No stigmatized group in U.S. history has benefited from as many policy and social attitude improvements as quickly as have transgender people. The current generations of transgender elders represent virtually the full history of the transgender experience, ranging from days when there was no word for their identity to today, when “transgender” has become a word even the U.S. President feels comfortable using on nationwide television (Obama 2015). That unprecedented diversity makes generalizations about this population beyond impossible; the goal of this chapter is therefore to explore just some of the major conundrums, challenges, and joys facing those who serve, research, make policy for, make community with, befriend, and love transgender elders.

The chapter starts with terms and definitions by focusing on how much change there has been around transgender issues during the lifetimes of current trans elders. This discussion should explain why a variety of terms will be used throughout this chapter: it is critical that those working with the transgender community not become wedded to any particular term or definition, as they are in constant flux and vary from individual to individual. (We do the same with pronouns, including using “they” as a personal pronoun, for the same reasons: to help the reader get used to recognizing that a variety of pronouns are currently being used within the trans community.) We next move on to explore generational issues affecting the trans community, including those that cause intra-community strife. After reviewing the limitations of existing research on trans elders, the chapter discusses what is known about trans-specific health care (hormone use and gender-related surgery), including trans older adults’ experiences of discrimination within the health care system. One of the ways the experience of trans people differs from their LGB peers is their dependence on professionals for health care and identification papers. The chapter covers the two primary approaches to trans health care—the Standards of Care and the informed consent models—and why identification documents are so important to trans people. General health, mental health, and violence issues are tackled together to reflect emerging research on the effects trauma has on physical as well as mental health. The section on therapy includes one expert’s “stages of emergence” of trans identity. The chapter then addresses social relationships, covering some of the issues with which SOFFAs (Significant Others, Friends, Family and Allies) may struggle. Sexuality and safe sex comes next, with brief discussions of sexual orientation and libido changes, how trans elders handle dating disclosure, and how religion has affected some trans elders’ sexuality. We end with an overview of recent policy changes in the lives of American trans elders, including developments related to marriage, Social Security, veterans, employment, housing, long-term care facilities, and services for victims of domestic violence, sexual assault, dating violence and stalking.

What all these variations—in terms, concepts, timing, demographic-based organizing, etc.—mean for trans elders is that saying anything about them as a group is nearly impossible. Even defining terms is problematic, because what “transsexual” means to one person may well be different from what it means to another person who also uses the label. That is why FORGE Transgender Aging Network teaches that what is most important to know about labels for trans people is the Terms Paradox. The Terms Paradox explains that it is critical for people to learn what term trans persons use for themselves and then reflect that term back to them in conversation. Using the same term affirms respect for trans persons’ right to their own identity. The paradox is that the term by itself is not meaningful without further discussion: two individuals who refer to themselves with the same label may have very different experiences and expectations. The only way to know what those experiences or expectations are is to ask that particular individual (FORGE 2012).

This lack of an agreed-upon history and culture can be problematic. One trans elder may harbor negative prejudices about another “type” of trans elder, and changes made to please some may upset others. At the 2014 Transgender Spectrum conference held in St. Louis, Missouri, the organizers proudly announced that all bathrooms had been made gender neutral. One trans elder, who had transitioned in mid-life, complained to organizers: “I wanted all my life to get out of men’s bathrooms, and now you’re saying it’s progress to have me go to a bathroom with a urinal in it?” (Anonymous, personal communication, November 21, 2014). Another trans elder wrote about an effort in her town, “There is an effort here to make bathrooms gender-neutral. To me that is the epitome of stupidness. I do not want to be in the same bathroom as a male or ‘gender-neutral’ person!” (Anonymous, personal communication, August 25, 2014).

The tension between trans elders and younger peers may also increase as completely different paths open to the younger population. In 2012, Riki Wilchins, a trans activist and author now in her 60s, published a very controversial essay called “Transgender Dinosaurs and the Rise of the Genderqueers.” In it, Wilchins wrote, “My political identity for 30 years has been built on the foundation of my being visibly transgender …. [W]hat if all that were wiped away? Who would I be? What would I have become? With[out] all the activism and writing that identity forced on me during the birth of transgender liberation, would I even be writing this today?”

Her point is that trans life has changed drastically. Rather than spending decades trying to fight who they are, an increasing number of children are not only publicly declaring their transgender identity, but also finding acceptance and support. Wilchins notes,

With adolescents increasingly taking androgen blockers [which will save many young transwomen from growing up with larger frames, deeper voices, and Adam’s apples and young transmen from growing breasts and menstruating] with the support of a generation of more protective, nurturing parents, public transsexuality is fading out. And I don’t mean only that in a generation or two we may become invisible in the public space. I mean rather that in 10 years, the entire experience we understand today as constituting transgender – along with the political advocacy, support groups, literature, theory and books that have come to define it since transgender burst from the closet in the early 1990s to become part of the LGB-and-now-T movement – all that may be vanishing right in front of us. In 50 years it might be as if we never existed. Our memories, our accomplishments, our political movement, will all seem to only be historic. Feeling transgender will not so much become more acceptable, as gayness is now doing, but logically impossible.

Although this view of the “generational” cracks in the trans community is extreme, it does point to a key truth: being a trans elder now is different than it ever was before, or ever will be again.

Research on trans elders is sparse. The first problem is defining who is under the “trans umbrella.” Does one include people who identify as the sex they were assigned at birth, but who dress in the “other” gender’s clothing? Are “genderqueers” who may present to the world as “typical” men or women but who have a different internal identity included? Or are we just talking about people who are living full-time in a gender not congruent with the sex they were assigned at birth?

Until very recently, there have been no nationally representative studies that have included questions around gender identity, and so no way to draw any conclusions about trans people as a whole. Instead, what research exists has been based on “snowball” or convenience sampling, in which trans elders are identified through organized trans or LGBT groups and/or by one trans elder connecting researchers to another. These research methods have many drawbacks in general, but the problems are intensified because of the unique way trans elders connect (or not!) with other trans people.

How involved any given trans elder is with the larger trans community obviously varies from person to person. In general, however, many try to connect with other trans people in local support groups and/or online in order to “learn the ropes” and find referrals to trans-friendly professionals such as therapists and doctors. Once they have successfully transitioned, however, many prefer to live their lives as any other man or woman would, and so they sever their ties to the trans community. This is one reason why it is so difficult to research trans elders: many are not connected to any trans group or even to other trans individuals.

A vivid example of the results of this “woodworking” or “going stealth” phenomenon comes from the groundbreaking 2011 survey of more than 6400 trans people, Injustice at Every Turn (Grant et al. 2011a). Although its authors—the National Center for Transgender Equality and what was then the National Gay and Lesbian Task Force—issued additional analyses of multiple sub-populations, they were reluctant to publish separate findings on trans elders because that data seemed so “off.” It took careful cross-walking of the data to understand what had happened: barely 2 % of the Injustice at Every Turn respondents age 55+ had been living in their current gender for more than 10 years. In other words, virtually all of them were mid- or late-life transitioners (Grant et al. 2011b). Because nearly 80 % of them were also MTFs, that means that most had likely had successful careers as men and faced anti-trans discrimination only late in life. They therefore had higher incomes, higher educational levels, higher home ownership rates, better health, and fewer discrimination experiences than their younger trans peers.

In contrast, the Aging and Health Report, which also published its first wave of data in 2011, recruited trans elders primarily through local LGBT aging groups (Fredriksen-Goldsen et al.). We can imagine that trans elders who connect with such groups do so because they are more isolated and/or have higher social and practical needs that they are trying to fill. The Aging and Health Report trans respondents produced data more in line with having experienced decades of discrimination, violence , and stigma.

The third primary source of data on trans elders comes from various FORGE studies, in particular ones focused on sexuality, sexual violence, and elder abuse (Cook-Daniels and Munson 2010). Although these were national, online studies aimed at all ages of trans people, our Transgender Aging Network and ElderTG programs led to much higher than usual elder participation. These three sources provide most of what we now know about current generations of trans elders, which we will review next.

Each of these studies recruited anyone who defined themselves as “transgender”, and so may include a wide variety of identities, physical presentations, and histories. FORGE surveys may also include SOFFAs speaking about their trans loved one’s experience.

The first health concern many people think of when they think of trans people is, “what are the health effects of long-term hormone use?” Most of the long-term prescription medications that Americans take—including anti-depressants, statins, beta-blockers, and pain-killers as well as hormones—have not been around long enough to show what happens when taking them for 30 years. However, a 2014 Medscape article, “Largest Study to Date: Transgender Hormone Treatment Safe,” reported that very few side effects were found among 2000 trans people who had taken hormones for an average of 5.6 years for the MTFs and 4.5 years for the FTMs (Louden 2014). The most common serious side effect was venous thromboembolism, which affected approximately 1 % of those taking estrogen, causing blood clots that can be serious or even fatal. Not all trans people take hormones, and dosages vary based on the prescribing physician, whether the person’s body is still producing its own hormones (which may need to be countered), and, in some cases, how old the person is or what other medical problems they have. Among the Injustice at Every Turn respondents, 76 % of the 55–64 year olds and 82 % of the 65+ respondents had had hormone therapy (Grant et al. 2011b).

What is actually a bigger issue for the health of trans elders is their surgical status. Until very recently, virtually no private health insurance company or public health care program would cover gender affirmation surgeries. Consequently, few elders have been able to afford to have genital surgery. Injustice at Every Turn found that only 21–23 % of MTFs and none of the FTMs age 55+ reported having had genital surgery (Grant et al. 2011b). The reason that this is a health issue is that without genital surgery, FTM and MTF elders cannot hope to “pass” when they are naked on the examination table: their transgender history is literally visible. This may well contribute to the reluctance of many trans elders to access health care. It may also cause trans elders to refuse recommended services such as home health care and nursing home placement.