BEST PRACTICES AT MICRO, MEZZO, AND MACRO LEVELS

Micro-level practice

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Ageism and bias against TNB people are widespread. Social workers improve their ability to practice effectively and appropriately with TNB older adults when they understand their privilege and identify and eradicate their own biases. Be sure to seek out trainings and build lines of accountability with people who will help you identify and address biased behaviors.

TNB older adults may be wary of social workers based on past discrimination. Build trust with this population by respecting their gender identity and expression and providing a safe experience. Instead of relying on records or legal documents, ask what name they use and note this prominently in records. During intake, ask all clients, “What is your gender identity?” to avoid misgendering and to appropriately match your client to services. Collect this information out of earshot of other people or through a written form to provide safety and support for disclosure. Some TNB older adults selectively express their gender identity. For example, your client may use a different pronoun with relatives or may hide their gender identity from cisgender peers. Learn how and when your client wishes to be addressed with a particular name and pronoun and honor this wish.

TNB older adults may feel vulnerable when disclosing their legal name and sex if these differ from self-identity. They may also be reticent to discuss physical transitioning. Request this information privately and only when necessary (e.g., billing or regulations may require legal name and sex assigned a birth). Information about physical transitioning will help you match a TNB older adult with appropriate medical screenings, develop safety plans, and advocate for the most comfortable room arrangement in assisted living. A legal identity mismatch may impact your client’s ability to collect retirement funds or have their wishes respected in end-of-life care. Explain why this information is needed, including who has access to it, how it will be used, and limitations on privacy or confidentiality.

Assess and bolster support networks

TNB older adults may have lost family, friends, faith community, or other supporters as they began to live in their authentic gender identity and expression. Support networks further weaken in older age as death and illness claim peers and supportive family. Screen for isolation, loneliness, and neglect. Identify existing sources of social, emotional, and material support along with gaps. Use your existing knowledge and professional networks to locate affirming sources of support, then present these to your client for consideration. If they identify with a faith or spirituality, discuss their current and desired practice and help them locate TNB-affirming options. More people need material support as they age, and TNB older adults may need more financial support than their cisgender peers. Ask your clients who helps them with needed chores, errands, or rides and who they can depend on to help with expenses.

Address impacts of past and current oppression

TNB older adults who have experienced employment discrimination or paid out-of-pocket for gender-affirming medical care may have debt and/or paltry savings. Assess their financial situation and connect them with financial supports. Help identify free or inexpensive ways to meet their needs. For example, local Area Agencies on Aging offer congregate dining programs, Meals on Wheels, transportation, chore assistance, and other support. Screen potential resources to understand their capacity to be TNB-affirming and share with your client so they can make an informed choice.

TNB older adults may need part-time or full-time employment, but age discrimination and TNB bias create challenges. Work together to write a resume that deemphasizes employment gaps. Practice answers to questions about such gaps that honor their wishes about disclosing their TNB identity. Strategize together about how to handle reference checks for jobs performed under a different name or gender identity. Help your client apply for positions with TNB-affirming employers.

Screen for mental health concerns

Cumulative impacts of oppression may affect the mental health of TNB older adults. Social workers gatekeep access to gender-affirming health care and legal recognition. Your client may have had negative or controlling experiences with previous mental health providers. Assure your client that you will not use mental health diagnoses to deny them access to gender-affirming care. Disclose any limits on this so they can decide what to share in their work with you.

Help your TNB older adult client address unresolved grief and the impacts of trauma. They may grieve losses from waiting until later life to express their authentic gender or from rejection experienced in past attempts at self-expression. They may have experienced violence and other trauma related to their gender identity and expression. Grief and trauma may be activated by stories of TNB youth who are well-supported. TNB people may benefit from storying their gender journey and reframing traumatic experiences as they approach the end of life.

Plan for end of life

Among older adults, end-of-life planning can contribute to a sense of agency, increase the likelihood that one’s wishes will be respected, and reduce stress and uncertainty among loved ones. Assist TNB older adults to prepare for a safe end of life that is lived on their own terms. People who are legally entitled to make financial and medical decisions for your client and to inherit from them may not be who your client trusts or chooses. Develop with your client a durable financial power of attorney that names a trusted person to handle their finances. Help your client outline expectations for gender presentation, name, and pronoun in their advance care directive. Identify with your client a person to make medical decisions and advocate for respectful gender recognition, then name this person in a health care power of attorney and advance care directive. Help your client create a legal will naming those they wish to provide with an inheritance.

Make a plan with your client to receive care from a person or service that is likely to be TNB-affirming and competent. Identify assisted living facilities that train their staff to provide affirming care to TNB residents and actively enforce nondiscrimination policies based on gender identity and expression. Ask administrators how they identify and address bullying. Help your client consider their options if a TNB-affirming facility or caregiver cannot be identified or afforded.