Caring for transgender & gender-diverse older adults

• Aging GSM individuals have multiple marginalized identities (e.g., gender minority, sexual minority, age minority, etc.), which can lead to increased levels of stress at the individual, community, and institutional levels (Barefoot et al., 2018).
• Transgender older adults experience rates of discrimination and mental distress compared to their cisgender heterosexual counterparts (Fredriksen-Goldsen et al., 2016).
• In addition to an increased likelihood of a chronic health condition due to aging, TGD older adults have unique stressors that put them at a higher risk of “fears of mistreatment in institutional elder care programs due to gender identity, social isolation, and ostracization by friends and family due to transphobia and perceived lack of control over one’s gendered narrative and identity as end of life approaches” (Adan et al., 2021, p. 340).
• Healthcare professionals who work with elders in hospice, palliative care, and long-term care facilities frequently report that patients who identify as TGD do not usually get their basic needs met, are discriminated against with their medical care access, or have been physically and/or emotionally abused (Stein et al., 2020).
• Successful aging can be improved with self-acceptance, advocacy, and caring relationships for TGD elders despite the barriers and stress factors they face (Coleman et al., 2022; Fredriksen-Goldsen, 2011; Witten, 2014).

The below list are common health issues: (Coleman et al., 2022; University of North Dakota Online, 2020):

• Eating disorders
• Body image issues
• Sex-related cancers (e.g., breast cancer)
• Human immunodeficiency virus (HIV)
• Acquired immunodeficiency syndrome (AIDS)
• Obesity
• Sexually transmitted diseases (STDs)
• Cardiovascular disease and venous thromboembolism (VTE)
• Anxiety and depression
• Substance use and abuse
• Suicidal ideation

• Stress factors
  • Vulnerability to financial uncertainty: TGD older adults experience an increased risk of financial insecurity due to discrimination and transphobia.
    • They may experience loss of employment and decreased professional opportunities due to gender-related discrimination (i.e., policies that discriminate against gender minority people in the workplace) (Adan et al., 2021).
• Resilience factors
  • Workplace policies: Protecting gender minority people in the workplace can be a protective factor for TGD people.
• Possible occupations impacted: Work (e.g., retirement preparation and adjustment), rest and sleep, IADLs, health management, and social participation.

• Stress factors
  • Terminology: Gender categories and sexual identity terminology have expanded and increased, but TGD elders may not be aware of or familiar with them (Hagai et al., 2020). Therefore, it is essential not to assume that a TGD elder is unwilling or afraid to talk about TGD-related topics (e.g., identity, pronouns, etc.) when it could be that the client is not familiar with the words.
  • Technology: There is limited research on TGD elders' technology, but it can be inferred from a general aging population study that TGD elders may have low technology literacy, an additional barrier to accessing education and resources (Wang et al., 2019).
  • Available options: Many TGD elders may not know the current social, medical, or surgical options available to help them meet their individual needs” (Coleman et al., 2022; Hardacker et al., 2019; Houlberg, 2019).
• Resilience factors
  • Information access: OTPs can help TGD elders explore their identity, connect with resources, connect with a community, learn more about vocabulary, and access other information (e.g., grooming, dressing, etc., in a way that affirms their identity) in relation to their identity.
• Possible occupations impacted: Social participation, leisure, ADLs, IADLs, health management, play, education, rest and sleep.

• Stress factors
  • Access to care: TGD individuals often experience fewer preventive health screenings and face inequities when accessing care due to discrimination and mistreatment.
    • Additionally, barriers to care increase as GSM older adults age (Catlett et al., 2023). GSM older adults may be unwilling to access health care services and housing due to negative past experiences of victimization and discrimination (Sumerau et al., 2023).
  • Fear of mistreatment in elder care: TGD older adults experience a fear of negative experiences in elder care facilities due to perceived mistreatment and non-affirmation of identity (e.g., misgendering, being forced to wear non-gender-affirming clothing).
    • Additionally, they may fear not having an advocate (either themselves or someone else) on individual and systemic levels. Potential physical and/or emotional abuse, being “outed,” or denial of gender-affirming care such as hormone therapy may also be sources of fear (Adan et al., 2021).
  • Healthcare system and provider inclusivity: Many TGD older adults experience mistreatment, discrimination, and non-affirmation of gender identity from healthcare systems and providers through verbal communication, body language, and medical records systems and procedures that are not designed to be inclusive of TGD individuals.
    • It is essential to note that long-term-care facilities need to consider facilitating an inclusive environment for the growing population of aging TGD people (Adan et al., 2021).
  • Mental health: GSM individuals generally have higher stress levels than their cisgender counterparts which can negatively influence their overall health. GSM individuals are also at a higher risk for all mental health issues and substance abuse than their cisgender counterparts. In addition, internalized stigma often contributes to increased stress (Adan et al., 2021).
• Resilience factors
  • Anti-discriminatory policies: Section 1557 of the Affordable Care Act prohibits discrimination in covered health programs and activities based on race, color, national origin, age, disability, or sex (inclusive of sexual orientation and gender identity) (Office for Civil Rights, 2023).
    • If a TGD older adult believes they faced discrimination based on any of these factors, they can file a complaint with the Office for Civil Rights. In addition, through the Health Insurance Portability and Accountability Act of 1996 (HIPAA), providers can not disclose any information about a client’s gender-affirming care without their consent except in limited circumstances (Office for Civil Rights, 2022).
• Possible occupations impacted: Health management, rest and sleep, work, leisure, social participation, ADLs, and IADLs.

• Stress factors
  • Socialization: TGD older adults may avoid socialization depending on local, state, or federal laws (i.e., if there are bathroom ban laws TGD older adults with incontinence or urgency issues may feel unwelcome or unsafe in social settings).
  • Physical location: It is essential to consider that there can be differences in TGD people’s connection with their community and environment depending on whether they live in a rural, urban, or suburban area.
    • If there are no other TGD individuals in the community, they may potentially face violence or isolation; if they live near other TGD individuals, they may feel more protected and supported.
  • Possible barriers: Food insecurity, transportation limitations, and housing insecurity can be exacerbated by TGD-related discrimination (e.g., if the sex on their ID does not match with someone’s chosen name or gender expression it can affect their ability to secure safe housing) (Coleman et al., 2022).
• Resilience factors
  • Giving back to one’s community: TGD older adults who desire and can engage with their community through financial donations, education, mentorship, and activism are often more resilient (Adan et al., 2021).
• Possible occupations impacted: Social participation, leisure, ADLs, IADLs, health management, work, education, and rest and sleep.

• Stress factors
  • Isolation and Loneliness: Older TDG adults face a higher rate of isolation and loneliness than their other peers, frequently exacerbated by lower access to social resources or the estrangement of family members or friends due to their TGD identity.
  • In The Transgender MetLife Survey, 30% of respondents were unsure who would care for them if they became ill (Adan et al., 2021).
  • Many TGD older adults also face increased challenges in finding a romantic partner due to possible emotional and physical intimacy discomfort with a transgender person.
  • TGD older adults are less likely to have children and extended family as interpersonal support than members of the cisgender population.
    • In addition, older adults may have concealed their identity for so long (e.g., not engaging in social activities or living “stealth”) that they have a lack of or limited platonic social support (Adan et al., 2021).
  • Compared with their non-GSM counterparts, GSM older adults are more likely to live alone, not have children, and be single.
  • GSM older adults also have disproportionately increased rates of disability and are at high risk for social isolation, neglect, and mental health concerns (Knauer, 2016).
• Perceived lack of agency: Many TGD older adults experience a fear of a lack of autonomy related to end-of-life decisions and care.
  • TGD older adults often fear that someone may change their narrative as a transgender person if they experience a cognitive decline, or that their transgender identity will be erased after death (Adan et al., 2021).
  • GSM older adults often receive care from their chosen family (e.g., friends and partners who are not related to the individual), who do not have legal recognition.
  • Medical decision-making (e.g., wills, durable powers of attorneys, and advance directives) defaults to their next of kin, even if this is not the person’s choice.
• Imposed rules: Some long-term-care facilities require their residents to wear gender-appropriate clothing with the residents’ sex assigned at birth, even if the clothing does not align with their gender expression.
  • In addition, some staff members have persisted in addressing transgender residents by their deadname and misgendering them (Knauer, 2016).
• Resilience factors
  • Points of resilience: Online communities (e.g., YouTube, Instagram, Facebook) can act as resilience factors against discrimination, stigma, and mental health issues by providing medical information, images, cultural knowledge, and a community. However, older TGD adults may have a hard time reaching these platforms due to possibly not being tech-savvy (Sumerau et al., 2023).
  • TGD elders’ chosen family: These individuals can help create a sense of joy and understanding, share cultural knowledge, and provide care for one another (Sumerau et al., 2023).
  • Embracing self-truth as a path to fulfillment: TGD people can experience a sense of pride, peace, and wisdom by accepting their TGD identity (Adan et al., 2021).
  • Living authentically: Healthcare services for aging adults where one does not live “in the closet” to survive, along with federal and state nondiscrimination laws, are greatly desired by GSM boomers (Sumerau et al., 2023).
  • Protective factors: GSM older adults often provide caregiver services while also receiving care from their chosen family, which can be a protective factor because it can help build a community and pride.
• Possible occupations impacted: Social participation, leisure, work, rest and sleep, play, and health management.

• Initiate open discussions with GSM & TGD individuals to help make them aware of their increased risk of physical and mental health issues due to age, sexual orientation, and identity.
• Understand preventive measures.
• Understand that providing gender-affirming care can increase TGD older adults' comfortability (Carroll & Bisshop, 2022).
• Be aware of signs of illnesses TGD individuals may have an increased risk of developing.
• Understand the unique disparities that TGD older adults may have experienced.

• Encourage spirituality, self-acceptance, self-efficacy, self-advocacy, an active lifestyle, and social participation, which are linked to successful aging (Coleman et al., 2022; Fredriksen-Goldsen, 2011; Witten, 2014).
• Advocate for, be inclusive of, and fight discrimination in relation to TGD older adults.

• Understand how the social determinants of health impact the quality of life of TGD older adults (economic stability, health care access and quality, social and community context, neighborhood and built environment, and education).
• Use the Minority stress theory (Testa et al., 2015), which includes:
  • distal stress factors (gender-based victimization, gender-based rejection, gender-based discrimination, non-affirmation of gender identity);
  • proximal stress factors (negative expectations for future events, internalized transphobia, and non-disclosure of one’s identity); and
  • resiliency factors (community connectedness and pride) impacting aging TGD individuals’ quality of life.