IMPROVING THE LIVES OF TRANSGENDEROLDER ADULTSRecommendations for Policy and Practice

SAGE (Services and Advocacy for GLBT Elders) and National Center for Transgender Equality (NCTE)

EXECUTIVE SUMMARY

Aging poses unique challenges for transgender older adults. They came

of age during decades when transgender people were heavily stigmatized

and pathologized. Some came out and made gender transitions during

these years, while many others kept their identities hidden for decades

and are now coming out and transitioning later in life. Many challenges

facing transgender elders are common to the broader older lesbian,

gay, bisexual and transgender (LGBT) population, but some are different.

With a growing older transgender population, there is an urgent need to

understand the challenges that can threaten financial security, health

and overall well-being.

Improving the Lives of Transgender Older Adults responds to these concernsby examining the social, economic and service barriers facing this population. This report includes a detailed literature review, profiles of the experiences oftransgender elders around the country and more than 60 concrete recommendationsfor policymakers and practitioners.

MORE ON SAGEUSA.ORGAND TRANSEQUALITY.ORG

Download the full report,Improving the Lives ofTransgender Older Adults,as well other resources on issues described in the report.

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Aging Service BarriersToday’s aging services network provides a wide range of critical services for olderadults, from meals and transportation to educational activities and legal help. Yet this network is currently ill-equipped to provide competent andnondiscriminatory services to transgender older adults, or to address their uniqueneeds. Few aging providers offer cultural competence training or outreach specific totransgender communities. Many transgender older adults are not getting the supportthey need, and many are reluctant to seek services at all.

Health Care BarriersA lack of cultural and clinical competence regarding transgender people and their health needs, as well as bias and outright discrimination by providers, create seriousbarriers to quality care for transgender older adults. These barriers, together withfinancial barriers, mean that many transgender older adults often avoid or delayseeking care. In addition, medically necessary care related to gender transition isoften arbitrarily excluded from public and private insurance. Inability to access thiscare can contribute to declining health, and these exclusions are often also used todeny coverage for preventive and other medical care transgender older adults need.

Health DisparitiesThe confluence of widespread discrimination across the lifespan, weaker supportnetworks, and barriers to quality care contribute to poor health outcomes for manytransgender older people. Transgender people report higher rates of disability, generalpoor health, depression, anxiety, loneliness and suicidal ideation. Thus, manytransgender elders enter their later years with severe health concerns yet without thesocial and community supports to manage their health.

DID YOU KNOW?

A recent Institute ofMedicine report on LGBThealth identified transgenderaging as a major researchgap, naming topics suchas elder abuse, substanceabuse, risks and bestpractices for long-termhormone therapy, sexualhealth and cancer as areasin which more transgenderresearch is needed.

Source: National Academy ofSciences. (2011). The health oflesbian, gay, bisexual, andtransgender people: Building afoundation for better understanding.Washington, DC: Institute ofMedicine of the NationalAcademies.

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Snapshot: Key Challenges Facing TransgenderOlder Adults

ViolenceMultiple studies have shown that transgender people across the age spectrum—and particularly transgender people of color—face alarmingly high rates of physical and verbal violence, including child abuse, sexual violence, intimate partner violence,workplace violence and hate crimes. With smaller support networks, transgender eldersare also at greater risk of elder abuse, exploitation and neglect, yet might be less willingto report cases of violence and abuse for fear of discrimination and further violence.Research has shown that transgender people’s experiences of trauma can increase the likelihood of long-term health and social problems. Agencies working to addresselder abuse may be ill-prepared to offer competent support to trans older adults.

Employment and Housing DiscriminationThe employment and economic security challenges experienced by many olderpeople are even more pronounced for transgender older adults. Transgender peopleface high levels of employment and housing discrimination, and consequent economicand housing instability. Many have lost jobs and homes due to discrimination. Theeconomic and personal impact of this discrimination can accumulate over a lifetimeand impact earnings, savings and Social Security benefits. Even those who transitionin mid-life and start out financially secure are often devastated by discrimination.

In 2011, members of the AdvisoryCommittee for the Transgender AgingAdvocacy Initiative met in Washington, DCto agree on immediate advocacy prioritiesthat would support transgender elders.Clockwise, from upper right: Aaron Tax, SAGE;Bishop Tonyia M. Rawls, Freedom Center for Social Justice; Masen Davis, Transgender Law Center; Barbara Satin, GLBT Generations;Earline Budd, Transgender HealthEmpowerment; Harper Jean Tobin, NationalCenter for Transgender Equality; and Joo-Hyun Kang, initiative facilitator. See the full list of committee members on the back of this summary.

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Privacy and Documentation IssuesIdentification documents are frequently required for employment, housing, publicbenefits, bank accounts and more. For transgender older adults, IDs and officialrecords that don’t accurately reflect their names and gender identities compromisetheir privacy and lead to harassment, discrimination and even bias-driven violence.Unfortunately, many states and some federal agencies impose intrusive andburdensome requirements for updating gender designations—such as documentingspecific surgeries or obtaining a court order—that many transgender people cannotmeet for financial, medical and other reasons.

Limited Knowledge BaseThe research base on transgender aging is severely limited, which makes it difficult to assess the specific needs of transgender older people, as well as craft effectiveinterventions for this population. An overarching problem is lack of data; mostfederal surveys and data collection systems do not assess gender in ways that allowfor transgender individuals to be identified. Little is known about the health needsof trans people in later life, including how transition-related medical care should bemonitored or modified as individuals age. Finally, there is a lack of information onbest practices in researching hard-to-reach elder people (including transgenderelders), which means that much of the existing data on transgender older people areunrepresentative of the broader population, particularly poor and low-incometransgender elders and transgender elders of color.

Community Support and EngagementWhile many transgender older adults have strong community ties and families ofchoice, too many are socially isolated and lack opportunities to be actively engagedin their communities. Many feel unwelcome at senior centers, volunteer programsand even at LGBT community centers, which they may perceive as unfriendly totransgender people or to elders generally. While personal faith and membership in a faith community have been important parts of many transgender older adults’lives, many find themselves estranged or disconnected from those communitieswhen they come out and transition. All of these barriers are not only detrimental to the well-being and health of individuals, but also to communities that couldbenefit from their energies and contributions.

To learn more about these topics, download the full report, Improving the Lives of Transgender Older Adults, at sageusa.org or transequality.org.

?DID YOU KNOW?

According to the 2011National TransgenderDiscrimination Survey, 90 percent of respondentshad experiencedtransphobic discrimination at work and 24 percenthad lost their jobs becauseof their employers’discomfort with theirtransgender identities.

Source: Grant, J.M., Mottet, L.A.,Tanis J., Harrison, J., Herman, J.L.,& Keisling M. Injustice at everyturn: A report of the nationaltransgender discriminationsurvey. (2011). Washington, DC:National Center for TransgenderEquality and National Gay andLesbian Task Force.

1 Strengthening the Aging Services Network

• The Administration on Aging (AoA)should clarify, through agency guidance,that LGBT older adults constitute a groupwith “greatest social need,” and thatfederally-funded service providers may notexclude LGBT older adults from programsand services.

• Congress should reauthorize and fullyfund the Older Americans Act (OAA), and should include LGBT older adults in data collection, project assessment andreporting requirements, and explicitlyinclude LGBT older adults in the definitionof greatest social need.

2 Strengthening Long-Term Servicesand Supports in Long-Term Care

• Federal and state agencies andcommunity organizations should develop and promote LGBT culturalcompetence training, best practices, andtools for long-term care facility staff,surveyors, ombudspersons, and homehealth care providers.

• The Centers for Medicare & MedicaidServices (CMS) should revise federalMedicaid conditions of participation to explicitly prohibit discrimination basedon gender identity and sexual orientationin home- and community-based services;and revise federal nursing homesurveyors’ guidelines to clarify the rights of transgender residents to respect fortheir gender identity, autonomy in theirgender expression, privacy regardingissues related to transgender status andfreedom from bias-related harassment,discrimination and abuse.

3 Protecting Individual Privacy

• The Social Security Administration (SSA)should eliminate gender as a data field inall its automated verification programs,and update policies to permit an individualto change the gender designation in her or his SSA record based on a letter from a physician stating that she or he hashad appropriate clinical treatment forgender transition.

4 Building a Foundation of Knowledge

• The Department of Health and HumanServices should include questions thatmeasure gender identity and sexualorientation in federal population-basedsurveys, such as the National HealthInterview Survey, as well as surveysfocused on older adults.

• The Office of the National Coordinator forHealth Information Technology shouldinclude the collection of data on sexualorientation and gender identity within itsmeaningful use standards for electronichealth records.

In addition, Improving the Lives of Transgender Older Adults includes more than 60 specific recommendationsto address the challenges described in the report.

Read more at sageusa.org or transequality.org.

Immediate Policy and Practice Priorities to Improve the Lives of Transgender Older Adults

In 2011 SAGE and the NationalCenter for Transgender Equalitylaunched a historic TransgenderAging Advocacy Initiative to outline the many policy and practice barriers facingtransgender and gender non-conforming older adults,as well as some key solutionsfor addressing these barriers.

To help inform and create this advocacy roadmap, webrought together a diversecommittee of leading expertsfrom around the country.

The Advisory Committee of theTransgender Aging AdvisoryInitiative (listed on the back of this executive summary)identified several immediate policy and practice priorities toimprove the lives of transgenderolder adults. While all of the issues outlined in the full report are important, the prioritieslisted below were identifiedbased on their expected impactif accomplished, as well as the expected feasibility ofaccomplishing them within thenext 1-2 years.

© 2012 Services and Advocacy for GLBT Elders and National Center for Transgender Equality

Services & Advocacy for GLBT Elders 305 Seventh Avenue 15th FloorNew York, NY 10001212-741-2247info@sageusa.orgsageusa.orglgbtagingcenter.org

National Center for Transgender Equality1325 Massachusetts Avenue, NWSuite 700Washington, DC 20005202-903-0112NCTE@transequality.orgtransequality.org

ACKNOWLEDGEMENTS

SAGE and NCTE would like to thank the Arcus Foundationand the David Bohnett Foundation for their generous supportof this initiative and this policy report. We are also deeplygrateful to the members of the Advisory Committee of theTransgender Aging Advocacy Initiative for offering theirwisdom, experience and commitment to this historic initiative.The ideas detailed throughout this policy report are largelyinformed by your unique insights. Finally, we would like tothank Joo-Hyun Kang for facilitating the 2011 gatherings ofthe Transgender Aging Advocacy Initiative.

Alan AcostaL.A. Gay and Lesbian Center

Kellan BakerCenter for American Progress

Hope A. Barrett, MPHCenter on Halsted (formerly)

Earline BuddTransgender Health Empowerment

Natalie ChinLambda Legal

Loree Cook-DanielsFORGE/Transgender Aging Network

Masen DavisTransgender Law Center

Robert EspinozaSAGE

Maximilian E. Fuentes Fuhrmann, Ph.D.Clinical Psychologist/Gerontologist

Amy E. GotwalsNational Association of AreaAgencies on Aging

Mara KeislingNational Center for Transgender Equality

Bishop Tonyia M. RawlsFreedom Center for Social Justice

Daniel R. RedmanNational Center for Lesbian Rights

Barbara SatinGLBT Generations and National Gay andLesbian Task Force

Beatrice SimpkinsFreedom Center for Social Justice

Moonhawk River Stone, M.S.LMHC, Psychotherapist

Harper Jean TobinNational Center for Transgender Equality

Serena WorthingtonSAGE

TRANSGENDER AGING ADVOCACY INITIATIVECOMMITTEE MEMBERS