LGBTQ Elders: The Growing Need for Gender-Affirming Care in Transgender Aging

Introduction: The Growing Need for Gender-Affirming Care in Transgender Aging

As I reflect on my personal journey of helping my father navigate the complexities of memory care following his diagnosis of Lewy Body Dementia, I am struck by the profound concerns I have for transgender individuals like me as we grow older. My father wasn’t trans or queer, but he was a fierce ally—someone who always supported my identity. Even as we faced the overwhelming challenges of his illness, he proudly acknowledged my earrings, a small yet significant affirmation of who I am. But as I spent time in the memory care facility, I couldn’t help but notice the subtle, poignant details of others who were navigating their own experiences. I saw the painted nails of a masculine-presenting patient, nervously hidden from the gaze of others. I caught glimpses of tear-filled eyes when a resident noticed my earrings, perhaps reflecting on a life where their own identity had to be carefully concealed.

These moments stay with me, and they raise troubling questions: What happens to transgender people like me when we age? Will we be met with the same understanding and acceptance that I was fortunate enough to experience? Or will our identities be overlooked, invalidated, or even erased in the very places meant to care for us? Now, as the Stonewall Generation—those who fought for LGBTQIA+ rights and visibility—enters their 70s and 80s, I find myself wondering how they are navigating these later stages of life. What happens when they require medical care, senior living arrangements, or memory care?

The 2021 Canadian Census marked a historic moment as it became the first national census to collect and publish data on gender diversity . Of the nearly 30.5 million people aged 15 and older in Canada, 100,815 were transgender or non-binary, accounting for 0.33% of the population . However, as these individuals age, the need for inclusive and gender-affirming care grows more pressing. Transgender elders, particularly those from the Stonewall Generation, face a healthcare system that was not designed with their identities in mind  .

This blog post will explore the urgent need for gender-affirming care for transgender and gender-diverse elders, with a focus on the unique challenges faced by those entering memory care, senior living, and long-term healthcare settings. I will also reflect on the intersectional barriers of ageism, racism, and transphobia that further complicate access to care. It is essential to create environments where trans elders, who have lived through decades of systemic discrimination, can age with dignity and pride.

Aging Out Loud: The Overlooked Struggles of Transgender Elders

Transgender aging is fraught with unique and compounding challenges that leave many older trans adults facing a crisis of care and support. These individuals—often referred to as part of the “Stonewall Generation”—have lived through monumental shifts in LGBTQIA+ rights. Yet, as they age, they find themselves navigating systems that remain deeply heteronormative and ill-prepared to meet their needs. While society has progressed in some areas, aging as a transgender person can feel like moving backward into an era of exclusion and invisibility.

One of the key issues transgender elders face is a lack of gender-affirming care in senior living and healthcare environments. The simple recognition of chosen names and pronouns, something foundational to one’s identity, is frequently overlooked in many facilities, causing profound emotional distress. According to Flanagan (2014), older transgender adults often avoid accessing essential social, psychological, and medical services due to fear of discrimination, leading to adverse outcomes in their physical and mental health (Flanagan, 2014). This avoidance, driven by concerns over misgendering and bias, underscores the persistence of “multiple jeopardy,” where ageism and transphobia intersect, creating significant barriers (Kattari & Hasche, 2016).

Furthermore, the NIH study on transgender older adults highlights that their gender identities are often undermined, putting their emotional and physical well-being at risk. This creates a tension between personal identity and the institutional realities they face (Kattari & Hasche, 2016). Such experiences underscore the need for a re-evaluation of aging systems and policies, particularly through the lens of queer theory, which advocates for “negotiating success on new terms” for marginalized communities (Kattari & Hasche, 2016).

To compound these difficulties, transgender elders are also more likely to experience social isolation, which is exacerbated by the loss of chosen families, who often serve as their primary support network. Mainstream senior care facilities rarely offer the affirming environments that LGBTQIA+ adults need to age with dignity. The fear of harassment or neglect in these settings can lead to further withdrawal from necessary support systems (Flanagan, 2014). This cycle of avoidance contributes to poorer health outcomes and highlights the critical need for inclusive, affirming care models.

By addressing the invisible struggles of transgender elders, we can begin to envision a future where aging systems reflect the diverse and intersectional realities of the people they serve.

Health Inequities and Gender-Affirming Care

Health inequities disproportionately affect older transgender individuals, creating challenges that are both systemic and deeply personal. As highlighted in the Transgender and Gender Nonconforming Health and Aging text, transgender elders face far greater health disparities than their cisgender counterparts, a reality shaped by decades of medical neglect, societal stigma, and compounded stress (Fredriksen-Goldsen et al., 2014). These disparities manifest in numerous ways: limited access to hormone replacement therapy (HRT), difficulty in finding healthcare providers who are knowledgeable about transgender health, and a significant lack of gender-affirming surgeries for older adults. These issues are part of a larger systemic failure to recognize and accommodate the needs of aging transgender individuals.

One of the most troubling aspects of these inequities is the erasure of identity in medical and caregiving settings. In my father’s memory care facility, I witnessed firsthand how subtle yet deeply personal aspects of identity—like gender expression—could be erased or disregarded entirely. While my father, a fierce ally, didn’t face the same challenges as a transgender person might, I couldn’t help but think about how much more devastating these experiences must be for transgender elders. I think often about the trans elders in similar facilities where care staff may not be adequately trained to understand or support their unique medical and emotional needs. If something as simple as a person’s chosen name or preferred pronouns can be neglected, it begs the question of how transgender patients’ more complex medical needs are being addressed—or more likely, neglected.

Research shows that transgender elders often avoid seeking medical care altogether due to fear of mistreatment, misunderstanding, or outright discrimination (Fredriksen-Goldsen et al., 2014). This avoidance can lead to delayed care, exacerbating chronic illnesses and contributing to poorer health outcomes overall. The fear of mistreatment is not unfounded. Transphobia, coupled with institutional ageism—a fear many of us share as we grow older—can cause a lifetime of accumulated trauma to resurface during the most vulnerable years of one’s life.

This avoidance is further complicated by the fact that many healthcare providers remain unaware of how to offer gender-affirming care. HRT, for example, is often treated as a treatment exclusive to younger trans individuals, with few options available for older trans people who either wish to start or continue hormone therapy in their later years. Additionally, gender-affirming surgeries—while more accessible for younger generations—are often out of reach for trans elders due to provider reluctance, lack of insurance coverage, or the assumption that such surgeries are not necessary later in life (Fredriksen-Goldsen et al., 2014). These systemic barriers highlight the urgent need for healthcare systems that prioritize gender-affirming care, regardless of a person’s age.

Ultimately, the health disparities transgender elders face are not just about physical well-being—they reflect a broader societal failure to recognize and validate their identities. Providing gender-affirming care is not only a medical necessity; it is an issue of dignity and respect. As we continue to advocate for improved healthcare access for all trans people, we must not overlook the specific needs of our elders, who deserve to age in environments that affirm their identities and experiences, not erase them.

Gender-Affirming Memory Care and Senior Living

The invisibility that transgender elders face in medical and long-term care facilities is one of the most urgent issues when it comes to aging with dignity. For transgender seniors, especially those living with cognitive decline or dementia, the lack of inclusive environments can have devastating effects on their mental and emotional well-being. As noted in Welcoming LGBT Residents, transgender elders often find themselves in environments that were not designed to affirm their identities, leaving them vulnerable to further trauma and isolation (Flanagan, 2014). For individuals who may no longer be able to advocate for themselves due to cognitive decline, having care staff trained in gender identity and affirming practices becomes essential to ensuring their dignity is upheld.

Staff training on the importance of respecting chosen names, gender-appropriate room assignments, and clothing is a foundational aspect of creating affirming care environments. These seemingly small details hold immense significance. A name, a pronoun, or even a choice of clothing can represent years of struggle, triumph, and self-realization for transgender individuals. When care staff disregard these details, it can reintroduce trauma that transgender elders have spent their lives healing from. In these moments of erasure, elders may feel their identities, once fiercely defended, are once again invalidated. It is not merely about comfort—these details are critical to an elder’s sense of self-worth and mental health. To ignore them is to ignore the whole person.

The implications of this are enormous. As more transgender elders enter long-term care and memory care facilities, the need for institutional changes is critical. According to research, transgender individuals often avoid or delay seeking out senior living arrangements due to fear of discrimination or being forced into environments where their identities are not respected (Flanagan, 2014). This fear, compounded by the physical and emotional toll of aging, leaves many trans elders in precarious positions, without access to the care they need.

For transgender individuals with dementia, gender-affirming care becomes even more complex and crucial. As memory fades, there is a risk that individuals may revert to early life experiences, including those lived before their gender transition. In these cases, care staff must be particularly sensitive to the possibility that a trans elder may unintentionally slip into using a former name or presenting in ways that reflect pre-transition identities. However, it’s essential that caregivers continue to affirm the elder’s current gender identity and not regress their care based on these moments of cognitive reversion. This balance requires care teams to have a deep understanding of gender identity and how dementia may impact transgender individuals uniquely.

Affirming care for transgender elders with cognitive decline involves acknowledging both the individual’s past and present identity. Even in moments where an elder may seem to forget their current gender expression, care teams must hold space for the person they are today. This compassionate, nuanced care can prevent additional psychological distress and uphold the dignity of transgender individuals who have fought long and hard to live as their authentic selves.

Creating gender-affirming senior living environments is not just about respecting identity; it’s about ensuring that transgender elders can age without fear of returning to the shadows of invisibility and discrimination. These environments provide a crucial space for healing, community, and dignity as elders navigate their later years.

The Intersectionality of Aging and Transgender Identity

Intersectionality—the concept that multiple identities and systems of oppression intersect to create unique experiences—is especially relevant when we examine the lives of transgender elders, particularly those who are Black, Indigenous, or people of colour (BIPOC). For these individuals, the challenges of aging while transgender are compounded by other factors such as racism, poverty, and disability, which further complicate their ability to access affirming care. Aging is already a vulnerable time, but for transgender elders navigating these intersecting forms of oppression, it can feel even more isolating and dangerous.

For transgender elders of colour, the healthcare system often reflects broader societal inequities. These individuals are more likely to face economic hardship, having been excluded from stable employment opportunities due to both transphobia and racism throughout their lives (Kattari & Hasche, 2016). As a result, they are often less financially prepared for aging, leaving them dependent on systems that may not cater to their needs or respect their identities. This economic insecurity is coupled with the challenge of finding healthcare providers who understand the complexities of aging as both a transgender and racialized person. The intersection of these oppressions means that transgender elders of colour are more likely to experience poor health outcomes, reduced access to appropriate care, and increased social isolation (Flanagan, 2014).

Disability also intersects with race and gender identity in powerful ways. Many transgender elders, particularly those who are BIPOC, are more likely to experience chronic health conditions exacerbated by a lifetime of stress, trauma, and discrimination. This reality places transgender elders with disabilities in an even more precarious position. The intersection of ableism and transphobia means that accessing supportive housing or medical care becomes not just a challenge, but a potential site of harm. Facilities that are ill-equipped to accommodate disabled transgender elders may overlook essential aspects of their care, leaving them vulnerable to both neglect and abuse.

At the heart of addressing these challenges is the creation of truly affirming communities. When transgender elders face not only transphobia but racism, ableism, and classism, they may withdraw from the services they so desperately need, fearing mistreatment or misunderstanding. It is not enough for senior living facilities to simply be “LGBTQ-friendly” on paper. These spaces must go beyond superficial gestures of inclusion and actively create environments where transgender elders of all backgrounds feel safe, valued, and a true sense of belonging.

Proactive inclusion must consider the intersectional experiences of transgender elders. This means that care facilities must be intentional about hiring and training staff who are equipped to understand and affirm the complex identities of transgender elders of colour. It means creating policies that don’t just tolerate but celebrate the diverse experiences of their residents, ensuring that transgender elders don’t have to choose between their gender identity and their cultural or racial identity when seeking care. These spaces must also recognize the specific economic challenges faced by transgender elders of colour and ensure that they are not excluded from care due to their financial situation.

Without this comprehensive and intersectional approach, transgender elders of colour will continue to face barriers to care, and their experiences of aging will be marked by fear and isolation. By committing to truly inclusive, affirming practices, senior living facilities and healthcare providers can begin to dismantle the oppressive systems that marginalize transgender elders and ensure that they are given the respect, care, and dignity they deserve.

Conclusion: Where Do We Go From Here?

As I continue to reflect on my father’s experience and the tears I’ve seen in the eyes of those unable to express their gender identity in their final years, I can’t help but worry about the future. What will happen when my peers and I need these services? Will we be treated with the dignity we’ve fought so hard to secure throughout our lives? Will the systems in place evolve fast enough to meet our needs, or will we be left in environments that erase our identities when we’re most vulnerable?

The truth is, the way we treat transgender elders today is a reflection of how we value their humanity. We must ask ourselves: are we prepared to ensure that those who have lived through a lifetime of systemic oppression, exclusion, and discrimination are allowed to age with dignity, care, and respect? Aging is not just a medical process—it is a deeply personal journey that intertwines with identity, community, and belonging. For transgender elders, the need for care that goes beyond basic medical needs and addresses the wholeness of their experiences is paramount.

It’s not too late to change the course of care for transgender elders. Providers, caregivers, and policy-makers alike must recognize that gender-affirming care in senior living and healthcare settings is not optional—it is a human right. The dire need for gender-affirming care cannot be overstated. This is not just about ensuring that names and pronouns are respected, but about creating environments where transgender elders feel seen, celebrated, and cared for in a way that affirms their identities throughout their final years. These individuals, many of whom have fought tirelessly for the rights of future generations, deserve to be honoured, not merely tolerated.

Where do we go from here? We must push for a future where transgender elders are not just cared for but uplifted by systems that celebrate the richness of their identities. A future where affirming, inclusive care is the norm, not the exception. By addressing the gaps in care now, we can ensure that transgender elders are surrounded by communities that honour their lives, support their journeys, and offer them the dignity they deserve in every stage of aging.

Let’s Continue the Conversation

If the ideas in this blog resonate with you or someone you love, I invite you to reach out. Whether you’re a therapist seeking guidance on providing gender-affirming care for transgender elders or someone navigating the complexities of aging and looking for support, I’m here to help. You may book individual therapy or peer consultations online. Be sure to bookmark this blog for future insights, reflections, and updates.

References

Flanagan, A. (2014). Welcoming LGBT residents: A practical guide for long-term care homes. Egale Canada Human Rights Trust.

Fredriksen-Goldsen, K. I., Kim, H. J., Emlet, C. A., Muraco, A., Erosheva, E. A., Hoy-Ellis, C. P., Goldsen, J., & Petry, H. (2014). The health and well-being of LGBT older adults: Disparities, risks, and resilience across the life course. The Gerontologist, 54(3), 488-500. https://doi.org/10.1093/geront/gnt021

Kattari, S. K., & Hasche, L. (2016). Differences in aging and health concerns among transgender and gender non-conforming adults: Implications for social work practice. Social Work in Health Care, 55(4), 227-243. https://doi.org/10.1080/00981389.2015.1134207