 2025; Valencia et al., 2023). Community partners recruited participants by posting information on social media, sharing information during their community activities and regular meetings, and through word of mouth. Individuals expressed interest in participating either by contacting a community partner or by emailing the research team using the contact information on the recruitment flyer. Eligible participants were then contacted by either the community partner or the research team to coordinate and schedule the focus groups.

Data Collection

Focus groups were conducted between July and October 2024 from seven rural counties and regional areas in California. In consultation with community partners, we decided to host two focus groups virtually (n = 13) on a secure Zoom platform and two in-person (n = 16). The virtual focus groups consisted of one focus group of 4 and another focus group of 9 participants. The in-person focus groups consisted of one focus group of 9 and another focus group of 7 participants. Community partners hosted and provided space for in-person groups. Virtual focus groups expanded access to participants with mobility issues and who lived far from the community partner’s physical spaces. Community partners also provided feedback about data collection to help reach saturation and conduct validation checks.

To ensure that participants from rural areas were fully included, we cross-checked participant demographic data. We used the 2020 Rural-Urban Commuting Area (RUCA) classification (Economic Research Service, 2025) and included codes 4–10 as rural areas to screen participants. RUCA codes were created by academic and government researchers to address limitations associated with county-based classifications, in which counties are too large to accurately identify rural and urban boundaries (Economic Research Service, 2025). RUCA Codes use census tracts to capture smaller geographic areas (Hankes et al., 2025). We also cross-referenced these codes with our community partners to ensure alignment with a “rural” designation. Two additional participants (one from an in-person group and one from an online group) were originally recruited through focus groups held with other community partners not specifically based in rural areas but who reported living in ZIP codes classified as rural according to the RUCA codes, thus bringing our total sample size to 31. We were able to incorporate their data because participants identified their pseudonym before talking in each focus group, and they used their pseudonyms to complete the demographic surveys.

For all focus groups, two trained facilitators led the session. Each began by reviewing the consent form. Participants then completed a brief demographic survey. After discussing focus group norms, the main discussion began, guided by the focus group protocol. Topics included challenges in general life, health, caregiving, social services, and housing, as well as the strengths and solutions to address these challenges. All participants selected the same pseudonym for the focus group discussions and their demographic survey. Focus groups lasted 90 to 120 minutes. Sessions were audio-recorded using digital recorders for in-person groups or Zoom’s recording function for online groups and subsequently transcribed by a professional transcriptionist outside the research team.

Data Analysis

The data analysis was conducted with Dedoose (2023) using a hybrid approach to coding that initially incorporated content analysis (Perone, 2023) driven by community-derived codes before organizing data around themes using thematic analysis (Braun & Clarke, 2022, 2023). We first applied an iterative coding approach through directed content analysis, based on the study’s research questions, the literature review, and a community-engaged focus on understanding LGBTQ+ older adults’ experiences (Ge et al., 2022; Shieu et al., 2023; Staniland et al., 2023). As a community-engaged project, an initial codebook was developed that followed categories identified by community partners (e.g., health, housing, social services, caregiving) that also included categories foregrounded in the literature (e.g., social isolation, connections) (Perone, Zhou, Coldon, et al., 2025). Guided by this approach, the first author created a codebook with main codes for the main topics of caregiving, health, housing, safety, etc., and subcodes under each category related to challenges, solutions, strengths, and suggestions. The co-authors then worked together on five randomly selected transcripts from the larger project to test the codebook through line-by-line coding. Additional codes were added, and the original codebook was revised as the analysis progressed (Ge et al., 2022). We subsequently employed a more inductive approach to identify emergent themes from this data. We developed research memos throughout the data collection and analysis process.

A team model for qualitative research, including multiple coders, can enhance rigor by incorporating and carefully considering diverse positionalities and reflexivity through the research process (Saunders et al., 2023). Throughout the analysis process, the three authors worked collectively as a team, reading transcripts, writing memos, and holding regular discussions to reflect on personal backgrounds and positionalities. Memos and team meetings were also used to discuss divergent codes and reach consensus. Rigor, including interrater reliability, was enhanced by following analysis protocols step by step, including (a) using qualitative data analysis training references and explanations of each code to guide coding and ensure shared understanding of the codebook (Giesen & Roeser, 2020); (b) conducting code comparisons after independently coding transcripts and resolving conflicts through team discussions (Terrizzi et al., 2023); (c) reflecting on data and connecting concepts with transcripts (Terrizzi et al., 2023); and (d) considering different positionalities when applying knowledge and experience (Saunders et al., 2023).

Findings

To answer our research questions, we identified interrelated challenges and strengths in six domains (health, housing, technology, transportation, caregiving, and community) for LGBTQ+ older adults in rural communities across three themes: fractured culturally responsive health care and family fortifications, social connections and space, and affordable and accessible housing. These themes help explain how challenges and strengths across these six domains shape opportunities for equitable aging for LGBTQ+ older adults in rural communities. Findings around health, housing, technology, transportation, caregiving, and community were interwoven throughout these themes and provide guidance for policymakers and practitioners to better support this population. They also underscore how challenges and opportunities across these domains are intertwined across levels and systems (micro, mezzo, macro), thus requiring multilevel solutions.

Theme 1: Fractured Culturally Responsive Health Care and Family Fortifications

LGBTQ+ older adults in rural communities reported several challenges and community strengths in accessing culturally responsive health care and the centrality of families of choice. These challenges underscored how fractured (and often inaccessible) services (often stemming from disparate policies at the macro level) left many without adequate care, but also how families of choice (at the micro and mezzo levels) leveraged community support to address some of these challenges to fortify health among LGBTQ+ rural communities. Several participants expressed gratitude for being able to access some culturally responsive services while also noting their limitations. For example, Sophia, a 64-year-old transgender woman, noted that her status as a veteran afforded her access to gender-affirming care–but only for certain services and through telehealth.

I’ve been really fortunate because I’m a veteran…. Our clinic here doesn’t provide gender-affirming care; I have to go through San Francisco VA, but it’s through telehealth…The only thing they provide is hormone replacement therapy, that’s really awesome, but anything else, that’s it.

For others, accessing any care proved challenging. For example, Candy noted that “there’s absolutely no type of mental health care.” Several participants discussed challenges in accessing good (or any) dental care. Sophia reported that “we don’t have enough dentists here. I’m having trouble getting a dentist and I have insurance.” Raven added:

I have a lot of dental stuff, and as I get older that is a worry. I’ve been to a couple dentists … but there’s this place called the [Center]. It’s where people go as a last resort or if you don’t have somebody. I’ve been to the dentist in town, but they did a really terrible job.

Accessing care is compounded by the sparsity of services in rural communities and challenges related to transportation, as explained by Ruthie below:

I don’t live in any of those bigger population areas, so accessing caregiving, social services—it’s over an hour drive for me to get anywhere, and if I don’t happen to be able to drive on the particular day when I might have an appointment, then it doesn’t happen.

Jackie reported that “to get out of town, you have to leave on Thursdays 8:30 in the morning, and you come back at 5:30 in the afternoon. If you miss that bus, you don’t make it back.” She added that the bus only comes out once a week and that “Uber won’t even come out here.” Rurality and transportation challenges also precluded some from accessing in-home care services. For example, Candy stated that “they have nobody that wants to come out and do [in-home care]…because of gas and the time it takes to drive out here.”

Accessible and inclusive care included not only gender-affirming care that could be accessed in participants’ geographic location, but also services that were culturally responsive to aging adults, as noted by Lola: “Every time I go in, ‘well, you know at your age-’ I’m so tired of hearing that. I am young, I am healthy.” Carolyn shared similar concerns about how healthcare providers were becoming more dismissive of her friends and her as they aged:

I got very concerned when my friends were getting into their later 80s, and even into their 90s. I’ve had a doctor now for about 15 years maybe. I feel like she doesn’t listen to me like she used to. I feel like things that I say are being discounted…. It’s almost like we’re children again.

Charlie emphasized how he struggles more with culturally responsive care for older adults than being LGBTQ+:

The age thing. Not so much the LGBT stuff. But the age thing comes in when I went to my doctor because I’d had some misses in memory things. Basically, I was told, ‘Oh, you’re just old, and it’s over, and it’s going to get worse.’ Almost exactly those words….Then, I decided that I’m not going to buy that and I went and had a psychiatrist do a whole set of tests, and basically, it was very clear that my ADHD, that was the biggest issue, and that I did well on the [memory] tests. I had a workable brain going.

Wolfer added that disability further complicates accessing good health care.

I am 52 years old, I am a disabled veteran, I have a brain injury, I have physical issues, I have all of this, I have medical issues that I can’t necessarily access up here.

Services tied to chronological age (and technology) continue to be a problem, too, as noted by Lola:

My internet is spotty. Sometimes it works, sometimes it doesn’t. Sometimes my phone works, sometimes it doesn’t. I live in the country, but I’m only seriously five miles from town. Internet is a problem for sure. Then when I was trying to retire, I’m 63, obviously, you can’t get on Medicare until 65. I went to [Organization], and they would not help me until I was eligible at 64 and a half to apply for Medi-Cal.

One participant, Hera, described how health-related services also include considerations for death and responsive services for disposing of one’s body after death. She noted that in her community, “they don’t pick up bodies. We have anybody passed away here, we have been told to take care of it ourselves. That’s the problem with that. I got told that three times.” Others in the focus group added that they visit each other in person to avoid what Carrie described as “bodies blowing up inside the housing.” Jeff shared that “I have a friend that I’ve been calling every night before nine o’clock for 10 years now. A gay friend….and we just check in, be sure we’re still alive. We’re both on our own, and it’s every night for 10 years. It’s really meant something to both of us.”

Several participants described the importance of visibility as a strategy for individual and more macro-level change. For example, Ruthie said the following:

I think one of my big strengths is that I’m willing to talk about anything. Somebody wants to ask me who I am, what I do, how I identify, what medical problems I have, how old I am, and I’ll put it out there. I don’t feel we’re serving anyone by hiding who we are. I try to live that way.

Sophia added that she “has a story to tell” and that she “know[s] that it has the potential to change lives.”

Theme 2: Social Connections and Space

Participants identified challenges and strengths for LGBTQ+ aging in rural communities that foregrounded the importance of social connections (and isolation) and space in shaping opportunities for equitable aging at the micro, mezzo, and macro levels. For example, Sophia reported that she “struggles to find a community of people of similar identities or similar mindsets, especially of the same age.” Sophia later added:

I’m newly out as a trans person. Being 64 years old, and being in a small rural area, my thing is trying to find like-minded people that I can get to know at my age. That’s where I’m struggling.

Kilo highlighted that there are few spaces for older adults who are LGBTQ+ to build community, given that LGBTQ+ events tend to focus on youth.

We also don’t have a gay bar. This is the first place I ever lived where there’s no—there are certain gay nights, but they tend to be for younger people. Yes, the age really comes into play. I think there are younger queers in our community that have much more of a connection and places that they go, but for us, it sucks.

Lola added: “There’s really no place to go gather. I’m 63, I’m over bars. In fact, I owned a bar for 16 years. I don’t want to go in a bar.”

Wolfer emphasized the importance of designated physical space for building social connections, resources, and support for older adults, particularly in person:

We do not have a community center here. We have no resources here other than [Organization] going online. Well, here’s something that senior citizens still have an issue with is being online. We don’t have something tangible that we can feel in our hands. I’m Gen X, I still want to be able to go look at a book.

Raven added that creating a physical space might not be too financially costly in a rural community: “I think it would be great to have an LGBTQ center, and I feel like it could be a small little thing that was $200 bucks a month to rent a space where people could actually walk in.” Raven also emphasized how physical space is important for older adults, especially as resources are being moved online:

When I was young, the LGBTQ Center is where you could go to find housing, to find work, to find community. They had bulletin boards…. I have a room for rent, or I need a room. I know that the [the local LGBTQ+ organization] has something like that on a Discord channel…but for people my age, I’m not on Discord. I tried to get on Discord. I don’t even understand. I couldn’t even stand the platform for 10 min.… Our generation is not going to find these boards and these online platforms. Having something physical or a space is so much more conducive for my age group.

Sophia, an older transgender woman, underscored challenges in building community when relying predominantly on Discord, a free online platform for texts and voice or video chats.

I’m 64… I’m just craving to be able to talk to people who’re going through what I’m going through my age. I haven’t found that yet, where I can actually talk to people. Right now, I’m forced to typing out little text and stuff on this Discord server, and frankly, that’s not enough.

Jackie added that “a lot of the elderly don’t have computers at home” and “they don’t even want a text.” However, others underscored the importance of online communities on Facebook that also allow people to meet and come together for in-person events. For example, Charlotte noted that “there’s a group [of older lesbians]—and this is a Facebook group, but we get together for events and an annual picnic.”

Several participants suggested mobile community spaces may help address challenges for creating one physical location that is accessible to everyone. For example, Ruthie stated:

One way around being able to reach more people instead of just having a community center in X because it’s so hard for some of us to get there, what about the model of the mobile blood bank or the mobile libraries that go and visit the outlying communities, and offer their services there. That way you’d reach more people.

Many participants emphasized the importance of families of choice in rural communities, too. For example, Jackie and Kilo noted that “we are a small town here. We have five of us in one room.” Jackie added that “I depend on all these guys right here. All of them. I don’t care…. In X Community, it’s easy. Everybody helps. It’s like family.” Kilo noted “it’s like a family” while Candy agreed that “we’re all like a family.”

Several older participants contextualized how spaces for building social connections and community evolve, including Peachy:

I’m 75, and I’ve seen some of the things in the social world exist and die. We had a great community center. Before that, we had [an organization], which was upstairs [and] had a lot of groups, and it had a big rainbow flag. Anybody driving by would see where it was. It lasted a couple of years. I remember the feeling of walking into a gay-friendly space was really wonderful. But also people like Mary created a Thanksgiving and…invited whoever wanted to go…we had a Thanksgiving alternative. You want to have places people can go. There have been evolutions.

LGBTQ+ older adults also described how they leveraged non-LGBTQ+ physical spaces for building LGBTQ+ aging community, including faith-based spaces, as described by Charlie:

We belong to the Unitarian Universalist Fellowship. It’s not a gay bar, it’s a queer house, but it’s very open, and a lot of people there have become our very best friends, and you feel comfortable, and you’re just the same as anyone else, and you can get support and you can get ideas about healthcare. Anyway, it’s just a good resource for anybody, community.

Hera added that building community around LGBTQ+ identity was not always her central goal:

For me, the left political community has been very important and continues to be the most important… I predominantly have lesbian friends, but that changes depending on where I’m living and what’s happening…. Being just with lesbians would not be enough because a lot of lesbians are not political in what I’m interested in and leftists are not lesbian, a lot of them.

Theme 3: Affordable and Accessible Housing

Affordable and accessible housing presented another space where several domains intersected across micro, mezzo, and macro levels for participants in ways that shaped equitable opportunities for basic needs (e.g., housing) across the life course. For example, Sophia shared concerns about homelessness in LGBTQ+ communities:

I help vulnerable populations find work, and many in the LGBTQ communities…A lot of them are homeless. The biggest issue I’m finding is finding housing for them. That’s the biggest thing. There are several places that provide housing, but many, many times they’re full.

Louise added that government subsidized housing (e.g., HUD) can be wonderful in terms of affordability, but the “waiting list is forever” and that while HUD has different programs to assist certain groups, “there’s nothing specifically for this group.” Carolyn also described difficulties in accessing affordable senior housing: “I just checked with X Housing (serving a wide geographic region) and found out that they closed their waiting list 2 years ago and have 800 people in it.”

In addition to waitlists, some participants described challenges in cleanliness and maintenance for some low-income housing that often has older adults. For example, Pink described a troubling experience when visiting her friend:

I have a friend in senior housing. She goes to the elevator, and it has three inches of urine across the floor. She walks down the hall. There’s poop in the hall because people don’t wear Depends, and they just shit in the hall as they walk down the hall.

In contrast, Hera described a much more positive housing experience–but one that was also tinged with trepidation that it could change at any moment:

Currently I live over at X, which is a senior residence for low-income and middle-income people. I think it’s really low income. I love it there because it’s in the country and it’s in nature and it’s real pretty. It feels secure up to a point. Every time I get secure, I get worried that something’s going to happen.

Wolfer, an older transgender veteran, underscored how his disabilities made it harder to find housing.

I have osteoarthritis, real bad, and I’ve had a spinal fusion…, and I just moved into a new place from a place that wasn’t as easy for me to get in and out of…. I just recently got a scooter, and I have to now somehow afford getting something to accommodate my vehicle.

Buck described challenges with high housing costs in California that require much of his income to go toward rent:

What’s affected me lately is that I was on CalFresh Food, food SNAP. They cut me off because they said I was making too much money and I don’t, because they don’t factor in that more than half my income goes towards rent.

Discussion

Equitable aging requires access to services, structures, and people who can help one age (Perone, Zhou, Coldon et al., 2025). It requires attention to fairness, justice, and power to ensure that interactions relating to health, housing, technology, transportation, caregiving, and community are not more favorable for some based on circumstances of their birth or where they have lived or worked, for example. And while communities that have experienced inequities in power have many community assets and strengths, equitable aging examines how and why those strengths are even necessary to overcome injustices across the life course. While less commonly examined in the vast body of literature on healthy aging, equity is an important component of this concept (e.g., Bethune, 2025). For LGBTQ+ older adults in rural communities in this study, equitable aging centered around how families of choice navigated fractured and inaccessible healthcare, how space (both physical and non-physical) hindered or facilitated social connections, and how affordable and accessible housing remained elusive for many participants. Technology, transportation, and caregiving were interwoven within these three thematic findings to help explain experiences of equitable (and inequitable) aging for LGBTQ+ older adults living in rural California.

The themes underscored how multiple levels (micro, mezzo, macro) are inextricably intertwined and must be examined as such to fully understand the challenges and solutions for supporting LGBTQ+ older adults. This entanglement of the levels also reflects an important component of the concept of equitable aging. For example, one important thematic finding centered around culturally responsive health care. Participants described how culturally responsive healthcare wasn’t just about LGBTQ+ or gender-affirming care at the interpersonal (micro) or organizational (mezzo) level but that it also stemmed from macro-level policies shaping power on who had access to healthcare (e.g., veterans, Medicaid or Medicare eligibility) and how (e.g., telehealth). It intersected with other important areas of their lives, too, including age, rural location, and disabilities that were further shaped by these intersecting levels. Many participants foregrounded challenges regarding aging (and rurality) more than sexual orientation or gender identity, which aligns with other research on LGBTQ+ aging in rural communities (Guest et al., 2023). Access to physical and mental health services, as well as dental care, proved challenging for many participants, even those with insurance. Over half of the participants were living at or near the federal poverty level, which meant that (depending on their age), they may have been enrolled in Medicaid (Medi-Cal) and/or Medicare. While Medi-Cal offers some dental coverage for older adults, traditional Medicare does not (except for very specific circumtances). Several described being enrolled in Medicare Advantage plans, a privatized form of Medicare that often offers some dental coverage. However, their rural location made accessing service providers very challenging, if not impossible. Several participants noted that they were slightly too young for Medicare (and thus also Medicare Advantage), which meant they were paying out of pocket to find services that were already difficult to access.

Intersections among aging, rural location, and sexual orientation and gender identity made culturally responsive care and affordable housing even more elusive for some. Participants described how certain health conditions or disabilities necessitated access to specialists that were difficult to find in their location. Accessing geriatricians generally was challenging, and many of the general practitioners they saw dismissed their conditions as part of normative aging, when there were signs of other issues (e.g., cognitive decline, ADHD, mental health issues). This reality left many participants underscoring (1) culturally responsive and accessible services at the micro and mezzo levels around their healthcare needs and aging and (2) macro-level policies that supported training and resources for rural aging; they were less focused on ensuring that their providers were also culturally responsive regarding sexual orientation and gender identity. However, invoking a paradigm of care that ignores sexual orientation and gender identity reifies the invisibility that many described as a challenge. And yet, this was a compromise that many described as necessary to access the immediate (and sometimes urgent) care they needed.

Accessible healthcare also involved providers and services that one could access within one’s geographic region (with or without transportation). Public transportation was virtually nonexistent for many and often unreliable or inefficient. Driving oneself often required scheduling an entire day for a short visit. These same barriers prevented service providers from coming to participants in their rural communities. Inaccessibility to necessary care due to geographic location precludes one from experiencing equitable aging, as they lack the same beneficial health experiences and culturally responsive providers that others in more resourced areas may have.

Technology provided a mix of both challenges and opportunities for LGBTQ+ older adults in rural communities. Services and resources available solely through digital means (e.g., websites, Discord) were challenging for some who struggled with (or had no interest in) using these technological tools for health services, social connection, or to find affordable housing. However, several participants acknowledged that using these tools helped them access resources or people that they would have otherwise not known.

Several participants also described challenges in accessing services related to death, including disposing of one’s body that cuts across themes. LGBTQ+ older adults have higher rates of social isolation and living alone (Erosheva et al., 2015) that may be tied to access to healthcare and affordable housing, which makes them more vulnerable to dying alone at home. This was a concern that several participants shared. They also identified community-based strategies at the micro and mezzo levels for addressing these concerns that involved building on community assets (people) to do home visits and check on each other. Many of the LGBTQ+ older adults described their relationships with each other “like family,” which resonates with other literature about how LGBTQ+ older adults build families of choice to support each other (Dakin et al., 2020; Perone, Toman, et al., 2025; Toze et al., 2023). Other strategies for navigating these challenges included vocalizing and sharing one’s story and elevating visibility for the needs of LGBTQ+ older adults with service providers.

Much of the data foregrounded concerns about accessing health-related services, but these services were also deeply intertwined with social connections (community), housing, and space. Participants consistently reported on the importance of families of choice and community allies for social support, physical space, and other resources. This finding contrasts with broader research on rural aging underscoring the importance of biological family (Hussain et al., 2023) but aligns with other research on LGBTQ+ rural aging noting less support from family members (McKay et al., 2024) and reliance on social networks with families of choice (Dakin et al., 2020). While gay bars have historical significance in providing LGBTQ+ communities to gather (e.g., Perone, 2024), many participants (including one former bar owner) reported that they do not want to gather in bars. They also lamented that many LGBTQ+ events are centered around youth. Many wanted physical space to gather with families of choice that was less centered around a bar/club scene. They reminisced about physical spaces like community centers and bulletin boards where they could find resources, including affordable housing with other LGBTQ+ people. Physical spaces (with rainbow flags) also gave some participants a sense of community and safety. The transition of resources to online spaces like Discord left many participants feeling excluded from opportunities and spaces to connect or live, which contravenes equitable aging. While some participants described the benefits of online groups on Facebook, because it left many feeling excluded, other structures and systems are necessary to create opportunities for equitable aging (e.g., mobile community spaces, physical spaces with ally organizations).

Participants also discussed challenges and strengths for equitable aging in the context of affordable and accessible housing. Housing serves as a physical space that meets basic needs and can help build LGBTQ+ community (Perone, Zhou, Reed, et al., 2025). Access to affordable housing is driven, in part, by macro policies but also was shaped by their own individual circumstances (e.g., disabilities). For most participants, finding affordable and accessible housing was difficult, especially when considering disability needs that increased across the life course. A few participants described the benefits of living in more pastoral places in rural communities, but even in rural communities with a lower cost of living, many LGBTQ+ older adults struggled to access affordable housing. While the literature is growing, housing remains an understudied area in LGBTQ+ aging. Emerging literature underscores how various LGBTQ+ communities experience heightened limitations in accessing affordable housing, which could be connected to individual challenges at the micro level (e.g., depression) (Uddin et al., 2023), organizational capacity at the mezzo level, and the need for more macro-level policies, but also how communities are accessing community strengths to re-envision what LGBTQ+ housing for older adults could look like (Perone, Zhou, Reed, et al., 2025; Putney et al., 2021). Several participants alluded to possibilities of shared housing, but also a need for more formal programs to support diverse types of affordable and accessible housing for LGBTQ+ older adults that could support equitable aging.

This study has several limitations. First, it collected data only from LGBTQ+ older adults in California. Additional studies outside California and the United States are needed. Second, the sample was predominantly white, female, and cisgender. More research is needed to capture the voices of men, transgender older adults, and older adults of color in rural communities. Third, the community-engaged research design foregrounded community partners as core collaborators for data collection. While the community partners involved in this study likely increased the overall sample, the community-centered design may have resulted in participants who were more socially connected than those who were unaware of or disconnected from the community partners (who helped recruit). More research (and funding) is needed that incorporates a multi-phased recruitment approach with LGBTQ+ older adults in rural communities that are recruited from additional avenues. Nevertheless, as noted above, this study offers important contributions and guidance for practitioners and policymakers in aging, including program interventions that facilitate opportunities for equitable aging for LGBTQ+ older adults in rural communities.

Conclusion

Overall, experiences of aging for many of the LGBTQ+ older adults in this study underscored how challenges and strengths shaped their opportunities for equitable aging. Inequities in health, housing, technology, transportation, caregiving, and community shaped opportunities for culturally responsive healthcare, social connections, and affordable and accessible housing. Families of choice helped to buffer some of these inequities. However, targeted supports at the micro, mezzo, and macro levels could strengthen opportunities for equitable aging for LGBTQ+ older adults in rural communities.