Trajectories and Status of Transgender Elderly Across the World and in Spain: A Narrative Review

Marta Evelia Aparicio García ^1,2,†,*, Roberto Andrés Lasso Báez ^1,†

1. Universidad Complutense de Madrid, Campus de Somosaguas, Madrid, Spain

2. Instituto de Investigaciones Feministas, Universidad Complutense de Madrid, Pabellón de Gobierno, Isaac Peral s/n, Madrid, Spain

† These authors contributed equally to this work.

* Correspondence: Marta Evelia Aparicio García

Academic Editor: Gloria Gutman

Special Issue: Elder Abuse in the LGBT Community: A Hidden Problem

Received: November 06, 2023 | Accepted: February 18, 2024 | Published: February 27, 2024

OBM Geriatrics 2024, Volume 8, Issue 1, doi:10.21926/obm.geriatr.2401271

Recommended citation: Aparicio García ME, Lasso Báez RA. Trajectories and Status of Transgender Elderly Across the World and in Spain: A Narrative Review. OBM Geriatrics 2024; 8(1): 271; doi:10.21926/obm.geriatr.2401271.

© 2024 by the authors. This is an open access article distributed under the conditions of the Creative Commons by Attribution License, which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original work is correctly cited.

1. Introduction

LGBTIQ+ (Lesbian, Gay, Bisexual, Transgender, and Intersex) individuals are increasingly visible in various spheres of public life, including politics, media, entertainment, and education. What was once considered private, shameful, something to be hidden, and at times, illegal is now a somewhat accepted and acknowledged reality. However, for many, this newfound visibility implies topicality and modernity, and they perceive this collective as exclusively composed of young people, when in fact, the gay movement, and subsequently the lesbian, bisexual, and trans movements, have been established in Spain for almost half a century [1]. LGBTIQ+ individuals have always existed, even when repressed by governments that viewed them just as criminals. Despite these social changes, the inclusion and visibility of older LGBTIQ+ people remain outside the collective image of this group. This is especially noticeable among older trans people.

The needs of trans individuals are often lumped in studies with those of LGB people. Yet, they are often a forgotten group within the general population, the LGBTIQ+ community, and the concept of older individuals [2]. It is estimated that globally, there are between 3 and 9 million trans individuals over the age of 65 [3]. In the United States, this group is already a visible cohort [4], with 217,000 people over the age of 65 identifying as transgender [5]. Therefore, considering that the number of older trans people will increase with advancing years due to the aging of the population, it is essential to understand the specific challenges that transgender individuals face as they reach late adulthood.

1.1 Historical Context

Like other dissident gender and sexual identities in Spain, transgender individuals were criminalized and pathologized for most of the 20th century. The laws of the Franco regime created a context that was not only socially hostile but also forced any person from the LGBTIQ+ community to conceal their identity under the risk of criminal prosecution. Up until 1983, genital surgery was considered punishable as "castration." In 1999, following a non-legislative proposal put forth by the Transexualia Association [6], Social Security began covering the medical transition process. More recently, in 2007, the Gender Identity Law was approved, allowing the change of the registered name without the necessity of undergoing genital surgeries [1]. To effect changes in the civil registry, trans individuals were often pressured to undergo psychological therapy to "confirm" their gender before starting hormone treatment. This association of transsexuality with suffering and a mental health issue has led many professionals to adopt a paternalistic role, directing and making decisions for the trans individuals they seek to assist [7,8] and maintaining a pathologizing perspective of trans identities through diagnostic manuals [9].

During 2022, the well-being of transgender individuals in Spain has been paradoxically jeopardized by the introduction of the preliminary draft of the "Trans Law" (Anteproyecto de Ley para la igualdad realy efectiva de las personas trans y para la garantía de los derechos de las personas LGBTIQ+ I). This draft bill was proposed to address the barriers faced by transgender people, to allow gender self-determination at the national level without the need for medicalization and pathologization [10]. However, numerous controversies have arisen, both from conservative groups and from the so-called "trans-exclusionary radical feminists" or "TERFs" [11]. Ultimately, the bill has been used to justify attacks and hate speech against trans people, even though its implementation represents a crucial legislative advance for the LGBTIQ+ community. The law was finally approved on February 28, 2023 (Law 4/2023).

However, it is to note that Spain is among the European, and undoubtedly global, countries with the most rights for LGBTIQ+ people [12]. Nevertheless, transphobic violence is on the rise. Trans individuals face discrimination in many areas, reflected in higher rates of unemployment and workplace violence [13], a higher risk of suicidal ideation and attempts [14], a higher likelihood of being victims of violence and hate crimes, and lower social support both within and outside the LGBTIQ+ community [15,16,17,18,19].

Considering the above and given that a person who is now over 65 years old was, at the least, born in 1957, we can deduce the generally hostile environment in which trans people developed during their formative years [20]. The lack of medical and endocrinological research, as well as the insecurity and illegality of the transition processes that existed, may have had long-term health effects, given that the physical and mental health of trans people are significantly more affected than those of cis people in the face of stigma [21]. Stigmas stemming from transphobia converge in adulthood with those arising from aging and ageism; that is, discrimination and oppression based on gender identity, age, or abilities combine and result in specific issues [22,23].

The objective of this review is to compile current information and knowledge about elderly transgender individuals, their reality, and their concerns so that it can be applied, both in future research and in the practice of care and interaction with this population.

2. Materials and Methods

A narrative literature review was conducted in September 2022, including scientific articles, books, and manuals related to older trans people. Search databases included Google Scholar, PsycNet, SCOPUS, Web of Science, and Mendeley. We also consulted the references of the selected articles. The search terms used were: "older trans people", "trans elders", "transgender elders", "trans aging" or "transgender aging", and they were eventually combined with other terms of interest such as mental health, physical health, social support, healthcare, etc. In total, 130 articles were reviewed, including 7 literature reviews on this topic, as well as books and manuals mentioned in the references when appropriate. To gather specific data about Spanish transgender individuals, we incorporated the term 'Spain' in a more refined, secondary search.

Inclusion criteria were: (1) any study, chapter, book, or grey literature that included quantitative or qualitative data about transgender adults and older people; (2) studies published between Jan 1, 2000, and September 2022; (3) studies published in English or Spanish. Primary exclusion criteria were: (1) studies published before 2000; (2) studies that do not include any data regarding older people.

Although the consensus is that the term "older people" refers to those over 65, most of the studies consulted on trans elders include people aged 50 years or over. This is a historical distinction since the first studies of older LGBTIQ+ people grouped the sample in this way [24]; the controversies and ways of solving this problem from the academic perspective have not yet reached a solution that would allow us to have all the available information by creating stricter exclusion criteria. Therefore, in this bibliographic review, we have included articles that discuss transgender individuals aged 50 or over. Although, as far as possible, we will try to differentiate between the group of "advanced adulthood" (between 50 and 64) and "old age" (over 65).

Initially, the identified articles, books, and manuals related to older transgender individuals were compiled from the mentioned databases and reference lists. Following this, the collected literature was carefully assessed based on relevance to the research focus.

The categorization process involved grouping the literature into thematic clusters (see Table 1), considering aspects such as mental health, financial concerns, HIV, social support, etc. Categories were established according to the prominent themes identified in the literature, ensuring a thorough coverage of the subject. The organizational and categorization process was carried out iteratively, incorporating feedback and discussions within the research team to guarantee a rigorous approach to the literature review.

Table 1 Overview of articles and topics included in the review of literature.

3. Results

Insights drawn from key literature reviews and articles were incorporated. Shankle et al., 2003, and Persson, 2009, are both review articles. Cook-Daniels, 2006, provides data from three surveys involving a sample of n = 57 transgender individuals aged 50 years or older, also offering qualitative descriptions of the covered topics. Finkenauer et al., 2012, is a systematic review of 34 academic and gray literature articles related to trans aging. Witten 104 a and b present findings from a re-articulation of the Trans Metlife survey, conducted with a sample of n = 1963 transgender-identified individuals. Lastly, Reisner et al., 2016, present a comprehensive review and synthesis of 116 studies on transgender health.

Building upon these literature reviews, a comparison of identified topics was undertaken, and new categories were crafted to encompass as much information as possible (refer to Table 1). The subsequent discussion will explore each category in detail to delve as deeply as possible into these issues.

3.1 Violence: Victimization and Discrimination

Discrimination is an ever-present reality in the lives of trans people, manifesting both directly and institutionally. Older trans individuals often encounter both forms of discrimination at various points in their life trajectories [25]. Stigma and victimization, considered risk factors, occur at higher rates among trans people compared to their LGB counterparts and are associated with poorer physical health outcomes, including higher rates of disability [21], as well as mental health challenges, such as depression, anxiety, post-traumatic stress disorder (PTSD), or eating disorders [26].

The distinction between victimization or abuse and discrimination or stigma depends on the nature of the actions: victimization involves actions that violate social norms, causing harm to the victim (e.g., sexual abuse) [22]. Discrimination, on the other hand, pertains to socially accepted attitudes that lead to adverse outcomes, such as, for example, being terminated from employment [27]. Both victimization and discrimination encompass acts of violence aimed at excluding and humiliating individuals. In the case of LGBTIQ+ people, given the close relationship between one's identity and the violence they endure, the potential impact on mental health can be more profound than if the same crimes occurred without a hate motivation [28]. Notably, many transgender individuals perceive the mistreatment they face as being motivated by transphobic prejudice [28], warranting further examination of this situation.

Regarding discrimination, comprehensive research has explored various microaggressions experienced by transgender individuals, including transphobic comments, the generalization of trans experiences, disapproval of the trans experience, support for normative and binary cultures, denial of the existence of transphobia, the assumption of transsexuality as a pathology, threats, and denial of bodily privacy, among others [29,30]. Notably, these studies have focused on everyday contexts. Still, the impact of discrimination intensifies when it occurs in critical areas such as employment, healthcare, or housing, which will be discussed in the "Structural Barriers" section. It’s essential to highlight the impact of economic discrimination, as it is a primary predictor of experiencing incidents of transphobia-motivated violence [31].

Focusing on violence, the prioritization of safety measures, and murder prevention among transgender older individuals underscores the severity of the challenges many of them face [32]. Disturbingly, in one study, while transgender people constituted only 2% of the sample, they accounted for 16% of murder victims, not including unreported or misreported incidents categorized as homophobic violence [31]. Furthermore, the prevalence of unreported assaults may be substantially higher, given that the historical context in which older trans people lived did not protect their rights. Consequently, what we now recognize as hate crimes were not conceptualized as such during that time. In cases of sexual violence, the system’s familiarity with cases involving female victims and male perpetrators can lead to the invisibility of other forms of violence, discouraging many from reporting [28]. In any case, studies on the prevalence of violence reveal figures ranging between 50% and 60% for physical abuse [31,33], 65% and 78% for psychological abuse [28,33], and an alarming statistic indicating that half of all transgender individuals have experienced sexual violence [34,35].

Regarding age-related violence, research suggests that younger transgender individuals are more likely to experience violence than their older counterparts [31,33]. One Spanish study revealed that a significant portion of sexual abuse experienced by transgender individuals occurred during childhood [36]. Nevertheless, new forms of victimization appear with age, including physical, sexual, emotional, or psychological abuse, financial exploitation, abandonment, neglect, and “self-neglect” [37]. The Transgender MetLife Survey (TMLS) conveys the added risks of ageism for older transgender individuals [25,38]. Furthermore, victimization experienced in one's younger years can heighten the risk of future abuse [39] and instill fears of recurrence, acting as barriers to receiving support, especially in cases of police violence or within the care sector [40]. Thus, it is imperative to comprehensively focus on the protection of both younger and older transgender individuals.

These fears may lead older trans people to contemplate “planned suicide” or self-euthanasia if they anticipate potential discrimination and violation of their human rights when seeking vital services [25]. However, it has also been found that as individuals age, they develop resources and coping mechanisms to address this violence [33].

3.2 Physical Health

Most of the studies on aging among trans people focus on clinical or care sectors [41]. While understanding transgender experiences in these domains is crucial, it is essential to underscore that a transgender person need not undergo medical transition, such as hormone therapy or surgeries, to be considered transgender. However, older transgender individuals often adhered more closely to binary gender norms due to their upbringing in a more binary-oriented society [38]. It is crucial to recognize the diversity of transgender experiences and consider the individual circumstances of each person, as different individuals may have undertaken various interventions at other points in their lives. Consequently, while the biomedical perspective may be oriented towards a more rigid and focused approach, sometimes prescribing specific medical and behavioral transitions on trans individuals [42], it is crucial to acknowledge the diversity of transgender experiences and tailor considerations to each person’s specific situation.

An examination of the most prevalent reasons for hospital admission among trans people in Spain has revealed a noteworthy pattern. The most common reasons for hospital admission were those associated with medical transition (59%), followed by HIV (4%) and mental health concerns [43]. It is essential to recognize that the findings of this study may carry a degree of bias arising from the necessity for transgender individuals to be diagnosed with a psychiatric disorder, often in the form of gender dysphoria, to be recognized as such and gain access to medical treatment. This information is beneficial for organizing and categorizing information on transgender people in Spain. It is helpful to structure the data presented below according to its apparent relevance to this population.

3.2.1 Medical Transition Processes

The most extensively studied topic in gerontological medicine concerning trans people pertains to transition processes, encompassing both genital surgeries and hormonal treatments. While not all individuals transition at the same point in their lives, it is now more common to do it during youth. However, many older individuals did not have this opportunity due to a lack of available information during their youth or social pressure. They chose to embark on their transition later in adulthood. Individuals transitioning into old age face distinct challenges compared to their younger counterparts, particularly in terms of health and socioeconomic issues [44].

Regarding genital surgeries, aging may limit the feasibility of such procedures in adulthood [45]. For vaginoplasties and orchiectomies, surgeries to create a vagina, there may be risks of fistulas and urinary tract infections, as for phalloplasties and metoidioplasties, surgeries to make a penis [46]. While subsequent complications have been studied (typically involving infections and bleeding, common in many invasive surgeries) [47], there is a lack of research on the long-term effects, potential issues for individuals over 65 years of age, or interactions with exogenous hormones or other medications [48]. In the case of hysterectomy, the removal of the uterus, some trans men undergo it to avoid the possibility of becoming pregnant and stop menstruation. Although it has primarily been studied in cisgender women, several complications, including neurological, hemorrhagic, lesional, infectious, and venous thromboembolic, have been associated with advanced age [49].

More comprehensive studies have been conducted on hormone treatment. The use of estradiol or estrogen (a hormone primarily by trans women) increases the risk of breast cancer, venous thrombosis, pulmonary embolism, and osteoporosis. The use of androgens or testosterone (a hormone mainly used by trans men) is implicated in the development of cardiovascular and liver problems and diabetes [46]; it also increases libido, unlike estrogen [28]. One study has highlighted that transgender women are at a higher risk compared to transgender men [50]. This, coupled with the fact that older trans women exhibit the highest prevalence of self-prescribing medication and perceive inadequate monitoring of their hormone levels by health services [51,52], underscores the need for specific attention to this group [53].

In addition to potential adverse effects associated with medical transition, it is essential to emphasize the significant benefits that these processes offer for trans individuals. Regardless of the individual’s age, the use of medical treatments, both hormonal [54] and surgical [55], has been shown to enhance their quality of life. Notably, older transgender individuals who initiate their transition at later stages in life report the same levels of quality of life as their younger counterparts who commence their transition at the same time and higher levels than older trans individuals who do not undergo medical transition [56]. This phenomenon can be attributed to various factors, including a sense of "catharsis" after enduring years of stigmatization [57] and a reacquisition of control over their bodies at an age often stereotypically associated with “loss of control” [58].

Given the specific social, physical, and mental health challenges that aging poses for transgender and gender-diverse individuals, it is essential for healthcare providers to adhere to the most up-to-date standards of care outlined by the World Professional Association for Transgender Health. Professionals are encouraged to engage in open discussions addressing aging-related psychological, medical, and social concerns, encompassing aspects such as mental health, gender-affirming medical interventions, social support, and end-of-life/long-term care [59].

A best practice is to collaboratively explore the available options within each of these domains, tailoring interventions to meet the unique needs of transgender and gender-diverse individuals. Furthermore, healthcare professionals should actively promote factors contributing to resilience and successful aging. This includes fostering spirituality, encouraging self-acceptance and self-advocacy, and endorsing an active and healthy lifestyle [59].

3.2.2 HIV/AIDS and Sexually Transmitted Diseases (STDs)

The second most common health issue among transgender people is HIV and AIDS. Given the prevailing concept of old age in society, it’s often assumed that older individuals are not sexually active and don’t engage in risky sexual behaviors [60]. However, research has shown that adults constitute a group with an increasing risk of these infections [61].

Transgender individuals, particularly trans women, are more vulnerable to HIV and other STDs [27]. Higher HIV prevalence has been observed in trans women compared to groups of gay men and injection drug users [62]. One possible reason for this is that vaginas constructed through vaginoplasty may be more susceptible to HIV transmission [28]. Trans men are also an overlooked population in this context, and it’s crucial to address the prejudices related to their sex lives, which, when combined with age-related biases, result in inadequate sexual education and riskier behaviors [63].

Specific challenges faced by older transgender individuals regarding HIV are associated with polypharmacy, HIV risk, and barriers related to education and stigma.

In the case of polypharmacy, given the rise of multimorbidity in later life stages, it becomes almost inevitable for transgender individuals living with HIV. Antiretrovirals may interact negatively with other medications and substances, including hormones [64] or recreational drugs, leading to adverse effects; these effects are further compounded by changes in liver and kidney function that come with aging [65].

Concerning HIV risk, older transgender individuals may lack education in safer sex practices and are frequently excluded from active targeting in prevention and testing campaigns, reinforcing ageist beliefs that older adults are not sexually active. Consequently, older trans adults are more likely to receive an HIV diagnosis later in life compared to younger cis adults. This delay can result in increased immune system damage, cardiovascular issues, and complications in the central nervous system, predicting higher mortality and morbidity [65].

Furthermore, the barriers related to education and stigma exacerbate the situation. The fear of discrimination can lead older trans people to conceal their HIV status, increasing the likelihood of potentially harmful drug interactions [66]. Therefore, it is crucial to (1) educate physicians and other healthcare professionals about these potential interactions, (2) provide information, treatment, and prevention within their communities [67,68], (3) consider the complexities of transgender aging, anatomy, and sexuality in research and intervention proposals [40], and (4) include trans people in state reports and plans, as they are currently not adequately addressed [49].

3.2.3 Substance Use

Another health issue affecting older transgender individuals is alcohol and substance abuse. Some studies with a trans population, in general, have reported high rates of substance use [24,69], which have been linked to experiences of transphobic discrimination [70]. This has been conceptualized as a coping mechanism to deal with these forms of violence and minority stress [27,71]. Similar to the case of HIV prevention, tailored interventions specific to this group are necessary [72].

3.2.4 Neurodegenerative Diseases, Disability, and Other Chronic Conditions

Another issue that arises in adulthood is neurodegenerative diseases, as well as disabilities and chronic conditions in general. An international survey found that about 30% of trans people had a chronic disease or disability [25], without significant differences by age. However, the 2013 study by Fredriksen-Goldsen et al. [21] specifically focused on older transgender individuals and revealed that 76% of them had some degree of disability or functional diversity. The presence of risk factors such as depression, loneliness, and substance abuse increases the risk of developing conditions like dementia [73], which is one of the primary concerns expressed by older transgender individuals [4]. In some cases, dementia has led to situations in which trans people forget their transition and revert to identifying with the gender assigned at birth [74,75]. Although there are several models to address the challenges arising from this situation [76], they may not be used due to discriminatory biases rooted in transphobia, ableism, and ageism. Victimization may escalate when transgender individuals do not fit within the male/female binary framework due to the effects of dementia on their perception of gender [77].

3.2.5 Access Barriers to Health Services

Discrimination risk is also prevalent within the healthcare sector [78]. Healthcare professionals may refuse to treat trans people, assign them to rooms based on their assigned gender at birth, or withhold necessary hormones. Trans individuals often find themselves in a position where they must repeatedly explain their status and why their bodies do not conform to societal norms [79]. In the healthcare and caregiving sector, a transgender person’s status is often a matter of public knowledge due to their lifelong need for hormones [79], especially in cases requiring home or residential care. Older transgender people frequently experience uncertainty in these contexts, as they may need to navigate multiple transfers before finding a professional knowledgeable about their specific needs. Even in such cases, appointment delays and cancellations are not uncommon [51]. These situations create discomfort for older individuals who desire to live their lives in their true gender while coping with the challenges of aging. In general, the experiences and realities of older transgender individuals are not well understood by healthcare professionals, which can lead to prejudice and substandard care [40,48,80].

3.3 Social Support and Loneliness

The relationship between a trans person's willingness to come out and their social environment is evident. Many individuals who transition into adulthood often mention that this transition becomes more feasible after certain life milestones, such as the independence of their children or the passing of their parents, making them feel less responsible to other people [79]. Retirement and the relief it brings from workplace pressures also play a significant role [45]. For these reasons, many find it more comfortable to embark on their transition during this stage [81], although this choice can come with specific medical limitations, as previously discussed.

Indeed, it’s also possible that older transgender individual initiated their transition in youth. In many cases, they were compelled by professionals or societal pressures to sever ties with their loved ones to transition and live in their authentic gender [82]. This sometimes meant establishing entirely new lives in anonymity, concealing their transgender identity [83]. Such a situation not only poses challenges in forming new relationships but also creates a shortage of support networks within the LGBTIQ+ community. Many trans adults do not hold positive feelings about belonging to this community [84]. Although transgender collectives do exist, they have typically been concentrated in urban and marginalized areas [82]. Consequently, some transgender individuals with more economic resources might have chosen a more discreet way of life [85]. In Spain, about 9% of transgender individuals travel to other Autonomous Communities for medical transition [43].

Both situations lead to many trans people having no family or social relationships [40] or that their social nuclei are small [45,86]. Due to the collective stigma associated with transgender identity, over 50% of transgender adults report losing friends, and 40% have been estranged from their children [87]. This can be attributed to the perceptions of responsibility release: families may feel that they are no longer a priority for the person undergoing a transition [51]. Furthermore, it has been observed that the longer a relationship adheres to the same established patterns (for example, a parent-child relationship sustained for three years versus 30 years), the more challenging it is to make adjustments. As a result, family reactions may be influenced by their prejudices, such as a sense of "betrayal" or "deception," as well as their difficulty in adapting to new family dynamics [44].

Regarding loneliness, 42% of older trans people live alone, compared to 18% of the general population [25]. Another layer of complexity arises in cases of divorce and the dissolution of family units, which often impacts the ability to establish new partnerships. Transphobia persists in both heterosexual and homosexual dating scenes [79]; however, dating is often not even considered by many older individuals. This lack of family support negatively affects the independence of older transgender individuals and their ability to reside in a familiar, secure environment [3], increasing the likelihood of needing access to care or residential services, with the accompanying uncertainty and vulnerability to victimization.

Another crucial form of social support within LGBTIQ+ communities is the concept of a “chosen family.” This alternative family unit consists of individuals within the community who provide assistance and mutual support to one another in the face of a discriminatory society [24]. These bonds, while not prevalent among many older transgender individuals [87], have been proven to be a critical factor in coping with situations involving victimization [88] and as a source of information and care [89], contributing to the overall quality of life [90]. Establishing a sense of community on a local level is indispensable [91]. However, it's important to note that during the early 2000s, internet forums and websites played a significant role in forging bonds within the transgender community [92]. They offered enhanced accessibility to information about gender diversity [93]. In whatever form of communication, promoting these support systems among LGBTIQ+ individuals is vital, as it has been found that the ability to discuss problems related to transsexuality with peers positively correlates with overall social engagement [82].

In general, social support significantly impacts physical health, with lower social support leading to more hospital visits and increased healthcare expenditures [46]. It also affects the quality of life [94] and mental health, with older transgender individuals experiencing more mental health challenges compared to cisgender LGB individuals [21,95]. Therefore, addressing and enhancing social support systems is crucial in improving the often neglected social aspect of the lives of older transgender individuals.

3.4 Mental Health

Intolerance, family stress, the pathologization of trans identities, and a lack of knowledge among professionals are significant factors that impact the mental health of LGBTIQ+ people [96]. Mental health is one of the most extensively studied topics concerning the well-being of trans people [27], primarily due to the cumulative effects of all these risk factors.

As mentioned earlier, the mental health sector has historically contributed to pathologizing trans individuals and asserting control over their lives and needs. In many cases, cisgender professionals lacked adequate information about these populations and, for example, did not permit homosexual trans individuals to undergo transition [93], as well as relying on other criteria rooted in gender stereotypes. They often relied on criteria rooted in gender stereotypes. While these dichotomies have largely been overcome, trans individuals who sought psychological assistance during their youth may have encountered such issues and developed a negative view of the field [79]. It has been observed that 75% of trans individuals, spanning all age groups, seek the services of psychologists [97], a much higher percentage than that of cisgender individuals [98], suggesting that the perception of psychology professionals may not be entirely negative despite these challenges.

Several adverse effects on mental health are linked to feelings of anger, fear, anxiety, or resentment stemming from the need for approval from multiple professionals to start a medical transition with hormonal treatment and/or surgeries (procedures that, in many cases, are more accessible to cisgender individuals) [79]. Additionally, internalized stigma is more prevalent at older ages [99] and is associated with worse physical health and premature mortality [100]. Hypervigilance, a result of being compelled to conceal one's identity and encountering rejection from both loved ones and strangers [101], is another significant issue. However, the most widely discussed aspects in the literature are depression, suicidal ideation, and, conversely, resilience.

3.4.1 Depression and Suicidal Ideation

Internalized stigma contributes to mental health crises, including depression and suicidal ideation [24]. Transgender adults have a higher prevalence and risk of depression compared to LGB individuals (48% vs. 30%) and cisgender heterosexual individuals (5%) [102]. This heightened risk can lead to the self-neglect mentioned earlier, a state in which individuals become too ill or depressed to attend to their basic needs, such as food, hygiene, or safety [28]. Alarmingly, approximately 27.3% of older trans individuals have reported experiencing this degree of self-neglect [28].

Exposure to violence can result in depressive symptoms and feelings of loneliness [103], which in turn contribute to suicidal ideation and attempts [87]. On a positive note, the risk of suicide and psychological issues within this population has been found to decrease with age [87,99].

3.4.2 Resilience

Trans people, in the face of the inequalities they have encountered, have shown the development of traits associated with resilience. These include nurturing their spiritual well-being, asserting self-agency, fostering self-acceptance, cultivating supportive relationships, engaging in advocacy and activism, and leading a healthy and active lifestyle [104,105].

Some authors have introduced the concept of "successful aging", which factors in the impact of stigma experienced throughout life, particularly in old age [86,106]. This approach offers a more comprehensive perspective on what constitutes “success” within these minority populations and enables a more thorough examination of the influence of resilience in older transgender individuals.

3.5 Structural Barriers

Transgender individuals face structural barriers that other groups do not encounter. The articles address several key areas, including employment, economic resources, housing, and legislation related to these issues.

Employment stands out as a primary concern for transgender individuals, and it can significantly influence their decision to come out [85]. Many fear discrimination, such as the risk of being terminated, demoted, or not promoted within their current workplace [31]. A striking 70% of transgender adults postponed their transition until after retirement [87], and a staggering 90% believe that their gender identity diminishes their employment prospects and career advancement opportunities [107]. Sadly, workplace discrimination is almost the norm for trans individuals [31].

In cases where individuals choose to transition before retirement, they face concerns about potential job loss and difficulty finding new employment due to gender identity discrimination. This is compounded by ageism [108] and bureaucratic challenges related to concealing their trans status when changing their employment history documents [44]. Those who transitioned during their youth may encounter difficulties securing savings and financial stability because trans people are more likely to experience unemployment compared to cisgender individuals [109].

Moreover, the importance of legal documents aligned with one's gender identity becomes evident, as it is suggested that possessing such documents can significantly increase the likelihood of success in the job market for trans women. Considering the significance of secure employment in influencing various aspects of life, barriers to legal name changes can exert a profound impact on the overall quality of life [110].

Regarding economic resources, in Spain, only 46% of trans people can meet their financial needs without difficulties; the remainder experience varying degrees of financial challenges, with 31% facing some problems, 14% experiencing difficulties, and 8% encountering significant challenges [111]. Transgender individuals face economic discrimination at three times the rate of cisgender individuals [31], their household incomes tend to be lower [48,112,113], and they experience higher poverty rates [109]. When considering older trans individuals, the study by Witten [25] revealed that roughly 60% received pensions or had retirement plans. At the same time, the rest depended on more minor pension disability benefits or lacked a specific financial plan. Accessing Social Security benefits can sometimes be complicated due to changes in names and gender designations [79,110]. In many cases, economic instability compels trans individuals over the age of 50 to forego planning for end-of-life care [114], thereby increasing the risk of poverty, homelessness, or legal issues [40].

Major global stressors, including pandemics and economic crises, can intensify these structural barriers. A notable example is the COVID-19 pandemic, which escalated mental and physical health challenges, disrupted social support and connections, impeded access to gender-affirming care, heightened financial concerns, and overall posed an additional risk factor to health and quality of life of older transgender individuals worldwide [115,116,117].

The search for skilled care facilities poses an additional challenge. Many LGBTIQ+ individuals have concerns about their well-being when considering admission to nursing homes, with the quality of care being a critical consideration in their decision to come out at an older age [24]. For transgender individuals, their inability to conceal their identity in such settings, at least from caregivers, makes them susceptible to violence and discrimination [59,118].

Despite most of these facilities being underprepared or unprepared, a growing number are providing adequate affirming care. This shift may be attributed to various training programs and guidelines aimed at enhancing competency and cultural humility in working with LGBTQ+ elderly individuals [119,120]. Key indicators to observe and prioritize include ensuring the acknowledgment of gender identity and sexual orientation during intake or assessment. If left unaddressed, initiating the conversation during these early stages becomes critical. Identifying signs such as training, visible visual cues, and employing appropriate body language is imperative for establishing a supportive and affirming environment [120].

3.6 Spirituality, Religion, End-of-Life Concerns

The term “End-of-life issues" pertains to preparations for death, which can include activities like creating a will or making funeral arrangements. It also encompasses decisions related to chronic illness or disability that may be faced in one's final years [24]. These matters often intertwine with religious or spiritual contexts, and this section explores the connections between them, as well as their impact on the quality of life for older transgender individuals.

3.6.1 Religion and Spirituality

The main religion in Spain is Catholicism, with 56.6% of the population identifying as believers, including both practicing and non-practicing individuals. A significant portion, 38.6%, does not adhere to any specific religion, comprising agnostics, atheists, and non-believers who identify as "indifferent." A smaller minority follows other religions, making up 2.6% of the population [121]. Notably, older individuals have the highest rates of religious belief, with 88.5% of those over 65 and 76.7% of those between 55 and 64 years of age professing a belief [122]. Studies conducted with older transgender individuals in the United States have found that they tend to be primarily affiliated with Abrahamic religions (Christianity, Judaism, or Islam), in contrast to other age groups, which lean more towards atheism, agnosticism, or "self-constructed" belief systems [25]. When comparing these findings across nations, it's interesting to note that Spain exhibits a weaker correlation between church or mass attendance and prejudice towards the LGBTIQ+ community. In contrast, such a correlation exists in the USA and Italy [123]. Despite this positive data, the prevalence of Catholicism in Spain and within this age group underscores the importance of examining its impact on the well-being of older transgender individuals.

Many religions have not historically shown positive attitudes towards LGBTIQ+ people [124], making their relationship with religious institutions complex at best [125]. Research yields diverse results regarding the religious affiliation of transgender individuals. Some studies highlight the significance of religion or spirituality in the lives of trans individuals, noting their higher engagement in such activities compared to their LGB counterparts [84]. Others suggest that this heightened participation is observed mainly in "affirming" religions for LGBTIQ+ individuals, with lower involvement in "non-affirming" faiths compared to the general population [2]. Additionally, some research indicates that older transgender individuals may become disillusioned with religion, leading them to identify as atheists, agnostics, or followers of unspecified spiritual beliefs [124]. They are also more likely to have ceased practicing the religion they were raised with and to have stopped practicing the religion they were presented with [126]. A study by Factor and Rothblum [127] also underscores these complexities. It reveals that although transgender individuals identify less with their "family" religion compared to their cisgender siblings, they attribute the same level of importance to religion and participate in religious ceremonies as frequently.

These intricate dynamics extend to interactions with the caregiving and medical sectors [128]. Beyond the discrimination issues that have been widely discussed, caregivers may lack the necessary training to provide inclusive spiritual support for transgender individuals [129], or in some instances, they may even assume that such support is unnecessary due to the perceived incompatibility between religion and sexual and gender diversity [130]. This presents a dual challenge: religion has been associated with successful aging and resilience [131,132], and it can help mitigate the effects of violence and abuse [133]. However, it's crucial to consider the possibility that transgender individuals may have faced direct discrimination in the name of religion [134]. They are recognizing the importance of addressing the spiritual needs of transgender individuals, which are relevant to all people, religious or not [135], efforts should be made to create safe spaces where transgender individuals can express their feelings regarding religion or spirituality. It’s equally important to acknowledge the differences in their religious practices compared to “normative” individuals [136].

3.6.2 End-of-Life Preparations

Regarding religious considerations and the concerns that older transgender individuals may have as they approach the end of their lives, a significant issue involves ensuring that their end-of-life plans are respected. Many transgender individuals express concerns about their tombstones, obituaries, or death certificates failing to honor their chosen names and gender identities. Regarding religious considerations and the problems that older transgender individuals may have as they approach the end of their lives, a significant issue involves ensuring that their end-of-life plans are respected. Many transgender individuals express concerns about their tombstones, obituaries, or death certificates failing to honor their chosen names and gender identities [3,25] or being denied the possibility of a religious farewell [40]. However, the prevalence of transphobia can make discussing these concerns with family members or other support networks challenging [25]. In a survey, 23% of respondents had not discussed their end-of-life plans with anyone, and 20.5% had made attempts to do so. The rest mentioned that they had “sort of tried” [38]. Among those who did discuss their plans with others, partners (43%) and friends (23%) were the primary individuals with whom they engaged. These findings underscore potential vulnerabilities for those who live alone.

In the United States, most people desire that their end-of-life wishes be respected, yet only one-third of them have completed essential documents such as wills to secure this [137]. In the specific case of older trans people, only 15% (aged 51-60) and 8% (aged 61+) have prepared a will, 9% have a living will, and 8% (aged 51-60) and 7% (aged 61+) have designated someone with the authority to make decisions on their behalf in case they become medically incapable [25]. This lack of preparedness is concerning, particularly for a stigmatized population whose care and wishes are often overlooked by many professionals. However, participants over 61 were the most confident when asked if they believed they would be treated with dignity and respect at the end of life [25].

It is vital to promote discussions on these topics, as they are crucial for achieving a high quality of life in one's final years and for coping with the inevitability of death [138,139].

4. Discussion and Conclusions

Through this comprehensive literature review, we have examined the various aspects of the lives of older transgender individuals, shedding light on the existing gaps in knowledge and the need for deeper exploration. The well-being of older transgender people demands action on multiple fronts, encompassing systemic and legislative changes, the transformation of societal attitudes, and the recognition of individual needs.

This review underscores the importance of recognizing and empathizing with the realities of trans people, whose needs have been historically underrecognized and sometimes disregarded. A crucial step in alleviating the burdens placed on this population is to address potential challenges and remain well-informed directly. In particular, the healthcare sector should shift away from binary thinking and adopt a more inclusive approach to diverse transition paths. Standardizing inquiries about self-identified gender, as well as the utilization of hormones or surgeries, should apply to individuals with both normative and non-normative bodies [82]. Acknowledging the uniqueness of each body, regardless of biological sex, and understanding the various factors influencing medical procedures are vital in dismantling the stigma surrounding older transgender people and enhancing the quality of medical care and outcomes.

In the same way, education must be prioritized across all sectors. The dissemination of accurate information about transgender individuals, coupled with efforts to integrate them into society and raise their visibility, is critical for preventing future abuses and violence. Such initiatives can also promote social support and the establishment of interpersonal networks. At a legislative level, facilitating gender self-determination and streamlining processes for name and registered sex changes represent initial steps in combating economic discrimination and enhancing access to employment. Additionally, providing aid to transgender individuals who have experienced reduced employment opportunities due to identity criminalization is another potential measure.

Some of the limitations of this review arise from the numerous challenges and barriers faced by LGBTQ+ individuals, making the selection of studies exclusively focusing on older transgender individuals challenging. Some of the reviewed articles encompassed a broader participant pool, such as the inclusion of elderly individuals within the larger LGBTQ+ community. Additionally, some studies addressed transgender and gender non-conforming individuals collectively.

A methodological challenge observed in the reviewed articles pertains to the absence of standardized terminology for defining transgender and elder identity. Furthermore, individuals within the population may identify as transgender but not use specific categorical terms for self-identification. It is also important to highlight that a substantial proportion of the studies in the review followed an exploratory or qualitative approach.

These limitations underscore the complexities inherent in researching transgender elderly individuals within the broader LGBTQ+ context, both globally and in Spain, and emphasize the need for more focused and standardized methodologies in future studies.

Lastly, within the realm of psychology, there is a need to eliminate the pathologization and medicalization of transgender identities. Developing protocols to address situations of discrimination, victimization, and abuse while bolstering self-esteem and resilience mechanisms is essential for this population.

In conclusion, this literature review underscores the imperative of comprehensive, multidimensional efforts to improve the lives of older transgender individuals. By addressing the systemic, societal, and individual issues they face, society can work towards a more inclusive, understanding, and equitable future for all its members.

Author Contributions

First author conceptualized and designed the review. All the authors screened the abstracts and reviewed the articles. First author wrote the first draft of the manuscript. Second author did an extensive review and edit of the first draft. All authors have read and agreed to the published version of the manuscript.

Competing Interests

The authors have declared that no competing interests exist.