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Transitioning later in life

Gender-diverse individuals and aging

As societal acceptance of LGBTQ+ individuals has improved in the United States, more people are openly identifying as gender-diverse. Indeed, a recent study by the Williams Institute reported that the population of gender-diverse* youth doubled from 2017 to 2022. While the number of gender-diverse adults (25-64) and older adults (65+) has remained steady over the same period, this number will increase as gender-diverse youth transition into adulthood. Therefore, as this burgeoning population is set to age, it is imperative that healthcare providers better understand aging-related health needs unique to gender-diverse communities. 

It is well-established that common problems among older adults include social isolation and loneliness, which can lead to worse physical and mental health statuses. These adverse outcomes are magnified among LGBTQ+ individuals, particularly in gender-diverse communities, since they also experience minority stress**. In one study, Fredriksen-Goldsen et. al. showed that older gender-diverse individuals experienced more discrimination and stigmatization relative to older LGB individuals, leading to worse mental health outcomes for older gender-diverse individuals. This disparity is likely attributed to less social support for gender-diverse individuals compared to cisgender sexual minorities.

Given the unique lived experiences of older gender-diverse individuals, those seeking gender-affirming surgical care may experience access and healthcare barriers that have not been researched. We believe it is important to address these gaps, since gender-affirming procedures afford notable mental health benefits to older populations.

To support this endeavor, the Gender Confirmation Center conducted a quality improvement project. We surveyed our older patients–those who are considering or have completed surgery–to understand their needs. The information we collected was then used to develop resources and solutions to the problems identified. While this was not a research study and our findings are not exhaustive, we hope our project will bring more awareness to this community. Lastly, we want to emphasize that gender-affirming procedures do not define the legitimacy of an individual’s gender identity. Every person’s gender journey is unique and legitimate, regardless of whether it includes gender-affirming surgical interventions.

• Herman, J.L., Flores, A.R., O’Neill, K.K. (2022). How Many Adults and Youth Identify as Transgender in the United States? The Williams Institute, UCLA School of Law; Herman, J.L., Flores, A.R., Brown, T.N.T., Wilson, B.D.M., & Conron, K.J. (2017). Age of Individuals who Identify as Transgender in the United States. Los Angeles, CA: The Williams Institute.
• Loneliness and Social Isolation Linked to Serious Health Conditions. (2021, April 29). Centers for Disease Control and Prevention. https://www.cdc.gov/aging/publications/features/lonely-older-adults.html
•  Fredriksen-Goldsen KI, Cook-Daniels L, Kim HJ, Erosheva EA, Emlet CA, Hoy-Ellis CP, Goldsen J, Muraco A. Physical and mental health of transgender older adults: an at-risk and underserved population. Gerontologist. 2014 Jun;54(3):488-500. doi: 10.1093/geront/gnt021. 
• Flores AR. National Trends in Public Opinion on LGBT Rights in the United States. Williams Institute, UCLA School of Law. Published 2014.
  https://williamsinstitute.law.ucla.edu/publications/trends-pub-opinion-lgbt-rights-us/
• Cai X, Hughto JMW, Reisner SL, Pachankis JE, Levy BR. Benefit of Gender-Affirming Medical Treatment for Transgender Elders: Later-Life Alignment of Mind and Body. LGBT Health. 2019;6(1):34-39. doi:10.1089/lgbt.2017.0262

* By “gender diverse” we refer to folks who identify as transgender, non-binary, gender-variant and/or gender-expansive.

** Minority stress is defined as excess, negative stress experienced by marginalized communities that is attributed to external (discrimination, prejudice) and internal (internalized homophobia, identity concealment) stress processes. 

Results from the project

1) Visibility

Visual and informational representation of who gets gender-affirming surgeries is important for many gender-diverse individuals seeking this kind of care. Many folks considering surgery look for narratives and pictures of individuals who have completed the process. While these online materials, such as before and after photos, can be validating, they can also feel exclusionary for individuals who are not represented in them. This was the case for many of our respondents. Indeed, many reported feeling dissuaded from seeking surgical care because of a lack of representation of elders in online materials. We believe this is a problem that extends beyond our survey population.

“I thought I was “too old” for this. I thought after THIS many years, why bother? It took a breast cancer scare to even think about the possibility of top surgery. If I were sick it would be a very easy choice for me. Perhaps if there were more visibility, I would have understood this as a choice I could make independent of any health scares. I simply didn’t understand it was on the table.”

To address this, we’ve included information in our website that’s tailored to older adults. In addition, we’ve also included a link to before and after pictures of some of our practice’s older patient’s surgical results. While this commitment will not fix an industry-wide and cultural problem, we hope to inspire broader change within the medical community.

6 Jones NL, Gilman SE, Cheng TL, Drury SS, Hill C V, Geronimus AT. Life Course Approaches to the Causes of Health Disparities. Am J Public Health. 2019;109(S1):S48-S55. doi:10.2105/AJPH.2018.304738

2) Support Systems

First, while emotional support around the time of surgery is important for patients of all ages, it may be particularly important for older patients. This was true for many of our surveyees. According to the life course theory, a person’s health is the product of cumulative life experiences. Since older adults grew up during an era with less social support for gender-diverse individuals, those seeking gender-affirming surgical care–a significant transitional commitment—may experience uncertainty with their decisions. 

“The support I needed was emotional support, encouraging me to focus on how I felt with my body and not being ashamed that I wasn’t comfortable with it and wanted to consider surgery. The support I needed first after surgery was physical to assist me in everyday living, eg. cooking, moving things.”

Second, older gender-diverse individuals may have more difficulty having their physical support needs met, such as receiving assistance with daily tasks after surgery. Since patients will have limited mobility after surgery, those who cannot find physical support systems may have to forgo surgical care. 

Even with the resiliency older gender-diverse individuals have developed as a result of experiencing discrimination, like all of our patients, having quality emotional and physical support is crucial when undergoing gender-affirming surgery. For individuals who may need emotional and/or physical support before and after their surgeries, please refer to the following resources. We also encourage patients to speak in-depth with their surgeons, physician associates, and medical assistants during pre-surgical appointments about their post-operative care needs.

3) Familial and Social Relationships 

Everyone’s journey with their gender identity is unique. Whether you have been openly identifying as gender-diverse or just recently began exploring your gender identity, your experiences are valid. From our project, we saw that some older individuals who began identifying as gender-diverse more recently, meaning later on in their life, were concerned about maintaining social and familial relationships when considering gender-affirming care. Some individuals have been able to overcome this hurdle and pursue surgery. 

“[I was concerned] about my immediate family and my daughter…suffice it to say, I handled it all by just putting one foot in front of the other and knowing that what I was doing was for the better and that long-term everyone would love me for me.”

We acknowledge that not all individuals are able to reconcile their desires for surgical care with commitments to long-time family members and friends. We also understand that some individuals may lose their support systems after committing to their procedures. We want you to feel supported regardless of whether you decide to undergo surgery, so please refer to this list of community centers and organizations that can help you connect with individuals who may have similar experiences to find community and resources and strategize around these potential barriers. 

4) Physiological Health and Medical Clearance

At the Gender Confirmation Center, we do not have a maximum age for surgical care, meaning that we do not arbitrarily discriminate against potential patients by their age. We rigorously assess every patient’s physiological health during the medical clearance process to ensure they are suitable candidates for surgery. From our investigation, we realized that some older individuals are worried about how pre-existing health conditions might impact their healing process and aesthetic results. 

We want to emphasize that eligibility for surgery is not determined by a person’s chronological age–the number of years a person has been alive–but rather by something that might best be thought of as someone’s “physiological age”, which considers lifestyle factors and health status. For example, a person who is 25 years old (chronological age) may not qualify for surgery based on parts of their health and lifestyle that may pose a serious risk if they were to undergo a specific procedure. Conversely, a person who is 65 years old may qualify for surgery because of being very fit overall, and in an optimized health status, and so might be thought of as being “physiologically young.”

If you are concerned about whether and how age and pre-existing conditions may affect your surgical journey, please relay this concern to your surgeon. We will ensure your concerns are fully addressed. Please know that in most cases, though this is dependent on the procedure, there are various accommodations our surgical team can make––such as changing the incision type or requesting insurance coverage for an overnight post-operative stay––to make sure that even with a pre-existing condition you can access care. We welcome you to reach out to our providers here to talk about the specifics of your case.

5) Gender identity and Gender-affirming Surgeries

The improvement in quality of life that gender-affirming surgical care provides is also true for senior members of the gender-diverse community. This point has been proven by peer-reviewed research and was made evident in the responses we received from our surveyees. Our project also shows that gender fluidity and expansiveness are not limited to younger generations. These identities have always been part of human nature. At the Gender Confirmation Center, we believe individuals can begin their gender journeys at any age and will help anyone who firmly believes surgery will help align their body with their internal sense of gender. 

“I am able to look in the mirror and what I see aligns with my internal sense of self…In public, I feel safe and am able to navigate the world with confidence…Also, I feel confident, grateful, and empowered to live my dreams whereas before transitioning I was mired in self-doubt and fear.”

7 Cai X, Hughto JMW, Reisner SL, Pachankis JE, Levy BR. Benefit of Gender-Affirming Medical Treatment for Transgender Elders: Later-Life Alignment of Mind and Body. LGBT Health. 2019;6(1):34-39. doi:10.1089/lgbt.2017.0262