This Sex and Intimacy in Later Life book series will explore, interrogate and enlighten upon the sensual, sexual and intimate lives of older people. The motivation for launching this series was a concern with the relative lack of attention in public, professional and academic/ intellectual spheres to sex and intimacy in later life (indicatively, Hafford- Letchfield, 2008; Simpson et al, 2018a, 2018b). The series is intended to contribute to and enrich the development of the field of studies in the intersections of age, sex, sexuality and intimacy as a critical and important area of scholarship. It is only beginning to be recognised as an important social, cultural and political issue within and beyond the ‘Western’ academy, from which it has emerged. Its earliest contributions, of which this volume are a part, are motivated by a desire to recognise and reject the pathologies and prejudices that have infused this intersection – what Simpson has termed ‘ageist erotophobia’ (Simpson et al, 2018b: p 1479) – and fuels the failure to acknowledge older people as sexual agents. This is both an intellectual and a political agenda, to question and evaluate the impact of real rather than assumed losses of cognitive, physical, social and sexual capacity, and to recuperate older people as sexual agents from dismissal, ridicule and trivialisation.

If the latter half of the twentieth century was characterised by challenges to the pathologies of social identities – particularly gender, ethnicity and race, disability, sexuality – and struggles for recognition, rights and liberties, more intersectional struggles and recognitions characterise the twenty- first century (on intersectionality, see indicatively Hancock, 2016; Hill Collins and Bilge, 2016). Significant among these has been the re- evaluation of what it is to age and to be an older agent in contemporary societies. Older people have historically experienced both veneration and respect and neglect and pathology, largely based on differing cultural stereotypes of the value of age (Ylanne, 2012). The most common characterisation is that older people are not sexual, past being sexual or represent a problematic sexuality – or their sexuality is a superficial concern and secondary to concerns of health, care, life course and support by public services and engagement and pensions/ resources. Such concerns are those mainly of ‘Western’ cultures and reflected in the Western influence across the globe in respect of state intervention and provision, but elsewhere they have been subsumed and often rendered invisible into family and kinship structures.

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.

Introduction

This chapter looks more closely at the challenges and opportunities that trans people face when accessing family and social support in later life. Social support is often cited as an important factor contributing to subjective wellbeing as one gets older (Diener and Seligman, 2002), and earlier chapters have already discussed some of the cumulative life experiences for trans people which may impact on access to the health and social care services they may use to support themselves in later life. In some global regions, there is a general presumption that an ageing population will give rise to an increased need for health and social care services. This is a complex picture (Health Foundation, 2021), and the demand for care will also be influenced by the availability of unpaid and informal care provided by family and friends. The picture for trans people in later life may however be more complex in terms of who is best placed to support them and the choices they have available. In Chapter 2, Callahan and colleagues articulate some of the proactive choices and responses to care barriers experienced when engaging with services that have historically not welcomed them. In Chapter 3, Toze highlighted the health and social care network alternatives created by and for trans people but which are often small and fragile and vulnerable to macro- economic and political influences. To be able to plan future service delivery effectively, policy makers will need to understand how any changes in population structure will impact overall demand; other authors in this book have discussed some of the barriers and necessary changes required to achieve this in relation to the ageing trans population. A social constructionist approach can also help us to critically examine discourses present within the wider cultural environment about ageing, families and caring and to challenge normative understandings about what a family is, to appreciate what might be different, similar or unique for older trans people.

This chapter draws on some of the themes from the authors’ findings in relation to a systematic review on the international literature on what is known about trans parenting (Hafford- Letchfield et al, 2019).

Introduction

The stigma, discrimination and violence faced by trans people globally is pervasive and well documented (Arayasirikul et al, 2022). While there is growing appreciation of intimate partner violence (IPV) and domestic abuse (DA) in relationships for lesbian, gay and bisexual (LGB) populations, trans people are a group of ‘hidden victims’ and there is very little literature on their experiences (Gelles, 1997, p 96). The dearth of empirical work and the invisibility of trans people when exploring intimate and familial relationships and the environments in which intimate and domestic violence takes place sits within the broader picture of LGB people being at an elevated risk of IPV (Langenderfer- Magruder et al, 2016; Valentine et al, 2017). This chapter considers what is known about DA and IPV perpetrated against trans people in later life alongside any literature on adult safeguarding that might overlap in presentation (Cook- Daniels, 2010). This lack of visibility of older people who are gender diverse, the failure to ask or record gender identity when people are accessing or using support services and/ or trans and non- binary individuals’ fear of sharing information with professionals and service providers are all contributing factors to the failure of being able to screen, recognise and assess IPV and DA.

This chapter is written from our experience of working in the UK as a trans historied woman and cis woman, one of whom has extensive practice expertise in DA and the other in researching LGBTQ+ later life experience of health and social care. We draw on the sparse but important body of work on trans DA along with some of the broader literature on identity abuse. This is used to articulate what can be learned to support trans people better in later life who have or may be experiencing DA. We first consider what is known about the broader issues of violence against trans people before going on to highlight the types of violence experienced by trans individuals and the settings in which DA and IPV occur. We highlight the epistemological, political and social context for trans DA and look at barriers and challenges in identifying, reporting and responding to DA for trans people in later life given the lack of research and practice guidance in health and social care.

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.