By Tarynn Witten, PhD, LCSW (Member, APA Division 44*) & Brian Carpenter, PhD (Member, APA Committee on Aging)
The award-winning Amazon Studios series, Transparent, highlights one of the most invisible of invisible groups – transgender older adults. The lead character, Maura Pfefferman (born Mort Pfefferman), has lived most of her life as a man and begins to express her female gender identity only later in life. This intersection of identities – an older adult + gender nonconforming identity – raises issues that are rarely seen or acknowledged. Transgender-identified individuals who are older face exponential challenges.
“I’ve been dealing with this for years, and it takes its toll.”
Although research is limited, studies tell us that transgender people often enter old age vulnerable due to a lifetime of concealment, stress, and prejudice. Compared to their peers, transgender older adults experience the highest rates of victimization, stress, unemployment, poverty, and compromised physical and mental health (Fredriksen-Goldsen, Cook-Daniels, et al., 2014).
- When it comes to healthcare, transgender individuals may be reluctant to interact with health care providers, including mental health providers, because of the historical marginalization they’ve experienced. For instance, in the Trans MetLife Survey (TMLS), 39% of respondents said they had no or little confidence they would be treated with respect by their health care professionals (Witten, 2014).
- Similarly, due to decades of discrimination and economic instability, transgender people who come out earlier in life tend to have fewer financial resources later on, which has significant implications for retirement planning and financial security in later years. In the TMLS survey, 47% of the respondents stated that they were under moderate to extreme financial strain.
- Amidst these challenges, transgender older adults may not have the social and community resources to help them cope. Often rejected by family and friends, transgender individuals may be more socially isolated in later life. In the TMLS survey 55% of the respondents stated that they had no children. In a recent national survey, 44% reported living alone, compared to only 18% of the general population (Fredriksen-Goldsen, Kim, et al., 2011). In another study, 40% reported they no longer have contact with their children because of their gender identity (Grant et al., 2011).
“I can’t even control who knows.”
How and when people express their gender identity is an extremely personal choice. Yet unlike gay, lesbian, and bisexual individuals, transgender people may not have complete control over who knows their gender identity. If they choose to live as their preferred gender, some people may have physical features they cannot change (or afford to change). So when a transgender person needs a physical exam from a physician, or needs help with bathing or dressing in an acute care or residential care setting, there is a risk of being found out, with the potential for subsequent discrimination or outright abuse (Cook-Daniels, 2015).
This kind of “nonconsensual outing” can also happen when I.D. (e.g., a Social Security card, driver’s license, or health insurance record) includes a name or pronoun that contradicts how a person presents. Transgender older adults may delay or avoid seeking assistance or services because they are concerned about detection and its consequences.
“I live with the choices I’ve made every day.”
While non-consensual outing is important, the endemic backstory of abuse and violence by healthcare workers against trans-persons has generated a fear of accessing elder care services. And some transgender older adults even develop suicide plans rather than enter elder-care facilities. As one TMLS survey respondent commented, “The day that I need a caregiver, I will implement my end-of-life suicide plan.”
Of course there’s great diversity even among transgender older adults. In part this diversity may depend on when people started to live openly as their true gender. Older adults who started their gender transition earlier in life may have faced years of discrimination, altering the trajectory of their social networks, career prospects and economic security, and physical and mental health in major ways for decades. Family relationships could have been strained for years. More limited work opportunities could reduce lifetime savings. And a lifetime of stress navigating a complicated life could add to health problems and even increased mortality risk later in life. On the other hand, although life may not have been easy, these individuals may have developed a substantial resiliency in the face of these challenges and benefited by living for decades as the person consistent with their internal gender representation.
“I learned to love myself before my transition and surgery. Since then, I have been consistently happy and content.”
For a variety of reasons, some trans-persons choose to live as their preferred gender only in their later years. Whatever benefits they might have accrued by living under the radar for most of their lives may be offset by suppressing an essential part of themselves for decades. When they finally take the step to approach health care professionals about a gender transition, they risk confronting ageism and transphobia in the form of an insensitive attitude about the value of transitioning at their age. Some professionals may question whether a transition is “necessary” when people are closer to the end of their lives (Siverskog, 2014).
Even though the 33-year-old ban on Medicare paying for gender reassignment surgery was lifted this year, the risks of surgery may be higher for older adults. Monthly costs for hormones and other treatments may be difficult for older adults living on a fixed income. And other practical challenges can arise. For instance, a transgender older adult could potentially lose access to a retirement account following a gender and/or name change (SAGE & NCTE, 2012). Yet people who choose to transition later in life may experience newfound peace at finally accepting themselves and living as the person they always felt they were (Fabbre, 2014).
“I feel I have aged successfully. I believe that being open and honest about myself and really being comfortable with myself have been the most important factors.”
There is welcome momentum to highlight the needs of transgender older adults, but there is still much we can learn and do. Some changes are relatively easy. For instance, health care professionals and researchers can routinely ask about gender identity and pronouns people use to describe themselves and ensure their paperwork forms do the same. Similarly, service providers should make accessible gender-neutral restrooms or allow transgender clients to use whatever restroom aligns with their gender identity. And at an institutional level, all health care organizations should adopt nondiscrimination policies that include gender identity and sexual orientation.
All of us can also make an effort to educate ourselves about the needs of this group. Several key resources can help.
- The National Resource Center on LGBT Aging, a technical assistance resource center that, among other things, provides cultural competency training to aging service providers through its online and in person training curricula. As of 2013, over 2,400 providers in 26 states had completed the training.
- The APA Lesbian, Gay, Bisexual, & Transgender Concerns Office and Office on Aging, which addresses the needs of LGBT older adults and those who provide services and care by highlighting APA resources as well as other helpful resources and organizations.
- The Healthcare Equality Index, published by the Human Rights Campaign, evaluates over 1,500 healthcare facilities regarding policies and practices related to the equity and inclusion of their LGBT patients, visitors, and employees. The site’s interactive map provides an easy way for consumers to investigate whether organizations have LGBT inclusive policies regarding patient non-discrimination, visitation, and training.
- A report from the Institute of Medicine in 2011, “The Health of Lesbian, Gay, Bisexual, and Transgender People: Building a Foundation for Better Understanding,” provides a helpful synthesis and also emphasizes the diversity across these groups.
- Services & Advocacy for GLBT Elders (SAGE) is the country’s largest and oldest organization dedicated to improving the lives of lesbian, gay, bisexual and transgender (LGBT) older adults.
- The National Center for Transgender Equality is the nation’s leading social justice advocacy organization winning life-saving change for transgender people.
- FORGE is a progressive organization whose mission is to support, educate and advocate for the rights and lives of transgender individuals and SOFFAs (Significant Others, Friends, Family, and Allies).
Transgender older adults are a rich resource in society. The challenges they face are many and great, and they deserve to be visible, on their own terms, and with the full support of others. Aging comes with enough challenges as it is. So does living as a transgender individual. The two together deserve special sensitivity and attention.
Tarynn M. Witten, PhD, LCSW, FGSA is a licensed clinical social worker and Professor of Biological Complexity, Emergency Medicine and Gender Studies at Virginia Commonwealth University where she conducts research on global aging challenges in the transgender and gender non-conforming population. She has published some 50 papers on a variety of issues around aging in this population and currently, with her co-author Dr. A. Evan Eyler, is completing an introductory textbook on transgender medicine for physicians, nurses and other healthcare delivery persons which is due out under the Springer logo later this year. Her counseling practice centers around gender non-conforming challenges as well as later-life issues.
Brian D. Carpenter, PhD, is an Associate Professor of Psychology at Washington University in St. Louis. He is a clinical geropsychologist whose research focuses on communication among older adults, their family members, and their healthcare providers, with an emphasis on how people talk with each other about dementia and end-of-life care preferences.
Cook-Daniels, L. (2015). Transgender aging: What practitioners should know. In N.A. Orel & C.A. Fruhauf (Eds.), The lives of LGBT older adults: Understanding challenges and resilience (pp. 193-215). Washington, DC: American Psychological Association.
Fabbre, V.D. (2014). Gender transitions in later life: A queer perspective on successful aging. Gerontologist, doi: 10.1093/geront/gnu079.
Fredriksen-Goldsen, K.I., Cook-Daniels, L., Kim, H.J., Erosheva, E.A., Emlet, C.A., Hoy-Ellis, C.P., & Muraco, A. (2014). Physical and mental health of transgender older adults: An at-risk and underserved population. Gerontologist, 54, 488-500. doi:10.1093/ geront/gnt021
Fredriksen-Goldsen, K.I., Kim, H.J., Emlet, C.A., Muraco, A., Erosheva, E.A., Hoy-Ellis, C.P., Goldsen, J., Petry, H. (2011). The aging and health report: Disparities and resilience among lesbian, gay, bisexual, and transgender older adults. Seattle: Institute for Multigenerational Health.
Grant, J.M., Mottet, L.A., Tanis J., Harrison, J., Herman, J.L., & Keisling M. (2011). Injustice at every turn: A report of the national transgender discrimination survey. Washington, DC: National Center for Transgender Equality and National Gay and Lesbian Task Force.
Services and Advocacy for GLBT Elders (SAGE) & National Center for Transgender Equality (NCTE). (2012). Improving the lives of transgender older adults. New York, NY & Washington, DC: Authors. Retrieved from: http://www.sageusa.org/resources/publications.cfm?ID=13
Siverskog, A. (2014). “They just don’t have a clue”: Transgender aging and implications for social work. Journal of Gerontological Social Work, 57, 2-4. doi:10.1080/01634372.2014.895472
Witten, T.M. (2014). End of life, chronic illness, and trans-identities. Journal of Social Work in End-of-Life and Palliative Care, 10, 34-58. doi: 10.1080/15524256.2013.877864
* APA’s Division 44 is the Society for the Psychological Study of Lesbian, Gay, Bisexual and Transgender Issues.