Understanding and working with transgender/nonbinary older adults

INTRODUCTION

Social work with TNB older adults attends to the impacts of a lifetime of genderbased oppression along with the impacts of ageism and other experiences of marginalization. Social workers who build their knowledge base, attend to their own biases, and actively advocate for anti-oppressive treatment, services, policies, and systems may effectively serve TNB older adults. This chapter highlights existing literature about the experiences, challenges, needs, and strengths of this population and identifies best practices for working with TNB older adults at the micro, mezzo, and macro levels. We also provide a case study and guiding questions to help you apply what you are learning and identify areas for additional study and training.

LITERATURE REVIEW: KEY FACTORS AFFECTING TNB OLDER ADULTS

Micro-level factors

Gender identity, transitioning, and disclosure

There are myriad experiences related to gender identity and transitioning, including whether and when one decides to transition. Older cohorts of TNB adults likely lacked social acceptability and role models when they were young, and may have felt it was untenable for them to transition (Siverskog, 2014). Other people may wait to disclose their TNB identity until later in life to avoid economic consequences while working. Some TNB older adults may not wish to transition at all, routinely changing their gender expression and/or identity and/or disrupting gender norms in other ways (Siverskog, 2015). TNB older adults who wish to transition may hesitate due to feeling that it is too late or they are “too old” (Fabbre, 2014, p. 167) or may be toldthat transitioning is not worthwhile in the time one has left to live (Siverskog, 2014). Chronic health conditions and other aging-related physical changes can complicate transition plans and the ability to be perceived as one’s gender (Siverskog, 2014). Health conditions in later life can pose enough risk that doctors might refuse to perform gender-affirming surgeries (Siverskog, 2014, 2015).

Some aging adults may stop identifying as transgender after transitioning (Fredriksen-Goldsen et al., 2011). People who openly identified as TNB in midlife may decide to pass as cisgender in later life due to safety concerns (Siverskog, 2014). TNB older adults may not be able to pass as cisgender in settings such as nursing homes where care providers have close contact with their body; in fact, they are at increased risk of having their identity divulged by staff who are unfamiliar with TNB people’s needs and bodies (Siverskog, 2014, 2015).

Physical health, disability status, and health promotion/risk behaviors

Health disparities that exist in earlier adulthood appear to persist into later life (Fredriksen-Goldsen et al., 2014). TNB older adults are more likely than their cisgender counterparts to report asthma, cardiovascular disease, diabetes, or a dental, hearing, or vision impairment, and are less likely to have HIV, hepatitis, or cataracts (Fredriksen-Goldsen et al., 2011). Some TNB older adults take hormones, so providers will need to pay attention to polypharmacy issues, including drug interactions (Finkenauer et al., 2012).

TNB older adults in the U.S. may be less likely to exercise than cisgender LGB older adults (Fredriksen-Goldsen et al., 2014). Gender identity differences in physical and mental health may be connected to a lack of exercise and obesity among TNB older adults (Fredriksen-Goldsen et al., 2014). TNB individuals may face higher rates of disability as they age than their cisgender lesbian, gay, and bisexual (LGB) counterparts (Fredriksen-Goldsen et al., 2011). Cook-Daniels and Munson (2010) found disability rates among midlife and older transgender adults “so potent that they were unable to take care of their own basic needs like food, cleanliness, and safety” (p. 174).

Mental health

TNB older adults report poorer mental health and higher rates of depression symptoms, anxiety, suicidal ideation, stress, and loneliness than their cisgender LGB peers (Fredriksen-Goldsen et al., 2011). They may struggle with unique anxieties about aging, such as a fear of forgetting that one has transitioned (Witten, 2014a).TNB older adults report greater internalized stigma than cisgender gay and lesbian older adults; such stigma is associated with poorer physical and mental health (Fredriksen-Goldsen et al., 2011). Protective factors for physical and mental health include positive feelings of belonging in a lesbian, gay, bisexual, and transgender/nonbinary (LGBTNB) community and greater social support (Fredriksen-Goldsen et al., 2014).

Legal documents and end-of-life planning

TNB people face unique considerations related to changing/updating identity documents and end-of-life planning. However, some adults avoid altering identity documents in order not to threaten their access to Social Security, veterans’ benefits, or housing (Porter et al., 2016). TNB adults show very low levels of end-of-life planning, such as developing a will, durable health care power of attorney, and instructions about how to recognize the end of one’s life (Fredriksen-Goldsen et al., 2011; Kcomt & Gorey, 2017). Rates are even lower among low-income TNB adults and those who are Latinx, African American, or Native American (Fredriksen-Goldsen et al., 2011).

Anticipated stigma in receiving services

TNB older adults likely anticipate continued stigma from health and social services in later life (Siverskog, 2014; Witten, 2014b), which may discourage them from seeking needed help (Witten, 2014a). Other stigmatized identities (e.g., being HIV positive) further contribute to fear of seeking services and disclosing TNB identities (Finkenauer et al., 2012; Witten, 2014b). Delaying care due to fear relates to health struggles for this population; fear of accessing health care may help account for the relationship between gender identity and health outcomes (Fredriksen-Goldsen et al., 2014). TNB older adults express concerns about institutionalized care in later life, including potential transphobia and incompetence from care providers (Witten, 2014a). Some TNB adults report they will self-euthanize if they cannot find competent care (Witten, 2014a).