“I Needed to be That Voice”: A Multi-Party Study of the Healthcare and Social Service Experiences and Needs of Transgender and Gender-diverse Older Adults in Canada

Statement on Ethics

This study underwent approval by The University of British Columbia’s Behavioural Research Ethics Board in Vancouver, BC, Canada, and all participants provided informed consent to participate.

Recruitment and Sampling

Drawing on a purposive sampling approach, we invited two categories of participants to take part in our study: (1) TGD older adults, which we defined as TGD-identified individuals ages 50 and older, and (2) self-identified service providers or community advocates involved in supporting or caring for TGD older adults in any capacity. Within the TGD umbrella, we included people who self-identified as Two-Spirit, transgender, transsexual, nonbinary, genderqueer and/or gender-diverse. In alignment with other research in the area of TGD aging, we chose the age threshold of ≥50 to account for barriers to recruiting members of this marginalized and often difficult-to-reach population (Catlett, 2024; Fredriksen-Goldsen et al., 2014). All participants were required to be residents of Canada to be eligible to participate. The partner organization supporting the study, together with a number of community organizations serving TGD people across Canada, helped disseminate the recruitment materials. Additionally, the research team used virtual peer networks on platforms such as Reddit and Facebook to recruit participants. Finally, to complement our direct recruitment strategies, we drew on a snowball sampling approach by inviting participants to circulate information on the study across their personal and professional networks.

In total, we recruited 21 participants, 10 of whom were TGD older adults (age range: 51–73, mean age: 58.9), and 11 service providers and community advocates (two of whom also identified as TGD older adults). Older adults in our sample were predominantly white (n = 8) and most commonly identified as trans women (n = 6) or reported using feminine pronouns (n = 8). One was a man and another was nonbinary. Service providers and community advocates described serving TGD older adults in a variety of capacities, including as paid social service and healthcare providers, support workers, activists, counsellors, and volunteers. Their ages ranged from 23–72 (mean age: 38.3). Supplemental Table 1 contains an overview of the sample’s demographic composition.

Data Collection

The lead author facilitated a total of six virtual focus groups, which ranged in length from 96–118 minutes. Three of the focus groups were with TGD older adults (each comprising two, four, and four participants), and the remaining sessions (involving three, three, and five participants) were with service providers and community advocates. We asked both groups of participants about their perceptions of existing gaps in services for TGD older adults and their understanding of what would be needed to improve systems of care for this population. We also asked each category of participants distinct questions. For example, in sessions designated for TGD older adults, we asked them about their experiences of seeking and receiving services across systems of care, both historically and in the present. We include the focus group guides we used to collect data as supplemental material (Appendix A). We compensated all participants with $50 CAD, which they could accept either as an e-transfer, or in the form of a gift card for a major retailer. Focus groups were audio recorded and transcribed verbatim by professional transcriptionists.

Data Analysis

Consistent with an ID approach (Thorne, 2016), the aim of our analytical process was to produce a conceptually rich, yet descriptive and pragmatic account of the healthcare and social service experiences and needs of TGD older adults involved in our study. To this end, the lead author (HK) and another primary analyst (CP) developed a preliminary codebook based on initial readings of the transcripts, which contained descriptive units of meaning corresponding to the data. As data were coded, the lead author collaborated with the team to develop increasingly consolidated, higher-order themes from the preliminary codes to construct an intelligible account of the healthcare and social service experiences and needs of TGD older adults. While the transcripts of the two categories of focus groups were analyzed in the aggregate, the team maintained a record of the source for each segment of coded text and drew on this information to contextualize the data. In this process, we relied on critical gerontology (Doheny & Jones, 2021; Marshall & Bengtson, 2011) to pay particular attention to historical and contemporary structural conditions that appeared to underlie TGD older adults’ experiences and needs, and integrated an intersectional lens (Collins, 2019; Wesp et al., 2019) to attend to potential variability in these conditions on the basis of service users’ differential exposure to factors such as racism, ableism, and poverty. Our process was characteristic of an ID-informed approach to iteratively coding data, gradually constructing themes based on recurrent patterns, and drawing on critical gerontological and intersectional scholarship as disciplinary frameworks against which to situate our data and consider pragmatic implications of our analysis (Thorne et al., 2004). To enhance the trustworthiness and confirmability of our findings, we incorporated a process of member checking (Thorne, 2016) by compensating two participants (both of whom identified simultaneously as TGD older adults and service providers) to review and provide feedback on our interpretations of the data.

Historical Context in Experiences of Structural Oppression

TGD older adults consistently described the impact of historical trans antagonism, particularly at the hands of the state and its institutions, in shaping their contemporary experiences across systems of care. Some, for example, discussed having been criminalized or pathologized by entities such as the police, psychiatry, and social welfare systems, and indicated that because of these experiences, they regarded public healthcare and social service systems with (at best) great skepticism. One Métis participant in her mid-60s, who identified both as a trans woman and as Two-Spirit, recalled having been arrested at a pride event during her early youth and then being brought into contact with child welfare workers, which tarnished her future interactions with agents of the state:

And in that parade in 1972, I got arrested for wearing a dress and they charged me with disturbing the peace because I wore a dress. And my experience with social services from day one became a living nightmare. I didn’t want to see those social workers. I didn’t want to see that child advocacy worker. I didn’t want to see any more police officers. It damaged me, by me being arrested.

Another participant, a Latina trans woman in her early 70s, who additionally supported the needs of other older TGD people as a healthcare service provider, discussed the critical role of historical context in influencing contemporary expectations of healthcare and social services, and in sustaining internalized forms of oppression:

The baby boomer generation, we’re the ones that straddle the lines between being pathologized and not being pathologized, between being criminalized and not being criminalized for our sexual orientation or gender identity … So, there’s a lot of internalized oppression and repression. And we’re just beginning to appreciate the impact of that kind of physical, emotionally draining cognitive process of … always being careful, being ultra vigilant, not being able to express your identity, not being able to approach a partner in public.

Emphasizing the impacts of historical (and subsequently internalized) expressions of structural oppression, TGD older adults most frequently emphasized the need for designing systems of care that could account for the impacts of this history on the social, physical, and mental health of this population.

(In)visible Precarity at the Nexus of Transness and Older Age

Both TGD older adults, as well as service providers and community advocates, discussed the distinctive precarity that individuals experience at the nexus of being TGD and aging, particularly in the context of accessing healthcare and social services. Across both sets of focus groups, participants regularly highlighted overt forms of mistreatment, such as stigmatizing language and discriminatory behavior, that older TGD service users appeared to encounter frequently across care settings, particularly when they became intelligible or (hyper)visible as TGD. For example, one white trans woman in her early 50s described being “fired” by her family doctor soon after starting to transition medically, and indicated this decision (which the participant attributed to the provider’s “discomfort”) had impacted her access to mental health and other critical services attached to this medical clinic:

I ended up fired by my family doctor who was a devout religious person. And I had been receiving, in connection with that family practice, counselling … And when they kind of boot you out for their own reasons you lose access to everything. So, I think that it’s imperative to recognize that, that certain aspects of your care … can be quite tied to the medical aspect, and if you find that somebody is not comfortable you lose all of that.

Additionally, some drew attention to implicit expressions of cisnormativity, including (among those who sought gender-affirming medical interventions) a lack of knowledge among healthcare providers regarding how to medically support gender transitions in older age. Several older adults and service providers contextualized this experience by describing the invisibility—or lack of consideration—of TGD older adults as a relevant population in policy and practice across formal systems of care, in some cases even within mainstream LGBTQ+ social service organizations.

Some participants alluded to the small and sometimes tenuous networks of social support among TGD older adults as markers of precarity for those whose support needs grow with age. A service provider in their late 50s, who also identified as a white gender nonconforming nonbinary person, provided a particularly insightful account. They explained that as many TGD older adults lack access to informal, kin-based care, support structures that could help these adults navigate their growing healthcare needs—and even help them age in place to avoid potentially antagonistic institutional settings—are often missing:

[One older adult I’m supporting is] resigning themselves to [not finding a partner, but] then how do you at that age access – how do you access services; how do you stay in your own home? All of the aging mechanisms that are in place for a heteronormative couple who may have children etc., aren’t [necessarily] accessible to someone who’s a trans elder, a single trans elder, right? And we can grab our community around us, but how sustainable is that care for us?

Intersectional Expressions of Contemporary State and Institutionally Sanctioned Oppression

Notwithstanding conditions of precarity that participants agreed were common for TGD older adults as a whole, a number of individuals described the particularly prominent contexts of oppression shaping the lives of TGD older adults who were also racialized, living with disabilities, and/or experiencing poverty. One participant, a feminine-identified South Asian trans person in her late 50s, explicitly discussed the compounding effects of transphobia, together with racism, xenophobia, and homophobia, in producing “layered” challenges in her health and well-being, and thus a level of precarity she likened to Humpty Dumpty’s shell:

A Caucasian don’t have to go through what I go through [in] that I feel racism. Then [my] being a Muslim [is a target] … then my sexuality, then my gender, then being immigrant. So you can see the layers I have to go through for small, small steps … So already when you are going through traumas and challenges … you are falling apart like a Humpty – that’s what I call my Humpty Dumpty.

One participant, a nonbinary South Asian service provider in their late 30s, independently elaborated on this idea by highlighting that TGD older adults who are affected by axes of oppression beyond those related to gender may be disproportionately vulnerable to the shortcomings of care systems that are already overburdened and affected by regimes of austerity:

It is the fact that the health care system is overburdened and bursting at the seams, but it’s also the fact that these individuals are more vulnerable and more marginalized to begin with. So whatever shortcomings the system has, even for the more privileged among us, affect these vulnerable and marginalized folks disproportionately. They’re sort of the canaries in the coal mine in that sense.

Indeed, participants frequently highlighted their perceptions that the state and its institutions (particularly public healthcare and social service systems) were complicit in reinforcing intersectional forms of oppression among diverse aging TGD people, often by way of an austere rationing of services that came at the expense of those furthest at the margins. For example, several indicated that subsidized housing programs often favor specific older TGD service users who are white, able-bodied, and do not report challenges in their mental health, and thus exacerbate insecure living conditions (and, in turn, exposure to stigma and discrimination) among those outside these categories. Racism, ableism, sanism/cogniticism (forms of ableism targeting people with cognitive and mental health disabilities [Baril & Silverman, 2022]), and poverty were most saliently discussed, though specific manifestations of oppression among TGD older adults often varied based on the distinctive constellation of systemic factors operating in their lived experiences.

Resistance of TGD Older Adults and Their Allies Across Service Settings

In spite of the many challenges that appeared to characterize TGD older adults’ experiences, several individuals across both participant categories—including service providers and community advocates positioning themselves as “allies”—described the historical and ongoing resistance of older TGD service users to conditions of oppression. Accounts of challenging institutional and relational forms of cisnormativity, often with little to no historical precedent, were not uncommon in focus groups with TGD older adults. For example, one TGD older adult in his mid-50s, who described himself as a white man of trans experience, indicated that at the start of his transition, he began asking staff at a trauma therapy program he was using at the time to use his name and pronouns, and explicitly noted that he may have been among the first service users to do so:

I transitioned with [the trauma therapy program], but it was – I just had to change – first I made them start calling me “he” and whatever … I was like, “I’m doing this trans thing.” You know and they never asked me how I [identified] – they just didn’t until I had to be like, you know, “Call me he” … I was their first …

Other participants indicated drawing on their historically negative experiences with healthcare and social services to become activists and advocates within their communities. For example, one of the participants quoted earlier, a Métis, Two-Spirit trans woman in her mid-60s, recounted how her difficult encounters with social services had eventually inspired her to become an advocate and community educator to effect change in her local context, often against currents of ongoing stigma:

[My past negative experiences with social services not] only set up the expectations for me but it also set up my understanding of what I need to do in society. That I needed to be that advocate. That I needed to be that voice … The unfortunate part is that there is [still] a lot of stigma, [but] those complexities … really kind of shaped me into the person that I needed to be to do the work that I do.

Indeed, participants frequently discussed the critical role that TGD older adults themselves have played in not only making healthcare and social services more responsive to TGD people of all age categories, but also in enhancing these systems of care for TGD older adults specifically. While some described pursuing such change with formal advocacy, others indicated putting pressure on systems by simply making themselves known to service providers as being part of a relevant client population and demanding appropriate, respectful care.

Closing Current Gaps: Ground-up Activities to Build Space for TGD Older Adults

Focus groups with TGD older adults, along with sessions involving service providers and community advocates, surfaced a broad range of ideas for strengthening the capacity of care systems to address the issues and needs of service users located at the intersection of aging and TGD identities. Most commonly, however, participants described the relevance of engaging TGD older adults in consultation and service provider education, the development of peer-based programming, and the use of community development initiatives to resource and fund appropriate systems of psychosocial support for this population. All of these interventions, at their core, appeared to be “ground-up” in that they involved working directly with TGD older adults to build care that would authentically represent their needs and interests. One TGD older adult, a white trans woman in her mid-50s, described her exceptionally positive experience with a peer-led program for queer and trans older adults (calling it her “second home”) to highlight the importance of such work:

They listen first of all, and they try to really help, and they’re like part of the family right now and it’s – and actually the community center is sort of like a second home to me … So, I’m kind of learning slowly, and just being given the chance to, you know, tell them what’s really been going on with me. And they sit and they listen. And they have little strategy projects. It’s not like they would brush you away and just say, “Oh, come back next week and we’ll look after you”.

Some participants reflected on the complexities of facilitating “ground-up” change in certain contexts such as rural settings, where bringing TGD older adults together in a shared physical space would be challenging. However, some service providers, in particular, remarked on the promise of using technology—including videoconferencing or simply the use of the phone—to connect TGD older adults located in remote regions with one another. For example, one rurally located service provider in their late 20s, who described themself as an Inuit and Innu gender-diverse person, reflected on feedback they had received (in response to system gaps) to develop a phone line for trans older adults situated in a geographically large, but sparsely populated region of northern Canada:

So yes, there’s a gap there where, you know, the feedback I received from [an older trans adult] was they would love to have even a line where there could be a peer on the other end, you know, a trans senior would be great.

Indeed, regardless of geographic context, participants across both categories of focus groups consistently recognized the importance of incorporating TGD older adults in every aspect of program design and execution in healthcare and social services intended to meet their needs.