Mezzo-level factors

Competency and preparedness of providers

Service providers are seldom prepared to effectively serve TNB older adults. Gerontologists are often unaware of TNB physiology or how to appropriately provide care toTNB people (Finkenauer et al., 2012).TNB older adults are more likely to report poor quality health care compared to cisgender LGB older adults (Fredriksen-Goldsen et al., 2011). TNB older adults reported a need for senior housing, transportation, social events, and support groups that are welcoming (Fredriksen-Goldsen et al., 2011). However, for such services to be offered to this population effectively, efforts are needed to increase service providers’ knowledge about TNB people and ensure these services are affirming, inclusive, and responsive to TNB people’s needs.

Social support network

Social support and a sense of LGBTNB community belonging are important to the health of TNB older adults (Fredriksen-Goldsen et al., 2014) and social support is often a key resource for assistance with household tasks. When TNB older adults without social support encounter significant health problems, they may ignore the problem and attempt to care for themselves or be forced to use institutionalized care (Siverskog, 2014). Fredriksen-Goldsen and colleagues (2011) found that TNB older adults have significantly less social support than their cisgender LGB peers, despite larger overall social network sizes. TNB older adults are more likely to attend spiritual or religious activities than cisgender LGB peers (Fredriksen-Goldsen et al., 2011), which may provide important social support. Siverskog (2014) notes challenges to social connectedness among rural-dwelling TNB older adults and those who do not know other TNB people. TNB adults can face a strained relationship with the larger LGBTNB community; TNB older adults are less likely to feel positive about their belonging in the LGBTNB community than cisgender LGB adults (Fredriksen-Goldsen et al., 2011).

Discrimination, harassment, victimization, and abuse

TNB older adults are more likely to experience discrimination, harassment, victimization, and abuse than cisgender LGB older adults, including discrimination in health care; verbal abuse from a partner, family member, or friend; and neglect (Fredriksen-Goldsen et al., 2011,2014). Compared to younger cohorts, TNB older adults are less likely to report that they have experienced discrimination, which may be a result of the timing of when people transitioned, generational differences in defining discrimination, and whether participants live part-time or full-time as their authentic gender (Kattari & Hasche, 2016).

Macro-level factors

Lifetime barriers to education, employment, and savings

TNB people face significant discrimination and harassment in education and employment (James et al., 2016). These challenges likely contribute to inadequate retirement savings and income support. Sex discrimination may exacerbate this, as transgender adults who were assigned male at birth are likelier to have pensions compared to those who were assigned female at birth (Witten, 2014a).

Non-discrimination policies affecting aging-related services

Few incentives or policy mandates exist to ensure TNB inclusion and competency from the agencies, staff, and volunteers offering services to older adults. The Older Americans Act has not designated TNB people as a “greatest social need” population, a categorization that could guide federally-funded service providers to serve this population without discrimination (SAGE & NCTE, 2012, p. 31). Long-term care facilities may not understand or enforce 42 CFR 483.10, which provides rights that protect TNB residents (National Long-Term Care Ombudsman Resource Center [NORC], National Resource Center on LGBT Aging, &c Lambda Legal, 2018). For instance, many institutions require a same-sex roommate (unless sharing with spouse) and assign rooms based upon sex designated at birth rather than gender identity (Porter et al., 2016).

Health insurance coverage and document-change policies

Many older adults access health care through the Veterans’ Health Administration (VHA), Medicare, and/or Medicaid. VHA offers transition-related medical care (e.g., hormone replacement therapy, mental health services, pre-operative evaluation, vocal coaching, post-gender-affirming surgery care), but does not offer gender-affirming surgery (VHA Directive 1341,2018). The VHA also directs its health centers to consistently use each person’s self-identified name and pronouns, to assign rooms based on self-identified gender identity, and to enforce non-discrimination (VHA Directive 1341, 2018/ Medicare covers gender-affirming surgeries and hormone replacement therapy it considers medically necessary, although it fails to cover many off-label transition-related drugs (SAGE, SHIP National Network, Justice in Aging, & Administration for Community Living [ACL], 2016). Each state determines its Medicaid coverage; currently, 19 states lack policy regarding coverage forTNB people and ten states exclude coverage (Movement Advancement Project [MAP], 2019).

Sex markers are listed on Medicare and Medicaid cards based upon Social Security records (SAGE Sc NCTE, 2012). To change one’s sex marker with Social Security, an individual must produce a passport or birth certificate with the correct gender, a court order, or a physician letter indicating appropriate treatment related to gender transition (Social Security Administration, 2019). Eliminating the sex marker field on identity cards would remove a barrier for recognition of TNB older adults (SAGE & NCTE, 2012).

Strengths and resilience

McFadden, Frankowski, Flick, and Witten (2013) identified six “resilience repertoires” (p. 260) among TNB adults aged 61 and older that contributed to successful aging, including: (a) nurturing the spiritual self (e.g., finding peace, using positive spirituality); (b) exercise of agency (e.g., goal-setting, making decisions to promote health, transitioning when desired); (c) self-acceptance (e.g., living an active and healthy lifestyle as a means to take care of oneself, being courageous); (d) having caring relationships (e.g., caring for future generations, loving others rooted in selfacceptance); (e) advocacy and activism (e.g., educating others, deep commitment to improving the lives of trans people); and (f) enjoying an active, healthy life (e.g., living proudly and honestly, letting go of things outside of one’s control, laughing, and enjoying life). Service providers can support the growth of resilience in TNB older adults by helping them strengthen their support systems, develop a positive sense of self, increase self-determination, and work for the liberation of TNB people.

Knowledge gaps

Studies of older TNB adults tend to be cross-sectional surveys using non-probability samples. Studies that include TNB older adults as part of a larger sample provide limited data about this population. We also know very little about nonbinary older adults, TNB older adults of color, those 80 and older, rural residents, and those outside of the U.S. (Finkenauer et al., 2012; Witten, 2014b).

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