Improving the Lives of Transgender Older Adults: Recommendations for Policy and Practice by SAGE

IMPROVING THE LIVES OF TRANSGENDER OLDER ADULTS Recommendations for Policy and Practice

SAGE (Services and Advocacy for GLBT Elders) and National Center for Transgender Equality (NCTE) 1

TABLE OF CONTENTS 1

Introduction

Current Knowledge about Trans Aging: A Literature Review 5

Transphobia and Culturally Competent Services in Healthcare

A Dearth of Relevant Knowledge and Outreach in Aging Settings

Disproportionate Experiences of Violence

Social Impact on Health of Transgender Elders

HIV/AIDS

Other Health Issues 15

Transition-Related Health Care

Limited Insurance Coverage

Mental Health

Veterans Issues

Employment and Housing Discrimination

22 A Note on Intersex Conditions 23 Gaining Visibility: The Challenges Facing Transgender Elders 29 Detailed Recommendations 31

Aging Services Network

Improving Health

Long-Term Services and Supports

Ending Violence and Abuse

Creating Equal Employment Opportunities

Housing

Improving Economic Security

Building a Foundation of Knowledge

Privacy and Documentation

Community Support and Engagement

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

49 Appendix A: Practical Guidance for Aging Providers

AUTHORS: Allison Auldridge, SAGE (literature review, pg 3), Anne Tamar-Mattis, Advocates for Informed Choice (note on intersex conditions, pg 22), Sean Kennedy (feature story, pg 23) and Emily Ames and Harper Jean Tobin, NCTE (detailed recommendations, pg 29). DESIGN: RD Design | PHOTOGRAPHY: Alan Acosta ÂŠ 2012 Services and Advocacy for GLBT Elders and National Center for Transgender Equality

Introduction Transgender older adults face profound challenges and experience striking disparities in areas such as health and health care access, physical and mental health, employment, housing and more. Research and experience also reveal that many transgender elders routinely encounter both a health care system and a national aging network that are ill-prepared to provide culturally competent care and services and create residential environments that affirm the gender identities and expressions of transgender older people.

Many transgender elders delay necessary care and are subjected to ignorance, prejudice, discrimination, hostility and even violence in the settings meant to support their successful aging. Policies and programs meant to support older people and other vulnerable populations often present significant barriers for transgender people, while initiatives that could address many of the disparities and challenges they face (such as elder abuse and housing costs) are neglected or underfunded. Moreover, transgender elders came of age during decades when transgender people were heavily stigmatized and pathologized. Some came out and made gender transitions during these years, while many others kept their identities hidden for decades and are now coming out and transitioning later in life. Many challenges facing transgender elders are common to the broader older lesbian, gay, bisexual and transgender (LGBT) population, but some are different. With a growing older transgender population, there is an urgent need to understand the challenges that can threaten financial security, health and overall well-being. Improving the Lives of Transgender Older Adults responds to these concerns by examining the social, economic and service barriers facing this population. This report includes a detailed literature review, profiles of the experiences of transgender elders around the country and more than 60 concrete recommendations for policymakers and practitioners. Our hopes are that this report inspires conversation, more research and policy analysis, and ultimately, action.

SAGE and NCTE May 2012 1

TRANSGENDER AGING ADVOCACY INITIATIVE In 2011, SAGE (Services and Advocacy for GLBT Elders) and the National Center for Transgender Equality launched a historic Transgender Aging Advocacy Initiative. The purpose of the initiative was to identify the range of barriers affecting transgender older adults and to outline an advocacy roadmap that would cut across issue areas, reach the full diversity of transgender elders, and meet both short-term and long-term goals. To inform this initiative, we brought together a diverse panel of experts on these issues, many of whom have blazed trails in their fields on these issues. The content of this policy report is the result of this initiative and the many leaders who have built a foundation of knowledge about transgender aging that this report continues. This initiative was generously funded by the Arcus Foundation and the David Bohnett Foundation.

ADVISORY COMMITTEE Alan Acosta Director of Strategic Initiatives L.A. Gay and Lesbian Center Kellan Baker Health Policy Analyst Center for American Progress Hope A. Barrett, MPH Senior Director of Public Programs Center on Halsted (formerly) Earline Budd Founder and Former Executive Director Transgender Health Empowerment Natalie Chin Staff Attorney Lambda Legal Loree Cook-Daniels Policy and Program Director FORGE/Transgender Aging Network Masen Davis Executive Director Transgender Law Center Robert Espinoza Senior Director for Public Policy and Communications SAGE Maximilian E. Fuentes Fuhrmann, Ph.D. Clinical Psychologist/Gerontologist Private Practice

Amy E. Gotwals Senior Director Public Policy and Advocacy National Association of Area Agencies on Aging Mara Keisling Executive Director National Center for Transgender Equality Bishop Tonyia M. Rawls Executive Director Freedom Center for Social Justice Daniel R. Redman National Center for Lesbian Rights Del Martin Memorial LGBT Elder Advocacy Initiative Barbara Satin Board Chair, GLBT Generations Institute for Welcoming Resources & Faith Works Associate National Gay and Lesbian Task Force Beatrice Simpkins Chief Financial Officer Freedom Center for Social Justice Moonhawk River Stone, M.S. LMHC, Psychotherapist Private Practice Harper Jean Tobin Policy Council National Center for Transgender Equality Serena Worthington Director of Community Advocacy and Capacity Building SAGE

Current Knowledge about Trans Aging: A Literature Review

Transgender and gender non-conforming adults face a myriad of challenges as they age. While very limited, the existing research on transgender people paints a picture of many people aging in isolation and without a network of knowledgeable or welcoming providers in the aging, health and social services arenas. Further, transgender elders often experience extreme disparities in access to health care and low rates of health insurance coverage due in large part to systemic discrimination from providers and insurance companies, as well as economic instability resulting from discrimination in employment and housing, among other areas.

An overarching challenge for policymakers and practitioners is the dearth in research examining the challenges facing this populationâ&#x20AC;&#x201D;and the types of policies and programmatic interventions that would improve their lives. While the need for better data and more research on lesbian, gay and bisexual communities has gained support over the last few years, gender identity remains largely absent from the scope of social research and analysis. Moreover, few studies have addressed the specific challenges facing transgender elders. Research focused on transgender people of color is even more limited, despite some studies suggesting that they experience high levels of violence and discrimination.1

Grant, J.M., Mottet, L.A., Tanis J., Harrison, J., Herman, J.L., & Keisling M. Injustice at every turn: A report of the national transgender discrimination survey. (2011). Washington, DC: National Center for Transgender Equality and National Gay and Lesbian Task Force.

Note on older adult respondents & transgender surveys

Key figures on transgender elder respondents from the National Transgender Discrimination Survey

n 2008, the National Center for Transgender Equality (NCTE) and the National Gay and Lesbian Task Force surveyed 6,450 transgender-identified people—including 110 older adults over the age of 65—for their historic National Transgender Discrimination Survey (NTDS). It’s important to note that older transgender adult respondents in this survey were less demographically diverse than their younger transgender counterparts, with a high number of respondents over age 65 who were white, identified as women, transitioned later in life and reported higher incomes. The reasons for this lack of diversity are not clear. There are many possible explanations, such as that older transgender men, people of color, those with lower incomes or those who transitioned earlier in life might not be as effectively reached through transgender networks and the Internet, might be

70% of transgender adults age 65 and older reported having delayed gender transition to avoid discrimination in employment.

13% of transgender adults age 65 and older reported abusing alcohol and drugs to cope with mistreatment.

16%

less likely to self-identify as transgender or might simply not live as long. Other surveys have been similar in regards to age, gender and income among older cohorts, such as findings on transgender adults over the age of 55 in the Transgender Law Center’s “State of Transgender California Report.”2 Researchers are advised to explore how survey methods can better capture data on transgender older adults that reflects poor and low-income elders, elders of color and other more vulnerable, harder-to-study populations. Older adult data from these transgender surveys should be read with caution. To read the full reports, please visit transequality.org and transgenderlawcenter.org.

of transgender adults age 65 and older reported attempting suicide at least once in their lifetimes. Source: Grant, J.M., Mottet, L.A., Tanis J., Harrison, J., Herman, J.L., & Keisling M. Injustice at every turn: A report of the national transgender discrimination survey. (2011). Washington, DC: National Center for Transgender Equality and National Gay and Lesbian Task Force.

E., Frazer, M. S., Wertz, K. and Davis, M. (2009). The state of transgender California: Results from the 2008 California transgender economic health survey. San Francisco, CA: Transgender Law Center.

Recognizing the limited research on transgender older adults, this paper also draws from the general research on LGBT elders to illustrate how persistent discrimination can result in economic instability and challenges in health, housing and employment.3 This paper also draws from studies on transgender people as a whole and suggests how challenges become pronounced as people age.

Transphobia and Culturally Competent Healthcare Many lesbian, gay, bisexual and transgender (LGBT) people routinely encounter ignorance, indifference and discrimination in mainstream healthcare settings—a reality both documented in large surveys and described anecdotally by many transgender people seeking care in a variety of health care settings including doctors’ offices, hospitals, mental health clinics, drug treatment programs and even emergency rooms.4 Barriers to adequate care include a lack of basic cultural and clinical knowledge among providers, refusal to care for transgender patients and harassment and abuse of patients. For transgender older adults, this heightened level of disregard from healthcare professionals can lead to apprehension and distrust of healthcare providers and over time can lead to increased social isolation, delayed care-seeking and poor health outcomes.5

‘’ DID YOU KNOW? Barriers to adequate care include a lack of basic cultural and clinical knowledge among providers, refusal to care for transgender patients, and harassment and abuse of patients.

A 2 011 report on transgender discrimination by the National Center for Transgender Equality and the National Gay and Lesbian Task Force (referred to in this paper as the “National Transgender Discrimination Survey” or “NTDS”) documents this pervasive insensitivity and violent treatment of transgender patients in emergency rooms, mental health clinics and drug treatment programs. Respondents reported differential treatment when their transgender statuses became known by providers, and being harassed by staff and/or being physically assaulted when seeking care. Nineteen percent of all respondents had been refused medical treatment altogether because of their gender non-conforming status, with 24 percent of transgender women and 20 percent of transgender men having experienced care refusal.6

While this paper draws from a variety of studies to illustrate the scope of barriers facing transgender older adults (and to suggest potential points of entry for policy and institutional reform), the transgender population cuts across a spectrum of experiences and identities, and the experiences described in this paper may not reflect all older transgender adults. For example, two factors that can create profoundly different aging experiences are age of transition and visible gender conformity. Transitioning at a later age might result in more economic stability for some transgender people who have avoided experiences of employment and housing bias. However, there might also be a range of negative mental health outcomes for transgender people who delay “coming out” until a later age.

While the literature has not done a sufficient job analyzing transgender-specific realities, SAGE’s experience as an aging provider suggests that transgender older adults face many challenges accessing healthcare that is culturally appropriate, affordable and suitable for an aging population. Additionally, although the small universe of research on transgender elders has substantiated these concerns, much more research is needed.

Kimmel, D., Rose, T., & David, S. (2006). Lesbian, gay, bisexual and transgender aging: Research and clinical perspectives. New York, NY: Columbia University Press.

Ibid.

This mistreatment was magnified among respondents with lower income levels and respondents who were people of color. Latino/a respondents reported the highest rate of unequal care among any racial/ethnic category (32 percent reported unequal care from a doctor or hospital and 19 percent in ERs or mental health clinics), while African American transgender respondents were among the most vulnerable to physical assault in hospitals and doctorsâ&#x20AC;&#x2122; offices.7 The literature argues that without the essential support of healthcare providers, and in order to avoid the stress of dealing with incompetent service providers, many transgender people do not seek care until they experience health emergencies and, in some cases, have died in the absence of medical care. For transgender people of color, a lack of healthcare access is especially true; the NTDS found that 17% of African American respondents and 8% of Latino/a respondents said that they utilized emergency rooms as their place for primary care treatment, as did 8% of respondents with household incomes of less than $10,000.8 Social and economic marginalization compounded the health disparities for Black and Latino/a respondents in the NTDS as both communities experienced discrimination and poor health outcomes at much higher levels than the general population, including higher rates of HIV infection, smoking, drug and alcohol use, and suicide attempts.9

â&#x20AC;&#x2DC;â&#x20AC;&#x2122; DID YOU KNOW? For transgender people of color, a lack of healthcare access is especially true; the NTDS found that 17% of African American respondents and 8% of Latino/a respondents said that they utilized emergency rooms as their place for primary care treatment, as did 8% of respondents with household incomes of less than $10,000.

Many transgender people also lack primary care doctors; a 2005 study in Philadelphia found that more than one-third of the transgender population surveyed had no regular doctor at all.10 The Aging and Health Report, published by the University of Washington in 2011, surveyed more than 2,500 LGBT older adults between the ages of 50-95 and found that one-third of transgender elders report being in poor physical health and that 22 percent of transgender respondents needed to see a doctor, but did not because they could not afford to do so.11 There are clear health implications for transgender older adults who do not feel safe accessing healthcare providers: delayed care can mean that preventable illnesses are not identified and diagnosed in time, health complications worsen and the costs for care increase, among other consequences.

Grant, J.M., et al. (2011). Injustice at every turn: A report of the national transgender discrimination survey.

Ibid.

National Gay and Lesbian Task Force, National Center for Transgender Equality, & League of United Latin American Citizens. (2011). Injustice at every turn: A look at Latino/a respondents in the national transgender discrimination survey. Retrieved from http://www.thetaskforce.org/reports_and_research/ntds_latino_a_ respondents; National Gay and Lesbian Task Force, National Center for Transgender Equality, & National Black Justice Coalition. (2011). Injustice at every turn: A look at black respondents in the national transgender discrimination survey. Retrieved from http://www.thetaskforce.org/reports_and_research/ntds_black_ respondents.

Kenagy, G.P. (2005). Transgender health: Findings from two needs assessments studies in Philadelphia. Health & Social Work 30 (1), 19-26.

Fredriksen-Goldsen, K.I., Kim, H.J., Emlet, C.A., Muraco, A., Erosheva, E.A., Hoy-Ellis, C.P., Goldsen, J., & Petry, H. (2011). The aging and health report: Disparities and resilience among lesbian, gay, bisexual, and transgender older adults. Seattle, WA: Institute for Multigenerational Health.

October 2011 meeting of the Advisory Committee for the Transgender Aging Advocacy Initiative, Washington, DC. Photo: Emily Ames, National Center for Transgender Equality

Such negative consequences were seen among respondents in The Aging and Health Report, which shows that a significant proportion of transgender elders have some form of disability. Even within the LGBT community, transgender older adults seem to experience heightened barriers to care and increased levels of physical impairments as they age. Forty-seven percent of all LGBT respondents in the survey had a disability, while 62 percent of transgender older adults reported having a disability.12

A Dearth of Relevant Knowledge and Outreach in Aging Settings Research suggests that aging providers specifically are uninformed and culturally insensitive on LGBT issues. A 2006 study found aging providers to be more intolerant toward the broader LGBT population than providers within the mainstream healthcare system.13 The two most cited reasons for this lack of cultural competence are: little to no outreach to LGBT communities in elder care, and little professional training among aging providers on the unique needs of LGBT older adults.

Ibid., 22.

Kimmel, D., et al. (2006). Lesbian, gay, bisexual and transgender aging: Research and clinical perspectives: p. 247-248.

October 2011 meeting of the Advisory Committee for the Transgender Aging Advocacy Initiative, Washington, DC. Photo: Bishop Tonyia M. Rawls, Freedom Center for Social Justice.

The available research shows that most aging agencies and facilities do not offer cultural competency trainings to their staff or residents about issues related to serving transgender clients.14 According to a 2009 nationwide study of area agencies on aging, only one-third of the participating agencies had offered their staff training on LGBT aging, and most of these training sessions were voluntary or part of a generalized training on nondiscrimination. The study found that conducting cultural competency trainings correlated to increased engagement with transgender elders. The 101 agencies that had conducted trainings specifically on transgender issues were three times more likely to report having received a request to help a transgender older adult in the previous year.15 This same survey also found that trainings helped staff understand LGBT health issues, how to provide LGBT-specific services and conduct effective outreach into LGBT communities. Unfortunately, few agencies had conducted training or done outreach to transgender older adults, with only 7.2 percent of agencies that responded offering services targeted at transgender elders.16

One consequence of this dearth in transgender competency is that it has contributed to basic misunderstanding among providers about the differences between gender identity and sexual orientation. See Knochel, K.A., Croghan, C.F., Moone, R.J., & Quam, J.K. (2010). Ready to serve? The aging network and LGB and T older adults.

Ibid., p. 8, 10.

Ibid., 13.

Many advocates and aging practitioners reason that a lack of training maintains an atmosphere of ignorance regarding transgender people in aging settings, can enable neglect and abuse, and establishes an environment where older adults feel unsafe to speak openly and honestly about their gender identities and expressions. In a recent survey on LGBT older adults in long-term care facilities, 80 individuals (more than 10 percent of respondents) said that they, a loved one or a client had experienced staff refusal to call a transgender resident by his or her preferred name or pronoun.17 Additionally, many elders fear having their transgender status “discovered” by insensitive health professionals. This concern is heightened among older adults who have not undergone transition-related surgeries and whose dress and appearance may be “incongruent” with their anatomies.18

‘’ DID YOU KNOW?

Disproportionate Experiences of Violence

From childhood through later life, transgender people suffer from some of the highest rates of interpersonal violence. Transgender people of color are at particularly high risk, with some research suggesting that non-citizen Latino/a people are often the most vulnerable to violence and abuse.19 According to the NTDS, students in grades K-12 who expressed a transgender identity or gender non-conformity reported distressingly high rates of harassment (78%), physical assault (35%) and sexual violence (12%).20 On the other end of the age spectrum, The Aging and Health Report found that transgender people age 50 and older were more than twice as likely to have experienced physical or verbal domestic violence in the past year than were their lesbian, gay, and bisexual peers regardless of age, income and education.21 Multiple studies have found that at least 50 percent of transgender people are survivors of sexual violence.22 As with other populations, experiencing one type of abuse frequently makes one more likely to experience another type of abuse. The 2011 FORGE study, “Transgender people’s

National Senior Citizens Law Center. (2011). LGBT older adults in long-term care facilities: Stories from the field. Washington, DC: National Senior Citizens Law Center, National Gay and Lesbian Task Force, Services and Advocacy for GLBT Elders (SAGE), Lambda Legal, National Center for Lesbian Rights, & National Center for Transgender Equality.

Cook-Daniels, L. (2008). Aging as ourselves: LGBT aging health issues for health care providers. Retrieved from http://www.dvsacmiami.org/Resources/Complete%20curricula%20text%20with%20references.pdf.

Grant, J.M., et al. (2011). Injustice at every turn: A report of the national transgender discrimination survey: p. 3.

Fredriksen-Goldsen, et al. (2011). The aging and health report: Disparities and resilience among lesbian, gay, bisexual, and transgender older adults: 20.

Kenagy, G.P. (2005). The health and social service needs of transgender people in Philadelphia. International Journal of Transgenderism 8 (2-3): 49-56; and Kenagy, G.P., & Bostwick, W. (2005). The health and social service needs of transgender people in Chicago. International Journal of Transgenderism 8 (2-3): 57-66.

October 2011 meeting of the Advisory Committee for the Transgender Aging Advocacy Initiative, Washington, DC. Photo: Masen Davis, Transgender Law Center.

access to sexual assault services,” documented that 52.3 percent of transgender people who had experienced child abuse, sexual abuse, dating violence, intimate partner violence or stalking experienced two or more of these types of crime. Unpublished data from a 2011 survey conducted by FORGE found that being a person of color as well as transgender dramatically increased the chances of being the victim of family violence.

‘’

Multiple studies have found that transgender people frequently experience violence in interactions with law enforcement officials; thus it is perhaps unsurprising that many transgender people may be hesitant to report violent incidents to police.23 Nearly half of all respondents in the NTDS reported being uncomfortable seeking out police for assistance, while a staggering 38% of Black respondents reported being harassed by police, 14% reported physical assault and 6% reported sexual assault by police.24 Sadly, transgender people also experience discrimination and harassment when seeking reprieve from violence from public support services. Of the transgender and gender

DID YOU KNOW? Higher rates of victimization among transgender people can impact the physical and mental health of transgender elders.

Witten, T.M. (2003). Life course analysis–The courage to search for something more: Middle adulthood issues in the transgender and intersex community. Journal of Human Behavior in the Social Environment 8 (2-3): 198; Grant, J.M., et al. (2011). Injustice at every turn: A report of the national transgender discrimination survey: p. 6.

Grant, J.M., et al. (2011). Injustice at every turn: A report of the national transgender discrimination survey: p. 6.

non-conforming people who tried to access rape crisis centers or domestic violence services, 5-6% reported unequal treatment, 4% experienced verbal harassment or disrespect and 1% were physically assaulted there.25 Higher rates of victimization among transgender people will certainly impact the physical and mental health of transgender elders. The Centers for Disease Control and Prevention has found that childhood abuse, neglect and other experiences of trauma increase the likelihood of long-term health and social problems including alcoholism, depression, risk for intimate partner violence and suicide attempts.26 Further, NTDS respondents who had experienced domestic violence were more likely to attempt suicide, experience homelessness and engage in sex work than those who had not been abused.27 Certainly, increased social supports for transgender elders are necessary to help these older adults cope with years of violence and discrimination. Yet they are also a resilient community. As Researcher Tarynn M. Witten has written: “Transgender and intersex persons must go through a great deal to survive. Those that manage to live long lives as transgendered or intersexed persons must have developed coping and survival strategies that were highly effective in the face of all that is against them.”28

‘’ DID YOU KNOW? Several studies have shown that transgender people access healthcare providers less frequently than the general population and this is especially true for people without networks of support in place.

Social Impacts on Health of Transgender Elders The general lack of professional training on transgender health compounded by discrimination in employment, education and housing, as well as the lack of social support systems, contribute to the chronic stress experienced by many transgender older adults. This amplified level of anxiety, common to groups who experience regular discrimination and violence, can lead to high-risk behaviors and poor health outcomes. Multiple studies have shown that transgender people are more likely than their nontransgender counterparts to engage in sex work, drug use and alcohol abuse, which can increase incidences of HIV, substance abuse, self-harm and suicide.29 For example, a New York City study of transgender people found that as many as 23.6 percent of respondents abused substances such as alcohol, marijuana, cocaine and amphetamines, and that the use of drugs increased the likelihood of engaging in unprotected sex.30

Ibid., 130.

National Center for Chronic Disease Prevention and Health Promotion, Division of Population Health. (2010). Adverse childhood experiences (ACE) study: Major findings. Retrieved from http://www.cdc.gov/ace/findings.htm.

Grant, J.M., et al. (2011). Injustice at every turn: A report of the national transgender discrimination survey: p. 88.

Witten, T.M. (2003). Life course analysis-The courage to search for something more: Middle adulthood issues in the transgender and intersex community: p. 216.

Clements-Nolle, K., Marx R., Guzman, R., & Katz M. (2001). HIV prevalence, risk behaviors, health care use, and mental health status of transgender persons: Implications for public health interventions. American Journal of Public Health 91 (6): 915-921.

Bockting W.O., Robinson B.E., & Rosser B.R. (1998). Transgender HIV prevention: a qualitative needs assessment. AIDS Care 10: 505-525.

Several studies have shown that transgender people access healthcare providers less frequently than the general population and this is especially true for people without networks of support in place. The Aging and Health Report found that regardless of socioeconomic status, transgender older adults have lower levels of social support than non-transgender older adults.31 The lack of professional resources in combination with the stress from systemic discrimination and poor social supports can complicate health issues for transgender people as they age.

‘’

HIV/AIDS A number of studies point to high-risk behaviors, such as sex work, unprotected sex and the unsafe injection of drugs, hormones or silicone, as prime contributors to the high rates of HIV/AIDS among transgender people. For example, data collected by the California Department of Health Services in 2003 showed a 6.3% rate of HIV diagnoses among self-identified transgender individuals—a rate higher than the infection rates found among groups considered high-risk, including men who have sex with men (4.2%) and partners of people living with HIV (4.8%).32 Again, these figures reveal racial disparities; transgender African Americans had significantly higher rates of HIV diagnoses than any other racial group, a finding that has been documented in several other studies on transgender HIV prevalence.33 Also, across studies analyzed by the Centers for Disease Control and Prevention’s HIV/AIDS Prevention Research Synthesis Team in 2007, male-to-female study participants were more likely to engage in risky sex behaviors (such as unprotected sex, sex work and sex with multiple partners), and reported higher rates of HIV diagnoses than female-to-male respondents.34

DID YOU KNOW? There are other factors to consider in contextualizing higher rates of HIV and AIDS in the transgender community, including the lack of “safe sex” education focused on the unique physical and emotional issues of transgender people.

There are other factors to consider in contextualizing higher rates of HIV/AIDS in the transgender community, including the lack of “safe sex” education focused on the unique physical and emotional issues of transgender people. The Transgender Aging Network (TAN) writes that transgender women who transition in mid- to late life may experience additional challenges in negotiating safe sex practices: “Frequently these MTFs [male-to-female persons] have been in heterosexual marriages for several decades, and may not have paid attention to safer sex messages because they felt the messages pertained only to gay men and/or younger people who were actively dating.”35

Fredriksen-Goldsen, et al. (2011). The aging and health report: Disparities and resilience among lesbian, gay, bisexual, and transgender older adults: p. 17.

Herbst, J.H., Jacobs, E.D., Finlayson, T.J., McKleroy, V.S., Neumann, M.S., & Crepaz, N. (2008). Estimating HIV prevalence and risk behaviors of transgender persons in the United States: A systematic review. AIDS and Behavior 12 (1): 1-17.

Ibid., 2.

Ibid., 10.

Cook-Daniels, L. (2008). Sexuality violence, elder abuse, and sexuality of transgender adults age 50+: Results of three surveys. Retrieved from http://forge-forward.org/2008/03/trans-aging-3-surveys/.

October 2011 meeting of the Advisory Committee for the Transgender Aging Advocacy Initiative, Washington, DC. Photo, from left to right: Joo-Hyun Kang, initiative facilitator and Serena Worthington, SAGE.

TAN also notes another risk factor for transgender populations, which is the possibility that the post-surgical vaginas of some trans women may be unusually susceptible to HIV transmission.36 Many more factors may affect HIV for transgender people, but more research is needed.

â&#x20AC;&#x2DC;â&#x20AC;&#x2122; DID YOU KNOW?

We know that transgender people face high rates of HIV/AIDS, and that the number of people over 50 living with HIV/AIDS is growing rapidly. However, little data is available about the impact of HIV/AIDS on older transgender people. One recent national study of LGBT older adults found that out of 174 transgender respondents, 3.5 percent reported they were living with HIV/AIDS. In the National Transgender Discrimination Survey, less than 1 percent of respondents over age 55 reported that they were HIV positive while nearly 8 percent reported they did not know their HIV status. However, these surveys relied on self-reporting and had significant sampling limitations. We do not yet have national HIV/AIDS surveillance data that is delineated by age category and transgender status. More research is needed to understand how

Research shows that few healthcare providers screen for HIV among older adults (under the assumption that sexual activity diminishes with age), and few HIV prevention marketing materials are targeted at older adults.

Ibid.

October 2011 meeting of the Advisory Committee for the Transgender Aging Advocacy Initiative, Washington, DC. Photo: Aaron Tax, SAGE.

many transgender older adults are living with HIV/AIDS, as well as the medical and other needs of older transgender people living with HIV/AIDS.37 Research shows that few healthcare providers screen for HIV among older adults (under the assumption that sexual activity diminishes with age), and few HIV prevention marketing materials are targeted at older adults. And as with the broader population, transgender elders with HIV include lifelong survivors, newly diagnosed and new infections; yet little research exists on the longitudinal effects of aging with HIV, the long-term effects of HAART (Highly Active Antiretroviral Therapy), and its relationships to transgender-related treatment and general aging health concerns. Transgender older adults who do not visit healthcare providers on a regular basis can face health challenges from HIV infection, beyond the complications that all older adults with decreased immune system functions face. Transgender older adults will likely have delayed diagnosis of the infection due to delayed care seeking, which increases the likelihood of comorbidities related to other untreated or previously undiagnosed conditions. A delay in HIV testing also increases the likelihood of a dual diagnosis of HIV and AIDS. By the year 2015, the Centers for Disease Control and Prevention

Population Reference Bureau. (2009). HIV and older adults in the United States. Todayâ&#x20AC;&#x2122;s Research on Aging 18: 1-7; Fredriksen-Goldsen, et al. (2011). The aging and health report: Disparities and resilience among lesbian, gay, bisexual, and transgender older adults; and Grant, J.M., et al. (2011). Injustice at every turn: A report of the national transgender discrimination survey.

(CDC) estimates that one in two people with HIV will be age 50 and older— a demographic shift that will have significant implications for transgender elders.

Other Health Issues The risk for developing certain cancers can be more acute among transgender people and worsened by the lack of insurance coverage for transition-related screenings and procedures. For example, some research suggests that transgender men have an increased risk of endometrial and ovarian cancers; this heightened risk is due in part to the lower rates of regular Pap tests and pelvic exams among transgender males who may be denied care from providers, may feel uncomfortable requesting these examinations or who might also be denied insurance coverage for these gender-specific screenings.38

‘’

Transition-Related Health Care Medical treatments to bring an individual’s physical attributes more in line with their gender identity, such as hormone replacement therapy and reconstructive surgery, are enormously beneficial to many transgender people. There is an overwhelming scientific consensus, based on decades of research and endorsed by the American Medical Association and other major medical associations, that these treatments are medically necessary for many individuals. The largest professional association for health care professionals specializing in care for transgender people is the World Professional Association for Transgender Health (WPATH), which was founded in 1979. WPATH publishes the internationally accepted Standards of Care for the Health of Transsexual, Transgender, and Gender-Nonconforming People. The Standards of Care have been developed and revised over more than thirty years by an international, interdisciplinary team of medical experts, and the seventh edition was published in 2011.39 However, many people are still unable to access treatments recommended by their medical providers because of financial and insurance barriers. In addition to the direct negative health impacts of barriers to appropriate care, some transgender women may resort to hazardous silicone injections as a form of self-treatment.

DID YOU KNOW? Transition-related medical treatments are generally understood to be very safe and highly effective... However, less is known about possible side effects and best practices for monitoring long-term hormone replacement therapy in older patients.

Transition-related medical treatments are generally understood to be very safe and highly effective. In the last decade research findings have led to the use of lower doses and, for transgender women, safer types of estrogens for hormone therapy. However, less is known about possible side effects and best practices for monitoring long-term hormone replacement therapy in older patients.40 Lab monitoring is an essential part

Feldman, J.L., & Goldberg, J.M. (2007). Transgender primary medical care. International Journal of Transgenderism 9 (3-4): 3-34.

World Professional Association for Transgender Health. (2011). Standards of care for the health of the transsexual, transgender, and gender nonconforming people. Minneapolis, MN.

Persson, D.I. (2009). Unique challenges of transgender aging: Implications from the literature. Journal of Gerontological Social Work 52 (6): 633-646.

of hormone therapy maintenance. Chronic health conditions more common among older people may also impact treatment options and the need for monitoring.41 Moreover, there are increased chances of developing surgery-related conditions such as rectovaginal fistulas and urinary tract infections. 42 Whether obtained on the street or under professional medical supervision, the health implications, if any, of prolonged hormone usage is unknown. Further, there is no research that illustrates the potential consequences for older adults who use hormones at a point in their lives when hormone levels usually drop off.43 One known outcome is a heightened likelihood of developing osteoporosis for those transgender elders who discontinue hormone use and are no longer able to produce their bodies’ “native hormones.”44

‘’ DID YOU KNOW? Health insurance companies often systematically exclude transition-related care even while covering similar or identical treatments for other indications, and in many cases these exclusions are used to deny coverage for a wide range of care for transgender people that may or may not have any connection to gender transition.

Limited Insurance Coverage Qualifying for health insurance coverage can be a balancing act for many transgender older adults. Health insurance companies often systematically exclude transition-related care even while covering similar or identical treatments for other indications, and in many cases these exclusions are used to deny coverage for a wide range of care for transgender people that may or may not have any connection to gender transition.45 For many transgender older adults, years of employment discrimination and unstable work tenure has limited their access to private insurance providers. In these cases Medicare or Medicaid might be their only insurance options. However, these programs frequently place arbitrary and discriminatory limits on coverage for transition-related and preventive care, requiring transgender elders to pay out-of-pocket for many expenses. Such out-of-pocket healthcare costs may “have an effect on medical treatment and hence on numerous mid-to-late stage life course factors.” 46

Berreth, M.E. (2003). Nursing care of transgender older adults: Implications from the literature. Journal of Gerontological Nursing 31 (7): 44-49.

Asscheman H., Giltay E.J., Megens J.A., de Ronde W.P., van Trotsenburg M.A., & Gooren L.J. (2011). A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones. European Journal of Endocrinology 164 (4): 635-642; Hembree, W.C., Cohen-Kettenis, P., Delemarre-van de Waal, H.A., Gooren, L.J., Meyer, W.J., Spack, N.P., Tangpricha, V., & Montori, V.M. (2009). Endocrine treatment of transsexual persons: An endocrine society clinical practice guideline. Journal of Clinical Endocrinology & Metabolism 94 (9): 3132-3154; Gooren, L.J., Giltay, E.J., & Bunck, M.C. (2008). Long-term treatment of transsexuals with cross-sex hormones: Extensive personal experience. Journal of Clinical Endocrinology & Metabolism 93 (1): 19-25; and Cook-Daniels, L. (2008). Trans elder health issues. Retrieved from http://www.forge-forward.org/handouts/ transelderhealth.pdf.

Cook-Daniels, L. (2008). Aging as ourselves: LGBT aging health issues for health care providers: 42.

Ibid.

Kong, M.E. (2002). Categorical exclusions: Exploring legal responses to health care discrimination against transsexuals. Columbia Journal of Gender and Law 11: 88-126; and Human Rights Campaign Foundation. (2012). Transgender-inclusive health care coverage and the corporate equality index. Retrieved from http://www.hrc.org/files/assets/resources/Transgender_Healthcare_ White_Paper_4.pdf.

October 2011 meeting of the Advisory Committee for the Transgender Aging Advocacy Initiative, Washington, DC. Photo: Loree Cook-Daniels, FORGE/Transgender Aging Network.

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As with the general population, many transgender people are uninsured and underinsured. Low-income elders are especially hard hit by the lack of healthcare coverage and often postpone medical care because they are unable to afford it. Although many older adults qualify for Medicare insurance coverage, more than 50 million non-elderly American adults are currently uninsured, many of whom lost employersponsored insurance coverage during the recent recession.47 The monthly costs of hormone medications and any other needed prescriptions can be an additional financial stress on transgender elders living on fixed incomes. The cost of hormone medications can range from $40-$100 per month.48

DID YOU KNOW? The monthly costs of hormone medications, which range from $40-$100 a month, and any other needed prescriptions can be an additional financial stress on transgender elders living on fixed incomes. 46

Witten, T.M. (2003). Life course analysis-The courage to search for something more: Middle adulthood issues in the transgender and intersex community. In M. Sullivan (Ed.), Sexual minorities: Discrimination, challenges, and development in America (189-224). Binghamton, NY: The Haworth Social Work Practice Press.

The Kaiser Commission on Medicaid and the Uninsured. (2010). The uninsured: A primer, key facts about Americans without health insurance. Menlo Park, CA: The Henry J. Kaiser Family Foundation.

Witten, T.M. (2003). Life course analysis-The courage to search for something more: Middle adulthood issues in the transgender and intersex community: p. 208, 212.

Mental Health Throughout the decades, the ways in which the field of psychiatry has understood concepts related to gender identity and gender transition have been the source of controversy. In general, this field has over time lessened its focus on defining a transgender person’s gender identity through a diagnostic lens and placed more emphasis on understanding the challenges that people face when they are raised in a gender that differs from how they self-identify.49 Transgender people experience significance disparities in mental health. Findings from the NTDS and The Aging and Health Report point to increased rates of depression, loneliness and suicidal ideation among transgender people. According to The Aging and Health Report, 71 percent of transgender older adults reported having contemplated suicide at some point, a rate much higher than the 35-40 percent reported by the survey’s LGB older adult respondents.50 One study found that transgender respondents ages 40-59 reported a lifetime prevalence of depression similar to younger respondents (52.4 percent versus 54.7 percent), but that depression manifested differently across the lifespan for different age cohorts. While younger respondents reported high levels of depression in early adolescence that declined significantly into early middle age, older respondents were more likely to report having experienced depression over longer periods of time. Among older respondents, more than half had experienced suicidal ideation at some point in life, more than one in four reported a suicide attempt at some point in life, and 6.7 percent reported suicide attempts during two or more stage of life.51

‘’ DID YOU KNOW? Many transgender people develop and rely upon a variety of coping mechanisms to help them survive the violence and discrimination they experience over a lifetime, and spirituality and religion can play an important part in helping mitigate these negative experiences.

Many transgender people develop and rely upon a variety of coping mechanisms to help them survive the violence and discrimination they experience over a lifetime, and spirituality and religion can play an important part in helping mitigate these negative experiences. A 2008 report examining the role of religion and spirituality in transgender-identified communities, found that midlife was an important time of reflection for many people and could also be a significant moment for deepening spiritual beliefs. This was seen to be especially true for transgender people who were parents.52 The study also documented a broad array of responses related to respondents’ belief structures, suggesting that broader constructs of faith and religiosity may be important for people supporting transgender older adults.53

See World Professional Association for Transgender Health. (2011). Standards of care for the health of the transsexual, transgender, and gender nonconforming people. Minneapolis, MN; and Vance, S.R., CohenKettenis, P.T., Drescher, J., Meyer-Bahlburg, H.F.L., Friedemann, P., & Zucker, K.J. (2010). Opinions about the DSM gender identity disorder diagnosis: Results from an international survey administered to organizations concerned with the welfare of transgender people. International Journal of Transgenderism 12 (1): 1-10.

Fredriksen-Goldsen, et al. (2011). The aging and health report: Disparities and resilience among lesbian, gay, bisexual, and transgender older adults: p. 27.

October 2011 meeting of the Advisory Committee for the Transgender Aging Advocacy Initiative, Washington, DC. Photo: Harper Jean Tobin, National Center for Transgender Equality.

Veterans Issues The NTDS found that 20% of respondents had served in some branch of the military, and these figures were 40% for those transgender elders aged 55-64 and 54% for those 65 and older.54 The Aging and Health Report found similarly high rates of military service among transgender older adult respondents, with 41 percent having served.55 These rates are much higher than the general populationâ&#x20AC;&#x2122;s 10 percent rate of service. With such high percentages of transgender people and transgender older adults in particular having served in the military, transgender advocates have paid close attention to how the Department of Veterans Affairs (VA) engages with issues of gender nonconformity and transgender patients, as the VA is a primary point of healthcare access for veterans. Many transgender veterans have acknowledged problems accessing

Nuttbrock, L., Hwahng, S., Bockting, W., Rosenblum, A., Mason, M., Macri, M., & Becker J. (2010). Psychiatric impact of gender-related abuse across the life course of male-to-female transgender persons. Journal of Sex Research 47 (1): 12-23.

Kidd, J.D., & Witten, T.M. (2008). Understanding spirituality and religiosity in the transgender community: Implications for aging. Journal of Religion, Spirituality, & Aging 20 (1-2): 37.

Ibid., 30.

Harper Jean Tobin, e-mail message to author, May 24, 2011.

Fredriksen-Goldsen, et al. (2011). The aging and health report: Disparities and resilience among lesbian, gay, bisexual, and transgender older adults: p. 3.

October 2011 meeting of the Advisory Committee for the Transgender Aging Advocacy Initiative, Washington, DC. Photo: Natalie Chin, Lambda Legal.

consistent and respectful care at VA facilities nationwide. The Transgender American Veterans Association (TAVA) published a survey in 2008 that found that respondents reported “organizational discrimination at the VA in a lack of clear and consistent practice, with little support for gender transitions…there were many reports of interpersonal discrimination, via lack of respect from VA doctors, non-medical staff, and nurses.”56 Though individual VA providers and centers vary in their approaches to transgender veterans, no uniform policy had mandated the fair treatment of transgender people and the provision of transition-related healthcare at all VA facilities, until the publication of a VA Directive on June 9, 2011. The new Directive clarified existing VA policy and emphasized that respectful healthcare services should be delivered to transgender veterans “without discrimination,” and that all medically necessary care is covered by the VA including sex-specific care such as mammograms.57 However, the Directive also reiterated that the VA will not cover sex reassignment surgery, a longstanding prohibition that is at odds with current medical science. The Directive is seen as an important step toward ensuring equal access and care for the many transgender veterans who seek care through the VA.

Bryant, K., & Schilt, K. (2008). Transgender people in the U.S. military: Summary and analysis of the transgender American veterans association survey. Retrieved from http://www.tavausa.org/Transgender%20 People%20in% 20the%20U.S.%20Military.pdf.

National Center for Transgender Equality. (2011). Veterans health administration transgender healthcare directive. Retrieved from http://www.transequality.org/PDFs/VHA _Trans_Health.pdf.

Employment and Housing Discrimination The workplace is another realm where transgender people experience frequent discrimination and abuse. As of January 2012, only 16 states and the District of Columbia had laws banning job discrimination based on gender identity or expression. According to the National Transgender Discrimination Survey, 90 percent of respondents had experienced transphobic discrimination at work and 24 percent had lost their jobs because of their employers’ discomfort with their transgender identities.

‘’

Job instability affects the economic security and the overall health of the aging transgender population. The NTDS found that participants who had lost a job due to discrimination were four times as likely to be homeless, 70 percent more likely to use drugs or alcohol to cope with stress, and more than twice as likely to have HIV as those who had not lost their jobs due to transgender bias.58

DID YOU KNOW? Job instability affects the economic security and the overall health of the aging transgender population. The NTDS found that participants who had lost a job due to discrimination were four times as likely to be homeless, 70 percent more likely to use drugs or alcohol to cope with stress, and more than twice as likely to have HIV as those who had not lost their jobs due to transgender bias.

The housing landscape for many transgender people remains equally unstable. The survey found that 19 percent of respondents had been refused a home or apartment and 11 percent had been evicted because of transgender-related discrimination.59 Findings from a 2009 report on LGBT health and human services in New York State show that three times as many transgender people were currently (3.7 percent) or formerly (29.6 percent) homeless, as compared to their non-transgender counterparts.60 Health disparities experienced by transgender elders are acquired through intersecting layers of discrimination and are “traceable to socioeconomic factors, stress caused by prejudice and stigma.”61 Though there is much more that needs to be done to ensure equal access to healthcare, housing and employment, transgender older adults are an engaged and resilient community. Many transgender elders are active in their communities through spiritual or religious services and are improving their health through wellness activities and physical exercise.62 The continued efforts of individuals, advocates and professionals working together will help achieve the vision of a healthier and more equitable transgender aging community.

Ibid, 3.

Ibid.

Somjen Frazer, LGBT Health and Human Services Needs in New York State, Empire State Pride Agenda Foundation, 2009: 12.

Cook-Daniels, L. (2008). Aging as ourselves: LGBT aging health issues for health care providers: p. 32.

Fredriksen-Goldsen, et al. (2011). The aging and health report: Disparities and resilience among lesbian, gay, bisexual, and transgender older adults: p. 17.

A Note on Intersex Conditions

ntersex conditions, or disorders of sex development (DSD), are a diverse group of conditions wherein a person is born with a reproductive or sexual anatomy and/or chromosome pattern that doesn’t seem to fit typical definitions of male and female. About 1 in 2,000 individuals is born with an intersex condition or DSD. In the United States beginning in the 1950s, infants and children with intersex conditions or DSD were routinely given surgeries or other medical interventions intended to make their bodies appear more typical. Their families were told to keep these conditions a secret, sometimes even from the child. Sometimes doctors didn’t tell the parents or the children the full truth about the child’s condition. At that time, doctors believed that early surgical intervention and secrecy would help the child develop a “normal” gender identity as either a boy or a girl. Even before the 1950’s, surgical intervention followed by secrecy was a common practice. In the 1990’s, intersex adults began stepping forward to say that the medical treatment they received in childhood was harmful, leading to sterility, ongoing pain, scarring, incontinence, loss of genital sensation and sexual function, and depression. Many also pointed out that the secrecy surrounding their conditions had led to damaging feelings of shame and stigma. Together with parents of affected children, they began to find each other and form support groups, advocating for models of care that take the experiences and wisdom of children and their families into account. These efforts have started to impact standards of care and support for research, but older individuals today who were born with intersex conditions or DSD are often living with the damaging effects of the secrecy, shame and aggressive early surgery that prevailed

in their childhood. Their histories may include medical experimentation and “medical display” (in which children or adults are made to display their atypical bodies in medical settings for teaching purposes or to satisfy providers’ curiosity). Many have a profound distrust of medical providers and may have put off needed treatment for years or decades. They may have unique medical needs related to their condition and treatment history— and if they discovered the details of their history only recently, or continue to experience trauma related to past medical abuse, may also have needs for emotional or psychological support. Most people with intersex conditions or DSD identify as male or female, usually in accordance with the gender they were assigned at birth. Most do not identify as transgender. In some cases, the gender of a person with an intersex condition or DSD was misidentified as birth, and may have been correctly identified later in life. Like transgender people, people with these conditions may encounter bias, ignorance, inappropriate treatment or invasions of their privacy by care providers because their anatomies or medical histories do not conform to typical expectations for men or women. As with transgender older adults, it is critical that those working with individuals with intersex conditions or DSD respect their dignity and privacy, protect them from mistreatment and ensure that their medical needs are fully understood and supported.

For more information on this topic, see: Intersex Society of North America www.isna.org Advocates for Informed Choice www.aiclegal.org Accord Alliance www.accordalliance.org AIS-DSD Support Group for Women and Families www.aisdsd.org CARES Foundation www.caresfoundation.org DSD Families www.dsdfamilies.org

SAGE and NCTE would like to thank Anne TamarMattis, Executive Director of Advocates for Informed Choice, for authoring this section.

Hypospadias and Epispadias Association www.heainfo.org

Gaining Visibility: The Challenges Facing Transgender Elders By Sean Kennedy

Like many women her age, Dawn Flynn, 63, is trying her best to stave off the ravages of time. “I use a lot of products to try to maintain a good-looking appearance,” the North Carolina museum curator says. “Everybody tells me I look great. Nobody guesses my age at all. They think I’m 10 years younger than I am.” But while she may be defying the physical signs of aging, Flynn is struggling with another problem, one that garners fewer headlines: discrimination because she’s transgender. Three years ago, Flynn, assigned male at birth and raised a boy, began transitioning to female. And though she’s been accepted by her children and by her colleagues at the Schiele Museum of Natural History in Gastonia, Flynn has faced severe hostility from her former church. She joined the Methodist congregation decades ago in the hope of finding a “spiritual answer” to feeling like she was a woman; she then felt the call of ministry, studying at the Duke Divinity School and serving as a pastor for 10 years. Flynn’s tenure came to an abrupt end, however, after she appeared in a “womanless” beauty pageant to raise money for a Relay for Life cancer walk. Though she “really got in touch with my female side, my church found out about it, and they were very upset.” Three people reported Flynn to her supervisor, and the national church body “called me on the carpet and told me I was sick and needed to get help. They wanted to do an evaluation to see if I could still be a pastor because of my ‘sickness.’ ”

Photo: Dawn Flynn, 63 Gastonia, NC

The views expressed in this article ("Gaining Visibility: The Challenges Facing Transgender Elders") are those of the author, Sean Kennedy. For permission to reprint this article, please contact SAGE.

Rather than submit to the church’s demands, Flynn quit. Within months, she was planning suicide. “I lost my wife, my friends, the church, and God. I lost everything. I just didn’t feel there was any reason to live.” Instead of killing herself, though, Flynn found a therapist and began living as a woman. She also joined a new church that accepts her for who she is. She teaches Sunday school and sometimes preaches. “I’ve got a tremendous family there that loves me and cares for me.” Her old church, however, has not come as far as Flynn: At the time she spoke in March 2012, she was fighting to gain access to the retirement account she has there under her former male first name. Even though Flynn legally changed her first name to Dawn, the church has cited the discrepancy in its refusal to transfer the account. If the church doesn’t budge, Flynn’s retirement savings will be decimated: she estimates the account comprises about 75% of her portfolio. Her museum job is part-time; she’s never been employed full time. “I haven’t been able to have a 401(k) or a full retirement plan,” she says. “The only retirement plan I’ve got is my Social Security, the church fund, and a little bit of savings. That’s it.”

“I got involved in advocacy because I did a lot of homework and set out to inform the world.”– Dawn Flynn

Flynn’s story of discrimination and its effects is shared by many older adults who are transgender. Due to pervasive social stigma concerning gender identity and expression, trans women and men face a multitude of issues that compound the extant challenges of aging. Among these issues: discrimination in health care and insurance; a lack of culturally competent services in settings from the doctor’s office to long-term-care facilities; and trans-specific health risks, not to mention the chronic stress that often accompanies stigma. And while lesbian, gay, bisexual, and transgender (LGBT) older adults as a group face marked discrimination and disparities, transgender elders are arguably the most vulnerable of this vulnerable population, given greater prejudice towards gender non-conforming people—a prejudice that also exists within the LGBT community.

“We need to be a stronger presence on the national agenda, and it’s a real problem because we don’t have a large, visible constituency,” says Helena Bushong, 61, a transgender and HIV/AIDS advocate in Chicago. “The biggest challenge right now is the federal government.”

The Freedom to Control One’s Dignity From appearing in local public-service announcements as a transgender woman to participating in a national HIV/AIDS strategy focus group at the White House, Bushong has certainly been doing her part to create visibility and change. As she says: “I got involved in advocacy because I did a lot of homework and set out to inform the world.” Bushong, a part-time librarian at a community college on Chicago’s south side, transitioned to female four years ago at the age of 57. “Being a trans person of color comes with a built-in stress factor,” she says. At work, her female colleagues “embrace me as an older female,” while the men tend to see her as “some kind of freak.” The students “can go either way. When they need something, you’re a mother. When they’re goofing off with their friends, they might crack a joke. It’s a challenge to walk through that gauntlet every day.” Despite her connections in the local LGBT community, Bushong, like many trans people, is estranged from her family of origin and doesn’t have any children. Although she’s been “adopted” by the family of a close friend, in no way has that eased her worries about the future. “My friend who’s adopted me is 60 and her husband is 76, so pretty soon we’ll be taking care of him,” she says. But what about when Bushong needs care—can she count on her friend’s adult children, now 28 and 24, to provide it, in addition to caring for their own parents? “I don’t think so.” “That’s really my biggest fear right now, not having the freedom to control my dignity,” she continues. An eldercare facility is out of the question. “No, I’m not going to no nursing home. There’s no place. You can’t convince me there’s a place.”

“That’s really my biggest fear right now, not having the freedom to control my dignity.”– Helena Bushong

Photo: Helena Bushong, 61 Chicago, IL

Health Care and Insurance Gaps Another area that can pose challenges to a transgender older adult’s dignity is health care and insurance. Transition-related health care is excluded by most private carriers, and transition-related surgeries are not covered by Medicare. “So older folks have to be able to afford this themselves,” says Moonhawk River Stone, 64, a transgender man and therapist who works with many transgender clients in the Albany, New York, area. For some people, affording such health care means “biting into their nest egg,” thus dealing a blow to their retirement income. Those who can’t afford it “have to be very creative in order to get the care they need.” For many, this means finding doctors who will code procedures in such a way so that they’re covered by insurance. Transgender-friendly medical providers are key for other reasons, too. For one thing, as stigma lessens over time, many transgender people seek surgery later in life, right when the aging process ramps up. And the older one is, the more risks surgery presents. As Stone puts it: “Anytime you’re having major surgery when you’re aging, you have one less major surgery in you.” Consequently, Stone has had to work with his clients’ medical providers to help them understand why a person of 50, 60, or 70 would opt for “elective” surgery given the risks. “Surgeons need to be comfortable operating on people who have some amount of existing risk but for whom surgery is not contraindicated and who have accepted that risk,” he says. “It’s a whole dialogue—informed “Surgeons need to be comfortable consent all the way around.”

operating on people who have That dialogue extends to other issues as well, like some amount of existing risk but for hormone treatment, which is “very different when people whom surgery is not contraindicated are aging.” Stone has and who have accepted that risk.” often had to educate endocrinologists “about just – Moonhawk River Stone what you do for people. This is how you manage this, this is difficult interfacing because…” The conversation itself can become difficult if a doctor feels his or her medical expertise is being challenged. Defensive providers have trotted out their credentials to Stone, challenging him in return—“Well, you didn’t take a residency in this”—but he typically knows more than them, based in part on information from his own network of medical professionals. “I work with a couple of people who really respect my opinion,” Stone says. That’s not, however, the case for many other transgender people. Photo: Moonhawk River Stone, 64 Albany, NY

Another potential medical risk is long-term hormone treatment, the effects of which are unknown. Although older adults receive many treatments and medications that have not been studied longitudinally, some transgender men are particularly worried about testosterone. Rene Hickman, 48, of Denver, has been on “T” for more than 15 years; though he hasn’t experienced any problems yet, he’s unsure of what the future holds. “Nobody really knows what the long-term effects of testosterone use are,” says Hickman, a former health technician now in social-work school. His concern is due in part to seeing a friend develop complications after being on testosterone for decades. And should complications arise for Hickman, he fears their treatment won’t be covered by insurance. “All the policies I’ve dealt with in the past denied any type of service related to SRS,” he says, referring to “sex reassignment surgery,” the clinical designation for a range of gender-altering procedures that insurance companies typically consider elective. “The wording is so general that anything can be applied to it.” Until that wording is changed, Hickman, a single parent, will continue to pay himself for medically necessary health care. Such expenses have already taken a toll on his personal finances. “I’ve had to do everything out of pocket,” including chest and genital surgeries and a hysterectomy. Altogether, Hickman’s health-care costs have “affected my ability to retire.”

A ‘Lost Generation’ of Transgender Elders Max Fuentes Fuhrmann, 52, has been on testosterone twice as long as Hickman, having begun his transition more than three decades ago at age 20. Like other transgender pioneers of the pre-AIDS era, he still carries the stigma of a time when prejudice against gender-nonconforming people was appreciably more virulent than it is now. “I’m part of a generation of people who transitioned back in the day who are cut off from a lot of the newer advocacy,” says Fuentes Furhmann, a clinical psychologist who lives in the Los Angeles area. “When I transitioned I could have been thrown out of university. I had no civil rights. I couldn’t travel to other countries when I was in graduate school because I couldn’t get a passport without having had genital surgery.” In that hostile legal and social environment, Fuentes Furhmann was told by his transgender mentors “to transition and never talk about it.” Photo above: Rene Hickman, 48 Denver, CO; right: Max Fuentes Fuhrmann, 52 Los Angeles, CA

He calls this cohort of “stealth” elders a “lost” generation—contemporary examples of figures like jazz musician Billy Tipton, discovered to be biologically female at his death in 1989. Because of such early stigma and advice, many people who transitioned a long time ago remain isolated, both from the wider LGBT community and from the medical establishment. “You were viewed as mentally ill, which obviously sticks with you,” Fuentes Fuhrmann says.

SEAN KENNEDY is a writer, editor and media consultant based in Brooklyn, New York. Formerly on staff at Interview, New York, and The Advocate, where he served as the news and features editor, he’s also contributed to CNN, Newsweek, The Daily Beast, Elle, Salon, Nerve, Time Out New York, and Out, among others. A 2000 graduate of the University of Virginia, he’s currently pursuing an MFA in fiction at Rutgers University in Newark. For more info, visit www.sean-kennedy.com.

Consequently, there’s an untold number of transgender older adults who are “terrified” of receiving routine medical care, like a pap smear. “These folks are dying from potentially treatable medical conditions because they haven’t had the bridges to feel comfortable enough to access services.” For those who don’t die outright, their treatable illnesses can turn into chronic ones, putting them at greater risk for long-term care. “People in their 50s” can wind up in care facilities, Fuentes Fuhrmann says, because of never seeing a doctor when they needed to. Residing in a long-term-care setting creates a host of problems on its own for transgender older adults. “When you have a gender-variant body and need physical care, like having a shower, being dressed, or being fed, you can see how you’re really at risk for physical abuse,” says Fuentes Fuhrmann, whose specialty is gerontology. “It’s a whole other level of safety. Most of the people who work in these facilities are paid minimum wage, and they’re often not real LGBT-friendly.” On top of that, “there’s great resistance to any kind of sensitivity training, at least in California. The attitude is, ‘We’re not going to spend the money to train our staff unless the state comes in and sanctions us.’” State budget trouble makes cultural competency even less of a priority, he adds.

“You were viewed as mentally ill, which obviously sticks with you.” – Max Fuentes Fuhrmann

And yet despite these and the myriad other difficulties they face, transgender older adults seem to agree on a key point: things can only get better. “We’re always making advancements,” says New York’s Stone, who has sat on the board of a number of LGBT organizations. “In the last fifteen years, the trans community has gone from horse and buggy to rockets. We’ll be up to interplanetary travel pretty quick.”

After all, the more visibility transgender issues in general gain, the more visibility transgender aging issues will receive, too. “We’re working on policy and we’re banging on doors in state capitals and Washington,” Stone says. “We’re going to increase our wellbeing and decrease our discrimination exponentially.”

Detailed Recommendations 31

Aging Services Network

Improving Health

Long-Term Services and Supports

Ending Violence and Abuse

Creating Equal Employment Opportunities

Housing

Improving Economic Security

Building a Foundation of Knowledge

Privacy and Documentation

Community Support and Engagement

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

* In 2011 SAGE and the National Center for Transgender Equality launched a historic Transgender Aging Advocacy Initiative to outline the many policy and practice barriers facing transgender and gender non-conforming older adults, as well as some key solutions for addressing these barriers. To help inform and create this advocacy roadmap, we brought together a diverse committee of leading experts from around the country. The Advisory Committee of the Transgender Aging Advocacy Initiative (listed on page 2) identified several immediate policy and practice priorities to improve the lives of transgender older adults. While all of the issues outlined in the full report are important, the priorities listed here were identified based on their expected impact if accomplished, as well as the expected feasibility of accomplishing them within the next 1-2 years.

October 2011 meeting of the Advisory Committee for the Transgender Aging Advocacy Initiative, Washington, DC. Photo, from left to right: Earline Budd and Barbara Satin, GLBT Generations and National Gay and Lesbian Task Force.

Detailed Recommendations Aging Services Network The Older Americans Act (OAA) is the nation’s largest vehicle for funding and delivering services to older adults. It created the country’s Aging Services Network, which includes the Administration on Aging at the federal level, as well as hundreds of state and area agencies on aging (AAAs) and thousands of service providers and Tribal organizations. Through this network, older adults have access to a wide range of services, including meal programs, social and educational activities, health promotion and disease prevention, legal help, transportation, in-home supportive services and elder rights education. Because this network encompasses so many programs that reach older adults, it is critically important that it be accessible to all older people. Unfortunately, research and experience indicate that today’s aging services network is frequently unprepared to provide competent and nondiscriminatory services to transgender older adults, as well as to address the unique challenges faced by this population.63 For example, transgender older adults might show up for a congregate meal or a legal intake only to be told to come back dressed in “gender-appropriate” clothes, harassed for using public restrooms, or asked humiliating questions. In many cases, transgender older adults choose not to seek services out of fear of encountering biased treatment. The OAA places particular emphasis on meeting the needs of older adults with the “greatest social need” and other vulnerable populations, but neither the Act nor the regulations issued under it have clarified that transgender and LGB older adults constitute a group with the “greatest social need.” Researchers, however, are beginning to recognize the distinct vulnerabilities of transgender older adults, including the Institute of Medicine, which concluded in a recent report that “LGBT elders experience stigma, discrimination, and victimization across the life course.”64

Knochel, K.A., et al. (2010). Ready to serve? The aging network and LGB and T older adults.

National Academy of Sciences. (2011). The health of lesbian, gay, bisexual, and transgender people: Building a foundation for better understanding. Washington, DC: Institute of Medicine of the National Academies.

The following policy steps should be taken to ensure that OAA programs adequately serve all older adults: The Administration on Aging (AoA) should clarify, through agency guidance, that LGBT older adults constitute a group with “greatest social need,” and that federally-funded service providers should not exclude LGBT older adults from programs and services.

Congress should reauthorize and fully fund the Older Americans Act (OAA), and should include LGBT older adults in its data collection, project assessment and reporting requirements; explicitly include LGBT older adults in the definition of greatest social need; and permanently establish the National Resource Center on LGBT Aging to ensure cultural competence training for generations to come.

It is also crucial that providers throughout the Aging Services Network understand— and are prepared to meet—the needs of transgender older adults. A recent survey of 230 area agencies and state units on aging found that more than one in four reported that transgender older adults would either not be welcomed by local service providers or the agency was unsure of how welcome they would be.65 Therefore, cultural competence training and technical assistance for these providers is essential. The AoA should continue to support the development and promotion of LGBT competence training and tools for area agencies on aging (AAAs) and aging service providers, including the training and educational resources created by the National Resource Center on LGBT Aging.

State and local transgender and LGBT organizations should partner with AAAs and aging service providers to improve access to welcoming services and opportunities for transgender older adults.

AAAs and aging service providers should use resources such as the National Resource Center on LGBT Aging’s Inclusive Services for LGBT Older Adults: A Practical Guide to Creating Welcoming Agencies to improve their training, policies and services.

Finally, the National Family Caregiver Program, funded by the OAA, is an important resource for people providing unpaid care for transgender older adults, particularly because so many transgender older adults rely on networks of friends and loved ones for support. The program offers counseling and other services and supplies to help relieve the emotional, physical and financial hardships of providing continual care. Community organizations should help ensure that LGBT older adults and their companions are aware of these benefits.

Knochel, K.A., et al. (2010). Ready to serve? The aging network and LGB and T older adults.

Community organizations should educate LGBT older adults about the resources available under the National Family Caregiver Program and should apply for caregiver support funding to assist LGBT people through AAAs and state aging units.

Improving Health Transgender older adults face numerous barriers to accessing quality health care. These include financial barriers, a lack of appropriate cultural and clinical competence among providers, the discomfort experienced by many older transgender people regarding physical exams and conversations about their bodies and the fear and reality of bias and discrimination in both insurance and the provision of care. These barriers all work to prevent individuals from accessing quality care. The Joint Commission, which accredits hospitals, requires hospitals not to discriminate on the basis of gender identity or sexual orientation, and has put out a guide to making facilities culturally competent to provide care to LGBT patients.66 To be accredited under these standards, hospitals cannot refuse to admit or treat patients because they are transgender or cross-dressing, and they cannot, for example, refuse to provide the same medically indicated gynecological services for transgender men that they provide to non-transgender women. Likewise, the Veterans Health Administration has issued a directive to its health centers to ensure the provision of appropriate and nondiscriminatory care to transgender veterans, as well as veterans with intersex conditions.67 Federal, state and local governments should incentivize the creation and implementation of similar policies, and they should be adopted by all health care facilities. All health care facilities should adopt nondiscrimination policies that include gender identity and sexual orientation.

Health care facilities should use resources such as the Joint Commissionâ&#x20AC;&#x2122;s Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual and Transgender (LGBT) Community: A Field Guide to develop comprehensive policies and procedures for serving transgender patients.

Health care providers should be trained on the identities, needs, rights and health disparities of transgender people, including transgender older adults, and clinical guidelines for caring for transgender people.

The Joint Commission (2010). Advancing effective communication, cultural competence, and patient- and familycentered care: A roadmap for hospitals. Oakbrook Terrace, IL: The Joint Commission.

Petzel, R.A. (2011). Providing health care for transgender and intersex veterans. Retrieved from http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2416.

Federal, state and local governments should provide incentives and, where appropriate, requirements for LGBT training for health care providers.

Professional training programs, including programs in gerontology, should incorporate discussion of the identities and needs of transgender older people into their curricula.

If health care providers receive Medicaid, Medicare or other federal funding, consumers are protected under the Affordable Care Act of 2010, which prohibits sex discrimination by health care providers that take federal funding. Courts and federal agencies have consistently interpreted sex discrimination laws like this one to prohibit discrimination against transgender people.68 This critical feature of the health care reform law, and its potential to offer rights and remedies for transgender consumers, has so far received little attention. The U.S. Department of Health and Human Services Office for Civil Rights should issue guidance making clear that discrimination against health care consumers because they are transgender or fail to conform to gender stereotypes is unlawful under the Affordable Care Act if a health care provider receives federal financial assistance.

Medicare covers much of the health care costs of millions of older adults and people with disabilities. Although it covers many of the medical needs associated with transition, including hormone replacement therapy, it still excludes coverage for sex reassignment surgery. Regulations governing the U.S. Department of Veterans Affairs include a similar ban. These exclusions are based on a decades-old determination that such procedures were experimental. Today, however, leading medical and mental health associations including the American Medical Association, American Psychological Association and American Academy of Family Physicians widely recognize these treatments as safe, effective and medically necessary and recommend that they be included in public and private health coverage.69 Eliminating limits on these earned benefits that target transgender older adults is both smart health policy and a matter of basic fairness.

The Centers for Medicare & Medicaid Services (CMS) should eliminate the arbitrary exclusion of transition-related surgical care from Medicare.

National Center for Transgender Equality. (2012). Health care rights and transgender people. Retrieved from http://transequality.org/Resources/HealthCareRight_March2012_FINAL.pdf; and Macy v. Holder, EEOC No. 0120120821 (2012).

Lambda Legal. (2012, Jan. 9). Professional organization statements supporting transgender people in health care. New York, NY: Lambda Legal. Retrieved from: http://www.lambdalegal.org/sites/default/files/publications /downloads/fs_professional-org-statements-supporting-trans-health_1.pdf; and National Center for Transgender Equality. (2012). A blueprint for equality: A federal agenda for transgender people. Retrieved from http://transequality.org/Resources/NCTE_Blueprint_ for_Equality2012_FINAL.pdf.

The Department of Veterans Affairs (VA) should amend regulations to eliminate the arbitrary exclusion of transition-related care from health benefits for veterans and dependants.

Dramatic numbers of transgender people are affected by HIV and AIDS, particularly transgender people of color.70 Because so many people living with HIV/AIDS are living longer and healthier lives thanks to developments in antiretroviral medications, increased funding for prevention and treatment is critical to the successful aging of many transgender people. Federal, state and local governments should increase funding to prevent and treat HIV/AIDS, including developing and implementing prevention strategies tailored to transgender and older populations.

The definitions of “greatest social need” in the OAA should explicitly name older adults living with HIV, recognizing the growing number of older adults living with HIV—including transgender older people—and the related health disparities, discrimination and stigma.

Long-Term Services and Supports All older adults should have the supports they need as they age. They should also have the freedom to be who they are and to live their lives as they choose. Transgender people deserve to have their identities respected, regardless of the level of care they need. That basic dignity is too often denied to a growing population of transgender older adults. The research shows that most older adults prefer to receive the services and supports they need at home or in a community setting, rather than in an institutional setting such as a skilled nursing facility.71 While public funding for home- and community-based care is expanding, explicit protections for the rights of individuals receiving care are often lacking or unenforced. Explicit nondiscrimination protections for transgender consumers are a critical missing piece. Currently, providers may be covered as health care providers under the Affordable Care Act or as housing providers under the Fair Housing Act. Both of these federal laws prohibit sex discrimination, including discrimination on the basis of gender identity or failure to conform to gender stereotypes (see discussion above). This means that, for example, it is unlawful to deny housing to a person because the person is transgender, to permit a pattern of harassment of a transgender resident or

National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Division of HIV/AIDS Prevention. (2011). HIV infection among transgender people. Retrieved from http://www.cdc.gov/hiv/transgender/pdf/ transgender.pdf; and Herbst, J.H., et al. (2007). Estimating HIV prevalence and risk behaviors of transgender persons in the United States: A systematic review.

AARP Public Policy Institute. (2009). Profiles of long-term care and independent living. Washington, DC: AARP.

to evict a resident because the resident cross-dresses or is beginning a gender transition. However, these laws do not cover all situations—and facilities, consumers and even local and state officials today are largely unaware that these laws protect transgender people. To ensure that violations of the rights of transgender individuals in home- and community-based care are recognized and remedied, we recommend that: The Centers for Medicare & Medicaid Services (CMS) should revise federal Medicaid conditions of participation to explicitly prohibit discrimination based on gender identity and sexual orientation in home- and community-based services.

Federal and state agencies should develop training, technical assistance and public education programs to educate long-term care providers and consumers about the rights of LGBT individuals, with particular attention to transgender older adults.

Transgender older adults may feel they have particular reason to fear entering a nursing home because of potential discrimination, hostility and violence from staff and other residents, and the possibility of receiving unequal care; yet health disparities and social isolation may put many at greater risk for requiring more intensive care. The federal Nursing Home Reform Act (NHRA) guarantees rights of privacy, dignity, autonomy and freedom from restraint and abuse in facilities that accept Medicaid and Medicare funds. Facilities violate these rights when they refuse to respect the identities of residents, such as by refusing to permit or assist them in wearing clothing consistent with that identity; when they deny hormone medication or refuse to provide personal care because staff are uncomfortable with a resident’s body; when they isolate transgender residents; and when they fail to prevent routine harassment by residents or staff. 72 Facility managers and even state officials might not recognize that such practices are illegal. To ensure that violations of the rights of transgender nursing home residents are recognized and remedied, we recommend that: The Centers for Medicare & Medicaid Services (CMS) should revise federal nursing home surveyors’ guidelines to clarify the rights of transgender residents to respect for their gender identities, autonomy in their gender expressions, privacy regarding issues related to transgender status and freedom from biasrelated harassment, discrimination and abuse.

In addition to clearer nondiscrimination protections, cultural competence training for long-term care staff is imperative to improving the experiences of transgender older adults in long-term care. The National Resource Center on LGBT Aging—seeded by

For more information, see: Chin, N., Chiplin Jr, A.J., Dayton, K., & Rowen, M. (2010). Asserting choice: Health care, housing, and property—planning for lesbian, gay, bisexual, and transgender older adults. Clearinghouse Review Journal of Poverty Law and Policy 43 (11-12): 522-533.

the U.S. Department of Health and Human Services (HHS) and the Administration on Aging in 2010—trains hundreds of aging providers nationwide on cultural competence and LGBT elders, and is a great resource for implementing a rigorous, comprehensive and evaluated training on these issues. Additionally, CMS has taken a lead on this issue and is creating LGBT training for facilities and state surveyors, and other agencies should follow suit. Long-term care facility administrators, staff, surveyors and ombudspersons, as well as home health care providers, should be trained on the identities, needs, vulnerabilities and rights of LGBT residents, working with the National Resource Center on LGBT Aging.

Federal and state agencies and community organizations should develop and/or promote LGBT cultural competence training, best practices and tools for longterm care facility staff, surveyors and ombudspersons, working with the National Resource Center on LGBT Aging.

Long-term care facilities should adopt policies to ensure fair and appropriate treatment of transgender residents.

Ending Violence and Abuse Transgender people face higher levels of abuse of all kinds throughout their lives, and later life is no exception. As with all elder abuse, the abuse of transgender older adults can be mental, financial, physical or sexual, and it can take place in the home, in a hospital, in a long-term care facility or any other setting. While abuse can be perpetrated by direct care workers, research suggests that violence and abuse are more frequently committed by family members and in social settings.73 The bias and stigma facing transgender people—which are compounded by both ageism and the challenges of social isolation and aging—embolden abusers and deter transgender older adults from reporting their abuse. In some cases, having physical features that might not appear congruent with their gender identities can also contribute to transgender older adults’ vulnerability (as well as their reluctance to report abuse or seek medical care or other services). State adult protective services agencies, long-term care ombudspersons and surveyors and direct care workers all play important roles in preventing and responding to elder abuse, and each of these groups need tools and incentives to effectively protect vulnerable transgender elders.

Witten, T.M. (2003). Life course analysis-The courage to search for something more: Middle adulthood issues in the transgender and intersex community.

The Elder Justice Act, part of the Affordable Care Act of 2010, creates a comprehensive set of programs and resources to combat and prevent elder abuse and neglect, both within and outside of long-term care facilities. Unfortunately, implementation of these programs has not subsequently been funded by Congress.

Congress should appropriate funds to fully implement the Elder Justice Act.

The U.S. Department of Health and Human Services (HHS) should take appropriate steps to ensure that grant recipients under the Elder Justice Act are made aware of the prohibition of discrimination based on sex under section 1557 of the Affordable Care Act and its applicability to transgender people.

Federal, state and local agencies should support the development and implementation of transgender-inclusive cultural competence training for adult protective services and elder abuse, neglect and exploitation forensic centers.

Adult protective services agencies and elder abuse, neglect and exploitation forensic centers should make efforts to enhance their ability to serve and protect transgender older adults through training, outreach and agency policies.

Additionally, the Violence against Women Act (VAWA) funds state and local efforts to address domestic violence, sexual assault and other forms of abuse against people of all ages. Unfortunately, the programs supported by VAWA have not been made consistently available to LGBT people, with individuals often being refused services, shelter or protective orders.74 As in homeless shelters, discrimination has been particularly common in programs aimed at women. In 2011, lawmakers proposed to include new provisions in VAWAâ&#x20AC;&#x2122;s reauthorization to prohibit discrimination against LGBT people in VAWA-funded programs and activities. These protections are essential for ensuring VAWAâ&#x20AC;&#x2122;s effectiveness for all people who experience gender-based violence and abuse. Congress should reauthorize the Violence against Women Act (VAWA) and expressly prohibit discrimination in VAWA-funded programs based on gender identity and sexual orientation.

The Department of Justice should issue program guidance to clarify the application of the Violence against Women Act (VAWA) and the Victims of Crime Act to transgender people, as well as the applicability of prohibitions on gender discrimination to transgender people, so that local agencies understand their obligations to serve transgender people.

National Coalition of Anti-Violence Programs. (2011). Lesbian, gay, bisexual, transgender, queer, and HIV-affected intimate partner violence in the United States in 2010. Retrieved from http://www.avp.org/ documents/IPVReportfull-web_000.pdf; and Grant, J.M., et al. (2011). Injustice at every turn: A report of the national transgender discrimination survey: p. 134.

The Office on Violence Against Women should, through guidance or regulation, mandate that the programs they fund not discriminate on the basis of gender identity or sexual orientation. Additionally, the Office on Violence Against Women should fund training and technical assistance programs specific to LGBT people, as well as require that its grantees receive cultural competency training on LGBT people.

Creating Equal Employment Opportunities According to the National Transgender Discrimination Surveyâ&#x20AC;&#x201D;which interviewed 6,450 transgender peopleâ&#x20AC;&#x201D;90 percent of respondents experienced transphobic discrimination at work, and 26 percent lost their jobs because of anti-trans bias. Respondents were unemployed at twice the national average, and those who lost jobs due to discrimination were four times as likely to be homeless.75 Besides making jobs difficult to obtain and keep for transgender people, including many older adults who experience the age-related difficulties of job insecurity and unemployment, this discrimination creates a ripple effect in the health and economic security of transgender communities as they age. For those who transitioned earlier in life, years of unemployment or underemployment can hinder the ability to save sufficiently for retirement and often make age-related supports such as long-term care unaffordable. Because Social Security benefits are based on oneâ&#x20AC;&#x2122;s lifelong earnings, those who have been unable to contribute significantly in Social Security taxes on earnings are left with disability or retirement payments that are not enough to meet basic medical or housing costs. And for those transitioning later in life, job discrimination, ageism and transphobia can disrupt careers and pose multiple barriers to finding new employment and their income can be dramatically reduced. The challenges associated with employment and economic insecurity experienced by many older people are even more pronounced for transgender older adults. There is no federal law explicitly prohibiting job discrimination based on gender identity, and currently only 16 states and the District of Columbia have laws explicitly banning such discrimination. Explicit job protections are a critical first step to ensuring employment opportunities for older transgender people. Federal, state and local lawmakers should expressly prohibit employment discrimination based on gender identity and sexual orientation by passing the Employment Non-Discrimination Act (ENDA) and equivalent state and local legislation.

Grant, J.M., et al. (2011). Injustice at every turn: A report of the national transgender discrimination survey: p. 3, 66.

Additionally, a growing number of courts and federal agencies have recognized that sex discrimination laws already protect transgender and other gender non-conforming people (including many lesbian, gay and bisexual people) from discrimination based on their gender identity or expression.76 Even without congressional action, then, federal and state agencies can protect transgender people from discrimination in employment. Federal, state and local agencies should use existing authority under sex discrimination laws to address discrimination against transgender people in employment, housing, lending, health care and other areas.

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Federal, state and local agencies should use outreach and public education activities to increase awareness among workers, employers and service agencies of existing protections for transgender workers.

Federal, state and local governments should fund research on workforce challenges facing transgender people.

Career centers and job training programs should make efforts to promote inclusion and prevent discrimination against transgender workers, including transgender older adults, through training and agency policies.

Federal, state and local governments should bring together experts on workforce development, older workers and transgender issues to identify promising strategies to employ and retain transgender workers, including older transgender workers.

Federal, state and local governments should support the development and expansion of model projects to increase employment opportunities for transgender people, including trans older adults.

Housing A growing number of older adults are homeless, with Baby Boomers having an elevated and sustained risk for homelessness.77 Because transgender people are more likely to age without children to help support them and manage their care, and because they often experience dramatically lower incomes than either the general population or the LGB population, access to affordable housing is a significant problem for transgender older adults. Housing discrimination against transgender people of all ages is also widespread, and can combine with other barriers that older adults might face seeking access to housing to create a double barrier for transgender older adults.

See, e.g. Macy v. Holder, EEOC No. 0120120821 (2012).

The Corporation for Supportive Housing. (2011). Ending homelessness among older adults and elders through permanent supportive housing. Retrieved from http://www.chapa.org/sites/default/files/ELI_policypaper_final.pdf.

While recent years have seen an increase in much-needed efforts to address homelessness among LGBT youth, homelessness among LGBT adults has received less attention. One critical step is to ensure that shelters are welcoming to transgender people of all ages, and local authorities and agencies in communities throughout the country—such as Washington, DC, New York, Boston, Chicago, Tucson, Dallas, San Francisco and others—have adopted policies to ensure that transgender people are provided equal access to shelters consistent with their gender identities. The Obama Administration has taken significant steps to address housing discrimination against transgender people and increase housing opportunities. In 2010, the U.S. Department of Housing and Urban Development (HUD) issued guidance clarifying that discrimination against transgender people based on their perceived failure to conform to gender stereotypes could constitute sex discrimination under the Fair Housing Act. In December 2011, HUD coordinated with the Administration on Aging and the National Center for Lesbian Rights to host a summit addressing the discrimination and legal barriers LGBT older adults face accessing affordable housing. In January 2012, HUD issued final rules explicitly prohibiting discrimination based on gender identity and sexual orientation in HUD-funded housing programs. The Equal Access to Housing Rule, announced in January 2012, will ensure that housing, federally funded through HUD, is made available “without regard to an applicant’s sexual orientation or gender identity.”78 The Rule also clarifies that LGBT individuals and couples are included in the definition of “family” and are eligible for HUD public housing and voucher programs. This federal action marks another important step forward in protecting transgender people from discrimination. Despite these advances, much more needs to be done. Many individuals and housing providers are still not aware of existing protections, and housing discrimination continues. And despite the need for more affordable housing, the nation’s stock of affordable housing has been shrinking. Federal, state and local lawmakers should expressly prohibit housing and lending discrimination based on gender identity and sexual orientation by passing the Housing Opportunities Made Equal (HOME) Act and equivalent state and local legislation.

Congress should fully fund implementation of the Federal Strategic Plan to Prevent and End Homelessness, including expanding the nation’s supply of affordable housing.

Donovan, S. (2012, Jan. 30). Ending housing discrimination against LGBT Americans. [blog]. Retrieved from http://blog.hud.gov/2012/01/30/ending-housing-discrimination-against-lgbt-americans/.

The U.S. Department of Housing and Urban Development (HUD) should interpret and apply fair housing laws and regulations to prohibit the exclusion of transgender people from gender-segregated housing, including homeless shelters, consistent with their gender identities.

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State and local governments should pass explicit employment protections based on gender identity and sexual orientation.

Federal, state and local governments and community organizations should identify and promote best practices for housing providers for serving transgender older adults.

Federal, state and local governments and community organizations should support LGBT elder housing projects.

Improving Economic Security Social Security and other public programs critical to the economic security of older adults continue to discriminate against LGBT people and their families, broadly defined to include friends, caregivers, and other loved ones. Many economic benefits, particularly workplace benefits such as employee pensions and employee health benefits, depend on state or federal government recognition of marriage and other family relationships. However, the federal Defense of Marriage Act (DOMA) and similar state laws means that many individuals are wrongly denied eligibility for crucial benefits and protections, often leaving them economically vulnerable. Transgender people and their spouses can be impacted by these laws whether they are in same-sex or different-sex relationships, due to inconsistent and often erroneous interpretation and application of the law. Couples who married validly as a different-sex couple under state law prior to transition can face having their benefit eligibility improperly questioned following transition because they are now a same-sex couple. This happens even though it is settled law that a valid marriage is ended only by divorce or death of a spouse. While the federal government has recently recognized that these marriages continue to be valid for purposes of federal employee benefits,79 other government agencies lack this kind of clear guidance. Different-sex couples who married after transition can face intense scrutiny regarding the details of their transition and whether it is recognized under state and federal law, often resulting in incorrect denials of benefits. Until these discriminatory laws are repealed, better guidance is urgently needed to ensure they are not applied overbroadly.

U.S. Office of Personnel Management (2011). Guidance regarding the employment of transgender individuals in the federal workplace. Retrieved from http://www.opm.gov/diversity/Transgender/Guidance.asp.

Long-term care is expensive, and for transgender people who have experienced decades of economic discrimination, the cost can be prohibitive. Yet Medicaid, the primary government funder of long-term care, may not offer sufficient protections to prevent a transgender or same-sex spouse of a Medicaid nursing home resident from losing their home. In June 2011, HHS took the commendable step of issuing guidance clarifying that state Medicaid agencies are empowered to treat same-sex domestic partners the same as married heterosexual couples when it comes to protection from “spousal impoverishment” under Medicaid.80 While this is a strong step forward, these protections should be mandatory for states, not optional, and there is much more that states and the federal government can do to protect the economic stability of transgender older adults.

Congress should pass the Respect for Marriage Act, which would repeal the Defense of Marriage Act (DOMA).

Federal and state agencies should provide clear and accurate guidance on marriage-related benefit determinations for transgender people and their spouses pursuant to existing laws, to ensure that couples are not improperly denied benefits for which they are currently eligible.

Federal and state agencies should use existing authority to provide critical economic protections, such as Medicaid spousal impoverishment protections, to same-sex spouses and partners.

State legislators should pass marriage equality legislation.

Building a Foundation of Knowledge A recent Institute of Medicine (IOM) report on LGBT health identified transgender aging as a major research gap, naming topics such as elder abuse, substance abuse, risks and best practices for long-term hormone therapy, sexual health and cancer as areas in which more transgender research is needed. The IOM also called for including questions about gender identity in federal surveys, including surveys of older adults by AoA and the Centers for Medicare and Medicaid Services (CMS), and in national standards for electronic health records. Currently, no government data exists on the growing population of transgender older adults. Without reliable national statistics on the geographic distribution, health and economic status, need for supportive services and the total number of transgender older adults (among other possible areas), it is difficult to understand their specific needs and even more difficult to advocate for improved policies to address those needs.

Department of Health and Human Services. (2011). Same sex partners and Medicaid liens, transfers of assets, and estate recovery. Retrieved from http://hsd.aphsa.org/SMD_letters/pdf/SMD/Same-Sex-Partners-SMD.pdf.

To identify and address the specific strengths and vulnerabilities of transgender older adults, federal agencies such as CMS and AoA should include questions on sexual orientation and gender identity in their research surveys and other data collection systems. Collecting this data will help CMS and AoA fulfill their missions to help researchers, clinicians and public health professionals improve research methods, clinical outcomes and service delivery, without incurring significant costs. Research questions that measure gender identity and sexual orientation should be included in federally-funded population-based surveys, such as the National Health Interview Survey, as well as the various federally-funded studies involving older adults.

The Office of the National Coordinator for Health Information Technology should include the collection of data on sexual orientation and gender identity within its meaningful use standards for electronic health records.

Federal and state agencies and academic institutions should support research on the social, economic and health needs of transgender older adults. The Centers for Disease Control and Prevention (CDC) should improve epidemiological surveillance systems and data collection by collecting data on gender identity and reporting data delineated by age. To support older adults with HIV, including transgender adults, the CDC should provide specific data delineated by age category for adults over age 55, especially among smaller age cohorts (55-59, 60-64, 65-69, etc.) This would allow for more detailed information and tailored interventions among a diverse aging population with HIV/AIDS.

Privacy and Documentation In todayâ&#x20AC;&#x2122;s world, identification documents (IDs) are frequently required to apply for employment, housing, public benefits, bank accounts and many other basic transactions. For transgender older adults, IDs and official records that contain information about their former names or gender can turn routine occurrences into incidents of harassment and discrimination. Gender-incongruent IDs deprive transgender older adults of the ability to decide when and how information about their transgender status will be shared, and the available research reveals that incongruent IDs lead to a range of negative outcomesâ&#x20AC;&#x201D;from job and housing discrimination to harassment and even biasdriven violence.81

Grant, J.M., et al. (2011). Injustice at every turn: A report of the national transgender discrimination survey: p. 5, 139.

Historically, state and federal governments have imposed intrusive and burdensome requirements for updating gender in ID and official records, such as documenting specific surgeries or obtaining a court order. For financial, medical and other reasons, many transgender people simply cannot meet these requirements. For those transitioning later in life, financial barriers and medical contraindications to surgeries might be even more prevalent. Fortunately, this trend is changing, with many states and federal agencies streamlining procedures and eliminating burdensome requirements. Transgender people can now update their U.S. Passport, federal personnel record, official immigration documents and VA patient record without these barriers. Additionally, roughly half of U.S. states have made it easier for transgender people to update their driver’s licenses and state identification cards. Finally, more states are moving to ease the process of updating birth certificates, with California and Vermont passing legislation in 2011. Unfortunately, many state and federal agencies still rely on outdated and restrictive policies.

States should adopt simple, user-friendly procedures to enable transgender people to update gender information on driver’s licenses and state IDs based on their gender identities, without proof of surgery or other burdensome medical treatments.

States should adopt policies, and legislation where needed, to enable transgender people to update gender information on birth records without proof of surgery or other burdensome medical treatments.

The National Center for Health Statistics should modernize the Model State Vital Statistics Act to reflect today’s best state practices for updating gender information on birth records.

In addition to driver’s licenses, state IDs, and birth certificates, transgender older adults still face barriers to updating gender in their Social Security records. Current Social Security Administration (SSA) policy requires transgender people to present documentation of sex reassignment surgery to change the gender data in their Social Security records. For a variety of reasons, including expense and personal preference, many transgender people cannot or choose not to undergo sex reassignment surgery. Because this gender data is shared through SSA computer matching programs, as well as listed on Medicare cards, outdated gender markers can “out” transgender people at work (i.e., reveal a person’s transgender status without their consent), in pharmacies and doctors’ offices, at DMVs and in many other settings, thereby placing them at risk of discrimination and public disrespect. While in 2011 SSA eliminated gender matching in the verification system that’s most often used by private employers, other matching systems continue the unnecessary and harmful matching of gender data.

Retaining outdated gender markers serves no SSA program purpose and in turn causes needless confusion for SSA and others. Gender change for SSA and other federal and state agencies should be based on a standardized, signed statement by a licensed physician noting that an account holder has had appropriate clinical treatment for gender transition to the new gender. The Social Security Administration (SSA) should update policies to permit an individual to change the gender designation in her or his SSA record based on a letter from a physician stating that she or he has had appropriate clinical treatment for gender transition. No additional medical information should be required.

The Social Security Administration should eliminate gender as a data field in all its automated verification programs. The Centers for Medicare & Medicaid Services (CMS) should remove gender markers from Medicare cards.

Increasingly, barriers to ID can also be barriers to the ballot box. Research has shown that for many older adults—and especially elders who live in rural areas, have limited access to transportation, live with disabilities or live on fixed incomes—strict voter ID laws pose barriers to voting and threaten to limit older people turnout. Transgender older adults are more likely to face these barriers, and also face additional barriers to obtaining ID that is congruent with their gender identities and expressions.82 Although presenting gender-incongruent ID does not violate any state legal requirement, it can lead to confusion, harassment and even being turned away from the polls. States should reject and repeal restrictive voter ID laws, and LGBT and aging advocates should actively oppose such laws.

Community Support and Engagement While many transgender older adults have strong community ties and families of choice, too many are socially isolated and lack opportunities to be actively engaged in their communities. Many feel unwelcome at senior centers and even at LGBT community centers, which they may perceive as unfriendly to transgender people or to elders generally. They might want to give back to their communities but fear being told they are “not a good fit” for working with populations such as children or frail elders.

Grant, J.M., et al. (2011). Injustice at every turn: A report of the national transgender discrimination survey: p. 5, 139.

For more information, see National Center for Transgender Equality (2011). ID documents and privacy. Retrieved from http://transequality.org/Resources/NCTE_Blueprint_for_Equality2012_ID_Documents.pdf; and Transgender Law Center. (2011). ID document change. Retrieved from http://transgenderlawcenter.org/cms/ content/id-document-change.

While personal faith and faith communities have been important parts of many transgender older adultsâ&#x20AC;&#x2122; lives, many find themselves estranged or disconnected from those communities when they come out and transition. Additionally, the pronounced social isolation common among older people as they age becomes even more profound for those with fewer family connections and more prone to stigma and discrimination. All of these barriers are detrimental not only to the well-being and health of transgender older adults, but also to communities that could benefit from their energies and contributions. Transgender older adults can be powerful advocates, activists, volunteers, mentors and community leaders. For transgender older adults to have meaningful opportunities to engage with their communities, local and community organizations must take steps to ensure that programming is inclusive of both transgender people and older adults. LGBT community organizations, including LGBT community centers, clinics and SAGE affiliates, should increase outreach, programming, services and state and local advocacy supportive of transgender older adults, and ensure that their other programs are also inclusive of transgender and older people.

Local aging providers, including area agencies on aging, should reach out to and engage transgender older adults, as well as local organizations working with LGBT communities.

LGBT community organizations should engage local faith leaders and communities in efforts to improve the lives of transgender older adults. Faith communities should make efforts to increase awareness and inclusion of transgender people of all ages, using resources such as transACTION: A Transgender Curriculum for Churches and Religious Institutes from the Institute for Welcoming Resources.83

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Faith community leaders should engage in affirming outreach to transgender people of all ages and promote an affirming public dialogue about faith and gender identity.

Senior volunteer programs should make efforts to increase awareness and inclusion of transgender older adults, including training for volunteer coordinators.

National Gay and Lesbian Task Force. (2009). TransAction: A welcoming curriculum for churches and religious institutions. Retrieved from http://www.welcomingresources.org/transaction_final.pdf.

Immediate Policy and Practice Priorities to Improve the Lives of Transgender Older Adults The Advisory Committee of the Transgender Aging Advocacy Initiative identified several immediate policy and practice priorities to improve the lives of transgender older adults. While all of the issues outlined in the full report are important, the priorities listed below were identified based on their expected impact if accomplished, as well as the expected feasibility of accomplishing them within the next 1-2 years.

Strengthening the Aging Services Network

• The Administration on Aging (AoA) should clarify, through agency guidance, that LGBT older adults constitute a group with “greatest social need,” and that federally-funded service providers may not exclude LGBT older adults from programs and services. • Congress should reauthorize and fully fund the Older Americans Act (OAA), and should include LGBT older adults in data collection, project assessment and reporting requirements, and explicitly include LGBT older adults in the definition of greatest social need.

Strengthening Long-Term Services

and Supports in Long-Term Care

• Federal and state agencies and community organizations should develop and promote LGBT cultural competence training, best practices and tools for long-term care facility staff, surveyors, ombudspersons and home health care providers. • The Centers for Medicare & Medicaid Services (CMS) should revise federal Medicaid conditions of participation to explicitly prohibit discrimination based on gender identity and sexual orientation in home- and community-based services; and revise federal nursing home surveyors’ guidelines to clarify the rights of transgender residents to respect for their gender identity, autonomy in their gender expression, privacy regarding issues related to transgender status and freedom from bias-related harassment, discrimination and abuse.

Protecting Individual Privacy

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

Building a Foundation of Knowledge

• The Department of Health and Human Services should include questions that measure gender identity and sexual orientation in federal population-based surveys, such as the National Health Interview Survey, as well as surveys focused on older adults. • The Office of the National Coordinator for Health Information Technology should include the collection of data on sexual orientation and gender identity within its meaningful use standards for electronic health records.

Appendix A: Practical Guidance for Aging Providers Inclusive Services for LGBT Older Adults A Practical Guide To Creating Welcoming Agencies

National Resource Center O N LG BT AG I N G

More at lgbtagingcenter.org Are you an aging provider, LGBT organization or an LGBT older person? Visit the National Resource Center on LGBT Aging to learn more about transgender aging and access various new and practical resources for effectively engaging transgender older people.

In February 2012, the National Resource Center on LGBT Aging— led by SAGE and 14 national partner organizations—issued Inclusive Services for LGBT Older Adults: A Practical Guide to Creating Welcoming Agencies, a unique guide created to help service providers understand the unique barriers that LGBT older adults face, as well as the many ways to improve and expand the continuum of care and services available. The following section is excerpted from this publication:

Transgender older adults may face additional challenges to successful aging than their non-transgender peers. In particular, transgender older adults face stigmas and myths about their identities and gender expressions. For example, many transgender older adults often report providers referring to them by incorrect names or by a pronoun that does not align with their gender identities.

A Working Definition The term “transgender” is used to describe the experience and feeling of a persistent disconnect between one’s “sex at birth” (sometimes called “sex assigned at birth”) and one’s gender identity and expression. For example, people born with male anatomy who have female gender identities may choose to express themselves as female through personal style (clothes and accessories), by changing their name (from Jack to Jane, for example), and by asking people to refer to them through their preferred gender pronouns (i.e., “she/her” rather than “he/him”).

Transgender people may or may not use medical intervention(s) such as hormones or surgery to bring their bodies’ characteristics more in line with their gender identities. Some transgender people may legally change their names and accompanying paperwork (e.g., insurance documents, Social Security card, and driver’s license). A person’s gender identity should be respected and not be contingent on whether the person has gone through particular medical interventions and/or a legal name change. A person’s gender identity should be honored regardless of whether the person has taken such actions. Because transgender people are subjected to an even higher level of discrimination and violence than their non-transgender lesbian, gay, and bisexual peers, issues of confidentiality, disclosure and privacy are critical. Many transgender people feel their bodies, histories or other gender-related information are very personal and private and therefore find some questions invasive and offensive. Before asking clients about their transgender status, staff members should think carefully about how they plan to use this data. Staff members should then explain to the client how they intend to use the information—a practice that will increase clients’ willingness to be open. Some examples of other best practices on dealing with transgender clients are included in this section.

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Checklist for Transgender Inclusion Staff should always know and use the pronoun that their clients prefer, even when the client is not within earshot. Where services (including shared rooms) are segregated by sex, assignments should be made based on the client’s gender identity, not his/her sex assigned at birth. If your staff administers or prescribes medication, it is appropriate to identify the various medications that a client is taking, including whether they are taking hormone medications. This will ensure there are no conditions or factors that serve as a reason to withhold a certain medical treatment. If you do not handle medications, you most likely don’t need to know whether a person is using hormones. If your staff is responsible for administering or arranging for certain sex-linked preventive care such as mammograms or Pap smears, it may be necessary to know what surgeries a transgender person has had to ensure they receive care appropriate for their bodies. If you are not responsible for such medical care, your agency staff most likely do not need to know what surgeries (if any) a transgender person has undergone.

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If assistance with bathing or other personal care is offered, all staff should have received training on providing professional care to all clients, including working with clients whose physical bodies are different from their outward gender expression or their inner gender identity. When billing health insurance companies, you may need to know if your client has insurance under a different name and/or gender. It is never appropriate to ask, “What is your real name?” Instead, if you need the data, ask the person “Can I make a copy of your insurance card?” and possibly an additional question to confirm that the name on their insurance card should be used for billing purposes. If your staff arranges clients’ appointments with other health professionals, discuss with transgender clients what personal information they are comfortable disclosing. It is not necessary to “warn” professionals that a client is transgender; that information is often unnecessary for appropriate treatment. Further, sharing it without your client’s permission is a breach of privacy and may violate HIPAA regulations. Staff should remember that transgender clients, just like everyone else, should be able to use whichever restroom aligns with their gender identities. Staff should always model proper behaviors such as calling someone by his/her preferred name and not engaging in gossip about clients. This sets the tone for other staff and clients.

About the National Resource Center on LGBT Aging Established in 2010 through a federal grant from the U.S. Department of Health and Human Services, the National Resource Center on LGBT Aging provides training, technical assistance and educational resources to aging providers, LGBT organizations and LGBT older adults. The center is led by SAGE in partnership with 14 leading organizations from around the country. Learn more at lgbtagingcenter.org.

About SAGE Services and Advocacy for Gay, Lesbian, Bisexual and Transgender Elders (SAGE) is the countryâ&#x20AC;&#x2122;s largest and oldest organization dedicated to improving the lives of lesbian, gay, bisexual and transgender (LGBT) older adults. Founded in 1978 and headquartered in New York City, SAGE is a national organization that offers supportive services and consumer resources to LGBT older adults and their caregivers, advocates for public policy changes that address the needs of LGBT older people, and provides training for aging providers and LGBT organizations through its National Resource Center on LGBT Aging. With offices in New York City, Washington, DC and Chicago, SAGE coordinates a growing network of 23 local SAGE affiliates in 16 states and the District of Columbia.

About NCTE The National Center for Transgender Equality (NCTE) is a national social justice organization devoted to ending discrimination and violence against transgender people through education and advocacy on national issues of importance to transgender people. By empowering transgender people and our allies to educate and influence policymakers and others, NCTE facilitates a strong and clear voice for transgender equality in our nationâ&#x20AC;&#x2122;s capital and around the country.

For additional information about many of the policy issues described in this report, please visit sageusa.org and transequality.org.

ACKNOWLEDGEMENTS SAGE and NCTE would like to thank the Arcus Foundation and the David Bohnett Foundation for their generous support of this initiative and this report. We are also deeply grateful to the members of the Advisory Committee of the Transgender Aging Advocacy Initiative for offering their wisdom, experience and commitment to this historic initiative. The ideas detailed throughout this report are largely informed by your unique insights. Finally, we would like to thank Joo-Hyun Kang for facilitating the 2011 gatherings of the Transgender Aging Advocacy Initiative.

Services & Advocacy for GLBT Elders 305 Seventh Avenue, 15th Floor New York, NY 10001 212-741-2247 info@sageusa.org sageusa.org lgbtagingcenter.org

National Center for Transgender Equality 1325 Massachusetts Avenue, NW Suite 700 Washington, DC 20005 202-903-0112 NCTE@transequality.org transequality.org