The unique challenges LGBTQ folks face when it comes to aging

People marching in a Pride parade
A person holds a transgender pride flag as people gather on Christopher Street outside the Stonewall Inn.
Angela Weiss | AFP via Getty Images

On the last day of Pride month, Dr. Abel Knochel, Associate Professor at the University of Minnesota, Duluth and the author of the Minnesota Trans Aging Project Community Report, and Anne Hodson, a transgender advocate and educator, speak to the unique challenges of aging when LGBTQ and the systemic change that can improve care.

The following transcript has been edited for length and clarity. Use the audio player above to listen to the full conversation. Subscribe to the Minnesota Now podcast on Apple Podcasts, Google Podcasts, Spotify or wherever you get your podcasts.

Knochel: I think there are some things that are related to physical transitioning, for example, there may be preventive care screenings around things like cancer, where there may be differences between a person's legal gender and the parts of their body. So there are things that come up. A bigger piece, though, that we found is just whether trans and nonbinary people are willing to go and see providers and what their experiences are once they get there.

In the study, we found that a lot of providers don't have the education or awareness. And some of that is just about how to engage in a relational way with transgender and nonbinary patients but a bigger part is about knowing what kind of care services they may need. And so transgender and nonbinary people in the study, and other research shows this, are often in this place of needing to educate their providers in order to then be able to access the care they need.

What's your personal experience Anne?

Hodson: I've been fortunate to continue to live at home. I'm not old enough yet that I feel like I need to go into a care facility but I certainly have some concerns about that experience if it comes up. For a lot of transgender people, there's a greater likelihood of aging alone because there's oftentimes less family support. I feel fortunate that I do have a reasonable amount of support.

I was surprised to learn that transgender nonbinary folks report higher rates of disability, depression, anxiety, general poor health, does that ring true to you? And if so, why?

Knochel: Yeah, you know, there's some bits of study starting to come out and a big piece of it Cathy is the result of oppression over the course of a lifetime. They find that if you've dealt with oppression, not just transgender and nonbinary people, but any group that's marginalized, it has impacts on your physical and mental well-being. And if you take someone who's older, then you're talking about the cumulative effects of that oppression over a lifetime.

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There is obviously a fair amount of homophobia, transphobia and lack of awareness of LGBTQ issues, especially trans identities in this world. But I'm wondering, do you find in the LGBTQ world there's also a fair amount of ageism and a lack of awareness about aging?

Knochel: Yes. You know, when transgender and nonbinary people are coming out in midlife or older adulthood and then accessing the support systems there are the bits of the community that are finding a much younger group. And maybe some of what they're facing is ageism and some of it is a generation gap. So I think that makes it a bit challenging to come into some of the trans and nonbinary spaces that exist.

Anne, what do you think of that?

Hodson: It seems like there is a growing number of people that are coming out as transgender in part, I think, because the definition of transgender has broadened from what it was in years past and the self-declaration of transgender and nonbinary identities are on the increase. What that means, for me, is a greater sense of hope that people are going to have a better understanding of this. And that as I get older, there will be more and more younger people that are going to understand what it is my identity is about,

Dr. Abel, you've noted that long-term care is a specific issue that trans and nonbinary folks need to think about when aging. Tell us a little bit more about that.

Knochel: In the two studies that we've done as part of the Minnesota Transgender Aging Project, when we talked about aging into care, and in particular, institutionalized long term care, people's fears were palpable and their responses around it were fairly stark. And that happens around any group of older adults when they're contemplating going into institutionalized long-term care but it's exacerbated by gender identity and some of the things Anne said certainly came up.

A portrait of a person.
Abel Knochel
Courtesy of Abel Knochel

There's also this piece about trans and nonbinary older adults, the ones who have made it to older adulthood, or are the survivors and the determined ones with hard won identities, who have educated and also advocated in order to be able to build and live a life as themselves. And so when they're contemplating aging into a place where they are too fragile, to be able to advocate for themselves in the same ways, and may not have the same support systems around them to do it, they get scared,

What needs to be done, what has to happen within the system?

Knochel: One thing that is a bit distinct in Minnesota is for a good decade, providers of aging services have had access to training. There's a program called Training to Serve that provides training all over the state. It trains providers about how to understand and work in a way that is respectful and welcoming with LGBTQ older adults, and is deliberate about including and educating providers around a gender identity. And so that's a good start. But along with getting that training, it's repeating that training every time there is staff turnover, it's going in and examining policies and practices and setting a standard for what's expected of staff, volunteers and even of residents or participants in aging programs about how they will interact with transgender and nonbinary people.

In my introduction, I mentioned that there is a social group for trans elders that has been in existence for a few years. And I know Anne you're part of this group, what does it mean to you to have a group of fellow elders to meet with on a regular basis?

A portrait of a person.
Anne Hodson.
Courtesy of Anne Hodson

Hodson: It's actually quite wonderful because it offers a sense of community that is free of concern from judgment, or wondering if someone's being critical of you because of your gender identity, even if they don't outwardly express it. And so there's an ability to kind of relax and be your full self and bring your whole self to that social setting.

May I ask, What do you talk about, just generally speaking, in the group?

Hodson: We talk about everything and surprisingly, not very much is about transgender identities. It's more a sense of just getting to be yourself and transgender identities are part of that but it's also something we can almost ignore.

As the population of transgender and nonbinary people grow, I'm wondering what needs to be done what kind of research do you want to see moving forward?

Knochel: The biggest need is the many, many trans and nonbinary older adults who are hidden. Folks who came out a few decades ago were expected to disappear, to transition themselves so that they could pass in this gender and society and then to do so and to consider being transgender a very temporary state that they were in. And so there are people who are aging into care now who have been hidden for decades and decades, and we don't know how to find them.

There are other folks who are hidden out of fear, like Anne had mentioned, people may revert their identity as much as they can if they're aging into dependence. And so being able to find this whole group of people who have been hidden for so long and understand what their life has been like and what they want as their aging into dependence is quite important.

We have a number of listeners who would be very interested in the social club. So, Dr. Abel, how can they join? What's the information?

Knochel: We're hoping that some people will will hear this who want to be a part of the group. So these days, it is meeting once a month by Zoom, that's been kind of a pandemic thing. It meets on the first Friday in the early afternoon, and we've talked about some different potential social gatherings outside of that. But if anybody is interested in it, they're welcome to contact me and I'd be happy to give them the link and have them join us the first Friday in July.

Correction: (June 30, 2022): Anne Hodson’s name was misspelled in a previous version of this interview. The interview has been updated.

Audio transcript

INTERVIEWER: Throughout my career, I've always been interested in stories related to aging and the challenges and joys that face elders. One little-studied area of aging deals with individuals who are transgender. Old age has come to the first generation of trans people who physically or socially transitioned in this country.

Now, getting old is hard for everyone, and there are some unique challenges for transgender elders. Since June is Pride Month, we wanted to cast a light on these issues. Dr. Abel Knochel at the University of Minnesota-Duluth conducted the first study of its kind on aging in the transgender community in Minnesota. It's called the Minnesota Trans Aging Project Community Report.

They also formed a trans elders social group for some of the participants in their study. One of those participants, Anne Hodson-- Anne is a transgender advocate and educator. Anne and Dr. Abel, welcome to Minnesota Now.

ABEL KNOCHEL: Thanks for having us.

SUBJECT: Thank you.

INTERVIEWER: I'm so glad you're with us. Doctor, I'm going to begin with you. As a result of your study, does aging present unique challenges to transgender people?

ABEL KNOCHEL: Absolutely, Kathy.

INTERVIEWER: Are there medically necessary care-related issues to gender transition that occurs in older age?

ABEL KNOCHEL: I think there are some things that are related to physical transitioning. For example, there may be preventive care screenings around things like cancer, where there may be differences between a person's legal gender and the parts of their body. So there are things like that that come up.

A bigger piece, though, that we found and focused on is just whether trans and non-binary people are willing to go and see providers and what their experiences are once they get there. In the study, we found that a lot of providers don't have the education or awareness. And some of that is just about how to engage in a relational way with transgender and non-binary patients.

And a bigger part is about knowing what kind of care or services they may need. And so transgender and non-binary people in the study, and other research shows, are often in this place of needing to educate their providers in order to then be able to access the care they need.

INTERVIEWER: Ah. Anne, that has to be exhausting. What's your personal experience?

SUBJECT: I've been fortunate to continue to live at home. I am not old enough yet that I feel like I need to go into a care facility. But I certainly have some concerns about that experience if it comes up. For a lot of transgender people, there's a greater likelihood of aging alone because there's oftentimes less family support. I feel fortunate that I do have a reasonable amount of support.

INTERVIEWER: Dr. Abel, can I go back to for just a moment? I was surprised to learn that transgender non-binary folks report higher rates of disability, depression, anxiety, general poor health. Does that ring true to you? And if so, why?

ABEL KNOCHEL: Yeah, there are some bits of study starting to come out. And a big piece of it, Kathy, is the result of oppression over the course of a lifetime. They find that if you've dealt with oppression, not just transgender and non-binary people, but any group that's marginalized, it has impacts on your physical and mental well-being. And if you take someone who's older, then you're talking about the cumulative effects of that oppression over a lifetime.

INTERVIEWER: There's obviously a fair amount of homophobia, transphobia, lack of awareness of LGBTQ issues, especially trans identities, in this world. But I'm wondering, do you find in the LGBTQ world there's also a fair amount of ageism and a lack of awareness about aging?

ABEL KNOCHEL: Yes. When transgender and non-binary people are coming out in midlife or older adulthood, and then accessing the support systems that are out there or the bits of community, they're finding a much younger group. And maybe some of what they're facing is ageism, and some of it is a generation gap. So I think that makes it a bit challenging to come into some of the trans and non-binary spaces that exist.

INTERVIEWER: Anne, what do you think of that?

SUBJECT: It seems like there is a growing number of people that are coming out as transgender, in part, I think, because the definition of transgender has broadened from what it was in years past. And the self-declaration of transgender and non-binary identities are on the increase. What that means for me is a greater sense of hope that people are going to have a better understanding of this and that, as I get older, there will be more and more younger people that are going to understand what my identity is about.

INTERVIEWER: So, Dr. Abel, I want to turn it back to you for just a moment. Anne was very eloquent talking about some issues around long-term care. And you've noted, Abel, that long term care is a specific issue that trans and non-binary folks need to think about when aging. Tell us a little bit more about that.

ABEL KNOCHEL: In the two studies that we've done as part of the Minnesota Transgender Aging Project, when we talked about aging into care and, in particular, institutionalized long-term care, people's fears were palpable and their responses around it were fairly stark. And that happens around any group of older adults when they're contemplating going into institutionalized long-term care.

But it's exacerbated by gender identity. And some of the things Anne said certainly came up. There's also this piece about trans and non-binary older adults. The ones who have made it to older adulthood are the survivors and the determined ones with hard-won identities who have educated and also advocated in order to be able to build and live a life as themselves. And so when they're contemplating aging into a place where they are too fragile to be able to advocate for themselves in the same ways, and may not have the same support systems around them to do it, they get scared.

INTERVIEWER: What needs to be done? What has to happen within the system, then, where we train more people to advocate on behalf of trans and non-binary older adults?

ABEL KNOCHEL: One thing that is a bit distinct in Minnesota is for a good decade, providers of aging services have had access to training. There's a program called Training to Serve that provides training all over the state. It started in the Twin Cities metro, but it's gotten all around the state.

And it basically trains providers about how to understand and work in a way that is respectful and welcoming with LGBTQ older adults, and is deliberate about including and educating providers around gender identity. And so there is training that is provided in the state and that providers have access to. And a number of providers have received that training.

And so that's a good start. But along with getting that training, it's repeating that training every time there's staff turnover. It's going in and examining policies and practices and setting a standard for what's expected of staff, of volunteers, and even of residents or participants in aging programs about how they will interact with transgender and non-binary people.

INTERVIEWER: In my introduction, I mentioned that there is a social group for trans elders that has been in existence for a few years. And I know, Anne, you're part of this group. What does it mean to you to have a group of fellow elders to meet with on a regular basis?

SUBJECT: Oh, it's actually quite wonderful, because it offers a sense of community that is free of concern from judgment or wondering if someone's being critical of you because of your gender identity, even if they don't outwardly express it. And so there's an ability to kind of relax, and be your full self, and bring your whole self to that social setting.

INTERVIEWER: May I ask, what do you talk about, just generally speaking, in the group?

SUBJECT: We talk about everything. And, surprisingly, not very much always about transgender identities. It's more a sense of just getting to be yourself. And the transgender identities are part of that, but it's also something we can almost ignore.

INTERVIEWER: This is a final question to Dr. Abel. And, of course, in my intro, I also mentioned that you were one of the first to do research. But as we move along here and the population of transgender and non-binary people grow, I'm wondering, what needs to be done? What kind of research do you want to see moving forward?

ABEL KNOCHEL: The biggest need is to find the many, many trans and non-binary older adults who are hidden-- folks who came out a few decades ago were expected to disappear-- to transition themselves so that they could pass as cisgender and society and then to do so and to consider being transgender a very temporary state that they were in. And so there are people who are aging into care now who have been hidden for decades and decades. And we don't know how to find them.

There are other folks who are hidden out of fear. Like Anne had mentioned, people may revert their identity as much as they can if they're aging into dependence. And so being able to find this whole group of people who have been hidden for so long and understand what their life has been like and what they want and need as they're aging into dependence is quite important.

INTERVIEWER: We have a number of listeners who would be very interested in the social club. So, Dr. Abel, how can they join? What's the information?

ABEL KNOCHEL: Oh, that's great. We're hoping that some people will hear this who want to be a part of the group. So these days, it is meeting once a month by Zoom. That's been kind of a pandemic thing. It meets on the first Friday in the early afternoon.

And we've talked about some different potential social gatherings outside of that. But if anybody is interested in it, they're welcome to contact and I'd be happy to give them the link and have them join us the first Friday in July.

INTERVIEWER: I appreciate your time, both of you. Thank you so very much.

SUBJECT: Thank you, Kathy.

ABEL KNOCHEL: Thank you, Kathy.

INTERVIEWER: Dr. Abel Knochel is an associate professor at the University of Minnesota-Duluth and the author of the Minnesota Trans Aging Project Community Report. Anne Hudson is a transgender advocate and educator.

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