The Manifestation of Multi-Level Stigma in the Lived Experiences of Transgender and Gender Nonconforming Older Adults

Abstract

Transgender and gender nonconforming (TGNC) people experience disparities in mental health when compared to non-TGNC sexual minorities and the general population. One line of inquiry with respect to these disparities is the examination of stigma and its connection to emotional and psychological well-being. Recent conceptualizations of stigma draw attention to multiple levels—individual, interpersonal, and structural—that are thought to impact well-being for TGNC people. However, little is known about how multi-level stigma is experienced by TGNC older adults, who navigate stigmatizing environments over a lifetime and who may be especially vulnerable to its cumulative effects. We conducted an interpretive content analysis of biographical interviews with 88 TGNC adults aged 50 and older, from across the United States, obtained from the photography and interview project To Survive on This Shore. Our analyses suggest that TGNC older adults’ mental health is indeed impacted by multiple levels of stigma. Individual level stigma is experienced as ongoing vigilance about aspects of oneself that break gender norms, often manifesting in internal conflicts. At the interpersonal level, TGNC older adults navigate unpredictable relationships marked by conflicting expressions of love, acceptance, strain, and exclusion. Structural stigma manifests in constraints brought about by transphobic policies and social norms but also sparks intentional action on the part of TGNC older adults to resist and change these social forces. Clinical interventions to combat stigmatization can use life narratives and a focus on consciousness-raising to promote empowerment and well-being for this group of older adults

Transgender and gender nonconforming (TGNC) people experience higher rates of poor mental health than non-TGNC sexual minorities and people in the general population (Bockting, 2014; Grant et al., 2011; Perez-Brumer, Hatzenbuehler, Oldenburg, & Bockting, 2015; White Hughto, Reisner, & Pachankis, 2015; Williams & Mann, 2017). One line of inquiry with respect to this disparity is to question the nature and role of stigma in the lives of TGNC people. Recent conceptualizations of stigma draw attention to multiple levels of stigma—individual, interpersonal, and structural—that are thought to have a significant negative relationship with health and well-being of TGNC people of all ages (Bockting, 2014; White Hughto et al., 2015). In this vein, scholars have called for further conceptual and empirical work that illuminates the process through which stigma impacts the well-being of TGNC people (White Hughto et al., 2015), particularly in regard to the health and well-being of older adults whose social welfare needs may increase in later life (Kattari & Hasche, 2016; White Hughto & Reisner, 2016).

TGNC people have higher estimated lifetime prevalences of suicide attempts (41%) than the general population (1.6%) (Grant et al., 2011; Perez-Brumer et al., 2015). Further, the estimated prevalence of depression among TGNC older adults is 40–48% (Clements-Noelle et al., 2006; Fredriksen-Goldsen, Cook-Daniels et al., 2013; Fredriksen-Goldsen, Bryan, Jen, Goldsen, Kim, & Muraco, 2017) in contrast to an estimated 4–8% of the general older adult population (Federal Interagency Forum on Aging-Related Statistics, 2016). The few investigations into TGNC older adults’ lives with respect to mental health have found that TGNC older adults are impacted by decades of navigating stigmatizing institutions (Kattari & Hasche, 2016) and many experience stress and anxiety about caregiving needs in later life, especially in relation to cutoffs from biological families who can no longer be counted on to provide this kind of support (Carroll, 2017; Cook-Daniels, 2015; Porter et al., 2016; Williams & Freeman, 2007). Many TGNC older adults also have complex histories of experiencing social pressure and punishment for transgressing gender norms in their families of origin and in key social contexts like school and work (Fabbre, 2014, 2015, 2017; Gagné & Tewksbury, 1998; Siverskog, 2014). These known risks and lifelong challenges make TGNC older adults potentially vulnerable to the negative ramifications of stigma in later life and necessitate greater understanding about these experiences and their impact on mental health and well-being.

Conceptualizations of Stigma

Grounded in the sociological work of Erving Goffman (1963), stigma is a social norm that devalues an identity as less than others (Corrigan, 1998; Link & Phelan, 2001, 2006; Hatzenbuehler, Phelan et al, 2013) and is said to “undermine” health through processes of social exclusion (Hatzenbuehler, Phelan et al., 2013, p. 3). Social rejection and the uncertainty surrounding a potential rejection is at the core of understanding stigma as a social process (Phelan, Lucas, Ridgeway & Taylor, 2014). Stigma is thought to significantly increase negative coping responses to stress (such as substance misuse) while also exacerbating existing mental health symptoms (Pachankis et al., 2018; Reisner, Pardo et al., 2015). Notably, research with TGNC people has shown that stigma contributes to social isolation, substance abuse, exacerbation of mental health symptoms, and the negative health impacts of stress, while also restricting the seeking and receiving of health services (White Hughto et al., 2015).

White Hughto et al. (2015) proposed a multi-level model of stigma with three distinct levels: (a) individual, (b) interpersonal, and (c) structural. This model explicitly expands the traditional focus of stigma on the individual to better understand how social processes and social structures contribute to the devaluation of identities. It is also poised to help illuminate the manifestation of stigma in the lives of TGNC older adults, many of whom experience disadvantage across multiple domains of social life and over long periods of time, including lack of funding to transgender-inclusive social services, reduced employment opportunities, negative healthcare interactions, and increased family separation and homelessness (White Hughto & Reisner, 2016).

Individual stigma draws attention to the ways in which individuals respond to and make sense of stigmatizing social forces through intrapsychic means. Internalization of stigma is theorized as a dual social process of experiencing enacted stigma, the actual experience of being stigmatized, and felt stigma, or the awareness and hypervigilance for real or perceived rejection (Bockting, 2013). Even if a TGNC person has not experienced an act of violence or discrimination, acute awareness of potential future victimization persists in daily life (Bradford, Reisner, Honnold & Xavier (2013); Ellis, Bailey, & McNeil, 2016). Ramifications of both types of stigma include negative coping mechanisms at the individual level to manage distress, such as substance abuse and avoidance of health services (Pardo et al., 2015). A stigmatizing social environment may contribute to an individual’s awareness and internalization that their identity is devalued in society, which in turn may lead to anxiety about social status loss, concealing one’s identity, low self-esteem and social withdrawal (Link & Phelan, 2014). Among TGNC older adults, this process has been linked to identity concealment, avoidance, and social isolation (Siverskog, 2014; White Hughto et al., 2015). Fears over loss of social support have also been reported to delay coming out and/or pursuing a gender transition until later life (Fabbre, 2014; Gagné & Tewksbury, 1998). In addition, after a lifetime of stigmatizing encounters, TGNC older adults develop anxiety about finding affirming health and social services as they age (Witten, 2015).

Interpersonal stigma refers to stigmatizing encounters and relationships with people known to an individual, such as family members, partners, coworkers, and healthcare providers (White Hughto et al., 2015). Lack of family support and maltreatment is associated with damage to the liftetime well-being for TGNC people (Factor & Rothblum, 2007; Koken, Bimbi, & Parsons, 2009; Nuttbrock et al.,2010; Rotondi, Bauer, Scanlon et al., 2011; Rotondi, Bauer, Travers et al., 2011). In addition, forced family separation in the lives of TGNC people often results in homelessness, which increases risk of exposure to trauma, extreme poverty, substance abuse, and related mental health problems (Simons, Schrager, Clark, Belzer, & Olson, 2013). Uncertainty in healthcare encounters also leads to anticipation of stigmatizing attitudes from providers on the part of TGNC people (Ellis et al., 2016; Poteat, German, & Kerrigan, 2013). In contrast, gender-affirming family members and friends consistently promote well-being for TGNC people (Bouris & Hill, 2017; Simons et al., 2013; White Hughto et al., 2015), including older adults (Fredriksen-Goldsen, Cook-Daniels et al., 2017; Poteat et al., 2013; White Hughto & Reisner, 2016).

Structural level stigma is conceptualized as the broad social, economic, and political forces—such as social norms, laws, and public policies—that limit the resources and opportunities of stigmatized individuals (Hatzenbuehler, Keyes, & Hasin et al., 2009, Hatzenbuehler & Keyes, 2013; White Hughto et al., 2015). For TGNC people, these forces include cultural norms that privilege the gender binary, lack of standard insurance coverage for gender-affirming medical care, lack of safe access to public bathrooms and other public spaces, reduced or nonexistent funding for transgender-specific social programs, and lack of training for helping professionals about how to provide transgender-affirming care (Reisner, White Hughto, et al., 2015; White Hughto et al., 2015). In addition, TGNC older adults who have spent decades being exposed to stigmatizing institutions may avoid interacting with these institutions as they age, which could result in life-limiting consequences (Porter et al., 2016).

Empirical evidence suggests that stigma has a deleterious impact on the health and wellbeing of TGNC people and that TGNC older adults may be especially vulnerable to experiencing stigma over long periods of time and in multiple domains of social life. The multi-level model of stigma proposed by White Hughto et al. (2015) holds great promise as an analytical tool for investigations into stigmatization and its consequences. Thus, this study aims to use this model to illuminate the ways in which stigma manifests in TGNC older adults’ lived experiences, in order to generate knowledge that can be used to support this group of older adults and promote social change.

Method

To explore the manifestation of multi-level stigma in the lives of TGNC older adults, we conducted an interpretive content analysis of a unique secondary dataset made up of 86 in-depth biographical and dialogical interviews (with 88 TGNC older adults) conducted for the project To Survive on This Shore: Photographs and Interviews with Transgender and Gender Nonconforming Older Adults (tosurviveonthisshore.com).

Data Source

Participants in To Survive on This Shore were recruited via the personal and professional networks of the cocreators between 2013 and 2017 to participate in a photographic portrait and biographical interview about their gender identity and lives over time. Participants were included in the project if they self-identified as transgender and/or gender nonconforming, were 50 years of age or older, and offered variance on characteristics such as age, race, and ethnicity, and geographic location. Eighty-six interviews were conducted with 88 people (two couples were included in which both people identified at TGNC). Everyone was asked the same initial questions: “How do you identify today and what are some of the major milestones on the path to this identity, from your perspective?” These questions served as a catalyst for participants to reflect on their lives, often delving into significant childhood experiences, family histories and relationships, employment, spirituality, health and mental health challenges, substance use histories, interactions with health care providers, and their evolving sense of themselves as TGNC people.

These interviews lasted about one hour each and were audio recorded and transcribed. All participants signed consent forms, agreeing that the photo and interview would remain the property of To Survive on This Shore co-creators and consenting for the use of these interviews and photographs in historical and research archives. The first author has deidentified the interviews for use in scientific studies. The Institutional Review Board at Washington University in St. Louis gave approval; Transgender Aging and the Life Course (201706001). In addition, all names used in this article are pseudonyms. The participants in this project are diverse in many respects and their demographic characteristics (provided through responses on original consent forms and during interviews) are outlined in Table 1

Table 1.

Participant Demographics

Characteristic	N	%
Trans Identity
Trans woman	46	52.3%
Trans man	34	38.6%
Non-Binary	8	9.1%
Age
50–55	29	33.0%
56–60	15	17.0%
61–65	18	20.5%
66–70	14	15.9%
71–75	5	5.7%
76–80	4	4.5%
81–85	1	1.1%
86–90	2	2.3%
Race/Ethnicity
Asian American	2	2.3%
Black/African American	20	22.7%
Latinx/Hispanic	9	10.2%
MultiRacial	1	1.1%
Native American	2	2.3%
White/European American	54	61.4%
U.S. Geographic Location
Northeast	22	25.0%
Northwest	6	6.8%
Southeast	3	3.4%
Midwest	16	18.2%
South	12	13.6%
Southwest	4	4.5%
West	25	28.4%

Note. N = 88

Data Analysis

We analyzed these data using an interpretive content analysis adapted from Sandström, Willman, Svensson, and Borglin’s (2015) qualitative content analysis method that utilizes a two-phase deductive and inductive coding process. We adapted this method because it lends itself to the application of a theoretical framework or model but also calls for a second round of analysis exploring latent meanings in qualitative data (Elo & Kyngäs, 2008; Sandström et al., 2015). Further, this two-phase process has previously been used to explore the nuanced impact of structural stigma on mental health (Yang et al., 2014); therefore, it suited our aim of exploring the manifestation of multi-level stigma in the unstructured life narratives that make up these secondary data.

For the first phase of analysis, we utilized deductive coding (Elo & Kyngäs, 2008; Sandström et al., 2015) based on White Hughto et al.’s (2015) model of multi-level stigma. We first developed a codebook with agreed upon meanings of individual, interpersonal, and structural level stigma and then discussed and reviewed these codes as the second author began applying them to the interview transcripts. Early in this process, we decided to add deductive codes reflecting “positive” or affirming experiences at individual, interpersonal, and structural levels so that we could capture additional data to contextualize negative experiences with stigma. Examples of this first phase of coding are provided in Table 2

Table 2.

Example of Phase I Deductive Coding

Stigma Level	Positive	Negative
Individual	But more and more I’ve begun to realize that the work that I do, the things that I say, the words that I write do make a difference and how I have come to that realization is that people tell me…People have started writing about it. Calling me for interviews. Wanting to take my photograph, doing all of these things that are like, wow. Somebody is being impacted by this. Patricia, 54	And so…it actually made me feel pretty bad about myself [and] my life… And I never really told anybody. It was just my deep dark secret. And I was always terribly afraid of getting caught, like that if I got caught, then my life would just end somehow— that nobody would talk to me or climb with me, or love me. Olivia, 69
Interpersonal	And the thing is that I told my mom…And she’s like, “You are who you are. You don’t need to change who you are, cause you are who you are. But if that’s what you need to do, then do it.”….A Catholic mom. So I was like, “Wow.” Cause the top line, I mean, she knew I was gay, she knows my sister’s gay, she knows [name of brother] is gay, and the top line is, she wants us happy. Mateo, 54	A few years ago, my oldest sister’s (son) got married, and the only reason I found out about it, was because I went to my brother’s house and I saw the “reserve the date” magnet, and I’m like “oh, my nephew’s getting married, and my sister didn’t tell me.” … I don’t know if they told anybody, but then I get this call from my nephew, and he said “I just wanted to let you know that we’re not inviting you to our wedding.” So that was a pretty painful moment. Beth, 52
Structural	I feel good about the work that the ministry does. And I feel good that we get the opportunity to tell other people, and younger people, you know, you don’t have to go through the same struggles that I had to go through when I was young because all of this out there available now. Ethan, 53	But it was still hard and I had come from one of those religions that were like really strict, you’re going to die and go to hell. I got thrown out of the church too. I was told I had to change my game and start wearing a dress. Axel, 61

The second author used NVIVO 11 (Version 11.4.1.1064; QSR Intenrational, 2014) qualitative data analysis software to organize and code the transcripts, which resulted in relevant text sorted into categories for each level of stigma. We also used analytical memo writing during this phase to reflect on the applications and limitations of the multi-level model to these data (Saldaña, 2016). Analytical memo writing is often used in interpretive research to sensitize researchers to the subjectivities that arise in analyzing qualitative data (Schwartz-Shea & Yanow, 2012); in this case we wrote memos to clarify the types of data that we were capturing with our codes, but also to note the ambiguous or conflicting nature of some data and difficulties in assigning deductive codes to these interview passages. These memos served as discussion points for the research team and aided in the development of findings.

For the second phase of analysis, we utilized inductive coding (Elo & Kyngäs, 2008; Sandström et al., 2015). As opposed to deductive coding, which utilizes predetermined codes, inductive coding facilitates additional interpretations on the part of researchers that are freer from the constraints of a priori concepts. Our meaning unit of analysis for this phase of coding (i.e. the text subject to coding) was any text that had been highlighted through deductive coding as representative of individual, interpersonal, or structural level stigma or related positive experience. We conducted the second inductive phase of analysis by drawing upon Graneheim and Lundman’s (2004) guidelines for latent content analysis in order to draw out additional nuance about the experience of stigma; this second phase entailed the second author identifying meaningful segments of data with respect to the experience of stigma and then generating condensed codes to capture their essence. The second author then grouped these codes together to develop main categories of experience under each level of stigma (Graneheim & Lundman, 2004). Examples of this second phase of coding are provided in Table 3. We developed findings based on these main categories through a process of memo writing and discussion of the most salient and illustrative lived experiences with respect to multi-level stigma.

Table 3.

Example of Phase II Inductive Coding

Individual Stigma Quotations	Subcategories	Generic subcategories	Main category
So that was, I knew something was up and as I say it, I didn’t learn to become a secret agent that left an alien territory. I sort of kept that other side of the self-hidden. Hidden away from everybody. Jackie, 77	Knew something was up Kept the self-hidden	Hiding as a response to constant early awareness	Constrained fearful approach to life
I kind of went into a cocoon then because by that time, my mannerisms, I couldn’t do like other children that make it work and really put on a good act, I just couldn’t. I couldn’t and I suffered for it a lot. And that’s how I just became just quiet. When we had family gatherings and stuff I would always make sure I sat somewhere and then I had done anything I had to do so I didn’t have to get up and walk. Because once I got up and walked, my ass was always high and deep. Jeannette, 55	Went into a cocoon Always aware of family watching
Yeah. I had already had people that I worked with, they could already see what was happening with me, though the choices that I made were really small. I’m often amused by what a big deal such small things are. Not to belittle that. But I think “wow, that was so fraught with fear to wear”–it’s funny to me, its often in a way too much about your clothing. Sigrid, 51	Fraught with fear	Hypervigilance of potential rejection
You know, when I was homeless, I was so afraid to tell them, ‘cause they kept saying, “Well why don’t you go to a women’s shelter,” “Well, let me give you this agency,” and they kept saying it, they kept saying it. There was this one time I was so desperately trying to save my hotel room, and it was a Friday, late, and it was like, “There’s nothing we can do,” and finally I just broke down crying. I said, “I—” and I was in the Baptist church, and I said, “There’s something I got to tell you. The reason why I’m not going to the shelters at night.” …. “Why didn’t you say something a long time ago?” And now I get you, and I’m going to talk to the senior pastor, because something needs to be done to help you.”…Rochelle, 51	Afraid to tell them Afraid to come out as trans and get needed services Fear to disclose

In order to bolster the rigor of our analytical process and illuminate unconscious bias related to our own social identities and professional experiences, we used critical discussion at each stage of the analysis to reflect on our decision-making process. For example, both authors have prior training and knowledge about transgender issues, mental health, and interpretive research, which brought many perspectives to bear on these data. Critical discussion helped to illuminate these multiple perspectives and leverage them to achieve the analytical goals of this study. In addition, To Survive on This Shore has received a positive response in LGBTQ communities for its nuanced representation of transgender aging and TGNC older adults (Harrity, 2018; Naughton, 2018), which speaks to the credibility of the data we analyzed.

Findings

Our analyses suggest that TGNC older adults are indeed impacted by multiple levels of stigma, which are often negotiated simultaneously in ways that profoundly impact mental health and well-being. Naomi, a 65-year-old Black trans (i.e. transgender) woman, captured this manifestation of multi-level stigma in her reflection on the challenges she has encountered over time:

Growing up [and] not being nurtured as my authentic self caused me harm. Going to school, and being so afraid to be a part of the classroom, that caused me pain…my mother not really loving me as I thought she could, that caused me pain…Among no other group of people can [one] go outside their house and run the risk of being verbally assaulted, physically assaulted, you know, and this is whether you can make it from Point A to point B.

Naomi’s reflection is echoed by many other participants in this study for whom the unpredictability of stigmatization and victimization is a central aspect of their lived experiences and often shapes their identity and outlook later in life. With respect to multi-level stigma, we also found that individual stigma manifests in vigilance and sometimes shame about one’s gender transgressions in society, which often causes self-imposed social withdrawal and psychological distress. Interpersonal stigma manifests in the negotiation of unpredictable, dynamic, and fluid relationships, which are both positive and stigmatizing. At the structural level, TGNC older adults are aware of stigmatizing social norms, laws, and policies, which often provide a catalyst for taking action to improve their own circumstances and those for TGNC youth.

Individual Stigma

TGNC older adults experience individual stigma as ongoing vigilance and control of aspects of themselves that break gender norms, while also navigating the potential for rejection or violence in relation to others. Often the response to this type of stigma is self-imposed social isolation and internalized shame. When talking about their past, participants recalled the constant feeling of not being “okay.” One participant, Olivia, a 69-year-old White trans woman who loves rock climbing, described how the fear of others’ rejection and self-imposed social isolation created a constrained and fearful approach to life:

And so…it actually made me feel pretty bad about myself [and] my life. Like, “What’s wrong with me that I want this?” And I never really told anybody. It was just my deep dark secret. And I was always terribly afraid of getting caught, like that if I got caught, then my life would just end somehow—that nobody would talk to me or climb with me, or love me.

This outlook was common for participants, suggesting that experiences of individual stigma inform both one’s sense of self and expectations of others. Johnson, a 52-year-old Black trans man, described this dynamic in recalling his anticipated loss of his parents’ support:

And I never thought that I would actually transition while my parents were alive. I thought, “Well it’s gonna break their heart.” This was all stuff that I was putting on myself… Even though they’ve always been the most open-minded people. But there was something about coming out as transgender to them, I was like, “Shoot, what’s my mother gonna say to this?”

Many TGNC older adults, who did not grow up with the Internet and its proliferation of transgender-related resources and opportunities for social connection, experienced a lack of awareness about transgender identities and opportunities for self-expression, which led to an internal sense that something was wrong with them. This internalization and reaction to gender normative social forces often started in childhood in conversations with parents, peers, and teachers. Ada, a 55-year-old Black trans woman living in the South, describes herself as entering a cocoon in order to try to repress her gender around family members:

I kind of went into a cocoon then because by that time, my mannerisms, I couldn’t do like other children that make it work and really put on a good act, I just couldn’t. I couldn’t and I suffered for it a lot. And that’s how I just became just quiet. When we had family gatherings and stuff I would always make sure I sat somewhere and then I had done anything I had to do so I didn’t have to get up and walk. Because once I got up and walked, my ass was always high and deep.

These reflections underscore the importance of viewing individual stigma as not only an internal psychological phenomenon but also an extension of the external world, as the fears and perceptions of social life stem directly from real world social forces surrounding gender norms. Benjamin, a 52-year-old White trans man, underscored this intertwining of internal processing of the external world:

No, no. I still was not out yet, even though my sense of myself was that I’ve always known that I’ve been a trans man, and it’s kind of weird about a thing like survival, that as young as I was, some part of me knew that it was better, that there was just no way the world was going to be okay with who I knew I was to be and that it was a better choice to be presenting as a lesbian.

From an early age, individual stigma manifests as constant awareness of potential rejection for violating gender norms and internalizing this stigma through constant monitoring of perceived flaws to avoid ostracization and potential loss.

Those who intensely felt fear, shame, and uncertainty, referred to the toll on their mental health, particularly prior to coming out. Charlotte, a 64-year-old White trans woman captured this toll:

But of course in the ‘50s and ‘60s, there was not much information about this.... And then in the mid-90s, I just had to do something. I was drinking, I was abusing drugs. I, I had to do something, it was just awful, and…basically, I came out.

Fourteen out of 88 participants in this study shared their stories of suicidal ideation or suicide attempts. One participant, Elliot, a 60-year-old White trans man living in the Northeast, spoke about how factors such as unemployment and homelessness play a complicating role in ongoing depression and long-term substance abuse:

I wasn’t happy about those circumstances, but it wasn’t a depression like in other time periods in my life…I had some really structural, logistical difficulties that made me not so happy. It was a very stressful time. My backup plan was if I depleted everything and was on the streets, that I’d kill myself, because I didn’t know what else to do.

For many participants who shared reflections on suicidal behavior, they referenced a deep internal desire not to succumb to society’s stigmatization of their identities and expressions, a desire which often surfaced at the threat of self-harm. For example, Louisa, a 64-year-old White trans woman living in the South recalled:

I considered suicide twice. I came very close both times. I mean, extremely close to where both events were planned to where no one would have known it was suicide. One of them, I was going to paddle my kayak out 6 miles into the ocean, drink a Demerol/Seconal cocktail, just go to sleep. And I had a chain. I was actually standing on the bank of the water, I had a chain I was going to wrap around my waist so when the waves knocked me over, I’d sink to the bottom and they’ve never find the body…[but then] a feeling came over me that just said, “No. Be who you are.”

The suicidal ideation and behavior described by participants in this study was most often linked to interpersonal and structural issues, more so than a bio-physiological mental health disorder. While many participants did share experiences of depression or anxiety, they often contextualized their symptoms in the context of stigma, rejection from others, fear, and internalized shame about their gender identity and expression. This ability to contextualize their mental health demonstrates a high level of awareness on the part of TGNC older adults about how individual stigma functions in their lives.

Interpersonal Stigma

Given the interpersonal and structural forces that influence the experience of individual stigma for TGNC older adults, interpersonal stigma manifests, not surprisingly, in their lives in overlapping ways. When describing the nature of relationships with others throughout childhood and adulthood, the participants in this study illuminated the unpredictable nature of interpersonal stigma. Many participants’ experiences of this type of stigma revolved around parents and early caretakers. Miles, a 54-year-old Black trans man living in the Northeast, reflected on his conflicting relationship with his mother in respect to his trans identity:

My mom is very religious and I was very, very scared to tell my mommy... So I was really, really quite terrified that she would vanish out of my life and tell me to go away and never come back. And she didn’t. She doesn’t understand. And I can understand how she doesn’t understand. For her gender is immutable. You are what you are and this is what you are…[so] she taught me the difference between love and acceptance. She may never accept what she sees as a decision that does not make any sense to her, but she does still love and care for me. I think we had a better relationship post transition than we ever did before, mostly because I am more open and feel less veiled…We get along well.

Miles’ experience in the relationship with his mother demonstrates that TGNC older adults often have to negotiate unpredictable and sometimes conflicting reactions on the part of family and friends. In this case, Miles benefits from his mother’s love and an improved relationship after coming out to her, but also experiences ongoing stigmatization of his gender identity in the form of her lack of acceptance.

Some relationships with family members do move from stigmatizing and harmful to accepting and nurturing. Many older adults in this study told stories about initially being rejected by families but finding ways to reconcile later on (usually after taking the initiative to repair the relationship). In some cases, participants also recounted other people’s stories as a means of processing their own experiences. For example, Jackie, a 77-year-old White trans woman who runs supportive housing for TGNC people who have experienced homelessness, compared their experiences:

Family…sometimes works out, sometimes doesn’t, which we all know. Justine here was kind of thrown out of the house at a young age, 12 years old? Had to live on the streets, you know, survived. But then, just recently she sent her mother books about and information about trans. Her mother read it and then just recently came up here and visited for a week. And now they are back together again. When I transitioned my parents were already dead but I’ve got four brothers. One will not see me. Two will. And my sister-in-law is fine with it.

While the trauma resulting from family exclusion and homelessness may continue to impact this young person’s life, this story and Jackie’s illuminate the dynamic and often unpredictable nature of relationships over the course of one’s life. This dynamism provides hope in some cases, but the unpredictability of these relationships takes an emotional and psychological toll on TGNC older adults, who often navigate these types of relationships for decades of their lives. In addition, the constant awareness of how other TGNC people are treated by their families amplifies this stress, such that many TGNC older adults are often in a permanent state of processing both their own experiences and those of others around them. For example, Stacey, a non-binary 78-year-old recalled, “Oh I was absolutely terrified. What if [my children said], ‘Oh you creepy bastard, you’ll never see my kids again.’ And I know girls that happened to. They have grandkids they’ve never seen.”

Though many participants in this study were apprehensive about the potential of being cut off from family, they gratefully recounted the experience of being embraced and accepted when they had not anticipated that outcome. The juxtaposition of these fears with positive responses from family members was often characterized as experiencing “luck” that they didn’t have it “as bad” as other TGNC people. For example, Rafael, a 59-year-old Latino trans man living in the Southwest recalled a significant visit to his father’s side of the family in South America:

And so [about] the trans part…I found nothing but love in my father’s entire vast expanse of his family and it’s been really a joy. I’m very lucky because it wouldn’t be expected to be that way. Because you would expect them to say, “No, God did this or God did that and why did you mutilate your body?” They didn’t go there, they just went, “You know, you’re the same as you always have been, and I’m just happy you’re happy, you look much happier.” And that’s kind of what they care about.

By framing his story as a fortunate exception to the norm, Rafael illuminated the ways in which interpersonal stigma functions through community-level dynamics to inform one’s own sense of self and the meaning of one’s relationships.

Every participant in this study described some experience with interpersonal stigma, whether with family members, friends, neighbors, or coworkers. However, many also shared the critical role that affirming professionals played in countering these experiences of stigmatization; these professionals were health care providers who sought out transgender-related knowledge in order to be supportive, religious leaders who embraced their gender identity, and most often a psychiatrist or psychotherapist who validated their sense of themselves and supported them through difficult decisions and life transitions. This experience is captured well by Esther, an 83year-old White trans woman, who shared, “I was just beside myself, I didn’t know what to do. I was cross-dressing. I went to a psychiatrist and said, ‘Hey, what’s with me?’…and [turns out] I wasn’t a stupid old man with stupid ideas.” In this case, the psychiatrist helped Esther through a gender transition in later life, which eased much of her emotional and psychological distress and marked the beginning of several self-proclaimed fulfilling years near the end of her life.

Structural Stigma

TGNC older adults in this study conveyed acute awareness of social structure and the many ways in which social norms, laws, and policies in the United States constrain transgender identities and gender nonconformity. This awareness was both historical and contemporaneous, in that participants felt the impact of key moments in history that advanced transgender rights but were also apprehensive about the “progress” of increased awareness of trans issues in popular media. For example, many participants recalled learning about Christine Jorgensen and being positively impacted by her public gender transition in the 1950s in that it offered a road map for coming out and may have helped to reduce transphobia in society. However, some also reflected on the potential downsides of contemporary trans celebrities like Caitlyn Jenner and Laverne Cox, as Naomi shared,

Things seem to get better. But you’re talking about a few people, like Laverne Cox, but they’re on TV so they’re in this whole ‘nother part of the culture, of pop culture, they’re not in the hood trying to go to the store. That’s a whole ‘nother take. So it’s a good thing and it’s a bad thing, this visibility, for those who live in the hood; people might see them and compare them to Laverne Cox, and say “that’s a man” and do something to them.

In addition, many noted that the progress made in the gay rights movement has not fully translated into civil rights for transgender people, and that they often are aware of the ways in which the so-called “LGBT” organizations or movements continue to marginalize trans people, as Danielle, a 51-year-old Black trans woman expressed,

We started it grassroots. Now you have all these [gay] people making these big salaries and they are not really doing anything for the team. For trans people. It is silent. But I bet you your bottom dollar I keep the T alive. I keep the T alive.

These concerns were also coupled with palpable fears about being vulnerable as an older person in a transphobic society. These fears often revolve around the potential need for long-term care, and many participants in this study are making plans for negotiating these systems later in life. For example, Casey, a non-binary 54-year-old recounted her decision to start taking hormones:

[It wasn’t] until I was in my late 40s, and part of the reason I did that was so I would have a physical and medical record of being trans because I am aware so many older LGBT people, when they become ill or if they start to deteriorate mentally and aren’t able to articulate things as well, end up just involuntarily, just by the assumptions of the people who care for them, being relegated back into the closet. So my fear was that I would become incapacitated in some way and then be stuck in a room full of old men…and I never, ever want to be an old man.

While many TGNC older adults in this study describe the process of coming to terms with their trans identity and surviving many challenges posed by others in society, they regularly worry about a lack of affirming care in later life and whether they will have to withdraw socially in order to survive.

In terms of structural stigma, geographic location and state-level policies play a big role in TGNC older adults’ daily experiences, but not always in expected ways. For example, many participants living in the Northeast (which has more trans-affirming laws and policies) “felt bad” for people living in the South (which has historically been more conservative and less trans-affirming); however, many midwestern and southern participants in this study were surprised by the amount of support they received. As Bryan, a 69-year-old White trans man living in the South described:

It’s so funny [that] they ask me to help with vacation bible school. I’m also an amateur artist and I was doing the arts stuff and they wanted me to come in and teach and be part of it and everything. And I did, but yeah, I’m teaching kids and nobody objects. In this part of [the South]. I’m just…I’ve been amazed.

This positive experience in the South was contrasted with another participant’s account of horrific elder abuse his spouse experienced in a long-term care facility in the Northeast. In this case, which occurred in the mid-2000s, direct care workers targeted this participant’s spouse because of her relationship to a gender nonconforming person. These surprising experiences caution against making assumptions about the potential for structural stigma based on geographic location alone.

Many negative experiences of structural stigma were directly combated with the support of families, friends, and professionals. The role of supportive family is illuminated by Ethan’s experiences as a 53-year-old trans man living in the South. With the support of his grandmother and physician, Ethan was scheduled to receive a gender-affirming surgery; however, at the last minute a hospital administrator tried to block the surgery for being “unnecessary,” which would have required an unexpected and large cash payment. In this case, Ethan’s uncle told him to call his grandmother, who said, “How much money did those assholes say they wanted?” and who ultimately helped him overcome the administrative barrier to care by paying in cash. This form of structural barrier, coupled with interpersonal support, demonstrates that for many TGNC older adults, unpredictability is embedded in their social lives.

These experiences, coupled with the knowledge of their structural underpinnings, compel many TGNC older adults to engage in activism, advocacy, and support for TGNC youth as a means of promoting social change and improving conditions for future generations. Ethan, for example, works as a minister with LGBT and homeless youth and reflected on the purpose of this work:

I feel good about the work that the ministry does. And I feel good that we get the opportunity to tell other people—younger people—you know, you don’t have to go through the same struggles that I had to go through when I was young because all of this out there available now…And I’m looking forward to the day when it will be accepted to the point that there’s no such stigma attached to it.

Further, involvement in the creation of transgender-affirming supportive services also gives meaning to many older adults’ struggles, as Patricia, a 56-year-old Black trans women recounted, “And that’s when my activism began, really as an immediate response of self-preservation.” When Marlene, a 62-year-old White trans woman, saw that there was no trans-specific support group yet at an LGBT community center, she started one and reflected on her involvement:

I think about 6 months after the first meeting...they did a trans panel in front of their [nontrans] peers on a Tuesday night and talked what it was like, their personal experiences.…and then [got] to watch their peers start to understand. [For me], I don’t want anyone to have to go through what I went through. That, and you know, I had a lot of people help me and I believe in giving back.

TGNC older adults expressed particular concerns regarding the suicide and homicide rates, substance use, and homelessness of young trans people. Many reported being hopeful that sharing their own biographical narratives would reduce feelings of isolation and push back on structural stigma. Alice, the partner of Abigail, a transgender veteran, described how creating an oral history archive of transgender veterans has increased Abigail’s self-worth:

When we’ve done interviews in our military video work, you talk to people, you get them to tell you their stories and it is an affirming process…and [if] other people have access to them, they say to themselves, “Maybe I’m worthy, maybe I did something, maybe I am someone who is worthy.”

In these accounts, TGNC older adults are not just passive “victims” of social structure but engage in developing their own interventions. Jeanette, a 55-year-old Black trans woman, described opening her home for health education community meetings with funding from a job at a local nonprofit:

It is always some new batch of girls that come who hear about it from other girls who had come….and we have open conversations about HIV prevention, we talk about hormones, black market hormone therapy, and we do ice breakers and all kinds of stuff but it is absolutely fun.

Jeanette’s work also highlights how structural support such as training and funding for grassroots projects assists in the creation of these spaces which in turn nurture new interpersonal opportunities for growth and well-being.

Discussion

Our research suggests that conceptualizing stigma at multiple levels and analyzing the biographical accounts of TGNC older adults is helpful for sensitizing researchers and practitioners to the complex ways in which stigma is experienced by TGNC older adults. The use of an interpretive approach helped to illuminate the subjectivity and nuance in how multi-level stigma shapes individual lives, thus adding to a growing body of knowledge about how stigma impacts the mental health and well-being of TGNC people. In addition, these levels of stigma are experienced in overlapping ways and thus should be considered concurrently.

Our results support previous research that illuminated a pervasive awareness of potentially life-threatening social forces, which are unpredictable and have a negative impact on mental health for TGNC older adults (Ellis et al., 2016; Fabbre, 2014, 2015, 2017; Poteat et al., 2013; White Hughto & Reisner, 2016). These findings also reinforce previous conceptualizations of felt and enacted stigma (Bockting, 2013) as crucial elements of lived experiences among TGNC people (Ellis et al., 2016). Further, coming out did not always alleviate these fears for participants in this study due to the real constraints of transphobic systems, a phenomenon that has been noted by other scholars (Cook-Daniels, 2015; Ellis et al., 2016; Kattari & Hasche, 2016; Porter et al., 2016; Siverskog, 2014).

The unpredictable nature of relationships and social forces exacerbates TGNC older adults’ distress, which is often marked by periods of substance abuse and suicidality. Several scholars have found that social support is protective against internalized stigma (Fredriksen-Goldsen, Bryan et al., 2013, 2017; Hoy-Ellis, 2015; White Hughto & Reisner, 2016); but for TGNC older adults in this study, social support often flucated even within the same relationship, drawing attention to the unpredictable nature of this aspect of their lives. The uncertainty and unpredictability that emerged in these life narratives reinforce Phelan et al.’s (2014) claim that uncertainty surrounding social rejection is at the core of the experience of stigma. However, TGNC older adults discussed the importance of sharing their own life narratives and becoming activists to give meaning to these struggles, reduce social isolation, and create resources for younger TGNC people. In this way, TGNC older adults are not passive recipients of structural stigma, but are actively engaged in combating it and promoting social change. Further, some scholars argue that activism plays a central role in interpersonal-level interventions for TGNC young adults (White-Hughto et al., 2015), and our results support the relevance of this argument for older adults as well.

Studies in sexual minority and TGNC mental health have used state-level and county-level policies to assess health and mental health risks (Hatzenbuehler, Keyes et al., 2009; Hatzenbuehler & Keyes, 2013; White-Hughto et al., 2016). This strategy is complicated by our results, which suggest that geography and state-level policy may not always predict individual experiences and outcomes well. For example, many participants in the Northeast and West, whose states have trans-affirming public policies, expressed concern for others living in the Midwest and South where fewer protections for trans people exist. However, one of the most traumatic cases of elder abuse recounted in these interviews occurred in the Northeast and many participants in the Midwest and South experienced support at critical times in their lives. Particularly for clinicians and providers, this study cautions against using geography as a proxy for structural stigma and against generalizing mental health risk and access to resources from national studies to the state or community level.

Limitations

This secondary data analysis is limited in that the interviews were not designed to explicitly explore stigma-related experiences or mental health, which may have minimized the degree to which participants shared these experiences. For example, suicidal behavior or experiences of violence may have been underreported because participants were not asked about these experiences directly. In addition, because exposure to violence is so high for transgender people (Stotzer, 2009) and could lead to premature mortality, we may have overemphasized resilience and resistance to stigma by learning from only those who have survived into later life. However, it is notable that despite not being asked directly about stigma, participants provided ample evidence to support the multi-level stigma model. Another limitation of our study is that the narratives came from people who consented to having their photographs taken for To Survive on This Shore, which means they may be more “out” about their identities than some other transgender people. This increased level of “outness” means these narratives may be limited in their accounts of how trans people conceal their identity, especially as doing so relates to the experience of felt stigma. An additional analytical limitation of our study is that we did not use an intersectional lens to analyze the data but instead foregrounded stigma with respect to gender identity. This foregrounding means our findings are limited in their ability to fully account for intersectional identities and related experiences of stigma.

Implications

Trans life narratives hold tremendous potential to inform antistigma interventions because they offer first-hand perspectives of these experiences that are diverse and nuanced. Such narratives offer unique insight into the unpredictable and often unrelenting nature of stigma but also highlight the role of self-awareness and collective consciousness in promoting resistance, empowerment and well-being. Such insights are likely useful both for reducing stigma in society and also for self-empowerment and consciousness-raising. For example, White-Hughto et al. (2015) highlighted a psychosocial intervention that uses videotaped narratives of TGNC people that can be shared with multiple groups as a means of reducing stigmatizing beliefs and behaviors. Our results suggest that, indeed, these types of narratives are powerful and effective means of illuminating the experience of stigma and educating others about its impact. In addition, social justice-oriented psychotherapeutic work can be bolstered by efforts to elicit TGNC clients’ biographical narratives, identify multiple levels of stigma, and promote conscious and intentional action to resist these forces, recover from harm, and self-direct one’s life.

TGNC older adults navigate stigmatizing environments and relationships for long periods of time and into later life, yet knowledge about their lived experiences in clinical and academic literature is limited. This study found that TGNC older adults experience stigma at multiple levels and in ways that profoundly impact their mental health and well-being. Individual and interpersonal stigma are often unpredictable and unrelenting, and structural stigma is pervasive. However, TGNC older adults demonstrate awareness of the ways in which stigma functions in their lives and engage in activism and meaningful community engagement as a means of countering its influence and changing the social forces around them. Eliciting and elevating life narratives is helpful for illuminating these lived experiences and holds the potential for empowerment and therapeutic gains for this group of older adults.

Public Policy Relevance Statement:

Transgender and gender nonconforming (TGNC) older adults experience multiple levels of stigma over the course of their lives, which often negatively impact their well-being. However, these older adults also find ways of resisting stigmatization and engage in action to improve both their own lives and those of TGNC youth. Autobiographical life narratives hold the potential to inform interventions to reduce stigma and promote therapeutic gains for this group of older adults.