Stigmatized Multiplied

Transgender andGender-NonconformingOlder Adults with HIV

By Kristen E. Porter and Mark Brennan-Ing

Little is known about older transgender and gender-nonconforming (TGNC) adults with HIV. Approximately 1.4 million people in the US and 0.5 percent of older adults are TGNC. The Centers for Disease Control and Prevention reports that the highest rates of HIV infection are in the TGNC population. Around 98 percent of TGNC people living with HIV are transwomen and two percent are transmen. In the US, close to one-third of transwomen and 12 percent of transmen are HIV-infected, including more than half of African-American transwomen. Approximately two percent of people with HIV over age 50 are TGNC. Due to HIV-stigma many TGNC adults are afraid to know their HIV status.

The Veterans Health Administration reports that TGNC veterans are six times more likely to be HIV infected than non-TGNC veterans, and have a four-fold higher rate of depression. Common psychosocial issues of TGNC veterans include mental health (i.e. post-traumatic stress disorder, suicidal ideation/attempts), homelessness, and sexual violence while serving in the military. In general, TGNC adults report double the rate of violence and abuse compared to non-TGNC adults, or older lesbian, gay, or bisexual (LGB) adults. Many older TGNC adults had postponed transitioning due to workplace discrimination.

Lack of safe, sensitive, and competent care for TGNC people with HIV is a major concern in institutional care settings, such as nursing homes. Fears include neglect, physical or psychological abuse, being ‘outed’ as TGNC or HIV-infected, and not being allowed to express their gender identity. These risks are increased for those needing assistance with everyday tasks like showering, which may result in unintended TGNC identity disclosure. Long-term care facilities typically place residents into shared bedrooms based upon gender. There are no official policies regarding classifying residents’ gender, and private rooms are not covered by Medicare or Medicaid. Thus, some TGNC older adults chose to ‘recloset’ or ‘detransition’ by reverting to presenting like their natal gender or reversing their medical transition (e.g. stopping hormones). Others plan suicide to avoid entering long-term care.

When TGNC adults with HIV are people of color, discrimination and stigma are exacerbated by racism. TGNC older adults living with HIV experience intersecting stigmatized identities (i.e. being TGNC, older, etc.). Many TGNC adults are rejected by family and feel like outsiders even in the LGBT community. As shared in a 2016 focus group of older TGNC women with HIV:

“I love my family, but they don’t want me because I’m a transgender. They threw me out. They disowned me. Today my family has not talked to me for 35 years. …Today, today they still, you’re a fag, you’re a punk, stay away from my kids…That type of hateful ignorance.

Incidence of depression and suicidality are high among TGNC adults; 41 percent report suicide attempts compared to only 1.4 percent of non-TGNC adults. Yet, TGNC adults aging with HIV also speak about self-reliance, contentment, and happiness rooted in gratitude, spirituality, and even four-legged support. Focus group participants shared:

“I’m around a lot of positive people instead of negative people…I left all this gossip and all this bullshit. I’m trying to...enjoy the rest of my life. I am and being positive with it.”

“Aging-wise I’m very happy. I have two dogs that keep me healthy. I take them out. I love them, they’re there for me. I finally decided in my old age I don’t need a partner. All I need is myself and my two dogs…

“It’s not easy being 50 plus and with HIV and being an African- American transgender in society today and having faith. I was a Christian for a long time until they just... I’m thinking, I’m accepted and everything else because God accepts me, but no they sit back and call me an abomination, everything else and they’re a Christian too. But see, the Bible said you can’t go to heaven unless you love me. So now I’m not, I don’t claim any type of religion. I’m spiritual.

Despite the challenges, and in an ever-changing environment of TGNC acceptance, TGNC older adults show great resilience that should be celebrated and supported within the LGBT community. How do we do that? Individually, we must stand up against transphobia and ageism on the streets and within our own LGBT community. This includes supporting LGBT groups of color and #BlackLivesMatter, as African-American transwomen are hardest hit by HIV. At the level of agencies and management, the creation of welcoming environments in every facet of life, from clinics to coffee shops, is a must. Staff cultural competency trainings should require LGBT aging and TGNC aging curricula. At the level of aging policy, institutionalized care settings, like nursing homes, must address the human rights, safety, and dignity of TGNC residents. And to TGNC older adults reading this article – get involved and be loud! As clinicians, researchers, program directors, and policy makers, we need to hear what types of programs, services, and supports are needed to help you face the challenges of aging with HIV in the context of transgender experience.

Kristen E. Porter, PhD, MS, MAc, LAc, JP, is a gerontologist, acupuncturist, death midwife, event producer, and social entrepreneur. Her resilience research on LGBT/HIV older adults is published in numerous peerreviewed journals. She is national Chair of the Emerging Scholars and Professional Organization for the Gerontological Society of America.

Mark Brennan-Ing, PhD, is Director of Research & Evaluation at ACRIA and Adjunct Assistant Professor at New York University’s Rory Meyers College of Nursing. His research focuses on LGBT and HIV-positive aging adults. He is past Chair of the American Psychological Association’s Sexual Orientation and Gender Diversity Committee and a Fellow of the Gerontological Society of America.

Art: Nadine Stransen†, Face. The artist, a long-time LGBTQ activist, was one of many trans-identified people to have been murdered worldwide in 2016.