Serious Illness Care Exclusion, Disclosure, & Trust For Older Gay Men & Caregivers in the Deep South.

CONTEXT: Older gay men in the Deep South experience serious illness within healthcare systems shaped by heteronormativity and structural racism. Although disparities in access and disclosure are documented, less is known about how negative or ambiguous healthcare encounters are interpreted in serious illness settings. OBJECTIVES: To explore how older gay men and their caregivers interpret experiences of exclusion, bias, communication gaps, and decision-making within serious illness care. METHODS: Using a community-based participatory research approach, we conducted semi-structured interviews with 16 participants (11 patients aged 50 years or older living with serious illness and 5 caregivers) residing in the Deep South. Interviews were analyzed using reflexive thematic analysis to identify recurring themes related to healthcare experiences, disclosure, trust, and perceived discrimination. RESULTS: Five themes emerged: discriminatory experiences and bias, clinician communication gaps, exclusion from decision-making, system-level gaps in care quality, and disclosure, trust, and safety. Participants described overt and subtle forms of bias, dismissal of partners in clinical encounters, rushed or unclear communication, and institutional barriers that intensified vulnerability during serious illness. Black participants more frequently identified racialized experiences and contextualized mistrust within histories of systemic racism. Disclosure decisions were shaped by ongoing assessments of safety, risk, and anticipated stigma. CONCLUSION: Routine clinical interactions may carry disproportionate meaning for older gay men navigating serious illness, particularly within contexts marked by structural racism and historical discrimination. Serious illness care must attend not only to overt bias but also to cumulative micro-level interactions that influence trust, agency, and engagement.