Introduction: writing about trans ageing

When writing about older trans people, there is a temptation to start with what a colleague once described to me as “the misery narrative”. I imagine my reader to be a busy social worker, or care home manager, or perhaps a student or academic in an allied discipline who has found a few free minutes in their day to briefly read up on older trans and gender diverse people. In the face of the pressures facing such readers, I feel the pressure to capture their attention and justify the use of their time. Implicitly, I seek to defend against the accusation that this is a very small population by using terms like ‘risk’ or ‘vulnerability’ to emphasise the disproportionate harms experienced by gender diverse populations. But I am also conscious of the limitations of this narrative. It tends to flatten different experiences into a monolithic account of vulnerability, and it tends to overlook the agency and resilience of older trans people in addressing the challenges they face. In this chapter, I seek to provide a more nuanced narrative, drawing on the accounts of older trans people in the UK to explore their experiences of navigating, challenging and, at times, rejecting services available to them.

This chapter therefore seeks to explore older trans people's experiences of care from a perspective that recognises both the challenges they face and their agency and abilities in navigating those challenges across diverse life courses. It draws upon interviews undertaken as part of my doctoral thesis in 2015 and 2016 exploring the experiences of LGBT people aged 60+ in the UK within primary care. Elements of this research have been published previously (Toze et al, 2020). This analysis focuses upon the 13 participants within that study who identified as trans or transgender. Nine of the participants were trans women, two were trans men, one was non- binary and one was a transvestite who lived fluidly as both male and female. Participants were aged 60–82, predominantly retired and all lived independently in the community.

This section provides two suggested learning activities for readers that connect explicitly with the content and themes that have arisen from the two chapters in Part I. These chapters discussed what is known about older trans people's lives and care needs arising from messages from research and the significance of trans people's own perspectives and accounts on ageing and later life.

Practitioners can use these learning activities to help develop and share knowledge, skills and values that will inform the development of affirmative and person- centred support for older trans people by:

• • extending your own personal and professional knowledge through relevant desktop research or practitioner enquiry;

• • facilitating critical reflection and learning through active discussion in your team and service.

Educators and trainers can use these activities to:

• • include trans ageing issues in the education and training of the workforce;

• • guide the aim and focus of trans issues drawing on the relevant evidence provided.

Managers can use these activities to:

• • embed the relevant topics, areas and learning resources into recruitment, induction, supervision, appraisal and career progression processes;

• • keep a record of key activities that can be drawn upon in practice reviews or benchmarks to demonstrate how the needs of older trans people are being addressed, including the potential to demonstrate legal compliance during statutory regulatory activities.

Activity 1: Promoting trans affirmative communication for people in later life

Giving affirmation to every individual person is a unique and personal process. We use the umbrella term ‘gender affirmation’ to describe a range of actions that we can take to demonstrate how we are actively recognising and giving value to a person's gender identity and their desire to thrive and take joy in living, surviving and thriving as their authentic gendered selves. The following suggestions provide a guide to some of the steps you can take to support this and to stimulate discussion on your own suggestions and actions for doing so:

Activity 2: Equality monitoring in the access and experience of care and support for trans people in later life

It is the duty of public bodies to collect and monitor information on the range of people accessing and using their services in relation to the diversity of their characteristics where these are protected in legislation.

The big messages

In this final chapter, we revisit the ‘big takeaway messages’ for health, community and social care practitioners that are woven across the chapters in this book, and we identify some future directions in research for supporting trans people in later life and developing trans- inclusive research and practice. In relation to improving care experiences across health and social care systems, a resounding message is the importance of developing and delivering a person- centred, person- led approach to care that is collaborative and centred on the wishes and preferences of older trans people as the experts on their lives. Promoting the autonomy of older trans people is an underpinning principle for delivering trans- inclusive and affirming practice.

Numerous authors in this book have stressed the importance of adopting an intersectional lens for better understanding older trans people's lives and the heterogeneity among this population. We would add to this the diversity between different generations of older trans people, as noted in Heyam's chapter (Chapter 10) on trans histories. Experiences of earlier life points will vary according to different generational cohorts in parallel with the chronological points when trans individuals ‘come out’ as trans. An intersectional lens deepens understanding of the complex connections between ageism and cisgenderism, and how these points of social marginalisation can undermine positive ageing experiences for trans people. The importance of recognising and assessing the social support networks of older trans people is another critical theme, taking into account the complexity of relationships with family members over time, potential experiences of familial estrangement and the scope of ‘families of choice’ for providing support in later life. A final resounding message is the ethical responsibility of helping professionals, such as social workers, community workers and healthcare professionals, to advocate for older trans individuals and to ensure that services for and accessed by older people are trans inclusive, cisnormative- critical and safe to access. As noted by Castle and Kimberley in their chapter, affirming experiences accessing healthcare will then lead to individuals feeling more willing to seek out healthcare services and clinicians.

This section provides three suggested learning activities for readers that connect explicitly with the content and themes that have arisen in the seven chapters in Part II. These critically examine the practices, views and attitudes of healthcare and social welfare professionals towards older trans people and have a focus on taking responsibility for education and professional development that support access to supportive and inclusive services.

Practitioners can use these learning activities to help develop and share knowledge, skills and values that will inform the development of affirmative and person- centred support for older trans people by:

• • extending your own personal and professional knowledge through relevant desktop research or practitioner enquiry;

• • facilitating critical reflection and learning through active discussion in your team and service.

Educators and trainers can use these activities:

• • to include trans ageing issues in the education and training of the workforce;

• • to guide the aim and focus of trans issues drawing on the relevant evidence provided.

Managers can use these activities to:

• • embed the relevant topics, areas and learning resources into the recruitment, induction, supervision, appraisal and staff career progression process;

• • keep a record of key activities that can be drawn upon in practice reviews or benchmarks to demonstrate how the needs of older trans people are being addressed, including the potential to demonstrate legal compliance during statutory regulatory activities.

Activity 3: The use of self and literacy on gender and sexual identities

Being open and accessible in how you communicate affirmation for gender diverse people in later life requires willingness and confidence in enabling individuals and their loved ones in the expression of their identities and relationships.

This reflective activity aims to promote your own awareness and insights into gender and sexual identities in later life and to identify the barriers to establishing rapport.

It draws on the social GGRRAAACCEEESSS model (Gender Geography Race Religion Age Ability Appearance Culture Class/ Caste Education Employment Ethnicity Spirituality Sexuality Sexual orientation) (Burnham, 2012) which helps practitioners to recognise factors which affect our position, powers and privileges. These factors influence relationships and interactions with others and can be used to deconstruct the power relationship between a practitioner and the older person when exploring the relevance and meaning of sexuality, sexual and gender identities, and what the practitioner or professional might bring to these interactions.

This section provides three suggested learning activities for readers that connect explicitly with the content and themes that have arisen in the final three chapters in Part III. These focus on the application of your learning to direct care practices that make a difference to improving care and support for trans people in later life.

Practitioners can use these learning activities to help develop and share knowledge, skills and values that will inform the development of affirmative and person- centred support for older trans people by:

• • extending your own personal and professional knowledge through relevant desktop research or practitioner enquiry;

• • facilitating critical reflection and learning through active discussion in your team and service.

Educators and trainers can use these activities to:

• • include trans ageing issues in the education and training of the workforce;

• • guide the aim and focus of trans issues, drawing on the relevant evidence provided.

Managers can use these activities to:

• • embed the relevant topics, areas and learning resources into the recruitment, induction, supervision, appraisal and staff career progression process;

• • keep a record of key activities that can be drawn upon in practice reviews or benchmarks to demonstrate how the needs of older trans people are being addressed including the potential to demonstrate legal compliance during statutory regulatory activities.

Activity 6: Supporting Amena

Case studies are designed to enable a more detailed and important understanding of issues that trans older people may face while there are gaps in the literature or in your direct experience. They draw on the book contributors’ discussion of issues that may inform how practitioners can improve their practice. We have provided an outline of an individual story with some suggested questions to support individual reflection and/ or active team discussion,

Amena's story

Amena is a trans woman of mixed heritage. Her father came to the UK from India after fighting with the Allies in the Second World War and married her English mother soon after. Amena was born in 1948 and is now in her 70s. She married Asfara at aged 26 and they had four children, and she reflects that this was on the whole a happy and supportive marriage.

Introduction

There has been growing attention to the needs of trans, non- binary and gender diverse populations from the 2010s onwards. Political and media discussion of the issue has often been heated and has tended to associate gender diversity with youth, sometimes presenting this as a generational ‘divide’. While there certainly has been a rise in the number of younger people openly expressing and exploring different identities, gender diversity is not a new phenomenon. Older gender diverse people are already accessing ageing services, and younger generations will need such services as they age. As the ageing population continues to grow, so will the number of gender diverse people seeking additional housing, welfare, health and social care and community- based support in later life. Professionals and practitioners who work with older people therefore need to be aware of the potential needs of gender diverse service users and consider how to make their services more inclusive. In 2023, the World Health Organization (2023) announced plans to develop guidelines on improving access and quality of care for trans and gender diverse people, in response to perceived need.

This book aims to support practitioners by exploring the context of gender diversity in ageing and providing practical guidance for practitioners who work with older people in a range of settings. In this introduction, we provide an overview of key terminology and concepts relevant to this subject area, which are then developed in more depth in three main sections. Part I explores what we know about older trans and gender diverse people from existing research. Part II explores perspectives from practice in a range of health, wellbeing and care settings. Part III considers how services can be made more inclusive, with a focus on identifying barriers and considering alternative perspectives on inclusivity. Each section incorporates activities and reflections to help you apply the information to your own professional or academic context. We have labelled these activities as ‘Over to you’ to reflect a focus on self-directed learning and application to your own practice.