- From invisibility to misclassifications and institutional biases, a variety of factors throughout history have prevented both transgender+ and intersex populations from being accurately recorded and studied in the medical field. Broadly speaking, how has that had a long-term effect on health outcomes (particularly sexual health outcomes) for older transgender+ and intersex people that grew up in that era of medical misinformation?
I would say that one of the main outcomes is that we don’t necessarily have a lot of long-term cohort-based studies around the community in general. Because of labeling, because of barriers to care, and all the factors that you outlined, a lot of the information that we have in terms of health outcomes of TGNB (Transgender Non-Binary) people…a lot of it is based on assumptions that we extrapolate from other communities that are better studied. I think some researchers might incorporate a trauma-informed lens, understanding how trauma informs and affects certain people throughout the life cycle, and hypothesize how that might affect trans communities when they’re older. The long-term impact is that we don’t necessarily always have the most robust data on health outcomes for wellbeing for the trans/intersex community in older ages because they have not been studied. A lot of what we say, and a lot of the data that we try to pull from in the field, comes from communities that may or may not be relevant to the experience of trans communities. The result of all this is that older TGNB and intersex people might be hesitant to access care because they are distrustful of the traditional medical establishment since they might, justifiably, assume that most healthcare providers are not familiar with treating members of their community.
- Self-reporting and data collection within patient portals could be one way to accommodate for the current dearth of information about these communities and their associated health conditions. However, some in the transgender+ and intersex communities may feel a hesitancy to disclose those identifying factors to their providers, even anonymously, because of an inherent mistrust in the healthcare system. How can providers and healthcare institutions work to rebuild trust that would allow for future voluntary participation in studies and self-disclosure reports?
I would say that the first thing providers can do is ensure that their offices are well-trained and well-versed in what it means to work with trans/intersex communities and individuals in a culturally competent way. So, just basic things, “Here’s what it means to not misgender people. Here’s what it means to not reduce a person’s identity to their gender expression. Here’s why we shouldn’t make assumptions about what a person’s presenting concerns are based on their gender identity.” Ensuring your provider office staff are fluent and comfortable working with the community respectfully is super important.
That doesn’t mean that every trans person or every intersex person is going to come to the door and want to disclose parts of their history or parts of who they are. I just think we have to accept that. Even in the best case scenario, where a doctor has a very welcoming office and the staff are very affirming, we live in a country that has become very hostile towards trans and intersex people, where there’s a potential for the persecution of trans and intersex people as a group. That poses a major threat to the well-being of trans and intersex people. So I think that:
- A provider should be okay if clients don’t want to disclose things, especially in writing. They should respect their wishes to keep things off the record to the extent that they are allowed by their medical licensure.
- Also, make sure that your office is a place where they can, maybe over time, feel comfortable enough to disclose what they want to about their gender.
- How has a lack of data, research, education, and cultural sensitivity in the medical field impacted aging transgender+ and intersex people who need screenings and treatment for cervical and prostate cancers?
I think a lot of it comes back to staff because there’s still not a lot of awareness around trans identity, what that means, and what the physical implications may be. Within health centers that don’t primarily serve the LGBT community and trans people coming in for cervical and prostate cancer screenings or treatments, they might encounter a lot of transphobia at the door. So the question of, “How has it impacted those who are seeking care?”, I would say that impacts them because it might make people who need treatment less likely to seek it out if they just do not want to encounter awkward stares, weird/invasive questioning, or outright bigotry each time they’re coming in for care.
At a systemic level (this is less true than it would have been 10-15 years ago, but it is still true), some insurance carriers will not cover, for example, a cervical cancer screening for someone who is a trans man, or who is male on all of their legal documents. So coverage or lack thereof is another way that the lack of data, research, education, and cultural sensitivity around trans/intersex communities impacts their ability to access care.
- Gender and sexual minorities are disproportionately at risk for sexual violence. We also know that sexual violence is an underreported crime that occurs across the lifespan, including elders. For providers who treat older gender and sexual minority survivors of sexual violence, what should they know, and what resources should they turn to, to learn more about trauma-informed treatment for this population?
This is true across age ranges, but particularly for older clients, and respecting people’s hesitancy to disclose is critical to building trust. I understand that providers have to ask certain questions or do certain kinds of screenings. Still, I think it’s really important to respect the privacy of all people, especially trans people and trans elders. I think there are many ways that the privacy of trans people is disgarded, especially when a person has experienced sexual assault. Non-trans people often think that they have the right to the narratives of trans people. There’s this insistence on, “Tell me more” or “Share this”...and I think that can be harmful for trans people in general, but especially for those who are survivors of sexual assault. Leading with respect for people’s privacy and honoring whatever they share or don’t share is critical.
I find that people who are older may be a little more hesitant to talk about the experience of sexual assault. That’s true for people across age ranges, but in my experience there’s a strong tendency to be judicious with one’s words that I have noticed is more prominent among older people in the community.
- For adults going through medical transition later in life, how might that process look different than a young adult’s journey? What do we know and what do we still need to research about those differing experiences?
That is a really interesting question. I think from a physical standpoint, for those who choose to opt in to hormones (not all trans people do take them or want to take them) or other select medical treatments, they do have the potential to work differently on the body depending on the person’s age. Hormone Replacement Therapy (HRT) is a unique experience for each person because it depends on many different factors like genetics, age, regiments, etc. I think the ways their transition might be different for older people is that their age may preclude them from safely engaging in those forms of treatment (not universally, but that’s one thing that might come up).
Interestingly, I find that gender fluidity is much more of something that is embraced by younger people (also not universal). In contrast, I have found in my experience that older generations, even ones that are trans, tend to have a more binary understanding of gender themselves. I think that means that people of different generations might speak about their gender in very different ways. I think older people might speak in more traditional ways, whereas younger trans people might not. In my experience, there’s more of an acceptance of fluidity in terms of gender among younger people.
- How does a lack of data about the intersection of racial, ethnic, and gender minorities impact our ability to confront health disparities faced by transgender+ and intersex people who hold multiple marginalized identities?
That’s a great question as well. I think this answer is similar to the first one I gave because we don’t have a lot of intersectional data, particularly as it pertains to the intersex and transgender communities. A lot of the assumptions we make regarding the health disparities these communities might experience are pulled from parallel examples. Again, those may be helpful but may not capture the full extent of the story. I don’t think that policymakers always make the most nuanced approach to drawing policies up because they don’t necessarily understand that this policy, even if it’s meant for a specific demographic, can land very differently depending on the sorts of identities people within that demographic might hold as well. I think one of the main outcomes is a lack of nuanced policymaking when it comes to the trans and intersex communities.
- How might chronic minority stress play a part in the long-term physical, mental, and sexual health of aging transgender+ and intersex populations? Is chronic minority stress still misunderstood by healthcare institutions and, if so, what do they still need to learn?
Chronic minority stress, in terms of the physical, mental, and sexual health among aging transgender+ and intersex populations, would play the same role that it would play for other marginalized minority groups. For example, if a person is experiencing discrimination in the workplace throughout their life cycle, they’re probably going to have less resources on which to live on in retirement as a result of that discrimination. That can lead to different health outcomes like higher blood pressure, higher cortisol levels, etc.
Even with regard to other minorities, in my experience, I don’t think that most healthcare institutions or providers have a sense of what being a marginalized minority is…I have not encountered many providers who have incorporated that in any way in their decisions. I personally have never seen it, so I think that we’re very much at the beginning stages. I don’t think chronic minority stress is understood to any meaningful extent by any of the healthcare providers I’ve interfaced with.
- The National Resource Center on LGBTQ+ Aging, a program of SAGE, is the country’s first and only technical assistance resource center focused on improving the quality of services and supports offered to lesbian, gay, bisexual, and/or transgender older adults, families and caregivers. What part of your organization’s work and education about the health and wellness of the aging LGBTQ+ community are you the most proud of?
Truly, every aspect of our organization is dedicated to the health and wellbeing of LGBTQ+ elders. I personally derive a great amount of pride from it. Our advocacy team mostly doesn’t work directly with clients. I think that, for those who aren’t directly working with SAGE, their work might be somewhat invisibilized. Still, they really do a lot of amazing work in different sorts of legislative environments. They’re interfacing with politicians, some of whom are friendly and some who are very much not friendly to the sort of causes that we champion. So I’m proud of that particular branch of SAGE’s work because so much of the well-being of our elders is linked to governmental policy, benefits that they can access, or laws that protect them. I think the advocacy team is standing up and posing challenging questions to lawmakers who may be hostile towards our communities, especially within this overall difficult political context that we’re in.
- Anything else you’d like to add?
Many aging and older trans or intersex people are also migrants or immigrants who might not have access to healthcare because of their status in this country. In a political environment where migrants are stigmatized, primarily because they don’t have the right to vote in this country, I think it’s important for healthcare providers and policymakers to think of ways to still address the health needs of those communities even though they are often pushed to the margins of our society by xenophobia and other forces.
This blog was published in The Resource 2025 online magazine special issue Sexual Violence and Sexual Health Outside the Gender Binary.
About the Author:
Kylie Madhav is the Senior Director of Diversity, Equity and Inclusion at SAGE where she defines the strategic vision for SAGE’s external-facing DEI work and leads in designing the organization’s DEI action plans, goals and benchmarks. Previously, she worked as the Clinical Support Services Manager at New York City’s Lesbian, Gay, Bisexual and Transgender Community Center. Over her career, she has worked on behalf of immigrant and LGBT communities in New York, the Dominican Republic and Mumbai, India. Kylie holds an MBA from the Yale School of Management as well as an MSW and BA in Linguistics and Law & Society from New York University. She is fluent in French, English, Spanish and Haitian Kreyòl and enjoys delving into the extensive literary canon of her fifth language: Tamil. She currently resides in New York City with her husband.