Reactions and Preferences for Training Among Area Agency on Aging Providers Working With Transgender and Gender Nonconforming Older Adults

Abstract

Transgender and gender nonconforming (TGNC) older adults face numerous barriers to healthy aging. These older adults may be less likely to seek out aging-focused services due to fear of discrimination and a lack of culturally competent services. There is a dearth of trainings for aging-focused professionals that would contribute to the development of affirming service environments for TGNC older adults. The current study explores providers’ responses to a professional development training made available nationwide to staff and volunteers of area agencies on aging. Participants’ (N = 155) reflections on what would be most helpful in their future work with TGNC older adults included requests for role-plays, instructions on creating more inclusive agency documents, increased contact with TGNC older adults, and managing discriminatory language in the workplace. Future directions include creating professional development opportunities that incorporate experiences with and exposure to both other aging-focused providers and TGNC elders.

Keywords

LGBTQ successful aging access to care gender home- and community-based care and services

Transgender and gender nonconforming (TGNC) older adults are an underserved and understudied population. Healthy aging among TGNC adults may be inhibited by social isolation, disproportionate poverty and health disparities, and a lack of access to culturally competent care, services, and supports (Fredriksen-Goldsen et al., 2011). Transgender older adults report concerns about quality of care when they experience discomfort with their providers, especially regarding a discrepancy between perceived gender identity and physical body state (Lev & Sennott, 2012). These older adults also report fear of increased barriers to care as they age, including being denied care (Espinoza, 2014). Fears of discrimination coupled with the lack of culturally competent services contribute to TGNC older adults being less likely than their cisgender peers to take advantage of aging-focused supports (Adams, 2011; Mayer et al., 2008). Although there are attempts and calls to develop innovative trainings for professionals, current levels of continuing education are insufficient for the appropriate and affirmative aging services needed by TGNC elders (Boggs et al., 2017; Hughes et al., 2016; Porter et al., 2016).

Published research on provider attitudes toward transgender individuals is minimal and tends to include a focus on lesbian, gay, bisexual, and transgender (LGBT) populations combined rather than specifically on transgender individuals (Shetty et al., 2016). Because attitudes toward lesbian, gay, and bisexual (LGB) individuals are likely to be more positive than those toward TGNC individuals (Norton & Herek, 2013), this conflation significantly limits the knowledge gained from LGBT-focused research. Negative attitudes, specifically transphobia, may act as a barrier to the provision of knowledgeable care; education alone, formal or informal, may not be sufficient to increase competencies for working with TGNC individuals among health care providers (Stroumsa, Shires, Richardson, Jaffee, & Woodford, 2019). It remains unclear how transphobia is directly addressed in the trainings being mandated and provided for aging-focused professionals across the United States.

Several states are leading the nation in a focus on mandated training for aging service professionals. The state of Massachusetts, for example, developed an innovative approach to inclusive aging programming that can function as a model for other states willing to actively serve older TGNC adults. The LGBT Aging Project, established in 2001 and now functioning as a nonprofit organization, aims to ensure older LGBT adults and their caregivers maintain equal access to services and institutions that are more easily utilized by heterosexual and cisgender older adults (Krinsky & Cahill, 2017). To facilitate change in existing systems, the LGBT Aging Project initiated cultural competency training, known as the Open Door Task Force, for Aging Service Access Points (ASAPs). This training specifically targets agencies that contract with the State Unit on Aging and provides a single entry point for elders to access various services and programs. In July 2018, a bill entitled “An Act Relative to LGBT Awareness Training for Aging Services Providers” was signed into law that expressly mentions both gender identity and gender expression. This is notable as TGNC aging continues to most often be lumped with the discussion of lesbian, gay, bisexual, and queer (LGBQ) aging even when research suggests elder transgender adults are at higher risk than older cisgender LGBQ adults for poor health outcomes and elevated levels of discrimination and victimization (Cartwright, Hughes, & Lienert, 2012; Fenge, 2012; Fredriksen-Goldsen, Hoy-Ellis, Goldsen, Emlet, & Hooyman, 2014; Haas et al., 2011). TGNC older adults also tend to have more limited physical activity and social support, which makes their needs for affirming aging services especially significant within a system that aims to help older adults age in place (Fredriksen-Goldsen et al., 2014).

Aging-focused organizations across the country might follow the example set by the LGBT Aging Project in Massachusetts, which included a call for training professionals. In 2008, California legislature followed suit and called for the California Department of Public Health to prescribe a training program aimed at preventing and ultimately eliminating discrimination against TGNC and LGBQ adults in skilled nursing facilities and congregate living facilities (SB-1729 Health facilities: training). The training curriculum was mandated to include a subsection focused specifically on transgender older adults (DPH-14-006; LGBT Training Requirements). Such state-sanctioned and funded opportunities exist in stark contrast to opportunities in other areas within the United States. Of 316 area agencies on aging surveyed across the United States, approximately one third offered or funded staff training about TGNC aging, whereas only 23 provided targeted services to TGNC older adults (Knochel, Croghan, Moone, & Quam, 2012). Approximately 60% of directors surveyed believed there was a need to address issues specific to TGNC older adults. This admission of need from providers as well as the lack of evidence-based educational programs for aging-focused providers should serve as the impetus for creating targeted training opportunities for professionals working with older adults.

In the discussion of training and educational programs, no study so far has considered the expressed needs and preferences of staff in aging-focused organizations. Agency context should not be overlooked as employees contribute significantly to the culture that is experienced not only by fellow employees but also by the older adults served by that agency. In addition, staff in aging-focused organizations may provide insight into idiosyncratic agency needs. Although there are movements within a few states to fully integrate professional education aimed at reducing discriminatory practices and creating affirming environments for older TGNC adults, there remains a dearth of empirically based information about what types of trainings are most needed, including types of continuing education. Similarly, the particular needs and reactions of aging-focused professionals have been overlooked.

The current study aims to explore providers’ responses to a professional development training focused on affirmative interactions with TGNC older adults. Specifically, the study reviews personal and professional experiences with TGNC individuals and explicates the connection between these experiences and the participants’ knowledge, attitudes, and self-efficacy related to gender identity, gender expression, and affirming interactions. Participants’ recommendations for future professional education opportunities are also included. The larger research literature on ageism suggests that personal and professional contact with older adults is an important predictor of attitudes and interest in receiving training (Levy, 2018; Qualls, Segal, Norman, Niederehe, & Gallagher-Thompson, 2002). Considering this, we were particularly interested in examining whether experience with TGNC older adults was related to attitudes, perceived self-efficacy for interactions, and interest in additional training opportunities.

Methods

Study Design and Participants

The data presented in this current study were gathered within the context of a larger study comparing different educational approaches for providers within area agencies on aging (AAAs). All assessment and intervention tasks were conducted online, which allowed for nationwide recruitment. The project was advertised through direct e-mails to administrators and directors of approximately 600 AAAs nationwide. E-mails to AAA directors and administrators included the invitation to participate in a “free professional education opportunity” and a brief description of the study as an attempt to evaluate “different educational strategies for how to provide more affirmative services to older transgender and gender nonconforming adults.”

Participants were employees or volunteers in AAAs across the United States (n = 155). The participants (Table 1) represented 32 states, ranged in age from 21 to 84 (M = 45.19, SD = 13.89) years, and the majority identified as women (85.2%), White/Caucasian (82.6%), and Christian (62.6%) with a median income of US$70,000 to US$84,999. Participants were primarily full-time AAA employees (87.1%) with an average of 7.05 years at their current agency (Table 2).

Table 1.

Demographic Characteristics of Participants (N = 155).

Characteristics	N	%
Employment status
Full-time	135	87.1
Part-time	14	9.0
Volunteer	6	3.9
Disciplinary background
Social work	45	29.0
Psychology	19	12.3
Business administration	16	10.3
Education	9	5.8
Medicine	5	3.2
Law	3	1.9
Other	58	37.4
Gender
Woman	132	85.1
Man	18	11.6
Transgender	2	1.3
Queer/Nonbinary	3	2.0
Sexual orientation
Heterosexual	120	77.4
Bisexual	13	8.4
Gay	7	4.5
Lesbian	5	3.2
Asexual	4	2.6
Queer	2	1.3
Not listed	4	2.6
Age, years
21-30	19	12.3
31-40	39	25.2
41-50	40	25.8
51-60	37	23.9
61-70	17	11.0
71-84	3	1.9
Racial/Ethnic identity
White/Caucasian	134	86.5
Black/African American	9	5.8
Hispanic/Latino	9	5.8
Biracial/Multiracial	6	3.9
Native American/Eskimo/Aleut	3	1.9
Asian/Pacific Islander	2	1.3
Prefer not to self-identity/Not listed	1	0.6

Table 2.

Demographic Characteristics of Area Agencies on Aging (N = 155).

Characteristics	N	%
Number of employees in organization
1-10	19	12.3
11-20	31	20.0
21-30	24	15.5
31-40	20	12.9
40+	61	39.4
Years at agency
Less than 1	23	14.8
1-5	63	40.6
6-10	25	16.1
11-15	24	15.5
16-20	10	6.5
21-25	4	2.6
26-30	3	1.9
31-35	3	1.9

Procedure

Individuals who met study criteria (i.e., an employee or volunteer within the agency and provided informed consent for the study) completed demographic items and six measures in addition to the open-ended survey assessment that is the focus of this article. The results presented in this article were all collected immediately after participation in the intervention. Postintervention data from all participants were pooled and used for these analyses. This project was reviewed by the associated university’s institutional review board (IRB; 810395-2), and approval was given before initiation of data collection. Participants were informed they would have the opportunity to enter a raffle for a new iPad following completion of the survey.

Measures

Descriptives

Participants provided basic demographic and professional information including age, gender and racial/ethnic identity, sexual orientation, employment status at agency, and disciplinary background and level of education. Agency-level information included location (state-level) and number of employees.

Transgender knowledge, attitudes, and beliefs

Participants completed the 10-item Knowledge of TGNC Terminology scale (Israel, Harkness, Delucio, Ledbetter, & Avellar, 2014), which measured objective knowledge of TGNC terminology. This measure requires participants to match each term (e.g., gender identity) to its respective definition. One point was provided for each correct answer and the total number of points earned reflected the participant’s total score with a maximum possible score of 10. This scale demonstrated excellent internal consistency in the current study (α = .79).

The 17-item Genderism/Transphobia subscale (e.g., People are either men or women) of the Genderism and Transphobia Scale–Revised (GTS-R; Tebbe, Moradi, & Ege, 2014) assessed negative attitudes toward TGNC individuals and demonstrated excellent internal consistency in the current study (α = .95). Items were rated on a 7-point Likert-type scale with response choices ranging from 1 (strongly disagree) to 7 (strongly agree). Item ratings were averaged to produce GTS-R subscale and overall scale scores, with higher scores indicating greater anti-TGNC prejudice.

The TGNC Language Self-Efficacy for Interactions subscale (e.g., I am confident I can ask an older adult their preferred pronouns; Warren & Steffen, 2018) assessed participants’ confidence in using affirmative language while conversing with TGNC older adults in a professional setting. The instructions and scaling were based on Bandura’s (2006) recommendations for the measurement of self-efficacy, using a 0 to 100 scale where higher scores indicated greater belief in their ability to perform the behavior. The subscale included six items and demonstrated strong internal consistency for postintervention scores (α = .89).

Gender role beliefs

The Gender Role Beliefs Scale (GRBS; Kerr & Holden, 1996) contained 20 items (e.g., The initiative in courtship should usually come from the man) measuring gender role ideologies (1 = strongly agree, 7 = strongly disagree). Higher scores indicate more feminist gender role beliefs. In the current study, this 20-item scale demonstrated excellent internal consistency (α =.90).

Traditional Beliefs about Gender and Gender Identity Scale (Dasgupta & Rivera, 2006) includes 15 items reflecting the degree to which individuals endorsed traditional prescriptive gender norms in various life domains (e.g., professional life and physical appearance) and the degree to which people were invested in emphasizing their heterosexual identity to others and to themselves. These items were rated on a 7-point Likert-type scale (1 = strongly disagree, 7 = strongly agree). Higher scores indicated more traditional beliefs about gender roles and gender identity. This 15-item measure demonstrated excellent internal consistency (α = .90) in the current study.

Experiences, reactions, and preferences for working with TGNC older adults

A seven-item assessment was created for this study and divided into Sections A and B. Section A provided a flexible, open-response format to assess participants’ experiences interacting with TGNC individuals in professional and personal contexts (e.g., “Approximately how many transgender or gender nonconforming persons have you had contact with in a personal context?”). For use in analyses, contact with TGNC individuals in personal contexts and contact in professional contexts were both recoded to reflect no contact or any contact (0, 1). Additional questions assessed worries and concerns related to working with TGNC older adults (e.g., “How did it feel to have this training?”) along with professional education needs relevant to this topic area (i.e., “What do you believe would be most helpful to you in your professional context should you need to learn more about working with TGNC older adults?”).

In Section B, participants were asked to use drop-down menus to rate the intensities of reactions during the professional development training using a scale of 0% to 100% (0 = not at all to 100 = most possible): eagerness to learn more, relieved to have the information, confusion, disgust, and anger. They were also asked, using a similar scale of 0% to 100% (0 = not at all worried to 100 = most worry possible) how much they worry about the following when working with TGNC older adults: feeling offended, offending the older adult, using the wrong pronoun, using the wrong name, feeling uncomfortable, making the older adult feel uncomfortable, not being able to perceive someone’s gender identity, feeling angry about working with the older adult, coping with discomfort using the terms TGNC, and working with an older adult who does not meet one’s idea of a “man” or “woman.”

Data Analysis

No missing values were present in this data set. All responses to primary measures were marked in the survey software as “required” items due to the anticipated difficulty in recruitment and potential dropout. As described above, all data were screened for high quality of responses. One participant was removed due to the length of time spent completing the study in comparison with others. All data were screened for normality; normality was not improved with transformations so no transformations were performed prior to analyses. In instances where statistical outliers were identified in the primary measures, mean value substitution was used to replace outlying values. This was infrequent and occurred in less than 4% of cases.

Independent sample t-tests were used to compare study completers and noncompleters on age, years at agency, and primary outcome variables. In addition, independent samples t-tests were used to examine the potential relationship between contact with TGNC individuals and eagerness to learn more about working with TGNC older adults. The relationship between the primary outcome measures (i.e., knowledge of TGNC terminology, anti-TGNC prejudice, and self-efficacy for affirmative interactions) and contact was similarly examined. The Pearson product–moment correlations for the variables used in this study are presented in Table 3.

Table 3.

Means, Standard Deviations, and Intercorrelations (N = 155).

Measure	M	SD	1	2	3	4	5
1. Knowledge of Transgender and Gender Nonconforming Terminology	7.23	2.54	__
2. Transgender and Gender Nonconforming Language Self-Efficacy Scale: Interactions	88.22	15.23	.39*	__
3. Genderism and Transphobia Scale–Revised	1.94	1.05	−.39*	−.46*	__
4. Gender Role Beliefs Scale	5.47	0.87	.40*	.43*	−.80*	__
5. Traditional Beliefs about Gender and Gender Identity Scale	2.20	0.93	−.47*	−.53*	.84*	−.81*	__

Note. Correlations significant at *p < .01.

Results

Because this study was conducted within the context of a larger study on educational approaches for providers within AAAs, participant dropout was examined. Individuals who provided consent, identified themselves as an employee or volunteer in an AAA, completed the preintervention measures, and did not complete the postintervention measures were considered noncompleters (n = 25). Two notable differences emerged between completers and noncompleters. Participants who dropped out prior to completing the postintervention measures tended to be older than those who completed the study (p < .01; age of completers M = 45.9, SD = 13.0; age of noncompleters M = 54.0, SD = 11.1). In addition, those who dropped out also demonstrated a lower preintervention level of knowledge of TGNC terminology (p = .01; Completers M = 6.7, SD = 2.8; noncompleters M = 5.2, SD = 2.4).

Descriptive Outcomes

The Pearson product–moment correlations for the formal measures used in this study are presented in Table 3. As can be seen from this table, all variables were significantly correlated.

Outcomes of Experiences and Preferences for Working With TGNC Older Adults: Section A

Personal and professional interactions with TGNC individuals

Responses in Section A varied greatly among participants because the format allowed participants to write in their responses. Most participants (n = 151; 98.1%) responded to questions about how many TGNC individuals they interact with in personal and professional contexts. A majority of participants (n = 105; 67.7%) reported they were aware of interacting with TGNC individuals in a personal context, and many participants (n = 99; 63.9%) noted they were aware of interacting with TGNC individuals in a professional context.

Independent samples t-tests were used to examine the potential relationship between contact with TGNC individuals and knowledge of TGNC terminology, anti-TGNC prejudice, and self-efficacy for affirmative interactions with TGNC individuals. For the variable that assessed contact with TGNC individuals in a professional context (Table 4), postintervention anti-TGNC prejudice was significantly lower for professionals who endorsed contact, M = 1.76, SD = .96, compared with participants who reported no contact with TGNC individuals, M = 2.20, SD = 1.14. Participants who reported contact with TGNC individuals in a professional context, M = 90.63, SD = 13.80, reported greater levels self-efficacy for interactions following the intervention than those who reported no contact, M = 85.08, SD = 16.60. Yet, individuals with professional contact with TGNC individuals, M = 74.4, SD = 33.8, were not more eager to learn additional information than individuals with no professional contact, M = 70.3, SD = 33.8.

Table 4.

Comparison Between Professional Contact With TGNC Individuals and No Professional Contact on Primary Outcome Measures and Eagerness to Learn (N = 152).

Variable	Professional contact (n = 88)	No professional contact (n = 64)	t	p value
Knowledge of TGNC Terminology	7.40 (2.72)	7.00 (2.32)	−0.95	.35
Genderism and Transphobia Scale–Revised	1.76 (0.96)	2.20 (1.14)	2.59	.01
TGNC Self-Efficacy Scale: Interactions	90.63 (13.80)	85.08 (16.60)	−2.25	.03
Eagerness to Learn	74.36 (33.83)	70.28 (33.85)	−0.73	.47

Note. TGNC = transgender and gender nonconforming.

Individuals who reported contact with TGNC individuals in their personal lives, M = 7.70, SD = 2.42, demonstrated higher levels of knowledge of TGNC-related terminology than those who reported no contact in their personal lives, M = 6.55, SD = 2.52 (Table 5). In addition, participants who reported contact in their personal lives, M = 1.68, SD = 0.94, reported lower levels of postintervention anti-TGNC prejudice compared with participants who reported no contact with TGNC individuals in their personal lives, M = 2.38, SD = 1.11. Participants who reported contact in their personal lives, M = 91.69, SD = 12.97, demonstrated greater postintervention levels of self-efficacy for affirmative interactions compared with participants who reported no contact with TGNC individuals in their personal lives, M = 83.02, SD = 16.91. However, individuals with personal contact with TGNC individuals, M = 76.1, SD = 32.7, were not more eager to learn than individuals with no personal contact, M = 67.6, SD = 35.4.

Table 5.

Comparison Between Personal Contact With TGNC Individuals and No Personal Contact on Primary Outcome Measures and Eagerness to Learn (N = 151).

Variable	Personal contact (n = 96)	No personal contact (n = 55)	t	p value
Knowledge of TGNC Terminology	7.70 (2.42)	6.55 (2.52)	−2.74	.01
Genderism and Transphobia Scale–Revised	1.68 (0.94)	2.38 (1.11)	4.13	.00
TGNC Self-Efficacy Scale: Interactions	91.69 (12.97)	83.02 (16.91)	−3.29	.00
Eagerness to Learn	76.13 (32.72)	67.58 (35.40)	−1.49	.14

Note. TGNC = transgender and gender nonconforming.

Professional concerns about interacting with TGNC older adults

Responding to open-ended questions, most participants (n = 149; 96.1%) identified and documented concerns and worries about interacting with TGNC older adults in their specific AAA. Many participants (14.8%) described worries about providing an inclusive environment for TGNC older adults, including being able to connect these older adults with affirming and supportive services in their area. These concerns included the potential lack of resources or lack of knowledge about resources in their area. Others (1.3%) expressed apprehension about consistency of data entry within their agency. Some participants (20.8%) articulated worry for these older adults both in the larger context of elder care services and in regard to how TGNC older adults may be treated by cisgender older adults. Others (14.8%) expressed nervousness about asking clients about gender identity and pronoun use, whereas other participants (29.0%) noted they fear “saying the wrong thing.”

Reactions following the professional training

Most participants (n = 147; 94.8%) responded to the open-ended items regarding how it felt to participate in this professional development training. Many participants’ written responses expressed satisfaction (45.6%) or dissatisfaction (22.4%) with the training and information. Those who expressed dissatisfaction noted they felt uncomfortable, bored, confused, or disgusted while completing the study. Some participants (12.9%) noted the information presented led them to reflect on their own identities more closely.

Recommendations for professional training

Participants (n = 146; 94.2%) also reported beliefs about helpful continuing education efforts related to working with TGNC older adults. As can be seen in Table 6, responses from this open-ended question ranged from how to shift the professional environment to coping with cognitive dissonance.

Table 6.

Participants’ Recommendations for Future Professional Trainings.

What do you believe would be most helpful to you in your professional context should you need to learn more about working with TGNC older adults?
	Percentage of participants
Additional trainings	43.1%
“Tip sheets” or other methods to communicate to agencies how they might create more inclusive environments	13.0%
Trainings that involve watching other professionals model affirming interactions with TGNC older adults	12.3%
Increased interactions with TGNC older adults in training contexts and in professional environments	11.0%
Instructions on how to change paperwork and other documents to reflect more inclusive langauge and fewer binary choices	3.4%
Opportunities to engage in role-plays	3.4%
How to handle discriminatory language used in the workplace or professional environment	2.7%

Note. TGNC = transgender and gender nonconforming.

Outcomes of Experiences and Preferences for Working With TGNC Older Adults: Section B

Reactions during the professional development training

In Section B, participants were asked to use a sliding scale of 0 to 100 to rate the intensities of experiences (n = 152; 98.1%) and worries (n = 154; 99.4%) while completing the study (Table 7).

Table 7.

Participants’ Reactions and Worries to the Professional Development Training.

	M	SD
When completing this professional development training, I felt:^a
Eager to learn more	72.62	33.56
Relieved to have the information	50.66	39.85
Confused	13.11	24.68
Disgusted by the information	3.46	13.14
Angry	3.01	12.56
When working TGNC older adults, I worry about:^b
Offending the older adult	52.47	34.69
Making the older adult uncomfortable	50.45	35.33
Using the wrong pronoun	45.19	32.88
Not being able to perceive someone’s gender identity	39.10	33.51
Using the wrong name	30.37	32.98
Coping with own discomfort when using the terms transgender and gender nonconforming	10.91	21.88
Feeling uncomfortable	10.09	18.89
Working with an individual who does not meet own idea of a “man” or “woman”	5.01	14.70
Feeling offended	4.40	13.80
Feeling angry about working with the older adult	2.19	6.00

Note. TGNC = transgender and gender nonconforming.

Scale 0 (not at all) to 100 (most possible).

Scale 0 (not at all worried) to 100 (most worry possible).

Discussion

This study primarily reviewed the feedback provided by AAAs employees and volunteers following their participation within a larger study that assessed the efficacy of online professional education interventions. Participants completed quantitative measures that assessed several constructs ranging from self-efficacy for use of TGNC-related terminology to genderism and transphobia. Participants also provided open-ended responses to questions aimed at understanding their experiences of the trainings and what information they may want in future educational presentations. Notably, many participants reported professional and personal interactions with TGNC persons. Contact was correlated with less transphobia, greater self-efficacy, and greater knowledge of TGNC-related terminology at the completion of the study. Perhaps surprisingly, contact was not associated with an eagerness to learn more about working affirmatively with TGNC older adults.

Participants’ reported worries tended toward concerns about creating affirming environments for older adults while their worries about managing their own thoughts and experiences were rated as less salient. For example, participants expressed greater concern about how they might make older adults comfortable and less concern about how to manage their own discomfort or opposing world views. They also expressed concern about how to find affirming community resources for TGNC older adults within their agencies. Participants expressed a desire to continue learning more and also endorsed relief in having the information. They indicated minimal confusion, disgust, and anger.

In response to being asked what might be helpful in the future, participants outlined specific action steps that would allow them to feel more supported in creating inclusive environments that contribute to the experience of affirming care for older adults. These steps include both learning to provide affirming care (e.g., role-plays and observation) and creating inclusive agencies (e.g., altering documentation, confronting the use of discriminatory language in the workplace). Although interrelated, these steps may require different approaches in practice. Participants also requested increased contact with TGNC older adults through community connections and particularly in continuing education contexts. Although contact was not associated with an eagerness to learn more, participants articulated a desire to understand more about the life experiences of these older adults as well as how they perceive service provision in AAAs.

As previously discussed, the GTS-R demonstrated a large negative correlation with the GRBS and a large positive correlation with the Traditional Beliefs about Gender and Gender Identity Scale. In addition, attitudes toward LGBQ individuals are positively correlated with attitudes toward TGNC individuals (Norton & Herek, 2013; Warren & Steffen, 2018). These high correlations suggest these measures are not capturing different constructs and instead may be reflecting an underlying similarity inherent in cissexism, heterosexism, and sexism. One supposition may be that this underlying construct is cisheterosexism, a neologism that captures the intersection of these concepts (Ziyad, 2015). These measures purport to measure attitudes toward TGNC people, gender roles, and also the degree to which people are invested in emphasizing their heterosexual identity to others. Traditional gender roles provide a framework for the interpretation of gender and function under the assumption that individuals are both cisgender and heterosexual. Cisheterosexism is “the system at the intersection of heterosexism and cissexism where attitudes, biases, and discrimination contribute to the oppression of those who do not conform to gender-normative, essentialist or binary behaviors, identities, presentations, or relationships” (Ziyad, 2015). This construct suggests that addressing knowledge and transphobia in health care and aging-focused settings may not be sufficient to positively impact the experiences of TGNC individuals.

Limitations

Although all AAAs across the United States were contacted about participation in the study, there were likely differences in how the study-related information was distributed to employees and volunteers. Administrators and other individuals in leadership positions chose whether to inform employees and volunteers about the opportunity to participate in this study; individuals contacted directly about the study served as gatekeepers for the entire agency. Similarly, because the study was described as “a free professional development opportunity” to evaluate “different educational strategies for how to provide more affirmative services to older transgender and gender nonconforming adults,” staff already familiar with TGNC individuals may have been more likely to participate, limiting the generalizability of the study.

An additional limitation to the present study was our focus on descriptive data without conducting multivariate analyses. Descriptive data and bivariate analyses do not allow for a thorough understanding of the constructs we examined; additional research will be needed to develop scales with strong psychometric properties that lend themselves to more formal model testing. Furthermore, the research literature on professionals’ reactions to working with TGNC older adults is so young that we did not have strong theoretical models to work from in forming predictions.

Practice Implications

Participants predominantly responded with openness and a desire to continue to learn more about the provision of affirming care within their agencies. This reflects the perspective of employees in aging-focused organizations not previously captured in surveys of agency employees across the United States. The current study suggests that intergroup contact, including friendships and professional relationships, may be important in the formation of more positive attitudes and behavioral intentions toward TGNC individuals. These results are consistent with what might be expected given that more positive attitudes toward TGNC individuals have been demonstrated by individuals with more personal contact with individuals from this heterogeneous group (Barbir, Vandevender, & Cohn, 2016; Case & Stewart, 2013). These results might also be considered in light of Allport’s (1954, 1979) contact hypothesis, later extended by Pettigrew (1998), which posits that changes in attitudes and beliefs about those in the outgroup occur through learning about the outgroup and creating new relationships through intergroup contact. This is consistent with current work on combating ageism (Levy, 2018) and likely applies to transgender-related attitudes.

The contact hypothesis (Allport, 1954, 1979) and the potential power of vicarious-contact interventions (Tompkins, Shields, Hillman, & White, 2015) that utilize perspective taking to reduce stigma and anti-TGNC attitudes suggest an array of potentially impactful interventions. Participants specifically commented on the potential benefits of observing other professionals engage in affirming interactions as well as role-plays. Results also indicate that many of these providers desire intergroup contact and want to learn more directly from these older adults. This integration of observation and contact may include having older adults from the community, particularly those who work as advocates and activists, speak directly to agency employees, and provide direct feedback about their needs through educational demonstrations. This approach would need to be thoughtful and considerate of not placing the burden of instruction on the older adults in such a way that is coercive.

The age difference between those who completed the study and noncompleters suggests continuing education and other professional education interventions should potentially target various age groups of providers due to cohort effects in exposure to affirmative social and educational environments. However, this age difference may also be indicative of a difference in training between those who recently graduated and those with earlier graduation dates. Regardless, because noncompleters also demonstrated a lower level of preintervention knowledge of TGNC-related terminology, future educational programming may want to consider a more developmental approach with increasingly complex knowledge base of the participants.

For TGNC employees, nondiscrimination policies and supportive coworkers are related to lower levels of perceived discrimination in the workplace (Ruggs, Martinez, Hebl, & Law, 2015). Because external factors (e.g., agency environment) may contribute to learning a new behavior (Bandura, 2001), the agency environment seems especially salient. For AAAs and other aging-focused contexts that seek to provide affirmative care to TGNC older adults, it may be important to consider the experiences of employees within the agency’s culture. Opportunities for coworkers to share experiences and approaches to working with TGNC older adults may function as powerful social interventions. A firm commitment to culturally competent care includes a commitment to an open and affirming work environment.

As discussed in the context of Massachusetts’ aging-focused programming, collecting data on older adults and gender identity is critical to meeting the needs of this population identified as having the “greatest social need.” The Older Americans Act survey collects sexual orientation data, but continues to ignore TGNC older adults (Knauer Maril, 2017). Without quantitative evidence to support the existence of TGNC older adults, social service agencies across the United States may struggle to develop appropriate and inclusive programming even though this type of programming may reduce isolation and have a significant impact on quality of life for these elders (Yang, Chu, & Salmon, 2018).

Although these recommendations do not ensure positive outcomes for TGNC elders, they contrast strongly with the mistaken assumption that older TGNC adults are not among the elders served by AAAs. This belief persists despite the evidence that TGNC individuals live in every state (Choi & Meyer, 2016; Gates & Newport, 2015; National Resource Center on LGBT Aging, 2016). Currently, it is unlikely that AAAs and state units on aging are fully prepared to meet the needs of TGNC older adults (Knochel et al., 2012; Krinsky & Cahill, 2017). However, agencies that recognize they are serving TGNC clients, specifically, may be more likely to offer professional development trainings on working with these older adult populations (Moone, Cagle, Croghan, & Smith, 2014).

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project was funded via a dissertation award from the Department of Psychological Sciences, University of Missouri-St. Louis.

ORCID iD

Allison R. Warren

References

An Act Relative to LGBT Awareness Training for Aging Services Providers (July 2018; Massachusetts).

Adams

(2011). LGBT advocate sees hurdles ahead. Retrieved from https://www.aarp.org/relationships/family/info-04-2011/biggest-issues-facing-older-lgbtamericans.html

Allport

(1954). The nature of prejudice. Cambridge, MA: Addison-Wesley.

Allport

(1979). The nature of prejudice: 25th anniversary ed. Cambridge, MA: Addison-Wesley.

Bandura

(2001). Social cognitive theory: An agentic perspective. Annual Review of Psychology, 52, 1-26.

Bandura

(2006). Guide for constructing self-efficacy scales. In Parjares

Urdan

T. C.

(Eds.), Selfefficacy beliefs of adolescents (pp. 307-337). Hartford, CT: Immunization Action Plan.

Barbir

L. A.

Vandevender

A. W.

Cohn

T. J.

(2016). Friendship, attitudes, and behavioral intentions of cisgender heterosexuals toward transgender individuals. Journal of Gay and Lesbian Mental Health, 21, 154-170. doi:10.1080/19359705.2016.1273157

Boggs

J. M.

Portz

J. D.

King

D. K.

Wright

L. A.

Helander

Retrum

J. H.

Gozansky

W. S.

(2017). Perspectives of LGBTQ older adults on aging in place: A qualitative investigation. Journal of Homosexuality, 64, 1539-1560. doi:10.1080/00918369.2016.1247539

Cartwright

Hughes

Lienert

(2012). End of life care for gay, lesbian, bisexual, and transgender people. Cultural Health & Sexuality: An International Journal for Research, Intervention and Care, 14, 537-548. doi: 10.1080/13691058.2012.673639

10.

Case

Stewart

(2013). Intervention effectiveness in reducing prejudice against transsexuals. Journal of LGBT Youth, 10, 140-158. doi:10.1080/19361653.2012.718549

11.

Choi

S. K.

Meyer

I. H.

(2016). LGBT aging: A review of research findings, needs, and policy implications. Retrieved from http://williamsinstitute.law.ucla.edu/wp-content/uploads/LGBT-Aging-A-Review.pdf

12.

Dasgupta

Rivera

L. M.

(2006). From automatic antigay prejudice to behavior: The moderating role of conscious beliefs about gender and behavioral control. Journal of Personality and Social Psychology, 91, 268-280. doi:10.1037/0022-3514.91.2.268

13.

Espinoza

(2014). Out & visible: The experiences and attitudes of lesbian, gay, bisexual and transgender older adults, ages 45-75. Retrieved from http://www.sageusa.org/resources/outandvisible.cfm

14.

Fenge

L.-A.

(2012). Gay, lesbian, bisexual, and transgender aging: Challenges in research, practice, and policy. British Journal of Social Work, 42, 1637-1639. doi:10.1093/bjsw/bcs184

15.

Fredriksen-Goldsen

K. I.

Hoy-Ellis

C. P.

Goldsen

Emlet

C. A.

Hooyman

N. R.

(2014). Creating a vision for the future: Key competencies and strategies for culturally competent practice with lesbian, gay, bisexual, and transgender (LGBT) older adults in the health and human services. Journal of Gerontological Social Work, 57, 80-107. doi:10.1080/01634372.2014.890690

16.

Fredriksen-Goldsen

K. I.

Kim

H. J.

Emlet

C. A.

Muraco

Erosheva

E. A.

Hoy-Ellis

C. P.

. . . Petry

(2011). The aging and health report: Disparities and resilience among lesbian, gay, bisexual, and transgender older adults. Retrieved from https://depts.washington.edu/agepride/wordpress/wp-content/uploads/2012/10/factsheet-keyfindings10-25-12.pdf

17.

Gates

G. J.

Newport

(2015, February 13). LGBT percentage highest in D.C., Lowest in North Dakota: All states within two percentage points of the overall national average of 3.5%. Retrieved from https://news.gallup.com/poll/160517/lgbt-percentage-highest-lowest-northdakota.aspx

18.

Haas

A. P.

Eliason

Mays

V. M.

Mathy

R. M.

Cochran

S. D.

D’Augelli

A. R.

. . . Clayton

P. J.

(2011). Suicide and suicide risk in lesbian, gay, bisexual, and transgender populations: Review and recommendations. Journal of Homosexuality, 58, 10-51. doi:10.1080/00918369.2011.534038

19.

Health Facilities Training, SB-1729, Chapter 550, (Cal. 2008).

20.

Hughes

A. K.

Luz

Hall

Gardner

Hennessey

C. W.

Lammers

(2016). Transformative theatre: A promising educational tool for improving health encounters with LGBT older adults. Gerontology & Geriatrics Education, 37, 292-306. doi:10.1080/02701960.2015.1127812

21.

Israel

Harkness

Delucio

Ledbetter

J. N.

Avellar

T. R.

(2014). Evaluation of police training on LGBTQ issues: Knowledge, interpersonal apprehension, and self-efficacy. Journal of Police and Criminal Psychology, 29, 57-67. doi:10.1007/s11896-013-9132-z

22.

Kerr

P. S.

Holden

R. R.

(1996). Development of the Gender Role Beliefs Scale. Journal of Social Behavior and Personality, 11(5), 3-16.

23.

Knauer Maril

. (2017, September). Trump’s administrative abuse and the LGBTQ community. Retrieved from https://www.hrc.org/resources/trumps-administrative-abuse-and-the-lgbtq-community

24.

Knochel

K. A.

Croghan

C. F.

Moone

R. P.

Quam

J. K.

(2012). Training, geography, and provision of aging services to lesbian, gay, bisexual, and transgender older adults. Journal of Gerontological Social Work, 55, 426-443. doi:10.1080/01634372.2012.665158

25.

Krinsky

Cahill

S. R.

(2017). Advancing LGBT elder policy and support services: The Massachusetts model. LGBT Health, 4, 394-397. doi:10.1089/lgbt.2016.0184

26.

Lev

A. I.

Sennott

(2012). Trans-sexual desire in different gendered bodies. In Bigner

J. J.

Wetchler

J. L.

(Eds.), Handbook of LGBT-affirmative couple and family therapy (pp. 113-128). New York, NY: Taylor & Francis.

27.

Levy

S. R.

(2018). Toward reducing ageism: PEACE (Positive Education about Aging and Contact Experiences) model. The Gerontologist, 58, 226-232. Retrieved from https://ezproxy.umsl.edu/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=psyh&AN=2018-14469-005&site=ehost-live&scope=site

28.

LGBT Training Requirements, DPH-14-006, Title 22 Section 72517, (Cal 2016).

29.

Mayer

K. H.

Bradford

J. B.

Makadon

H. J.

Stall

Goldhammer

Landers

(2008). Sexual and gender minority health: What we know and what needs to be done. American Journal of Public Health, 98, 989-995. doi:10.2105/AJPH.2007.127811

30.

Moone

R. P.

Cagle

J. G.

Croghan

C. F.

Smith

(2014). Working with LGBT older adults: An assessment of employee training practices, needs, and preferences of senior service organizations in Minnesota. Journal of Gerontological Social Work, 57, 322-334. doi:10.1080/01634372.2013.843630

31.

National Resource Center on LGBT Aging. (2016). Inclusive questions for older adults: A practical guide to collecting data on sexual orientation and gender identity. Retrieved from https://www.lgbtagingcenter.org/resources/pdfs/Sage_CollDataGuidebook2016.pdf

32.

Norton

A. T.

Herek

G. M.

(2013). Heterosexuals’ attitudes toward transgender people: Findings from a national probability sample of US adults. Sex Roles, 68, 732-753. doi:10.1007/s11199-011-0110-6

33.

Pettigrew

T. F.

(1998). Intergroup contact theory. Annual Review of Psychology, 49, 65-85. doi:10.1146/annurev.psych.49.1.65

34.

Porter

K. E.

Brennan-Ing

Chang

S. C.

dickey

l m

Singh

A. A.

Bower

K. L.

Witten

T. M.

(2016). Providing competent and affirming services for transgender and gender nonconforming older adults. Clinical Gerontologist, 39, 366-388. doi:10.1080/07317115.2016.1203383

35.

Qualls

S. H.

Segal

D. L.

Norman

Niederehe

Gallagher-Thompson

(2002). Psychologists in practice with older adults: Current patterns, sources of training, and need for continuing education. Professional Psychology: Research and Practice, 33, 435-442. doi:10.1037/0735-7028.33.5.435

36.

Ruggs

E. N.

Martinez

L. R.

Hebl

M. R.

Law

C. L.

(2015). Workplace “trans”-actions: How organizations, coworkers, and individual openness influence perceived gender identity discrimination. Psychology of Sexual Orientation and Gender Identity, 2, 404-412. doi:10.1037/sgd0000112

37.

Shetty

Sanchez

J. A.

Lancaster

J. M.

Wilson

L. E.

Quinn

G. P.

Schabath

M. B.

(2016). Oncology healthcare providers’ knowledge, attitudes, and practice behaviors regarding LGBT health. Patient Education and Counseling, 99, 1676-1684. doi:10.1016/j.pec.2016.05.004

38.

Stroumsa

Shires

Richardson

C. R.

Jaffee

K. D.

Woodford

M. R.

(2019). Transphobia rather than education predicts provider knowledge of transgender health care. Medical Education, 53, 398-407. doi:10.1111/medu.13796

39.

Tebbe

E. A.

Moradi

Ege

(2014). Revised and abbreviated forms of the genderism and transphobia scale: Tools for assessing anti-trans* prejudice. Journal of Counseling Psychology, 61, 581-592. doi:10.1037/cou0000043

40.

Tompkins

T. L.

Shields

C. N.

Hillman

K. M.

White

(2015). Reducing stigma toward the transgender community: An evaluation of a humanizing and perspective-taking intervention. Psychology of Sexual Orientation and Gender Diversity, 2, 34-42. doi:10.1037/sgd0000088

41.

Warren

A. R.

Steffen

A. M.

(2018). Development of a transgender and gender nonconforming language self-efficacy scale for social service providers working with older adults. Journal of Applied Gerontology, 39(5), 555-560.

42.

Yang

Chu

Salmon

M. A.

(2018). Predicting perceived isolation among midlife and older LGBT adults: The role of welcoming aging service providers. The Gerontologist, 58, 904-912. doi:10.1093/geront/gnx092

43.

Ziyad

(2015, September 1). Word of the day 9.1.15: Cisheterosexism. Retrieved from http://racebaitr1.rssing.com/browser.php?indx=52449504&item=10