Equitable Aging in Health Framework: A Multi-Systems and Multilevel Approach to Health Challenges and Supports for Transgender Older Adults

Background and Purpose: Existing research underscores that transgender older adults face elevated health disparities and concerns as well as a long history of resistance to structural barriers that exacerbate these disparities. While research on transgender older adults and health is growing, gaps remain about transgender older adults of color, immigrants, and other groups with intersecting minoritized positionalities. This article aims to address these gaps by examining health challenges and supports among transgender older adults—many of whom are older adults of color and immigrants—through an Equitable Aging in Health framework. The Equitable Aging in Health conceptual framework uses a multilevel lens of power (e.g., intrapersonal, interpersonal, disciplinary, structural, cultural) to link social and political determinants of health in six categories (i.e., laws/policies, economic stability, education access/quality, health care access/quality, neighborhood and built environment, and social and community context)

Methods: This community-driven study incorporates qualitative data from 37 transgender older adults from a larger study of 23 focus groups with 208 LGBTQIA+ older adults in California to examine challenges, thriving and surviving strategies, and community-grounded recommendations regarding health, housing, social services, and caregiving. Of the 23 focus groups, 20 were inter-categorical (included both transgender and cisgender older adults, and three were intra-categorical (included only transgender older adults). Data foreground experiences of low-income transgender older adults, older adults of color, and older immigrants.

Findings: Transgender older adults identified challenges related to healthcare access, housing, employment and economics, and violence that often intersected with (dis)ability and aging. Transgender older Latina immigrants experienced elevated challenges related to language barriers, immigration status, and discrimination. Supports included community connections, financial and legal assistance, educational workshops, and homeharing programs. Healthcare access, health experiences, and overall wellbeing were intricately tied to challenges and supports in housing, social services, healthcare systems, and employment that existed at micro, mezzo, and macro levels. Moreover, while intersecting systems and levels shaped health-related challenges and supports for all transgender older adults in this study, intersecting positionalities (e.g., racism, income, immigration status) further shaped their experiences (e.g., older transgender Latina immigrants reported challenges and supports that were connected more deeply to basic needs). Transgender older adults excluded from formal support systems (e.g., federal financial support for housing, health insurance for gender affirming care) relied more heavily on informal supports from families of choice or community networks, or went without those supports.

Conclusions and Implications: The Equitable Aging in Health framework helps illuminate how challenges and supports (e.g., substandard housing, discrimination, concerns about violence and job security, community supports) described by transgender older adults, including immigrants and older adults of color, can shape health-related experiences for transgender older adults. While housing and health services, programs, and policies, for example, are often treated as distinct areas, this study underscores how interconnected they are for the health and wellbeing of transgender older adults. Services, programs, and policies targeting transgender older adults, thus, would benefit from a multi-level, multi-systems approach.