Abstract
Problem:
Transgender and nonbinary (TNB) older adults endure discrimination from medical providers and expect it in institutional long-term care. Gender identity–based discrimination is connected to negative health outcomes and reluctance to access needed care.
Objective:
The aim of this study is to explore how gender identity affects TNB older adults’ fears, hopes, and plans for use of institutional long-term care.
Method:
Co-investigators conducted semi-structured interviews with 24 TNB older adults in Minnesota, collaboratively analyzed the results using reflexive thematic analysis, and member-checked emergent themes.
Findings:
Oppression is central to participants’ consideration of future long-term care. They fear mistreatment and loss of authentic gender expression and recognition in long-term care facilities. Fears of oppression factor into consideration of suicide and physical transition, although some participants hope societal shifts will lead to unbiased long-term care.
Conclusion:
Creation of anti-oppressive institutional and community-based long-term care options is critical to effectively serve TNB people as they age into dependence.
Introduction
Transgender and nonbinary (TNB) people are subject to discrimination by health care providers (James et al., 2016; Snow et al., 2019). This discrimination and fear of it are correlated with negative health outcomes (Fredriksen-Goldsen et al., 2014; White Hughto & Reisner, 2018), reluctance to access needed care (Bradford et al., 2013; Fredriksen-Goldsen et al., 2014; James et al., 2016), and suicidality (Seelman et al., 2017; Witten, 2014). Health care discrimination is widespread for TNB older adults, as indicated by two national studies. Forty percent of TNB older adults reported denial of health care or poor quality care (Fredriksen-Goldsen et al., 2014), and TNB older adults were somewhat more likely than younger TNB adults to experience victimization by health care providers in the past year (Kattari et al., 2020).
Although federal regulation 42 CFR 483.10 provides protection for TNB residents (National Long-Term Care Ombudsman Resource Center et al., 2018), anecdotal evidence indicates that providers discriminate against TNB people in institutional long-term care settings, including through deliberate use of incorrect names and pronouns (National Senior Citizens Law Center, 2011). Long-term care staff may resist learning about TNB older adults, including refusal to participate in employer-mandated training (Hardacker et al., 2014). TNB people in long-term care facilities may also face discrimination from other residents; older adults are more likely than other age groups to hold bias against TNB people (Miller et al., 2020).
The first studies to explore TNB perspectives on institutional long-term care have been published this decade. TNB older adults were interviewed individually in Sweden (Siverskog, 2015) and in groups in Canada (Pang et al., 2019). TNB adults were surveyed in a primarily U.S.-based sample (Witten, 2014, 2016). Jihanian (2013), Kortes-Miller et al. (2018), and Putney et al. (2018) included transgender older adults alongside cisgender lesbian, gay, bisexual, and/or queer age peers and provided limited findings from transgender participants. TNB adults fear they will experience bias and mistreatment in institutional long-term care (Kortes-Miller et al., 2018; Pang et al., 2019; Putney et al., 2018; Siverskog, 2015; Witten, 2014). TNB older adults want to be understood and acknowledged in their gender (e.g., through use of their name and pronouns) and assisted in expressing their gender in ways that are authentic for them (e.g., through choice of clothing and grooming) when they are in long-term care facilities (Jihanian, 2013; Putney et al., 2018; Witten, 2014). TNB older adults may fear dementia’s impact on their ability to complete life in their authentic gender and receive supportive treatment from providers (Putney et al., 2018; Witten, 2016).
Passing, in the context of gender, means being related to by others as the gender one is expressing. A TNB person may seek to pass as cisgender, transgender, or nonbinary. Passing may complicate treatment in institutional long-term care. Most TNB older adults report that they pass as cisgender only occasionally or not at all and they are likelier to report discrimination than those who pass as cisgender all or most of the time (Kattari & Hasche, 2016). Most TNB older adults have not fully transitioned their physical body (Cook-Daniels, 2016). TNB older adults fear that perception of their bodies as incongruent will lead to bias in long-term care (Kortes-Miller et al., 2018; Pang et al., 2019; Siverskog, 2015; Witten, 2016), and some TNB adults are determined to complete their physical transition in order to pass as cisgender both clothed and unclothed in long-term care (de Vries et al., 2019; Witten, 2016).
TNB older adults, especially those who transition later in life, are struck by the limited time that remains to live in their authentic gender (Fabbre, 2014). The potential loss of opportunity to live and be recognized in their true gender, through discrimination or cognitive decline, may contribute to high rates of suicidal ideation in TNB older adults. Transgender older adults are more likely to consider and attempt suicide than their cisgender age peers (Progovac et al., 2020). TNB adults may choose suicide or death at home to avoid discrimination and disrespect in long-term care (Putney et al., 2018; Witten, 2014).
This study adds to the small but growing body of literature on TNB aging by exploring ways that gender identity affects TNB older adults’ fears, hopes, and plans for future use of institutional long-term care. It is one of the first in the United States to sample only TNB older adults. This study was completed as part of a larger project intended to inform providers’ practice with TNB older adults.
We utilized a framework, emerging from Siverskog (2015) and Toze (2019), that combines critical gerontology, transfeminist theory, and queer theory. This framework makes several assertions. First, TNB older adults face oppression, or the devaluation, exploitation, and severe restriction of a social group (Barker, 2003), within systems of care due to their nonconformity with socially constructed gender norms. TNB older adults have the right to self-determine how they identify and express their gender, including whether and when they seek to pass as nonbinary, transgender, or cisgender and what if any physical transitioning they will pursue. Finally, this self-determination may be constrained by their environment, bodily limitations, and other social identities, and it may be influenced by societal expectations and treatment. Consonant with this framework, we designed and conducted research that centered the experiences and perspectives of TNB older adults to unveil oppression and help to change it.
Method
Participants
The co-investigators (the co-authors), who identify as transmasculine, used purposive sampling to recruit participants through social media, TNB support groups and social groups, and flyers distributed by clinical providers. We screened potential participants and accepted all who were aged 55 and above, identified with a gender different from the one assigned to them at birth, and resided or received care in the Twin Cities metropolitan area or the Arrowhead region. While people in their 50s are considered midlife, differences in TNB people’s lived experience (e.g., victimization) can prompt aging-related limitations (e.g., physical health and ability) earlier than their chronological age would suggest (Fredriksen-Goldsen et al., 2014).
Twenty-five people provided written informed consent for the study. Twenty-four people completed an interview and were included in the analysis. Participants were offered a US$50 gift card.
Procedures
We developed a semi-structured interview guide. The guide explored expectations of institutional long-term care; experiences with providers of health, social, and aging services; and perspectives on living into and through old age. See Table 1 for questions that yielded data about long-term care. In keeping with our theoretical framework, we sought to understand how gender identity shapes expectations of treatment in nursing homes and assisted living facilities.
Interview Questions That Included Responses Addressing Long-Term Care.
Data Collection
Participants were interviewed individually by us. Most interviews lasted 45 to 90 minutes. Interviews were conducted between March 2016 and November 2016 in community settings or participants’ homes. Permission was sought to audio record the discussions and each participant gave consent.
Human Subjects
The University of Minnesota Institutional Review Board provided ethical approval for the conduct of this study.
Sample Characteristics
Eighteen participants (75.00%) resided or received services in the Twin Cities metropolitan area and six participants (25.00%) lived or received services in the Arrowhead region. Participants resided in cities, suburbs, small towns, and rural areas. Twenty-two (91.67%) of the participants identified as White. Participants ranged in age from 56 to 73, with a mean age of 63.46 and a median age of 62.50. See Table 2 for demographics broken down by participant.
Demographic Data per Participant.
Note. Age and transition start (years ago) were calculated for timing of interview (2016). Two participants did not identify when their transition began. Nonbinary means someone whose gender does not fit squarely into the man/woman binary. MTF = male-to-female; FTM = female-to-male.
Most participants (91.67%) self-identified on the gender binary and two participants identified outside of the gender binary (nonbinary). Of the participants on the gender binary, 81.82% identified as MTF (male-to-female), transwoman, female, or MTF transwoman, while 18.18% identified as a transguy, transgender man, or FTM (female-to-male). TNB communities challenge the labels placed on them by medical authorities and the language generated within TNB communities continues to evolve. Participants are identified by their self-described gender identity throughout this article, consistent with the right to gender self-determination embedded in our theoretical framework.
Half (50.00%) of the participants were in the process of physically, socially, and/or legally transitioning and 45.83% indicated that they had completed their transition. One participant hoped to resume a paused transition. Most (66.67%) of the participants began to transition sometime between 2000 and 2016, 25.00% began to transition between the 1970s and the 1990s, and two (8.33%) did not specify when their transition began. The average participant began to transition at age 50 (M = 50.41, SD = 10.86; Mdn = 50.5; range = 22–71). Two participants began their transition in their 20s and 30s (early adulthood), 16 began in their 40s and 50s (midlife), and four began in their 60s and 70s (older adulthood).
None of the participants had resided in long-term care facilities, which may be attributed to the relatively young age of the sample. Twelve of the participants (50.00%) had provided care to parents, spouses, former spouses, or other close relatives in nursing homes or assisted living. Four participants (16.67%) worked or volunteered in long-term care or had done so in the past.
Data Analysis
The data set was analyzed in a collaborative, recursive process using reflexive thematic analysis (Braun & Clarke, 2006, 2012), which is described in the rest of this section. Interviews were transcribed verbatim from the audio recordings. The qualitative data were analyzed using QSR International's software, NVivo 12, to manage codes, themes, and subthemes and collate data. We each reviewed the first six transcripts twice to identify meaning and patterns and generate initial codes. We discussed, revised, and merged this initial set of codes to ensure consistency, then we each coded half of the remaining transcripts. We met during this data grouping process to further revise the coding and discuss emerging themes. Consistent with the theoretical framework, these themes identified ways in which anticipated bias, included limitations on gender identity and expression, factored into expectations and plans around aging into care.
Interview participants were invited to meet in fall 2017 to discuss the emerging themes and half attended. The participants confirmed the analysis and offered additional insights. We refined the themes and identified subthemes, using participants’ feedback to more accurately represent the data. One of the investigators collated the coded data into the themes and subthemes.
Long-term care expectations were coded into three themes and 10 subthemes. Next, we re-read the data extracts in the context of each transcript and excluded extracts that were unconnected to considerations of gender identity. The names of themes and subthemes were adjusted to more clearly reflect the data, and quotes were selected to provide illustrative examples from a variety of participants. Finally, we related the themes and subthemes back to the research question and the larger body of literature.
Findings
The main themes Apprehension, Hope, and Plan each include between two and four subthemes, presented here with illustrative quotes. Participants are identified by their unique identifier number, gender identity, and age.
Apprehension About Mistreatment and Identity Loss
Most participants discussed worries and concerns about how they would experience institutional long-term care, which they described as a gender segregated environment. Many participants expressed apprehension that they will be mistreated because of their gender identity and feared that their gender would not be recognized, upheld, and respected in institutional long-term care. A few participants worried they would lose their gender identity through dementia.
Mistreatment due to gender bias
Participants expressed strong concerns about mistreatment in long-term care due to their gender identity and expression. Several feared mistreatment by long-term care staff. One 67-year-old MTF participant, who endured misgendering and stares while visiting a loved one in long-term care, expressed concern about how nursing home staff might react if they were to find out she is transgender. A 56-year-old transwoman explained that she feared mistreatment because she is unwilling to deny her authentic gender.
I’ve been out of the closet for so long it’s hard for me to stuff myself in even temporarily . . . If somebody asks me if I’m trans, I will tell them, or if they figure it out, I’ll confirm it. (P16)
Several participants tied their apprehension of gender-based mistreatment to physical or mental limitations that will put them under the care and direction of long-term care staff. They viewed frailty, which might prevent self-protection, as an exacerbating factor.
In situations where other people have care and control over you, whatever biases they are carrying they can bring to you in that setting and you’re not able to do much to protect yourself. (P9, Transwoman, 69)
Several participants feared they may be unable to report a negative experience or self-advocate in long-term care due to incapacitation. For one MTF transwoman, aged 58, the inability to protect herself raised the potential for sexual abuse by untrained long-term care staff.
They’re not really educated about us . . . I worry about, how will the staff treat me? Will I be sexually abused? . . . [Y]ou get older and you become a little bit more defenseless . . . Because I’m trans, you know? It’s scary to me. (P8)
Loss of gender identity through misgendering or dementia
Participants expressed concern that they would be treated as the wrong gender in long-term care. This included bathroom use, living arrangements, and gender expression. Some transwomen feared they would be addressed as “sir” and related to as men. An FTM participant worried he would be housed with a woman and dressed as a woman.
That’s gonna feel uncomfortable . . . They better not put me in some little female nightgown type crap, ya know, ’cause that would be demoralizing to end my life that way. (P22, FTM, 60)
Both transmen and transwomen expressed concerns that staff would refuse to provide hormone replacement therapy, which helps to maintain their physical transition.
. . . [M]y biggest fear, is, “Well, we’re not putting up with that anymore—you are off your hormones and you’re just gonna be an old guy.” (P3, MTF, 60)
Some transwomen worried they would not receive a daily facial shave.
I’m mostly worried about shaving. If I can’t really shave myself, then I guess I’ll be a bearded lady or something. (P4, MTF, 62)
A couple of participants feared that dementia would steal their TNB identity. One transwoman expressed concern about retaining her authentic gender identity if she is isolated in long-term care.
Am I just gonna forget who I am? Or that I’ve transitioned . . . [W]hat’s gonna happen to me there as I’m left alone? (P17, Transwoman, 58)
Hope to Avoid Mistreatment and Identity Loss
Apprehension about mistreatment and gender identity loss in long-term care undergirded a range of wishes expressed by participants. While many hoped to die before they require institutionalization, some participants expressed optimism that they would find more welcoming, less biased facilities or avoid awareness of mistreatment through dementia. A few participants hoped for a complete physical transition to conceal their TNB identity.
Death first
Several participants identified specific types of accidents (e.g., motor vehicle crash) or physical ailments they hoped would end their life before they need institutional long-term care. These participants directly connected their expected treatment as a TNB person in long-term care to their wish to die. Participants expressed how their anticipated lack of self-determination in long-term care had led them to hope for preemptive death.
I expect it’s gonna be a nightmare and the only hope I have is if I have another heart attack that’s fatal before I end up having to be in a nursing home. (P13, Transwoman, 60)
Unbiased, respectful care
Most participants viewed long-term care as a possibility only in the distant future, which may be connected to their age (mean age was 63). Among them, some participants expressed optimism that long-term care would improve for TNB people because of growing societal awareness of this community.
I certainly hope to be treated well. I guess I feel like the odds are pretty good that I will be. I think for better or for worse, we are more visible as a community than we’ve ever been. (P6, Transwoman, 62)
A couple of participants wished to find a facility that serves the lesbian, gay, bisexual, and transgender community. They loosely described existing facilities and reflected on the need to develop more. They hoped these facilities would provide appropriate, unbiased care without the need for further education or advocacy. One transguy reflected on a lesbian-specific assisted living facility he knew of and wished he would be allowed to reside there.
It won’t work, but [laughs]—or maybe, I don’t know, [I could] say, “Hide me, would you?” (P20, Transguy, 63)
The same participant identified family members he hoped would advocate for him if he entered long-term care. After expressing fears of TNB-related mistreatment, he shared his wish that people close to him would ensure he was located somewhere he would be treated well.
You just would hope you’re able enough to . . . have someone get you out of there and put you in another place. (P20, Transguy, 63)
Dementia to avoid distress over bias
A couple of participants expressed hope they would develop dementia. They explained that this might prevent awareness of discriminatory treatment as TNB people in long-term care.
If my mind goes sufficiently, then perhaps I won’t care what’s happening in a long-term care place. (P21, Transgender man, 64)
Conceal gender identity through physical transition
A few participants wished for gender confirmation surgery before they enter long-term care. They hoped that this would allow them to hide their gender identity, a strategy to avoid abuse or mistreatment.
I haven’t had my bottom surgery yet . . . Hopefully I’ve got another 20 years before I’m in one of them homes, but . . . I would hope that I would have my surgery completed by then. (P8, MTF transwoman, 58)
Plan for Avoiding or Navigating Long-Term Care
Apprehension about mistreatment and gender identity loss in institutional long-term care was evident in participants’ strategies for meeting their future needs. Many participants planned to remain in the community through family caregiving or independent living supports. Some intended to commit suicide to avoid long-term care; others intended to navigate long-term care through concealing their gender identity or fighting for unbiased care.
Remain in community
Several participants planned to receive caregiving from family members who have offered it. Some viewed relatives as a good alternative to long-term care while others expressed they would be willing to do just about anything to avoid an institution. Participants described paid arrangements and concessions they expect to exchange for caregiving.
I told my daughter . . . when I have to go into a nursing home, if I have any money let’s put it in your account and I’ll come stay with you. I’ll try to be quiet, but I’m not going to a nursing home. (P13, Transwoman, 60)
One participant noted that relatives who do not accept his identity have made plans to care for him in older age.
It’s difficult because [with] the box that they put me in . . . and their religious beliefs, it really is very difficult for them to accept that part of me. (P22, FTM, 60)
Participants with a same-age spouse worried that their spouse may be unable to provide caregiving. An FTM participant felt hopeful that his newfound younger partner would care for him.
There is an age gap. It’s an advantage for me at my age . . . I’d have somebody that loves me in that aspect that would take care of me that way until I passed. (P22, FTM, 60)
Some participants identified adaptations to maintain independent living. A handful of participants explained this as the catalyst for moving, or intending to move, into new housing. Some participants indicated they would use home meal delivery, home health care, transport programs, and other services to maintain their independence. One participant is recruiting younger community members to share her home and provide paid care.
[I]f the community is just bright and strong enough, that’s the way to go . . . And it’s like okay, I’ll pay you. (P4, MTF, 62)
Other participants cited good health and self-care skills.
I enjoy taking care of myself anyway, you know. Even after losing [wife], it was nothing for me to take up the cooking and stuff, because I was a good cook before we got married. (P23, Nonbinary, 65)
Suicide
A few participants considered suicide to avoid feared mistreatment as TNB people in long-term care. Participants discussed suicide directly and with gravity.
I know how vulnerable a nursing home patient can be. A lot of very intimate bodily needs. . . . I’ve heard of people anecdotally who actually detransition when they go into a nursing home for that reason, which wouldn’t be possible for me. I’ve contemplated simply stepping in front of a bus or something rather than going into a nursing home. (P11, Female, 63)
Physical transition
Some participants, all assigned male at birth, had undergone gender confirmation surgery and felt it would help them pass as cisgender in long-term care. This was particularly true for those who already passed as cisgender in their daily lives.
I don’t think I’ll have trouble because things have smoothed out and people nowadays take me as female . . . Because I have transitioned really well, I’ll be put into a room with a female. (P18, Female, 62)
One nonbinary participant considered gender confirmation surgery to allow them to pass as cisgender while reflecting on how this would compromise living an authentic life.
That’s at odds with the fact that I’m just getting more and more comfortable with . . . tell[ing] people I’m both. (P24, 60% Transwoman, 40% Gay male, 60)
Fighting
A couple of participants identified plans to advocate against TNB oppression in institutional long-term care. One participant, after discussing her expectation that her gender identity will be disrespected, shared that she would fight discrimination even if it was poorly received.
I’m gonna have to complain. And I don’t know how effective I’ll be, but I expect to fight a lot. I already told my daughter, expect me to get kicked out of every nursing home . . . because I’m not gonna put up with it. (P13, Transwoman, 60)
Another participant contemplated activism to address TNB-related bias in long-term care.
. . . [L]ong-term care . . . can get really sticky for transgender people . . . If there’s a long-term thing that I’m inclined to be an activist about, that might well turn out to be it. (P21, Transgender man, 64)
Discussion
Oppression was at the heart of TNB older adults’ expectations and preparation for aging into dependence. Participants feared that gender identity–related bias would lead to mistreatment when they are unable to self-advocate. They worried their authentic gender would neither be recognized nor allowed free expression. These findings of expected oppression within systems of care lend support to the theoretical work of Siverskog (2015) and Toze (2019). Like Kortes-Miller et al. (2018), Pang et al. (2019), and Siverskog (2015), participants in this study feared discrimination due to exposure of incongruent bodies and their inability to self-advocate. Participants worried about disrespectful treatment and being othered, similar to findings of Pang et al. (2019) and Witten (2014). Unique to this study, some participants expressed optimism that societal shifts would lead to unbiased treatment in long-term care. While their future experience in long-term care may differ, the ill-treatment of TNB older adults in institutional long-term care is documented (National Senior Citizens Law Center, 2011) and the expectation of bias by many TNB older adults influences their actions.
The strategies that TNB older adults identified for aging into dependence demonstrate efforts to make the best choice among limited options. Some participants cultivated caregivers to maintain community-based living, although a few participants anticipated that these caregivers would limit the acknowledgment and expression of their authentic gender. Participants who expected to self-advocate for less biased long-term care may be stymied by physical or cognitive decline.
Social workers and other providers can help TNB older adults to build strong, affirming, multigenerational support networks. Participants who plan to rely on a same-age spouse may need an alternative depending on their spouse’s health and mortality. Providers can partner with TNB older adults to bolster their support systems, including identifying ways to compensate and support caregivers, and work with caregivers to improve their acceptance and welcome of TNB loved ones. Such supports may make it possible for a TNB older adult to maintain expression of their self-determined gender identity and receive needed help in the community. Supporters may also provide monitoring and advocacy for TNB older adults who do enter long-term care. While Long-Term Care Ombudsmen are a good resource to investigate mistreatment, allies who visit a TNB older adult and keep an eye on their care will be equipped to file a report or directly advocate for better treatment.
TNB older adults identified desperate wishes and choices for their bodies in the face of oppression. A handful of participants connected their anticipated safety in long-term care to passing as cisgender in bodies that have undergone a full physical transition, consistent with de Vries et al. (2019) and Witten (2016). This finding lends support to our theoretical framework, which asserts that considerations of physical transitioning may be influenced by societal expectations and treatment. Genital reconstruction surgery is expensive, not accessible to all who seek it, carries significant risk of complication for aging bodies, and may not enable a person to pass as cisgender. While such surgery improves well-being for many TNB people, it is disquieting that TNB people may contemplate this step to avoid mistreatment in long-term care. Some TNB people, including those who identify as nonbinary, do not wish to pass as cisgender men or women, and such passing may compromise their well-being. Passing as cisgender may also put TNB older adults at risk of not receiving essential health care that matches their particular biology, such as life-saving cancer screenings.
While a few participants feared that dementia would steal their gender identity, others hoped for dementia to avoid awareness of biased treatment in institutional long-term care. This is a novel finding. TNB older adults expressed wishes to die and intentions to commit suicide to avoid discrimination in long-term care, mirroring findings from Putney et al. (2018) and Witten (2014). These choices by TNB older adults about continuation of life and their expressed hopes for cognitive decline in relation to oppressive societal treatment expand our theoretical framework’s consideration of self-determination (and its constraints) beyond physical transition and gender presentation.
Some participants hoped that long-term care facilities would become safer, more inclusive places for TNB people by the time they require such care due to growing social awareness and transgender community visibility. This will require intentional, comprehensive, enforced policy and practice reform in long-term care facilities. Federal statute 42 CFR 483.10 protects the right of long-term care residents to safely live in their authentic gender, but this regulation is not well understood or enforced in relation to gender identity. This nursing home statute stipulates respectful, individualized, culturally appropriate treatment; the right to privacy; and self-determination about clothing, community activities, and visitors.
Long-term care facilities can develop policies that ban TNB-based discrimination; provide guidance to staff, residents, and residents’ families about language and practices that maintain the safety and dignity of TNB residents; and enforce these policies. Frequent training to reach certified nursing assistants and other workers in high turnover positions and across schedules, training that deepens awareness and focuses on implementation, and mandatory training for management and frontline staff may improve the effectiveness of these efforts (Petrie & Cook, 2019; Sussman et al., 2018; Warren & Steffen, 2020). Nursing home administrators may audit current practices around room sharing, gender segregated activities, restrooms, showers, and gender expression to identify and implement changes that improve the environment for TNB residents. Research suggests that effective change is likelier when it is planned in partnership with TNB communities and involves residents and residents’ families (Sussman et al., 2018). Once long-term care facilities have implemented anti-oppressive training, policy, and practice changes, they can target their outreach and marketing to alert TNB people to safe, appropriate long-term care options.
Limitations
This study is limited by its geographic scope (two regions of one Midwestern state), the size of the sample (n = 24), and the participants’ race (mostly White), age (average age of 63), gender (mostly transwomen), and health (none have lived in long-term care). Future studies that diversify the sample by race/ethnicity, gender (e.g., more transmen and nonbinary people), and regions of the United States may yield different insights. Studies that include more participants in their 70s, 80s, and 90s may capture differences in preparation, expectations, and experiences due to age-cohort effects.
This study focused narrowly on long-term care in assisted living and nursing home facilities. Future research that asks specifically about at-home skilled nursing can help distinguish expectations and strategies for in-home versus institutional long-term care. Finally, research with TNB people in long-term care is needed to understand their lived experience and their strategies for navigating the environment.
Conclusion
Transgender/nonbinary older adults harbored deep-seated fears about what long-term care would mean for their safety and ability to live as their authentic gender. Their strategies for navigating dependence in later life are limited by gender-based oppression. There is work to do, in collaboration with TNB people, to create institutional and community-based long-term care options that nurture their full selves. This multilevel work includes practice changes, policy enforcement, and bolstering of support systems.
Footnotes
Authors’ Note
The research reported in this article was approved by the University of Minnesota IRB (Institutional Review Board) under approval number 1510S79022.
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 work was supported by the University of Minnesota Clinical and Translational Science Institute—Community Health Collaborative Grant and the University of Minnesota Office of the Vice President for Research—Serendipity Grant on Aging. Research reported in this publication was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health (Award Number UL1TR000114).
