Table 2.

Key Themes with Definition and Supporting Quote

Key theme	Definition	Supporting quote(s)
(1) Fear of mistreatment in elder care	Fear of nonaffirming care in elder care facilities, ranging from use of incorrect pronouns to acts of physical or sexual violence	“I worry about whether or not the people who are assisting me are going to be judgmental, are they going to be mean or be professional and take care of me like any other patient…Will I be abused in the nursing home because I am a trans person?” (Participant M, age 64, transgender man)
(2) Isolation and loneliness exacerbated by transgender identity	Lack of social connection heightened by transgender identity, including estrangement from spouses, partners or family members, concerns over accessing social resources	“[loneliness] can be more prevalent for trans people, because so many have had their families or partners abandon them and never rally back. They may have difficulty finding a partner who is comfortable with having a trans partner.” (Participant O, age 79, transgender man)
(3) Vulnerability to financial stressors	Increased risk of financial insecurity due to transphobia, such as loss of employment or professional opportunities due to transgender identity	“Getting fired from jobs because I was transgender were not happy or expected things.” (Participant C, age 70, transgender man)
(4) Perceived lack of agency	A perceived lack of control over how one will be treated at end of life or in nursing homes, potentially complicated by dementia, also includes lack of agency over one's narrative as transgender, such as fear of incorrect pronoun use in an obituary	“I worry about how my family is going to bury me and how they are going to show me in my casket. When I die and I am buried, I would like to be as the female I have become now.” (Participant Q, age 67, transgender woman)
		“It's the loss of independence and loss of control. The worse case scenario would be I would lose all control over my life, how I would dress and everything else.” (Participant I, age 76, transgender woman)
(5) Health care system and provider inclusivity	The extent to which health care systems and providers are sensitive toward transgender individuals, including verbal communication and body language; medical records that accommodate gender identity	“I have literally been escorted out of an Ob-Gyn office. I was almost dragged out and was told we don't see your kind here…The younger men and women now don't have to go through that.” (Participant R, age 72, transgender man)
(6) Giving back to one's community	A desire to engage with and give back to one's community, through one's profession, activism, financial donation, education, youth mentorship or other means	“Over the years, I have put about $200,000.00 or more into the trans movement. That was money spent to support the early organizations.” (Participant D, age 78, transgender woman).
		“I work in psychiatry and there are so few practitioners. Some of the clients we serve are homeless people and 95% of them are drug and alcohol addicted. As long as I can work, I want to serve these people and it's like another life mission.” (Participant O, age 79, transgender man)
(7) Embracing self-truth as a path to fulfillment	Self-acceptance of transgender identity as a source of happiness, inner peace and wisdom and a catalyst for improved mental health	“I didn't know much at twenty…Over a period of time I became more comfortable with me, and especially after transitioning…The sooner that you're comfortable with who you are, you don't worry so much about what other people think.” (Participant A, age 82, transgender woman)