Forgotten lives: Trans older adults living with dementia at the intersection of cisgenderism,ableism/cogniticism and ageism

Abstract

There is little research at the international level to help us understand the experiences and needs of trans people living with dementia, despite population aging and the growing numbers of trans people including the first cohort of trans older adults. There is a need to understand the widespread barriers, discrimination and mistreatment faced by trans people in the health and social service system, and the fears trans people express about aging and dementia. Anecdotal evidence from the scarce literature on the topic of LGBTQ populations and dementia suggest that cognitive changes can impact on gender identity. For example, trans older adults with dementia may forget they transitioned and reidentify with their sex/gender assigned at birth or may experience ‘gender confusion.’ This raises crucial questions, for example regarding practices related to pronouns, care to the body (shaving, hair, clothes, etc.), social gendered interactions, health care (continuing or not hormonal therapy) and so on. This article fills a gap in current literature by offering a first typology of responses offered by academics who analyzed the topic of dementia and gender identity, to trans older adults with dementia who may be experiencing ‘gender confusion,’ namely: (1) a gender neutralization approach; (2) a transaffirmative stable approach; and (3) a trans-affirmative fluid approach. After providing critical reflections regarding each approach, we articulate the foundations of a fourth paradigm, rooted in an interdisciplinary dialogue regarding the interlocking systems of oppression faced by trans older adults with dementia, namely ageism, ableism/sanism, and cisgenderism.

Keywords

Ableism/cogniticism ageism cisgenderism/transphobia dementia trans and non-binary people

When dementia and transness meet: ‘Losing your mind’… losing your gender identity?

A few years ago, the story of Hélène Tremblay Lavoie, a French Canadian with Alzheimer's disease who lived full-time speaking in English for 30 years, made headlines after she ‘reverted back to French, her mother tongue’ (Waldie, 2018), making it difficult for her to access health care services in English. Memory and language transformations have been noted in people living with dementia (abbreviated as PLWD) (McMurtray et al., 2009), raising questions regarding how to intervene with people who, temporarily or permanently, ‘live in the past’ due to dementia.¹ While there is empirical data documenting the impacts of dementia on memory or language, no empirical studies have analyzed the intersections of dementia and gender identity despite anecdotal evidence suggesting that dementia can elicit changes in gender identity and expression (Ansara, 2015; McGovern, 2014; Witten, 2016). What happens when a trans² older adult develops dementia? This under-documented topic deserves attention based on the following observations: (1) The population is ageing rapidly, as is the number of PLWD (Alzheimer Society of Canada, 2018); (2) The number of trans people is growing and there is now a first visible cohort of trans older adults (Witten, 2009, 2016); (3) Trans older adults seem to have a higher risk of developing dementia than non-trans people, based on the presence of documented risk factors such as depression, isolation, tobacco, alcohol, and drug use (Hulko, 2016; Westwood, 2016); (4) Trans older adults face widespread barriers and discrimination in health and social services (Fredriksen-Goldsen et al., 2014; Namaste, 2000); (5) Trans people have expressed that their most prevalent ageing-related fears are to live with dementia, to forget their chosen gender identity and be mistreated by healthcare professionals (Witten, 2016); and (6) There is little research to help us understand the experiences and needs of trans people living with dementia (abbreviated as TPLWD) based on their intersecting identities and oppressions. As a result, we have very little knowledge or tools to guide social policy or to support practitioners, carers and organizations to respond to the needs of this growing population (Westwood and Price, 2016).³

According to anecdotal case studies recounted by healthcare professionals in the limited literature on TPLWD, dementia can cause gender identity ‘confusion’ or gender re-transition, for example a trans older adult forgetting their transition and reidentifying, partially or totally, with their gender assigned at birth (Barrett et al., 2015; Marshall et al., 2015). This article uses the phenomenon of potential gender ‘confusion’/re-transition as an entry point to help unpack the implicit theoretical and epistemological frameworks underlying the few intervention strategies with TPLWD that have been suggested in the literature. With the guiding question: ‘What are the different paradigms underlying intervention strategies with TPLWD, including their theoretical and epistemological assumptions and implications?’ we offer a first typology of intervention paradigms, namely: (1) a gender neutralization approach; (2) a trans-affirmative stable approach; and (3) a trans-affirmative fluid approach. After providing critical reflections on each paradigm, we initiate an interdisciplinary dialogue regarding the intersections between the multiple systems of oppression faced by TPLWD, namely cisgenderism,⁴ ableism/cogniticism⁵ and ageism. Mobilizing the examples we put forward in this intersectional analysis, we conclude by articulating the foundations of a fourth paradigm that is trans-affirmative,⁶ crip-positive⁷ and age-positive, and which we believe provides the basis for new ways of supporting TPLWD.

Theoretical paradigms for intervention with TPLWD

‘I’m terrified of dementia. I guess it relates to losing my sense of identity.’

‘I am concerned that I will be unable to maintain my identity.’

‘I am worried that I will develop dementia and will not remember that I have transitioned.’ (Witten, 2016: 112–113)

The statements of the three people quoted here reflect the top ageing-related preoccupations of the 1963 trans participants in the Trans MetLife Survey led by Tarynn Witten (2016). Trans people are afraid that ageing will involve becoming disabled, developing dementia and becoming dependent, fears that are anchored, as we discuss later, in forms of ageism and ableism/cogniticism. While there is a growing literature on trans ageing, there remains a dearth of research addressing dementia-related concerns, despite the fact that the trans population is ageing and it is estimated that globally there are between 3.3 and 9 million trans individuals over the age of 65 (Witten, 2009). In the past two decades, increasing attention has been given to LGBTQ issues within ageing studies, covering a wide range of topics (e.g. King et al., 2019; Ward et al., 2012). However, among the growing literature on LGBTQ ageing, publications specifically addressing dementia are rare. The existing work is composed of gray and academic literature (e.g. McGovern, 2014; Westwood and Price, 2016) that discusses the specific hurdles, challenges, forms of violence and discrimination faced by LGBTQ people with dementia. Despite the inclusion of trans people in the acronym LGBTQ, most of the literature reproduces an erasure of trans specific realities (Namaste, 2000) through a merging of trans realities with sexual minority experiences. Trans specific needs and problems are more properly addressed in the limited but growing body of research dealing directly with trans and ageing (e.g. Bailey, 2012; Cook-Daniels, 2015; Fabbre, 2015; Finkenauer et al., 2012; Fredriksen-Goldsen et al., 2014; Pearce, 2019; Persson, 2009). Yet specific literature on transness and dementia remains extremely scarce. Within the literature specific to TPLWD (Barrett et al., 2015, 2016; Hunter et al., 2016; Latham and Barrett, 2015; Marshall et al., 2015; Westwood, 2016; Withall, 2014; Witten, 2016), several strategies are outlined regarding intervention in the case of anticipated or actual gender ‘confusion’/re-transition. We have classified these strategies into a typology of three paradigms. We explore the underlying epistemological and theoretical assumptions of each paradigm, in order to bring to light their potential practical implications.

Paradigm based on a gender neutralization approach

The first paradigm is based on the work of Marshall, Cooper and Rudnick (2015), who document the only case study of a TPLWD. In this paradigm, authors seem to adhere to a binary biomedical perspective on sex and gender (Toze, 2018). The approach they articulate encourages conformity to gender binary categories and, in the case of gender ‘confusion,’ this approach suggests avoiding gender markers. We have named this approach ‘gender neutralization,’ as it advocates avoiding gender as a way of dealing with instances of gender fluidity. We believe that this paradigm, through its suggestion of gender neutralization when people ‘fail’ to conform to binary categories, as well as its adherence to a discourse on dementia that involves decline, loss of personhood and identity, is neither trans-affirmative nor crip-positive. Marshall, Cooper and Rudnick (2015: 112) outline the case of Jamie, a 94 year old trans person living with dementia, described as a ‘patient who is no longer able to express a consistent gender preference due to moderate dementia.’ They write:

[T]he staff noted she was confused as to whether she was male or female, asking, ‘What am I?’ She frequently looked down at her breasts and asked, ‘Where did these come from?’ At times she expressed a desire to dress and be addressed as a female, and at other times as a male … She was able to recall that she had been ‘living off and on as a woman’ since her 80s. She also recalled that she had been taking estrogen at one point in time. She stated that she would now prefer to live as a man, and to be addressed as ‘he.’ She indicated her preference was to wear masculine clothing, but when identifying what that would look like, she pointed to women's clothing in her closet. At night she continued to request to wear a woman's nightgown because this was more comfortable. She wished to keep the name Jamie. She stated that she wanted to be male, and when asked to elaborate, she replied, ‘… because I should be male,’ and also because she felt pressure from her daughter. (Marshall et al., 2015: 113–114)

In this case, cognitive disability is seen as removing the trans person's agency to make decisions. Due to ableist/cogniticist assumptions, the authors claim that Jamie is confused and no longer has preferences. Yet, as it is evident in this excerpt, Jamie does have clear preferences and is able to make choices regarding name, pronouns, clothing, and so on. This case brings to light the forms of ableism/cogniticism at play in discourses on dementia, associating it with a lack of agency and decision-making power. It also highlights a non trans-affirmative perspective, as Jamie is seen as confused because she does not fit into binary gender categories in a stable manner. The authors conclude that there are two main solutions for the ‘confusion’: (1) avoid gendering Jamie by ‘behaving with Jamie in as gender neutral a manner as possible, for example, by avoiding the use of pronouns and dressing Jamie in a gender neutral manner’ (Marshall et al., 2015: 116); or (2) ask Jamie's power of attorney (her transphobic/cisgenderist daughter) to state in which gender Jamie should live. In addition to the implicit ableism/cogniticism and ageism inherent in the second solution by denying Jamie's agency, it seems that having an inconsistent gender identity is categorized as pathological (a ‘confused state of mind’), a position that is dismissive of non-binary identities and which does not recognize the socially constructed aspects of sex and gender (Toze, 2018). The first solution, which has the appearance of being more respectful, is also problematic, as gender neutrality can be experienced as a form of violence for some trans people for whom gender identity recognition is crucial (Ansara, 2015; Baril, 2015b).

Paradigm based on a trans-affirmative stable approach

While Marshall, Cooper and Rudnick (2015: 116) argue that gender ‘confusion’/re-transition is a possibility for TPLWD, authors working within what we name the ‘paradigm based on a trans-affirmative stable approach’ stipulate that TPLWD are not confused about their gender. However, two factors could lead TPLWD to dis-identify with their chosen gender: (1) external cisgenderist pressure; (2) cognitive decline. Social, institutional, medical and family pressures exerted on vulnerable populations, such as people with dementia, is the first factor that could push them to conform to their sex/gender assigned at birth (e.g. Ansara, 2015; Bailey, 2012; Barrett et al., 2016; Latham and Barrett, 2015). We qualify this approach as trans-affirmative because it valorizes the historical chosen gender identity of the trans person and argues for measures to sustain this identity in the face of cisgenderist barriers. Barrett et al. (2015, 2016) and Latham and Barrett (2015) also present a case study of a TPLWD who experiences gender ‘confusion’/re-transition, yet they question whether dementia really leads to gender ‘confusion.’ The case involves a person described as a trans woman with dementia living in a masculine identity due to family pressure. Barrett et al. (2015: 36) write:

Conflict with family of origin, particularly children, was also an issue for trans people living with dementia … This was highlighted in the story of Edna who was given an ultimatum by her son to present as male or she would never see her grandchildren again. While the service providers empathised, they were unsure how to challenge Edna's family and were concerned that doing so would jeopardise her access to her grandchildren. Edna's experience highlights how expressing gender can be infringed if transphobic family of origin intervenes. In these situations, it is important that changes to gender expression are not read as the loss of desire to maintain their gender (for Edna, of being a woman).

These authors are not alone in insisting that it is social and familial pressure that leads to a gender ‘reversion’ or re-transition and that trans-affirmative action would entail supporting the trans person in their historical (pre-dementia) self-identified gender identity; most researchers, as well as LGBTQ organizations and trans people in surveys about ageing and dementia adopt this approach (e.g. Persson, 2009; Withall, 2014; Witten, 2016). While Latham and Barrett (2015: 9) have, in one of their texts, nuanced their position by acknowledging more gender fluidity for TPLWD, the overall approach articulated here is one based on affirming and reconfirming the historical chosen gender identity of the TPLWD.

The second factor explaining potential gender ‘confusion’ within this paradigm is a person's medical condition; as such, any dis-identification with the chosen gender does not represent the ‘real’ identity of the person. According to this approach, gender identity is seen as a stable component of identity that is undone by dementia, particularly in a cisgenderist environment that doesn't support chosen identity. In other words, gender identity instability is interpreted as a symptom of dementia.

While this second paradigm is trans-affirmative, the fact that transness is privileged over cripness has unintentionally ableist/cogniticist consequences. For example, as illustrated in the following passage, the authors presume that people with dementia lack the capacity to express their needs and to advocate for themselves when reliant on caregivers:

Edna was reliant on service providers to advocate on her behalf … As a consequence of her dementia, Edna lost the capacity to educate staff about her needs, and was more vulnerable to the transphobic demands of her family. She was dependent on others who did not sufficiently understand her transgender needs and she was incapable of self-advocacy. (Barrett et al., 2016: 103)

While we support these authors' desire to critique the cisgenderist context that feeds the myth that most TPLWD will revert to their sex/gender assigned at birth, we are concerned that this position invalidates the identities expressed by older people with cognitive disabilities. This perception of dementia contradicts current work in critical dementia studies (e.g. Bartlett, 2014; Boyle, 2014; Ward and Price, 2016) that interrogate how self-determination, agency, and advocacy are often viewed and acted upon, through an ableist/cogniticist lens. In addition, this trans-affirmative approach could have paradoxical cisgenderist consequences, as it seems to privilege gender stability over the potential desire of some trans people for gender fluidity and/or de-transition.⁸

Paradigm based on a trans-affirmative fluid approach

While the second paradigm is based on the idea that self-identified gender should remain stable in TPLWD, what we name the ‘trans-affirmative fluid approach’ favors gender flexibility. This approach focuses on the present moment, aiming to accompany the TPLWD in their daily or weekly moods, preferences, and needs. For example, Hunter, Bishop and Westwood (2016: 133–134) affirm that being supportive of TPLWD involves accepting their self-identification at the time they claim it (Sandberg, 2018; Ward and Price, 2016; Westwood, 2016). These authors even suggest that the disinhibition often associated with dementia can encourage gender exploration with less guilt and shame. In other words, instead of interpreting potential gender ambivalence as a symptom of a disease, it could be reconceptualized as a form of gender agency and dementia as a facilitator of this agency. A trans-affirmative fluid approach respects trans-binary and non-binary people and their self-identified gender identity, all while recognizing the self-determination of PLWD. However, this third paradigm does not, in our opinion, go far enough in its engagement with crip and disability theory. As we discuss in the following sections, we would like to see a robust anti-ableist/anti-cogniticist and anti-ageist perspective that adopts an approach which takes into consideration the ableism/cogniticism and ageism involved in living at the nexus of transness, old age and cognitive disability. Furthermore, it is important to recognize that a trans-affirmative fluid approach has the potential to dismiss the cisnormative context in which care is provided. Would experimenting with gender expose TPLWD to further discrimination? In practice, would this approach apply to cisgender older adults through encouragement to explore their gender identity, or would they be reminded of their ‘true’ gender identity while TPLWD would be encouraged to re-transition? These questions raise important challenges to the application of a trans-affirmative fluid approach in concrete care contexts saturated by cisgenderist, ableist/cogniticist, and ageist assumptions; hence the importance of taking into consideration the interlocking dimensions of identities and oppressions when it comes to thinking about intervention strategies.

Living at the intersection of cisgenderism, ableism/cogniticism and ageism

Following this typology, we now turn our focus to the intersections between cisgenderism, ableism/cogniticism and ageism. Understanding these intersections is foundational to the development of a fourth paradigm that is trans-affirmative, and crip and age positive. While it is beyond the scope of this article to provide an exhaustive examination of these intersections, we outline a few key examples in order to articulate the main components that we believe should form the basis of intervention strategies for TPLWD. With a few exceptions (e.g. Hulko, 2016; King et al., 2019), intersectional approaches remain nearly absent from the literature on trans and ageing. First theorized by black feminists (Crenshaw, 1989), intersectionality aims to understand the co-construction of identity components, as well as the effects of interlocking systems of oppression such as sexism, racism, and classism. The absence of intersectional analyzes regarding TPLWD is demonstrated by the fact that gerontology and dementia studies have given little attention to trans realities (Sandberg, 2018; Westwood, 2016) and trans studies has given little attention to old age and (cognitive) disability (Baril, 2015a, 2015b). Gerontology and dementia studies' discourses are typically founded on cisnormative assumptions that older adults and people with dementia are cisgender; trans studies' discourses, with their focus on trans youth or younger adults and able-body/mind subjects, are founded on ageist and ableist/cogniticist assumptions. The field of disability studies has also focused on youth and younger adults, relegating dementia to the field of gerontology (Thomas and Milligan, 2018). As examples of the intersections between cisgenderism, ableism/cogniticism and ageism, we identify three interconnected forms of violence experienced by trans people, older people and disabled people (including people with cognitive disabilities): (1) degenderization; (2) denial of agency; (3) gatekeeping.

Forms of degenderization

Degenderization, that is the delegitimization or devaluation of people's self-identified gender, is common among trans people, older people and people with disabilities. While trans people's gender is often considered artificial or less ‘real’ (Ansara, 2015), older and disabled people are often cast, according to ageist and ableist/cogniticist gender norms, as genderless (Baril, 2015a, 2015b; Clare, 2009; Sandberg, 2018). Dominant masculinity and femininity rest upon normative standards based on youth and able-body/mind, relegating those who don't fit these restrictive criteria to the margins. Simultaneously, authors such as Sandberg (2018: 26) demonstrate that the ‘loss of personhood’ among people with dementia is strongly tied to the ‘loss of gender and gender intelligibility.’ Sandberg shows that demented subjects who comply more closely with gender norms are at lesser risk of experiencing stigmatization related to their cognitive disability. In other words, there is a double bind for older people and people with disabilities: they are both subjugated to forms of degenderization by others who see them as less masculine or feminine than younger able-bodied/minded subjects, and normatively constrained to continue to perform masculinity or femininity to avoid further ageist and ableist/cogniticist forms of violence. As illustrated in the case study recounted by Marshall, Cooper and Rudnick (2015), old age and cognitive disability elicit degenderization, and expressing too much gender ‘confusion’ makes someone appear ‘insane,’ in turn reinforcing ableism/cogniticism.

Forms of denial of agency/self-determination

While degenderization is one way that people are denied agency and self-determination, the denial of agency can take several forms. Similar to the long history of the pathologization of transness as a mental disorder that curtailed trans people's choices (Ansara, 2015; Baril, 2015a, 2015b), disabled people have been pathologized and denied the right to make choices regarding their sexuality, reproductive rights, housing, education and work (Clare, 2009). This is particularly salient for people with mental/cognitive disabilities, as well as older adults, who are cast as incompetent in many contexts and have their rights removed (Bartlett, 2014; Boyle, 2014; Thomas and Milligan, 2018). For example, anecdotal cases have reported that some trans older people were forced to discontinue hormonal treatment for no valid reason after moving into residences (Barrett et al., 2016; Marshall et al., 2015). In the same way that trans studies has advocated for trans people's agency, recent work in the fields of disability and dementia studies have argued that people with cognitive disabilities need to be treated as full citizens who retain rights and agency (Bartlett, 2014; Boyle, 2014).

Forms of gatekeeping

Denial of agency leads to forms of gatekeeping that can occur in several spheres, including personal, social, medical and legal. Baril (2015a, 2015b), in his intersectional analysis of transness and disability, shows how infantilization, paternalism and the negation of agency in ableist/cogniticist contexts disadvantage trans people when it comes to transition, in turn reinforcing gatekeeping:

[T]ransitions differ depending on a person's physical, mental, and emotional abilities. Compared to an able-bodied person, the disabled trans person is disadvantaged in the ‘performance’ of feminine or masculine codes communicated through gestures, stride, speech, and bearing. As a result, a ‘successful’ transition is judged according to dominant ableist criteria, in addition to sexist and gender stereotypes. What role does the paternalism directed at disabled people (infantilization, discourse delegitimization) play in potential access to authorizations and health care for disabled trans people? (Baril, 2015a: 38)

Trans older adults face increased forms of gatekeeping (Latham and Barrett, 2015; McGovern, 2014) which become stronger once a TPLWD is deemed legally incompetent due to cognitive disability. Gatekeeping goes beyond medical care and extends to daily activities/choices in residential settings. For example, ageist assumptions, combined with heterosexist norms, encourage older women to dress ‘appropriately’ according to age (Pearce, 2019; Sandberg, 2018). It is possible to see how gender expression is controlled according to both cisgenderist and ageist norms and how gender expression outside these norms can be used against the person to reinforce their ‘senility.’

This discussion illustrates how intersectional analysis can add complexity and nuance to our perceptions of TPLWD. From a non-intersectional perspective, we may think that a trans person is denied transition-related health care based on cisgenderism, while in fact ageism could be more at play in a surgeon's refusal to perform surgery deemed not life-saving on a 75-year-old (Pearce, 2019). We may also think that gender dysphoria experienced by a trans person may be based on gender issues, while in fact it may be triggered by an experience of the degenderization of older people in ageist contexts. From a non-intersectional perspective, we may also think that dementia is the key factor governing the behaviors of an older trans person who ‘dresses inappropriately’ for their age, while in fact the trans person may be experiencing a second puberty and experimenting with their gender expression like a teenager (Ansara, 2015; Bailey, 2012). These examples illustrate the extent to which we need to start conceptualizing the complex and messy relationships between gender identity, (cognitive) disability and age and the experiences of oppression at the nexus of those identities.

When trans-affirmative, crip-positive and age-positive approaches meet: A fourth paradigm

The foregoing examples concerning the intersections between cisgenderism, ableism/cogniticism and ageism allow us to outline the principles of a fourth paradigm. How can we avoid the degenderization so common to trans people, older adults, and people with disabilities that is prevalent in the first paradigm? How can we avoid the removal of agency of older adults and people with (cognitive) disabilities, and its accompanying gatekeeping, that prevails in the first and second paradigms? Guided by an intersectional perspective, we propose the foundations of a fourth paradigm based on the following principles.

Trans-affirmative fluid approach: Building on the third paradigm, we advocate a trans-affirmative fluid approach that supports the potentially changing nature of the TPLWD's gender identity and expression. We propose that from a trans-affirmative perspective we should refrain from imposing a gender identity on a person, even if that identity was historically claimed and embodied. Inspired by Sandberg (2018), we argue that the notion of personhood should not be predicated on the biographical continuity of gender, or by having one's gender expression easily ‘read.’ Practically, there are numerous interventions that could support a person's self-determined gender, such as providing a diversity of pins/badges that the person could wear to indicate the pronouns they prefer, and having masculine, feminine, and ‘neutral’ clothing items in the closet for the person to decide. Areas that are more difficult to manage include decisions about hormonal therapy, as the frequent stopping and starting of hormones is not recommended. Legalities can also complicate a trans-affirmative fluid approach, if, for example, the TPLWD has articulated advance directives regarding gender.

Crip-positive: Following the idea that the biographical continuity of gender should not be intrinsic to notions of personhood, we affirm that cognitive changes are not representative of a decline of personhood or the loss of self. Inspired by Ward and Price's (2016) articulation of a ‘politics of senility,’ as well as crip theory that aims not only to eradicate social and structural barriers but also to value the identity of disabled people,⁹ we assert that all forms of cognitive difference should be supported and validated. Based on anti-ableist/anti-cogniticist and crip perspectives, we advocate for a vision of the self that is multi-faceted, changeable and not normatively ‘rational.’ This also builds on the work done in the field of critical dementia studies to counter biomedical discourses of decline and to introduce new notions of selfhood including embodied elements (Kontos and Martin, 2013). While building on this work, we are extending it to include gender identity, that is, recognizing that cognitive changes that might impact on gender identity should not be seen as forms of decline.

Age-positive: Complementing trans-affirmative and crip-positive tenants, we assert that any paradigm of intervention with TPLWD has to be anti-ageist and age-positive. Not only should forms of ageism be combated, but TPLWD should be actively respected and supported in the expression of their gender identity, whether binary or fluid, whether static or changing. When it comes to trans youth or younger adults, a trans-affirmative approach entails facilitating their transition at their own pace without forcing them to transition at a rhythm that they may not want. Yet the infantilization and denial of agency of older adults and people with disabilities can prevent TPLWD from receiving the same type of support. We believe that all older people, whether cis or trans, whether living with dementia or not, should be given the right to gender self-determination.

We recognize that the afore-mentioned principles can be structurally and personally confronting. We live in a cisgenderist/ableist/cogniticist/ageist society in which people with dementia suffer greater discrimination when they can no longer be ‘read’ as binary (Sandberg, 2018). The ableism/cogniticism directed towards PLWD is more prevalent when the gendered self is troubled. Therefore, encouraging a trans-affirmative approach allowing gender fluidity might place them at increased risk of cisgenderist violence, leading to increased ableist/cogniticist attitudes towards PLWD with non-normative gender (e.g. mistreatment by peers and staff in institutions). These structural realities, combined with the challenges that come with being a trans person, an older person, and a PLWD, can make the everyday lives of TPLWD extremely difficult. We do not want to negate TPLWD's lived reality and hardship and we acknowledge that new models of intervention will not change these realities quickly. Nor do we want to negate the potential suffering of TPLWD's carers, who may find it difficult to interact with the TPLWD as they express a new and/or changing gender identity.

This article has offered a first typology of intervention strategies with TPLWD, as well as thoughts regarding a new paradigm that mobilizes an intersectional analysis of cisgenderism, ableism/cogniticism, and ageism. There is more work to be done. In addition to the need for empirical research that seeks to understand the lived experiences of TPLWD, areas for future work include further intersectional analysis, as well as exploring the use of advance care directives related to gender identity. The future well-being of TPLWD depends on our collective ability to remember past errors, in particular the erasure of the complex, intertwined power relations that mark the lived experiences of marginalized populations.

Footnotes

Acknowledgements

The authors would like to thank the guest editors of this special issue for their helpful support throughout the publishing process, as well as the two reviewers for their insightful and helpful comments. Thank you to Françoise Moreau-Johnson and the Centre for Academic Leadership for providing supportive writing conditions.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: We would like to thank the Social Sciences and Humanities Research Council of Canada for funding that allows the authors to work on the topic of trans older adults with dementia.

Notes

Alexandre Baril, PhD in Women’s Studies, is an Assistant Professor in the School of Social Work at the University of Ottawa. He has published articles in several journals such as Hypatia: Journal of Feminist Philosophy; Feminist Review; TSQ: Transgender Studies Quarterly; Frontiers: A Journal of Women Studies; Journal of Literary & Cultural Disability Studies; Disability & Society. His intersectional research places gender, feminist, queer, trans, and disability/crip studies in dialogue.

Marjorie Silverman, PhD in Social Work, in an Associate Professor in the School of Social Work at the University of Ottawa. She works on topics related to older adults and family care from a critical social gerontology perspective, and has published articles in journals such as Dementia, Journal of Aging Studies, Journal of Gerontological Social Work, International Journal of Care and Caring, and Qualitative Social Work.

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