Elderly trans people: aging with dignity

When we talk about transgender people, we almost always think of young people in transition, of adolescents finding their place in the world, of young faces on social media. Rarely do we think of a 75-year-old trans woman in a nursing home, of an 80-year-old trans man who no longer leaves his house, of a person who has endured decades of stigma and who now, at an age when they should have the right to peace, finds themselves fighting battles they thought they had already won. Elderly trans people exist. They are among us. But they are, to a large extent, invisible — to society, to the healthcare system, to public policy, and too often, even to the LGBTQ+ community itself [1][2].

An invisible generation

Trans people who are over sixty-five today were born into a radically different world from the current one. They grew up in an era when being transgender was not just stigmatized, but actively criminalized and pathologized [3]. In Italy, before Law 164 of 1982, trans people had no legal recognition whatsoever. They could not change their name or sex on documents. Police would stop them for “disguise” under regulations dating back to the fascist era. Psychiatry classified them as mentally ill.

Those who survived that era did so, in most cases, by hiding. Many elderly trans people lived their entire adult lives without ever coming out, without ever transitioning, without ever being themselves except in the most absolute secrecy [2][4]. Others transitioned in their youth at an enormous cost: loss of family, employment, housing, and social ties. The result, in both cases, is a generation that learned to make itself invisible in order to survive — and that now, in old age, remains invisible even when they no longer wish to be.

An absence in the data

The invisibility is not just social: it is also statistical. There are no reliable data on the number of elderly trans people in Italy. ISTAT surveys on the living conditions of older people do not record gender identity. Research on trans people, when it exists, focuses on younger age groups. The result is a knowledge gap that feeds on itself: data are not collected because the problem is not perceived as relevant, and the problem is not perceived as relevant because there are no data [7][8].

At the international level, available estimates suggest that elderly trans people represent a significant proportion of the transgender population. SAGE, the main U.S. organization dedicated to LGBT aging, estimates that approximately three million LGBT people over 65 live in the United States, a growing proportion of whom identify as transgender [1]. In Europe, the 2020 FRA survey documented the experiences of trans people in the EU, but without a specific analysis for the older age group [4].

Social isolation

The loss of support networks

Social isolation is the most widespread and least recognized problem among elderly trans people. It manifests on multiple levels and has deep roots. Many trans people of the generation now elderly were rejected by their family of origin at the time of coming out or transition — often decades ago [2]. Unlike cisgender people, who in old age can rely on children, grandchildren, siblings, elderly trans people have significantly higher rates of absent family ties.

International research indicates that elderly trans people are much more likely than the general population to live alone [1][7]. This is not just a sociological datum: it is a medical risk factor. Social isolation is associated with an increased risk of depression, cognitive decline, cardiovascular disease, and premature mortality. For elderly trans people, these risks are compounded by the specificity of an isolation that is not merely a consequence of aging, but the cumulative result of decades of exclusion.

The chosen family and its fragility

Faced with family rejection, many trans people have built over the course of their lives a “chosen family” — a network of deep friendships, often with other LGBTQ+ people, that has filled the emotional and practical functions of the biological family [1][3]. This network, however, is structurally fragile. It has no legal recognition: a friend of thirty years has no right to make medical decisions, cannot visit in intensive care without specific authorization, and cannot object to placement in an inadequate facility.

As age advances, the chosen family thins out. Friends fall ill, die, or move away. The network crumbles precisely when it would be most needed. And the elderly trans person finds themselves alone — not by choice, but through an accumulation of exclusions that spans a lifetime.

Going back into the closet

A particularly painful phenomenon is what scholars call “re-closeting”: going back into the closet [2][7]. When elderly trans people lose their autonomy and become dependent on others — family members, healthcare workers, residential facilities — many of them choose to hide their identity again. They do so out of fear: fear of being mistreated, fear of being rejected, fear of losing the care they need. After decades of hard-won freedom, they return to living in secrecy. It is one of the cruelest forms of regression that our care system imposes, through omission more than intention.

Health and access to care

Healthcare barriers

Elderly trans people face a double healthcare burden: the medical challenges associated with aging and those specific to being transgender [6][7]. The interaction between these two aspects is complex and poorly studied, and the healthcare system is largely unprepared to manage it.

The first barrier is access to care itself. Many elderly trans people avoid or delay medical visits out of fear of being discriminated against, of having to explain their history, of being misgendered, of being treated with morbid curiosity rather than professionalism [2][7]. This fear is not irrational: it is the product of concrete experiences. A person who has been treated by medicine for decades as a “clinical case” or as “mentally ill” has well-founded reasons to distrust the healthcare system.

The second barrier is medical competence. Few geriatricians have training in the specific healthcare needs of trans people. Few general practitioners know how to manage interactions between hormone therapy and medications for age-related conditions. Few specialists know that a trans woman who has been taking estrogen for thirty years has a cardiovascular risk profile different from that of a cisgender man of the same age — but also from that of a cisgender woman [6][7].

Interactions with age-related conditions

Aging brings an increased risk of chronic conditions: hypertension, diabetes, osteoporosis, cardiovascular disease, dementia. For trans people who have been on hormone therapy for decades, these conditions present in a specific physiological context that requires targeted medical attention [6][7].

Long-term estrogen therapy in trans women is associated with an increased thromboembolic risk and, potentially, an increased risk of cardiovascular disease, especially after age sixty [6]. Testosterone therapy in trans men can affect lipid profiles and cardiovascular health. Osteoporosis represents a significant risk, particularly for trans people who have discontinued hormone therapy or who never took it after gonadectomy [6][7].

These specificities are not insurmountable. They simply require informed physicians and a healthcare system that does not treat elderly trans people as an anomaly, but as patients with specific and legitimate needs.

Dementia and the loss of self

A particularly distressing aspect concerns elderly trans people with dementia. Cognitive decline can lead to loss of memory of one’s transition, the re-emergence of memories linked to pre-transition identity, and confusion between past and present [7]. For untrained care staff, this can translate into a denial of the person’s identity: if the patient “does not remember” being a woman, why treat her as one?

International guidelines are clear: a person’s gender identity does not depend on their cognitive capacity [6]. A trans woman with dementia remains a trans woman. Her pronouns remain her pronouns. Her name remains her name. But in the absence of specific training and clear protocols, these guidelines remain a dead letter.

Residential care facilities: an open problem

Nursing homes: structural inadequacy

Residential care facilities represent one of the most problematic contexts for elderly trans people [5][7]. Nearly all Italian nursing homes are organized according to a rigidly binary model: separate rooms for men and women, separate bathrooms, separate activities. For a trans person, this means being assigned to a ward based on legal sex — which may not correspond to their gender identity — or, in the best case, being placed in an ambiguous situation that exposes them to questions, curiosity, and potential hostility from other residents.

The problem is not just logistical. It is cultural. Staff in nursing homes, in the vast majority of cases, have received no training on gender identity. They do not know what misgendering means. They do not know what deadnaming means. They do not know that continuing to call a trans woman “sir” is not a matter of grammatical formality, but an act that denies her identity and causes real suffering [2][7].

Forced detransition

The most extreme case is that of forced detransition in care facilities. It happens when a trans person enters a nursing home and the staff, out of ignorance or prejudice, discontinues hormone therapy, removes clothing and accessories related to gender expression, and systematically uses the legal name and incorrect pronouns [5][7]. The person, deprived of their autonomy and dependent on the facility for every aspect of daily life, does not have the strength — and often not even the ability — to object.

These are not edge cases or theoretical scenarios. Research conducted in the United States and the United Kingdom documents that a significant proportion of elderly trans people in residential facilities have experienced at least one form of identity denial from care staff [1][5]. In Italy, there are no specific data — which does not mean the problem does not exist, but that no one has measured it yet.

The situation in Italy

An institutional void

Italy has no specific policies for elderly trans people. There are no national guidelines for the reception of trans people in nursing homes. There are no mandatory training programs for residential facility staff on gender identity. There are no dedicated services, information desks, or helplines [8].

The Infotrans portal of the Italian National Institute of Health, which represents the main institutional point of reference for trans people in Italy, offers information on transition pathways, legal aspects, and specialized centers [8]. But it does not specifically address the topic of aging. The health section contains no guidance on interactions between hormone therapy and geriatric conditions. The rights section does not mention protections in residential facilities.

Associations as the only safety net

In the absence of institutional responses, the burden of assistance falls almost entirely on associations. Organizations such as MIT (Trans Identity Movement), Arcigay, and local groups offer support and accompaniment, but with limited resources and on a voluntary basis. There are no residential facilities in Italy specifically designed for elderly LGBTQ+ people — a model that has begun to develop in other countries.

Italy’s gap is not only regulatory: it is a gap in knowledge. We do not know how many elderly trans people live in Italy. We do not know under what conditions. We do not know how many of them have access to adequate care. We do not know how many live alone. We do not know how many have gone back into the closet. And until we do, we cannot address the problem.

Hormone therapy in old age

Continuity and monitoring

The question of hormone therapy in old age is among the most medically relevant. The WPATH guidelines (Standards of Care, version 8) are clear: gender-affirming hormone therapy can and should be continued in old age, with adequate and personalized monitoring [6].

For trans women taking estrogen, monitoring should include regular checks on venous thromboembolic risk, blood pressure, lipid profile, and bone density [6][7]. As age advances, thromboembolic risk increases, and it may be necessary to adjust dosages or modify the route of administration — preferring, for example, transdermal over oral, as it is associated with a lower thromboembolic risk.

For trans men taking testosterone, it is important to monitor polycythemia (excessive increase in red blood cells), lipid profile, liver function, and cardiovascular health [6]. Breast cancer screening remains recommended for trans men who have not undergone mastectomy, as does cervical screening for those who retain their uterus.

The risks of discontinuation

Discontinuing hormone therapy in old age — as sometimes happens by unilateral decision of non-specialist physicians or care facilities — can have serious consequences [6][7]. Beyond the psychological distress caused by the reappearance of unwanted secondary sex characteristics, abrupt discontinuation of estrogen therapy can accelerate bone density loss, increasing the risk of fractures. Discontinuation of testosterone can cause fatigue, loss of muscle mass, and mood changes.

The fundamental principle is that gender-affirming hormone therapy is a long-term medical therapy, not an optional treatment that can be suspended for organizational convenience or out of ignorance [6]. Any modification must be agreed upon with an experienced endocrinologist and with the patient, never imposed.

Resilience and wisdom

Surviving as an act of resistance

It would be a mistake to reduce the narrative about elderly trans people to a list of problems and suffering. Those who have endured decades of stigma, criminalization, pathologization, and marginalization and have reached old age have demonstrated extraordinary resilience [2][3]. This is not rhetoric: it is a finding that emerges clearly from the scientific literature. Elderly trans people who have been able to live openly and who have had access to support networks show levels of psychological well-being and life satisfaction comparable to — and in some cases greater than — those of the general population of the same age [2].

This resilience does not arise from nothing. It is the product of a lifetime of adaptation, problem-solving, building meaningful relationships in hostile environments, and the capacity to reinvent oneself. These are skills that positive psychology recognizes as protective factors in aging — and that trans people have had to develop out of necessity.

The role of mentorship

Elderly trans people play a crucial — and often invisible — role within the LGBTQ+ community [1]. They are the keepers of a historical memory that risks being lost: they know what it was like to live before Law 164, before accessible hormone therapies, before the internet. Their experience offers younger generations a perspective that no book can replace.

In contexts where they are valued, elderly trans people become role models, mentors, and anchoring points for a community that often lives in an eternal present. Their contribution is not merely emotional: it is political. They remind us that the rights enjoyed today did not fall from the sky, but were won — often by people who could not benefit from them.

What can be done

Training healthcare and care staff

The most urgent priority is training. Staff in nursing homes, retirement homes, home care services, and hospitals must receive specific training on gender identity, on respecting pronouns and chosen names, on continuity of hormone therapy, and on managing the specific needs of trans patients [1][6][7]. These are not optional courses or generic awareness sessions: they are professional competencies necessary to ensure adequate care.

Inclusive protocols in residential facilities

Nursing homes and retirement homes must adopt protocols that explicitly provide for the reception of trans people: room assignment consistent with gender identity, use of the chosen name in all contexts, continuity of hormone therapy, staff training, and awareness-raising among other residents [5][7]. These protocols do not require new laws: they require administrative will and awareness of the problem.

Programs against isolation

Municipal social services and LGBTQ+ associations must develop specific programs to combat the isolation of elderly trans people [1]. Support groups, accompaniment services, dedicated phone lines, inclusive recreational activities: the tools exist and work, but they must be adapted to the specific needs of this population.

Data collection and research

Italy needs data. Without quantitative and qualitative knowledge of the living conditions of elderly trans people, any intervention remains blind [4][8]. ISTAT should include gender identity in its aging surveys. The Italian National Institute of Health should integrate the topic of aging into the Infotrans portal. Universities should promote specific research.

Legal protections

Legal recognition of the chosen family is needed, guaranteeing non-biological emotional bonds a role in medical and care decisions. Explicit inclusion of gender identity among the factors protected from discrimination in all contexts, including residential facilities, is needed. It is needed that the right to one’s own identity does not expire the moment a person loses their self-sufficiency.

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No person should be forced back into the closet. Not at twenty, not at fifty, not at eighty. Elderly trans people have endured decades of hostility to win the right to be themselves. They have paid prices that most of us cannot even imagine. The least society can do is ensure they age with the same dignity they had to earn on their own — and that, this time, should no longer depend on their strength, but on our civilization.