A call to action: Advancing research, practice, and policy for middle aged and older transgender and nonbinary communities

Across the world, the proportion of older adults is rapidly increasing. In the United States, adults aged 65 and older comprised just 4.7% of the population a century ago (Caplan, 2023); by 2030, that figure is projected to reach nearly 20% (World Health Organization, 2022). Furthermore, within the next decade, the number of people aged 65 and older is expected to surpass the number of individuals under the age of 18 living in the United States (Vespa, 2019). Despite this demographic shift, transgender and nonbinary older adults remain critically underrepresented in health and social research (Flatt et al., 2022). Their needs are overlooked not only in the broader gerontological literature but also within key clinical frameworks, including the Endocrine Society’s Clinical Practice Guidelines and the World Professional Association for Transgender Health (WPATH) Standards of Care. This omission does more than neglect their challenges—it erases their stories of resilience, survival, and thriving. We do not yet know how a lifetime of exposure to stigma, discrimination, and minority stress has shaped their physical, emotional, cognitive, and social health. Nor do we fully understand what supports healthy aging for transgender and nonbinary communities and how many have resisted, adapted, and built lives of strength and meaning in the face of these adversities. Without a contemporary, evidence-based understanding of how transgender and nonbinary adults are aging—both positively and negatively—we lose critical opportunities to foster longevity, dignity, and hope for future transgender and nonbinary generations. To address these critical gaps, this perspective issues a call to action for researchers, clinicians, policymakers, and funders to prioritize and invest in the health, aging, and well-being of transgender and nonbinary older adults.

Problem: The overlooked aging experiences of transgender and nonbinary adults

An unprecedented increase in the number of adults aged 65 and older is reshaping the demographic landscape of the United States. The risk of many chronic health conditions, including cardiovascular disease, cancer, Alzheimer’s disease, and diabetes increases with age (National Center for Chronic Disease Prevention & Health Promotion, 2024). As the proportion of adults aged 65 and older continues to rise, the prevalence of these conditions is expected to increase, placing increasing demands on healthcare systems, research infrastructure, and policy development. In recognition of these trends, substantial investments have been made in aging research across biomedical, public health, and social science fields. However, this expansion of aging research has largely focused on the general population, with minimal attention to the specific aging experiences and health trajectories of transgender and nonbinary communities. The invisibility of transgender and nonbinary adults within aging research perpetuates critical gaps in understanding how intersecting experiences of stigma, discrimination, and systemic marginalization across the lifespan influence aging outcomes.

The field of transgender health has evolved significantly over the past century, with accelerated growth in both research and advocacy during the last two decades. More recently, this work has centered largely on the needs of youth and adolescents, with particular attention to gender-affirming medical interventions and social support for transgender and nonbinary youth and their families during gender-affirming social and medical transitions. While this emphasis has been critical for addressing gaps in knowledge and expanding access to affirming and medically necessary care, it has also been shaped by contemporary sociopolitical forces. Transgender and nonbinary youth have been increasingly targeted in public discourse, policy debates, and through legislation aimed at restricting access to medically necessary care and undermining their fundamental rights. Politicians have exploited misinformation about gender-affirming care to mobilize political support, further politicizing the health and well-being of all transgender and nonbinary communities. These dynamics have intensified public focus on youth, leaving the experiences and needs of older transgender and nonbinary adults largely unexamined and overlooked. This imbalance has consequences not only for research and policy but also for the ways transgender and nonbinary youth envision their futures. In addition to navigating hostile sociopolitical climates, academic and social pressures, and developmental transitions, many transgender and nonbinary young people express uncertainty about living into older adulthood; some do not expect to live beyond the age of 35 (The Trevor Project, 2023, January). By failing to study and affirm the lives of older transgender and nonbinary adults, we risk reinforcing narratives of premature mortality, invisibility, and hopelessness. The absence of research that highlights resilience, thriving, and aging well among transgender and nonbinary communities denies younger generations vital models of survival, strength, and possibility.

Older transgender and nonbinary adults face significant structural barriers to health equity. Loneliness, social isolation, chronic health disparities, and compounding forms of discrimination, including ageism, transphobia, and racism create hostile environments and often inaccessible environments for aging transgender and nonbinary communities (Baril & Silverman, 2024; Catlett, 2024; Fredriksen-Goldsen et al., 2024; Fredriksen-Goldsen et al., 2014; White Hughto & Reisner, 2018). Many older transgender and nonbinary adults experience what has been described as “re-closeting” in later life or withdrawing from openly expressing their gender identity due to increasing physical vulnerability, fear of discrimination, and reliance on formal and informal caregiving networks that are not always affirming or safe (DuBois et al., 2023; Walker et al., 2023). These experiences are compounded by historical trauma; many older transgender and nonbinary individuals underwent social and/or medical gender-affirming transitions during periods when medical and behavioral health providers explicitly advised the concealment of their identities. The cumulative effects of aging and gender-based marginalization deeply shape transgender and nonbinary older adults’ health and well-being, yet these experiences remain significantly underexplored in research.

Call to action: Advancing research, practice, and policy for aging transgender and nonbinary communities

The health and well-being of middle-aged and older transgender and nonbinary communities demand urgent and sustained attention across research, clinical practice, and policy. First, there is a pressing need to expand empirical research focused on healthy aging among transgender and nonbinary communities. Longitudinal studies should examine the effects of lifetime exposure to gender-affirming hormone therapy, including variations in dose, formulation, administration route, and the potential need for clinical adjustment with age. Similarly, the long-term outcomes of gender-affirming surgical interventions remain underexplored. Research must also address chronic disease management, cognitive and psychological well-being, and gender identity development through adulthood. These investigations must attend to the heterogeneity of aging experiences across transgender and nonbinary communities using an intersectional lens—recognizing how gender identity, race, ethnicity, socioeconomic status, ability, and geography shape health trajectories and access to care (Wesp et al., 2019). Research must center the embodied knowledge of transgender and nonbinary people with multiple oppressed identities and name the power structures and social forces of domination and control that affect transgender and nonbinary communities differently (Wesp et al., 2019), to ensure that solutions to problems do not merely obscure self-perpetuating systemic crises. Importantly, studies should not focus solely on adverse outcomes or health disparities; a community strength–centered approach is needed to illuminate joy, resilience, and identity-based strengths in later life. Notably, research about other traumatized populations (e.g. Holocaust survivors who were children in the camps) has shown extreme resilience with increased well-being, joy, and happiness in later life, compared to peers with less extreme early life trauma (Stessman et al., 2023). The recent pandemic revealed amazing adaptation and coping in older adults (Fuhrmann & Shevlowitz, 2022). This highlights the importance of examining both the burdens and adaptive capacities of TNGE elders through a similarly nuanced lens.

Second, greater attention is needed to the social and structural challenges faced by transgender and nonbinary adults as they age. Critical areas include long-term care needs, end-of-life planning, and navigation of legal and social systems that do not inherently address their identities and often marginalize them (Anderson et al., 2022; Catlett et al., 2023; Knochel & Flunker, 2021; Simmons, 2020; Willis et al., 2021). Investigating the experiences of transgender and nonbinary adults in both community and institutional settings, as well as their financial security, family structures (both chosen and biological), and formal/informal caregiving networks, is vital. Social isolation, loneliness, and spiritual disconnection remain significant yet understudied determinants of health. Research should also explore the benefits of spiritual practices and interpersonal connections as pathways to resilience, psychological well-being, and quality of life in older adulthood (Fabbre & Siverskog, 2019; Li et al., 2023).

Finally, researchers and clinicians must design and evaluate interventions that foster social support and community continuity. Intergenerational programs that connect transgender and nonbinary youth with older transgender and nonbinary adults hold promise for addressing social isolation while enhancing mutual resilience, empathy, and well-being. Older transgender and nonbinary adults can help transgender and nonbinary youth cope with the current threatening environment by sharing how they negotiated extreme forms of discrimination across their lifespan, providing transgender and nonbinary youth a greater understanding of aging while overcoming adversity and improving health and well-being (Cockrell, 2022). To support these efforts, systemic change is needed across health professions education, and care delivery. Curricula must prepare both generalist and gerontological providers to deliver affirming, culturally responsive care. Medical institutions, long-term care settings, and regulatory systems must also confront and dismantle structural transphobia. A community strength–centered approach—one that affirms joy, resilience, and identity in later life—should guide all future efforts.

While not exhaustive, these priorities represent a foundation for meaningful progress in ensuring that transgender and nonbinary people are supported and celebrated as they age. Notably, we know that many older transgender and nonbinary people, just like older people across the sexual minority spectrum, often try to hide their TNGE status from others and may resist participating in research. They may work to conceal their transgender and nonbinary status within mainstream institutions due to previous abuse and discrimination. However, not all of them are reluctant to engage, particularly if they know that their participation will help other community members. Researchers will have to work to identify and collaborate with these individuals and their communities because ageism, frailty, and transphobia often render older transgender and nonbinary people invisible (Adan et al., 2021; Catlett et al., 2023).

The urgency amid political attacks

The need for research, clinical innovation, and advocacy for middle-aged and older transgender and nonbinary communities is even more urgent in the current political climate. Recent edicts and legislative actions in several states and countries targeting transgender rights, gender-affirming medical interventions, and scientists’ academic freedom, threaten not only the health and safety of transgender and nonbinary individuals but also the ability of clinicians, researchers, and institutions to pursue work that affirms and uplifts these communities. The chilling effect on federally funded research, including from agencies such as the National Institutes of Health, is already apparent. However, political hostility must not deter the advancement of critical knowledge. Research on the health and well-being of transgender and nonbinary communities across the lifespan is a moral and public health imperative. In the absence of federal support, it is essential for foundations, corporations, philanthropic organizations, and private institutions to step forward and invest in this critically needed work. Sustaining and expanding research focused on aging transgender and nonbinary adults will ensure that no generation is left without the tools, visibility, and support they need to thrive.

Vision for the future

Illuminating pathways to healthy aging has the potential not only to improve the lives of today’s older transgender and nonbinary adults but also to expand what is imagined and what is possible for future transgender and nonbinary generations. Research must inform revisions to the WPATH Standards of Care and other clinical guidelines to address the distinct needs of older transgender and nonbinary communities. Creating visibility for older transgender and nonbinary individuals affirms for younger transgender and nonbinary people that survival, health, connection, and joy are not only possible but attainable across the lifespan.

We call on researchers, clinicians, and policymakers to take up this challenge. Contribute to a body of knowledge that reflects the full spectrum of transgender and nonbinary experiences across the lifespan, to guide and improve clinical practice and expand access to affirming, appropriate, and equitable healthcare. Despite advances in transgender health, the field has historically neglected the needs of middle-aged and older transgender and nonbinary communities and specific supports needed for their well-being in later life. Let us change that. Middle-aged and older transgender and nonbinary adults should be recognized not solely through the lens of struggle, but as individuals whose endurance and resilience offer powerful models of empowerment and inspiration. Their lived experiences and historical contributions form the foundation of contemporary advocacy, policy advancements, and community-building efforts, and should be honored accordingly. Give our older transgender and nonbinary adults the recognition they deserve—for their struggles, their endurance, their resilience, and their contributions. And give transgender and nonbinary youth a future they can envision, one marked by longevity, dignity, the promise of golden years, and the opportunity to become wise elders themselves.

Jamison Green
Independent legal scholar, Vancouver, Washington, USA
Jude Patton
Therapist in private practice, Yuba City, California, USA
Danit Ariel
Department of Medicine Division of Endocrinology, Gerontology and Metabolism, Stanford University School of Medicine, Stanford University Medical Center, Stanford, California, USA
John C. Capozuca
Psychologist in private practice, New Hope, Pennsylvania, USA and Amsterdam, The Netherlands
Max Fuhrmann
Private Practice, Beverly Hills, California, USA
UCLA Luskin School of Social Welfare, Los Angeles, California, USA
Ames Simmons
Duke University School of Law, Washington, District of Columbia, USA
Ethan C. Cicero
Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA
ethan.cicero@emory.edu

Funding Statement

Dr. Cicero was supported by grants from the Alzheimer’s Association (23AARGD-NTF-1028973), the National Institute on Alcohol Abuse and Alcoholism (R01AA030275), and the National Institute on Aging (K23AG084851). The statements in this article are solely the responsibility of the author and do not necessarily represent the views of the Alzheimer’s Association or the National Institutes of Health.

Disclosure statement

The authors declare that they have no conflicts of interest.