Social support and unmet needs among older trans and gender non-conforming people during the COVID-19 ‘lockdown’ in the UK

Abstract

Background

Previous research has suggested that older trans and gender non-conforming (TGNC) people may face particular challenges related to stigma, social exclusion and discrimination in later life. However, direct data on social support and needs in older TGNC population both internationally and within the UK is limited due to the small, dispersed nature of this population, and the absence of specific data collection on aging TGNC populations. During the UK COVID-19 lockdown in summer 2020, older people and those with long-term health conditions were advised to adopt particular precautions.

Aims

This study aimed to explore older TGNC people’s social support networks, key concerns and unmet needs during the COVID-19 ‘lockdown’.

Methods

A UK cross-sectional survey of LGBT + people aged 60+ (n = 375) was undertaken during the lockdown. This paper analyses responses from the subset (n = 38) of TGNC participants.

Results

The majority of TGNC respondents described diverse social networks, often centered around friends and non-kin social networks, although partners and adult children were also significant for some. In most cases, those with existing strong networks continued to maintain social connections during lockdown, albeit with some regrets about loss of activities and face-to-face connection. However, a minority of respondents had experienced greater challenges prior to lockdown, and may have been at increased vulnerability during the pandemic, for example indicating that they had no-one to call on for practical support in an emergency. When asked about unmet needs and challenges, social isolation was repeatedly raised as the most frequent concern. Several respondents also mentioned issues specifically affecting TGNC communities, including access to gender affirming care and a perceived rise in social intolerance.

Conclusions

Health and social care providers should be aware of the diversity of support networks within TGNC communities. There may also be benefits in community sector interventions to help older TGNC build and maintain strong social networks.

Introduction

This article reports on a subset of findings from the recent UK study on the impact of COVID-19 on older lesbian, gay, bisexual and trans (LGBT) people. It describes and considers data from 38 trans and gender non-conforming (TGNC) participants aged 60+ who participated in a survey of 375 older LGBT people. The lives of older TGNC people are under-researched, although it is recognized that their aging experiences are nuanced, and aging vulnerabilities heightened, through the lens of their gender identities, particularly in relation to minority stress (Hendricks & Testa, 2012; Hoy-Ellis & Fredriksen-Goldsen, 2016, 2017).

At times of public health crises, often the most vulnerable populations are disproportionately adversely affected. This study both offers new insights into the lives of older TGNC people living in the UK but also how their lives have been impacted by COVID-19.

Background

TGNC aging

In the recent years, there has been growing scholarly interest in needs of aging trans and gender non-conforming (TGNC) populations. However, at present, UK data remain limited, not only with regard to understanding the needs of this population, but also more broadly in relation to the demographics of aging TGNC people. Estimates suggest that, depending on definition, TGNC people represent between 0.1% and 2% of the population, with the smaller estimates focusing on those who access gender-affirming medical care and/or receive diagnosis, and the larger estimates using self-report criteria (Goodman et al., 2019). There appears to have been both a temporal shift and an age shift, with most datasets showing a greater number of trans people coming forward at a younger age (Goodman et al., 2019), meaning that future numbers of older TGNC people accessing services can be expected to increase. However, key data sources such as national censuses in the UK and elsewhere have often not recorded TGNC populations, and have had difficulty identifying ways of doing so that are both robust and acceptable to respondents (Meerwijk & Sevelius, 2017; Office for National Statistics, 2020). Lack of good quality monitoring data, combined with a likely increase in demand, may mean that services are under-prepared to meet the needs of older TGNC people.

The evidence that is available suggests that there are likely additional vulnerabilities and risks for some within the aging TGNC population beyond those affecting older people in general, linked primarily to minority stress (Meyer, 2003). The minority stress model,

…describes pathways by which external and internal minority stress processes (i.e., stigma) operate relative to other minority statuses (e.g., race/ethnicity, gender) to impact mental health outcomes among sexual… and gender minorities…The most internal of minority stressors are the long-term concealment of minority identity… including gender identity… and the internalization of stigma attached to a given minority status, including transgender (Hendricks & Testa, 2012).

The accumulative and compounded effects of minority stress are closely connected with poor physical and mental health in later life, notably among older TGNC individuals (Hendricks & Testa, 2012).

Older TGNC people may experience worse health outcomes linked to minority stress arising from the accumulative effects of stigma associated with gender-identity-based discrimination, victimization, social and familial exclusion, inadequate social support, socioeconomic disadvantages, and ongoing fears of prejudice and discrimination (Hendricks & Testa, 2012; Hoy-Ellis & Fredriksen-Goldsen, 2016, 2017; Willis et al., 2020). These risks can be mitigated by factors which promote resilience (Meyer, 2015). Taking steps toward living authentically in line with one’s gender identity can be one such factor, via a positive and agentic process of self-determination (Bailey, 2012; Fabbre, 2015; McFadden et al., 2013; Pearce, 2018; Willis et al., 2020; Witten, 2014). Other factors which can buffer the impact of minority stress can include self-affirmation, adaptability and flexibility, positive mental attitude, understanding the processes of oppression, and strong social support networks (Fredriksen-Goldsen et al., 2017; Meyer, 2015; Singh et al., 2011). Older TGNC people have also been reported to have higher psychological resilience than younger TGNC populations, possibly due to more developed coping skills and stronger social support networks (Jackman et al., 2018; Tan et al., 2020).

For those individuals receiving hormone therapy or surgery there may be additional issues impacting their physical and mental wellbeing (Feldman, 2016; Persson, 2009). For example, some trans women may be at increased risk of ‘breast cancer, deep vein thrombosis, pulmonary embolism, and osteoporosis’ while some trans men may be at increased risk of ‘cardiovascular disease, liver disease, and diabetes’ (Persson, 2009, pp. 636-638). Some have argued that older trans people are at increased risk of dementia, associated with gender-identity minority stress (Witten, 2014). Trans women and trans men are concerned that dementia-related memory loss may impact their ability to remember that they have transitioned (Hunter et al., 2016; Scharaga, Chang, & Kulas, 2020; Willis et al., 2020). These challenges are compounded by health and social care services which often lack sufficient knowledge about the needs of (older TGNC) people, are based on cisgender norms and can be discriminatory (Bailey, 2012; Fredriksen-Goldsen et al., 2014; Persson, 2009; Witten & Eyler, 2016).

Witten (2009), Bailey (2012) and Pearce (2018) point to the potential implications of different trajectories in trans people’s experiences of aging: some older trans people ‘came out’ as trans early in life and then aged, while others will have come out as trans when they were already in later life. These different trajectories are likely to mediate experiences of minority stressors, social support and resilience in aging. For example, some TGNC older people will have been visible to others as trans for much of their adult life, potentially raising the likelihood that they will experience long-term stressor effects of stigma, discrimination and socio-economic exclusion but also potentially giving them time to develop trans-aware social networks that they can draw upon in times of challenge. Conversely, individuals who had successful careers, relationships and children prior to ‘coming out’ may potentially have greater preexisting financial or support resources, but may also risk losing existing resources and support if and when they publicly express a TGNC identity. Concealment of identity or self-limitation of gender expression may also contribute to minority stress, internalized prejudice and depression within older trans populations (Fredriksen-Goldsen et al., 2014; Hoy-Ellis & Fredriksen-Goldsen, 2017). Current social tensions regarding the recognition of trans people’s gender identities also often focus upon age at transition: trans people who ‘come out’ while young are often portrayed as vulnerable and potentially mistaken, while trans people (especially trans women) who transition as mature adults are frequently framed as sexually deviant and even potential predators (Ashley, 2020; Boukli & Copson, 2019; Serano, 2020). Trans people may therefore face different forms of discrimination and opprobrium depending on the age at which they ‘come out’. All of these aspects of trans lifecourse trajectories are also likely to be mediated by other factors, including access to and engagement with local LGBT + communities, and other dimensions of identity, expression and life experience.

There is limited data on family and other informal support networks for older TGNC people in the UK. A recent systematic review found no studies focusing on trans people’s experiences of being grandparents, or of parenting later in the lifecourse (Hafford-Letchfield et al., 2019). Bouman et al. (2016) reports that of the trans women aged 50+ newly referred to the UK gender clinic, 63% had children and 27% were currently married or in a civil partnership. The UK Government Equality Office LGBT survey, which received responses from around 900 trans people over the age of 55, did not capture parental status, but reports that 44% of trans people aged 55-64, and 39% of those aged 65+ were married, in a civil partnership or cohabiting with a partner (Government Equalities Office, 2017). However, the status of being married or having children does not necessarily indicate that individuals can and do call upon those family members for support, especially given frequent reports of family estrangement in trans populations. The 2012 UK Trans Mental Health Study, although not focused on older people, reported that some trans parents lost or had reduced contact with their children after coming out, that 25% of participants had at some stage moved away from friends or family due to being trans, that individuals tended to have more close friends than family members who they could confide in, and would be more likely to contact friends than partners or family members for urgent support (McNeil et al., 2012). Evidence from the United States indicates that trans older people have lower levels of social support than LGB people who are not trans, but that where it is available, social support is protective against both physical and mental ill-health (Fredriksen-Goldsen et al., 2014). Participants in the US Trans Metropolitan Life Survey similarly cited the development of caring relationships, both within family relationships and within trans communities, as an important factor in resilience (McFadden et al., 2013). In the general population, objective measures of social isolation, subjective feelings of loneliness and living alone are all known to be associated with increased mortality and worse health outcomes (Holt-Lunstad et al., 2015; Smith & Victor, 2019). Understanding trans people’s social support networks in later life may therefore have benefits in identifying sources of resilience and support that can promote and enhance good health and help to mitigate the impact of minority stress.

COVID-19 and the UK ‘lockdown’

On 23 March 2020, the UK, following the example of many other countries, entered into a ‘lockdown’ due to the COVID-19 pandemic. All members of the UK population were instructed not to leave their homes for any reasons other than essential shopping, exercise, caring for vulnerable people or work that could not be performed from home (UK Government, 2020c). Two additional categories of individuals who were at higher risk were also identified. The ‘clinically vulnerable’ category included everyone over 70, as well as individuals with specified health conditions, many of which are common in later life, such as heart disease, respiratory disease, diabetes, kidney disease and liver disease. This group was advised to follow the lockdown rules particularly carefully, but were not specifically advised to take additional actions. A second group, the ‘clinically extremely vulnerable’ included those with a narrower range of conditions, including severe respiratory conditions, organ transplant recipients and certain cancers. This group was advised that they should be “shielded” for a period of 12 weeks, and so not leave their homes for any purpose (Department of Health & Social Care, 2020; NHS England, 2020). In practice, there were media reports of confusion over the terminology and advice, and the government acknowledged that there had been mixed messages and inconsistent guidance on identifying individuals who met the ‘extremely vulnerable’ criteria (Allen-Kinross, 2020; HM Government, 2020). It is therefore likely that some individuals who were in the less stringent ‘clinically vulnerable’ group in fact did ‘shield’, either on a precautionary principle, or because of confusion over the criteria. In July 2020, the national restrictions were significantly loosened, allowing most individuals – including those who had previously been shielding - to begin socially mixing with a limited number of others again, although there remained restrictions on the number of households that could mix socially, and on the operations of many types of business (Department of Health & Social Care, 2020; UK Government, 2020b).

For all members of the UK population, but particularly those who were shielding or advised to take additional precautions, the lockdown arrangements potentially created a number of challenges, including delivery of food, medication and other necessities, difficulty accessing medical services, changes to existing arrangements for social care, and changes to emotional and support networks. Government advice encouraged those who were reducing their level of social contact due to COVID-19 to seek support from family, friends or neighbors in the first instance, or if necessary to seek support from statutory services and charities (UK Government, 2020a). However, given that the existing literature suggests that older TGNC people are disproportionately likely to have experienced family estrangement, social hostility in their local community and discrimination in health and other services, they may experience additional challenges in identifying and accessing reliable sources of support. This may in turn impact their wellbeing during the COVID-19 lockdown, particularly within the context of minority stress.

This study aimed to explore older TGNC people’s social support networks, key concerns and unmet needs during the COVID-19 ‘lockdown’, by means of a rapid ‘temperature check’ undertaken during the first phase of lockdown in Spring/Summer 2020. It draws upon a health equity framework that considers the effect of intersecting social positions on TGNC health outcomes across the lifecourse, recognizing that factors such as social networks and availability of support are likely to affect TGNC older people’s response to adverse circumstances such as COVID-19 and the associated ‘lockdown’. (Fredriksen-Goldsen et al., 2014; Westwood et al., 2020).

Methodology

Design

The broader research project, comprised a survey with both qualitative and quantitative questions, and additional qualitative interviews. Only the survey findings are reported here. Ethical approval was given by the University of York’s Economics, Law, Management, Politics and Sociology ethics committee. The data reported here are findings from 38 TGNC respondents, out of a whole sample of 375 respondents. For some quantitative measures, the results of the full sample are also presented for comparison purposes.

Measure

The COVID-19 and Older LGBT + People survey (Westwood et al., 2020) is a non-validated online survey, designed specifically for this project, of LGBT + people aged 60+ and living in the UK. The survey had both quantitative and qualitative components to its questions (see Table 1 for a list of all the questions and the response methods).

Table 1.

Questions in the COVID-19 and Older LGBT + People survey (Westwood et al., 2020).

How old are you? [Select box] How would you describe your  Sex/gender [Free text answer]  Sexuality [Free text answer]  Ethnicity [Free text answer]  Is your sex/gender the same you were assigned at birth? [Y/N] Do you consider that you have a disability? [Yes/No]  If Yes, please describe [Free text answer] Do you have any significant health conditions? Yes/No.  If Yes, please describe [Free text answer]  Do you come under the ‘Shielded’ category according to Covid-19 regulations, due to your health condition? [Yes, No, Don’t know] Are you living alone or with others? [Alone/with others]  If living with others, what best describes their relationship to you? [Free text answer] What are your top 3 concerns about how you are currently affected by Covid19? [Free text answer] Do you have someone you can call upon in an emergency? [Y/N]  If yes what is that person’s relationship to you (e.g. friend, neighbor, brother, sister, etc.) [Free text answer] How are you getting essential food, household supplies and medication? [Free text answer] What are your usual support networks? [Free text answer] How are your support networks affected by mandatory isolation? [Free text answer] How are you maintaining connections with your support networks? [Free text answer] What challenges if any, are you experiencing in maintaining connections with your support networks? [Free text answer] Have your support networks changed due to Covid-19 regulations? Yes/No.  If Yes, in what way? [Free text answer] What do you think about your PHYSICAL health and wellbeing during mandatory social isolation? [5-point Likert scale – lot better; slightly better; no difference; slightly worse; lot worse]. What do you think about your MENTAL health and wellbeing during mandatory social isolation? [5-point Likert scale – lot better; slightly better; no difference; slightly worse; lot worse]. Do you provide support to others? [Y/N]  If yes, what is your relationship(s) to them? [Free text answer]  If yes, how is mandatory isolation affecting how you now provide that support? [Free text answer] What strategies are you using to cope with social isolation due to COVID-19? [Free text answer] Do you think you have any unmet needs due to COVID-19? [Y/N]  If yes, what are those unmet needs? [Free text answer]  If yes, how would you like those unmet needs to be met? [Free text answer]  If yes, who would you like to meet those unmet needs? [Free text answer] Is there anything else you would like us to know and/or think we should address in relation to older LGBT + people and Covid-19? [Free text answer]

Recruitment

Participants were recruited via LGBT + community organizations and social media networks between 1^st June and 7^th August 2020. Purposive outreach was made to encourage representation from across the older LGBT + community. Data collection was undertaken in Qualtrics©.

Data analysis

Both quantitative and qualitative data were produced from the survey. The quantitative data were analyzed by Researcher (1) using simple descriptive statistics, i.e. a count of specific binary responses, and their percentages calculated. Quantitative data were then cross-checked by a research assistant recruited specifically for this task by [institution] (this otherwise being a non-funded research project). The TCNC qualitative data was analyzed using content analysis (White & Marsh, 2006). While the data was driven by the questions asked, analysis was undertaken in three stages. First there was an overview of the free text responses by section, by Researcher (1), and easily identifiable aspects of text content (‘manifest content’) were identified. Second, there was a key word search for those words noted to recur frequently, initially using Excel search facilities. These were then tabulated by Researcher (1) for further analysis. Third, there was a closer textual analysis, again by Researcher (1) taking a pragmatic approach, i.e. looking for how issues where framed within a TGNC individual’s personal context. Key quotes were also selected for a) either their representation of themes and/or added nuance to them, and included in an overview summary, comprising the identified issues/themes, the key word frequencies (tabulated) and the key quotes. This summary was then reviewed, and discussed, by Researcher (2) and Researcher (3), with Researcher 1. There was then a combined synthesis of meta-themes, based on saliency (Buetow, 2010), and an integration of the initial issue/themes, key words and quotes.

Results

Participant demographics

Among an overall sample of 375 respondents, 38 were categorized as TGNC. This comprised 28 participants who stated that their gender was different to that assigned at birth (23 trans women, 3 trans men, 2 individuals who indicated other gender identities), 9 additional participants who stated that their gender was the same as that assigned at birth but who indicated non-binary, fluid or other identities and 1 participant who described both their gender identity and sexuality as ‘queer’. The majority of trans participants were women (n = 23, 82%).

In terms of age, 15 (54%) of the TCNC participants were in the 60–64 age band, 4 in the 65–69 (14%) age band, 7 (35%) in the 70–74 age band, and 2 (7%) in the 75–79 age band. This compares with, in the full sample, 34% in the 60–64 age band, 30% in the 65–69 age band, 20% in the 70-74 age category, 10% in the 75–79 age band and 3% aged over 80 (see Table 2). The TGNC sample is therefore younger than the full sample.

Table 2.

TGNC responses to emergency contact question in the COVID -19 and Older LGBT + People survey (Westwood et. al., 2020).

	Someone to call in an emergency?
	Yes	No
TGNC participants in current study	79%	21%
All participants in current study	90%	10%

In terms of sexuality, of the 23 trans women, 9 identified as lesbian; 5 as bisexual; 1 as gay; 1 as queer; 1 as pansexual; 1 as asexual; 1 as heterosexual (‘straight’); and 4 as ‘other sexuality’ (‘open to offers’; sexually varied’; ‘I don’t know’; ‘female’). The 3 trans men all identified as gay. The queer person identified as gender and sexuality queer. The participants with non-binary, fluid or other identities used a range of definitions of their sexualities, including: lesbian, gay, celibate, ‘hetro’ (‘long-term cross-dresser’); ‘heterofluid’; fluid; ‘a long term transvestite’ and ‘attracted to women’.

In terms of disability, almost a third of the TGNC participants reported having a disability, a higher proportion than the full sample of whom only 18% reported a disability. Only one TGNC participant clearly identified themselves as being from a Black, Asian or Minority Ethnic (BAME) background. 22 of the TGNC respondents 23 (61%) were living alone, compared with the main sample in which 51% said they lived alone. The majority of those who were cohabiting were living with a spouse, civil partner or other partner.

Personal, practical and social support

Emergency support

When asked if they had someone to call upon in an emergency, as can be seen from Table 2, among the TGNC respondents 30 (79%) said they did, and 8 (21%) said they did not. This compares with the full sample of which 90% said they had someone that they could call on in an emergency and 10% said they had not.

The responses suggested that TGNC people were relatively likely to call on non-kinship social contacts (e.g. friends and neighbors) in an emergency, rather than biological family. However, this may be shaped by the context of COVID, where the types of emergency individuals envisaged may have been those requiring someone in close proximity.

Practical support

Participants were asked how they were getting essential food, household supplies and medication. As can be seen from Table 3, over half of the participants (n = 23) were doing their shopping and pharmacy collections in person (some supplementing with online shopping), 10 were doing online shopping, while 5 had their shopping done for them by others (spouse, volunteers, charities). Five participants had medication delivered by their pharmacy. Two reported doing online shopping but collecting medication in person, and one reported mostly shopping in person but sometimes having assistance from a neighbor.

Table 3.

TGNC responses to practical support question in the COVID -19 and Older LGBT + People survey (Westwood et. al., 2020).

Doing own shopping (either wholly or supplemented with online shopping and pharmacy deliveries)	23 (61%)
Online shopping and pharmacy deliveries only	10 (26%)
Shopping done by others	5 (13%)

Social support

Participants were asked about the composition of their usual support networks. As can be seen from Table 4, the most frequent responses from TGNC participants were friends (n = 21); family (n-9); LGBT+/trans-specific support groups only (n = 7) and local charities. Again, the responses show a strong tendency to identify friends and social organizations as a source of support. 5 out of the 38 (14%) TGNC participants said they had no support networks.

Table 4.

TGNC participants’ social support networks according to responses in the COVID -19 and Older LGBT + People survey (Westwood et al., 2020).

Friends	Family	LGBT &/or trans specific support group	Local charities	Colleagues	Faith group	NHS	Neighbors	Ex-partner	Housemates	Spouse	None
21	9	7	4	3	3	2	2	1	1	1	5

The participants who said they had social support networks were asked how their support networks have been affected by mandatory isolation. The most frequent responses were lessening/cessation of type/frequency of social contact (n = 14); continuing via online media (n = 6); “Generally OK”/No change/Positive comments (n = 5); Increasing isolation from network (n = 3).

When asked how they were maintaining contact with their support networks, respondents cited either telephone (n = 17), or a range of online and social media networks, with Zoom being the most frequently mentioned specific platform (n = 11). Only one participant referred to non-electronic communication (‘letters’). However, when asked about challenges, participants identified several key challenges linked to e-communications, which cohered around: technology and technological skills; timing (e.g. others being busy); a perceived reduction in quality of contact online; additional effort; and resource limitations (e.g. high demand on telephone helplines).

Participants were asked whether their support networks had changed due to COVID-19 regulations, and if so, in what way. Two-thirds (67%) of the participants said that nothing had changed (including those who said they did not have a support network). A third (33%) of the participants said their networks had changed. Eight made broadly positive comments, predominantly related to better levels of contact with people using video conferencing and texts, and/or a sense of improved community in their local neighborhood. Two made negative comments, one related to only being able to contact friends by phone, and one related to a change in work and living circumstances due to COVID-19. Two participants indicated that community and friendship networks had improved, but contact with family had not.

Supporting others

Participants were asked whether they provided support to others. 23 out of 38 TGNC participants said that they did. Of these, the support they provided was to: friends (n = 9), neighbors (n = 4); older parents/family member (n = 4), partner/spouse (n = 3), adult children (n = 2), colleagues and ex-colleagues (n = 2), ‘family’ (n = 2), fellow-members of religious organizations (n = 2), ‘anyone who needs it’ (n = 1), fellow members of U3A (n = 1), members of LGBT communities (n = 1), tenants (n = 1).

Participants were asked how mandatory isolation was affecting how they now provide that support. Participants’ responses included: shift from face-to face to online and/or telephone support (n = 7); changed quality/availability of support (n = 6); unable to provide direct support (n = 2); waiving tenants rents’ affecting own cashflow (n = 1); no change in support (n = 1); improvement on support provided (n = 1).

Impact of COVID-19 lockdown

Major concerns

Survey participants were asked to list their top 3 concerns. As can be seen from Figure 1, the most frequent answers among the 38 TGNC respondents were categorized as: Loneliness and isolation (n = 13); Fear/risk of contracting COVID-19 (n = 11); Being separated from family and friends (n = 6); Health and well-being (n = 6); Dissatisfaction with the government (n = 5); Mental health (n = 5); Heightened vulnerability to COVID-19 (n = 4); LGBT issues (n = 4); Obtaining food, medicine, etc. (n = 4).

Figure 1.

TGNC responses to ‘Top 3 concerns’ question in the COVID -19 and Older LGBT + People survey (Westwood et al., 2020).

Health and wellbeing

Participants were asked to rate the impact of mandatory social isolation on their physical and mental health. As can be seen from Table 5, overleaf, the perceived impact of COVID-19 on physical health was perceived by the TGNC and full sample to be fairly neutral, with over half (n = 20, 53%) of the TGNC participants reporting no change in their physical health, 11 (29%) stating their physical health was either slightly or a lot worse, and 7 (18%) stating their physical health was either slightly or a lot better. This compares with the full sample of which 46% reported no change, 31% reported their physical health was either slightly or a lot worse, and 23% reported it was slightly or a lot better.

Table 5.

TGNC and full sample responses to question about the impact of COVID-19 on their physical health, in the COVID -19 and Older LGBT + People survey (Westwood et al., 2020).

	A lot better	Slightly better	Neither better nor worse	Slightly worse	A lot worse
TGNC sample	1 (3%)	6 (16%)	20 (53%)	8 (21%)	3 (8%)
Full sample	18 (5%)	69 (18%)	174 (46%)	92 (25%)	22 (6%)

By contrast, as can be seen from Table 6, the impact of COVID-19 on mental health was perceived to be more negative, with slightly over half (53%) of the TGNC participants reporting that their mental health was either slightly or a lot worse, 40% reporting no change in their mental health, and 3 (8%) reporting that their mental health was either slightly or a lot better. This compares with the full sample of which 43% reported no change, 48% reported their mental health was either slightly or a lot worse, and 9% reported it was slightly or a lot better.

Table 6.

TGNC and full sample responses to question about the impact of COVID-19 on their mental health, in the COVID -19 and Older LGBT + People survey (Westwood et al., 2020).

	A lot better	Slightly better	Neither better nor worse	Slightly worse	A lot worse
TGNC sample	1 (3%)	2 (5%)	15 (40%)	12 (32%)	8 (21%)
Full sample	6 (2%)	26 (7%)	161 (43%)	145 (38%)	37 (10%)

The differences in physical and mental health responses are summarized in Table 7, overleaf.

Table 7.

Comparison of TGNC responses to questions about the impact of COVID-19 on their physical and mental health, in the COVID -19 and Older LGBT + People survey (Westwood et al., 2020).

	A lot better	Slightly better	Neither better nor worse	Slightly worse	A lot worse
Physical health	1 (3%)	6 (16%)	20 (53%)	8 (21%)	3 (8%)
Mental health	1 (3%)	2 (5%)	15 (40%)	12 (32%)	8 (21%)

Coping strategies

Participants were asked what strategies they were using to cope with social isolation due to COVID-19. The TGNC participants described a range of activities. These could be broadly grouped into: keeping busy with volunteering, hobbies or activities around the house (e.g. ‘making homemade bread’, ‘gardening’); social contact by telephone or online; activities focused on wellbeing (e.g. ‘Listening every day to motivational and self-help recording’), as well as a selection of slightly more lighthearted responses (e.g. ‘Netflix. Wine’)

Several participants commented that they were not feeling isolated, and hence did not need coping strategies. Some highlighted benefits from being able to take life at a slower pace, or spend more time enjoying nature. Overall, the responses to questions about coping strategies were largely positive, and emphasized the overall resilience of TGNC people. However, the survey question about coping strategies was likely to produce narratives from people who were successfully using them. There were intimations that some people might be finding lockdown less easy to deal with. For example, several participants mentioned having to regulate their alcohol consumption and two participants intimated that they were having a difficult time:

Trying not to crash and burn. Trying to just hunker down until it passes [SUR087, trans woman, heterosexual, 60-64]

Telling myself that I can survive alone [SUR099, trans woman, ‘lesbian romantic, but sexually varied’, 70-74]

Unmet needs

Participants were asked whether they had any unmet needs due to COVID-19 and 22 out of 38 (58%) TGNC participants responded that they did. Participants who stated that they had unmet needs were asked what those needs were, who they would like to meet them, and how. Nine participants emphasized social interactions, including both social participation (e.g. ‘feeling very cut out of society), and also physical contact with others (e.g. ‘Social interaction. Cuddles’). They indicated that this unmet need was largely out of anyone’s control, since resolution would require an end to lockdown, and ultimately some kind of resolution to the COVID-19 pandemic. Two participants mentioned ‘social bubbles’ [measures introduced by the UK government as lockdown eased to enable individuals living on their own to socialize with one other household] as mechanisms for permitting contact with key loved ones. Two participants referred to unmet sexual needs, again noting that there was little that could be done to resolve these until restrictions were lifted. Two participants referred to delayed health care treatment, which they wished the NHS to resolve. Two participants identified sex as an unmet need, one person observing ‘I would usually visit my dominatrix once a month’ [SUR038, genderfluid, ‘heterofluid’, 70-74]. One person wanted postponed gender affirmation surgeries to take place. Another needed an orthopedic appointment.

Survey participants also mentioned a diverse range of other unmet needs, including being able to check on properties they owned, being able to undertake musical performances, being able to participate in cultural and travel activities, and challenges in providing a volunteer advice service due to increased demand. Several participants referred to the impact of lockdown on identity issues. One participant wrote, ‘I am a long time cross dresser, I tend to get ratty if I can’t do this’ [SUR352, cis man, ‘hetro’, 65–69]. Poignantly, one survey participant stated that an unmet need was: ‘I can’t be me, I don’t have the energy’ [SUR087, trans woman, heterosexual, 60–64] and that being unable to meet other trans people face to face was difficult for her.

Participants were asked in a final question if they wished to make any other comments or raise any other issues. Social isolation was mentioned by 11 of the TGNC participants, sometimes highlighting concerns for the trans community in general rather than their own experiences, with comments reflected in the following:

People with a T background are significantly more likely to be isolated as having this background is still highly stigmatized, even within the LGB communities. The self-isolation brought on by COVID-19 must be having a big impact for our group. [SUR342, trans woman, lesbian, 60–64]

Four mentioned concerns about accessing services, for example, the same participant also observed: ‘Given past hospital experiences, I am worried how well I would be treated if I became seriously ill’ [SUR342, trans woman, lesbian, 60–64]. Another participant wrote,

I worry about my health because of failings in prescription supply (shameful National HRT shortages, ongoing from mid-2019 but conveniently hidden/overlooked by Covid-19 focus) adding to health concerns generally associated with being older and a general lack of understanding of trans healthcare needs. [SUR322, trans woman, ‘possibly asexual’, 60–64]

Four mentioned differences among members of the TGNC community, for example:

I am comfortable and happy to continue as I am but I am aware of others who have little or no support and worry for their continuing physical and mental wellbeing. [SUR044, trans woman, lesbian, 60-64]

Three participants commented on government policy (in regard to both trans rights and COVID-19 policies). Two participants made comments regarding their preferences of identity terminology, and one participant queried whether it was necessary to consider LGBT populations separately in regard to COVID-19 experiences. Several participants concluded by offering broader thoughts and advice, which included:

Loving people doesn’t always need physical contact [SUR043, trans man, gay, 75–79]

My advice to everyone is: for goodness sakes, get yourself online. [SUR137, trans woman, lesbian, 60–64]

I am concerned we have learnt nothing from this period about our relationship with the rest of nature. [SUR216, non-gender-binary trans person, gay, 60–64]

Discussion

This study has produced wide-ranging insights about the lives of older TGNC people living in the UK, both specifically in relation to the COVID-19 lockdown and more broadly. The data indicate considerable diversity among older TGNC and considerable variation in social support and experiences during lockdown. The majority of TGNC survey participants lived alone. However, many TGNC participants discussed diverse and active social support networks. Friends tended to be most frequently highlighted as sources of support, but there were also references to the important of intimate partners, adult children, other family members and neighbors. Many TGNC participants also discussed participation in a range of social and community activities, including LGBT/trans-specific organizations, but also a range of other faith, community and hobby activities.

For many participants the interruption to social contact and social activities appeared to be keenly felt during lockdown, but they had often found ways of maintaining contact online or by telephone and many were confident that they could draw on their networks if they needed to. Many TGNC participants also highlighted that they themselves were engaged in care activities, including providing practical and emotional support to others; and working to keep community organizations operating before and throughout the pandemic. These accounts complement previous research suggesting that older trans people are often actively engaged in pursuing goals important to them (Fabbre, 2015; Willis et al., 2020), and that highlights the importance of social support in mitigating minority stress (Fredriksen-Goldsen et al., 2014). It is therefore important that older TGNC people are not stereotyped as being passively lonely or vulnerable.

A minority of TGNC participants in this study seemed to have less-well-developed social networks, fewer sources of support and were more concerned with feelings of loneliness and isolation. These participants typically lived on their own, and most could not identify anyone who they could call on in an emergency. This suggests that they might be at additional risk both from the pandemic, but also more broadly if they experienced other challenges around aging and health.

The importance of social contact and strong social networks was also emphasized when participants were asked about concerns, unmet needs and for any final comments, with social isolation being repeatedly highlighted in the responses to these questions. Even those who did not appear to be currently isolated nonetheless often mentioned it as a concern within TGNC communities.

Several participants also mentioned issues specifically affecting TGNC communities, including interrupted access to gender affirming care during the lockdown period and a perceived rise in intolerance toward TGNC people. In interviews, interviewees sometimes drew explicit connections between these issues: for example, that the pandemic might have increased distrust of those who were perceived to be ‘different’, or concerns about the quality of care they would receive if they were to become ill. Such expectations of discrimination can themselves be a source of minority stress (Hendricks & Testa, 2012). By contrast, other participants felt that the pandemic had promoted community cohesion and reciprocal support.

As noted at the outset of this article, during public health crises, often the most vulnerable populations are disproportionately adversely affected. This study would suggest that while older TGNC people are potentially a disproportionately vulnerable aging population, this is not an inevitability. Many TGNC people have inner and social resources, and considerable adaptability in the face of adversity, which have supported them well during the lockdown. For others, already isolated and in poor physical and/or mental health, the lockdown has served to compound and exacerbate previous difficulties. What appears to differentiate the two groups is the ability to make, sustain, and renew meaningful social connections in the present day, and for there to be sufficient social resources available to support doing so. This would appear to support previous literature which suggests that the ability to form sustaining relationships is paramount for TGNC wellbeing in later life, with or without a pandemic.

From a health equity framework, it is clear that social connectivity is crucial for TGNC wellbeing in later life. There are multiple factors which inform and promote/impede social connectivity. Further research is needed to both understand how they intersect and impact later life, and, crucially, the key points in TGNC lifecourse pathways where health and/or social care interventions might promote connections and mitigate potential relationship ruptures. Our research suggests that for some TGNC people, the COVID-19 crisis has increased social connectedness, with local communities reaching out to provide reciprocal support. This demonstrates the potential for increased community integration of older TGNC people, which in turn promotes their health and wellbeing. The next step is to identify how this can be achieved without needing a pandemic to act as a trigger.

Strengths and limitations

This study has produced one of the largest ever datasets of the experiences of older TGNC people living in the UK regarding social support and social networks during a crisis. As such it makes a unique contribution to the current knowledge gaps in relation to the lives of this population. However, the study has several limitations. It used survey and interview data to consider older TGNC people’s social support networks and concerns at a time when many individuals faced significant disruption and unexpectedly needed (or were called upon to offer) additional support. As such, it contributes to a very limited knowledge base about support networks and response to crisis in the older TGNC population in the UK. Some aspects of the findings may be transferable to other contexts. For example, it seems likely that individuals who did not have anyone to call on in an emergency during COVID-19 might also have a lack of support in other crisis situations. However, it is also possible that some elements of this situation would not apply to considering TGNC older people’s social networks or access to support under other circumstances.

The demography of older TGNC communities in the UK is poorly understood. The low proportion of trans men, TGNC people over 80 and TGNC people of color within the TGNC sample in this study is consistent with other data on older UK trans populations (Bouman et al., 2016; Government Equalities Office, 2018; Willis et al., 2020), and may to some extent reflect differences in lifecourse trajectory, or the intersectional effects of current and historic barriers to openly asserting a TGNC identity. However, it is also possible that there are seldom-heard populations of TGNC older adults that this study failed to reach. In particular, ethnic minority populations are consistently underrepresented in the UK health research, and also face barriers to inclusion within TGNC community spaces (Choudrey, 2016; Smart & Harrison, 2017). Ethnic minority populations were disproportionately affected by the COVID-19 pandemic, reflecting existing and deep-rooted social inequalities (Lassalle et al., 2020; Yaya et al., 2020). The failure to reach ethnic minority populations within this survey may be associated with the authors’ own personal profiles as White researchers, alongside other contributory factors such as digital exclusion and language barriers. These limitations within the sample may mean that the findings do not fully address intersecting or additional challenges faced by ethnic minority and other underrepresented groups.

More broadly, participants were a self-selected, voluntary sample, participating in an online survey. Digitally excluded TGNC people may have been less likely to participate. The voluntary nature of the study may have led to a self-selection bias. It could potentially have resulted in fewer responses both from those who were very severely affected by COVID-19 (who may, for instance, have been ill, caring for others, or simply distressed by the topic), and also those who were very little affected by COVID-19 (who may have perceived that they had little to say on the topic).

Conclusion

This study identified substantial diversity in TGNC older people’s social support networks in the context of the COVID-19 pandemic. Many participants reported diverse and active social networks, and having individuals that they trusted to help in an emergency. However, a minority of participants had more restricted social networks. In addition, social isolation was often highlighted as a potential challenge or concern, even for those who currently had active social support. Some participants also identified additional challenges they faced during the COVID-19 crisis, such as reduced access to specialist healthcare and a perceived increase in hostility and prejudice. Understanding potentially distinct needs, as well as the diversity in older TGNC people’s social networks, and that some TGNC people may have no-one they can call on in a crisis, while others may rely on friends rather than biological family, may help health, social care, housing and other service providers better tailor the support they provide to this community.

Further research could usefully explore in more depth protective and risk factors for isolation, loneliness and lack of social support for older TGNC people, how to combat the impact of temporal minority stress, as well as assessing options to practically ameliorate these. Living alone, family estrangement, rurality, poor health and poor access to support from services may be potential risk factors contributing to isolation and lack of support in a time of crisis. It may be beneficial for service providers and researchers to consider developing interventions to help older TGNC people build links with others, for example via third sector or community organizations with an understanding of their needs.

Disclosure statement

No potential conflict of interest was reported by the author(s).