You are currently viewing Affirming Care for Transgender Older Adults with Loree Cook-Daniels

Affirming Care for Transgender Older Adults with Loree Cook-Daniels

Episode #34 & 64 (repost)June 9, 2021

Transgender Awareness Week (November 13-19) is a week when transgender people and their allies (like me!), take action to bring attention to the transgender community by educating the public.

This education includes describing who transgender people are, sharing stories and experiences and advancing advocacy around the issues of prejudice, discrimination and violence that affects the transgender community (GLAAD, 2020)

This week leads up to the Transgender Day of Remembrance on November 20, the day in which we honor the memory of transgender people whose lives were lost in acts of anti-transgender violence. I hope that you join me on November 20 in taking a moment of silence and thinking about the lives lost over this past year.

Transgender folks have heartbreaking rates of suicidal ideation and attempts. According to a 2019 study, suicidal ideation averaged 46.55% and attempts averaged 27.19%. Suicide rates were highest among non-White folks and those who had lower levels of education, reminding us of the phenomenon that people who hold multiple minority identities experience higher rates of risk and harm (known as double and triple jeopardy, etc).

There are many factors that increase the risk for suicide and mental health concerns among transgender folks, including: trauma, discrimination, minority stress, rejection from family, and exclusion from society.

This is why I’m devoting today’s episode to deepening our understanding of the unique mental health needs of transgender seniors. Each of us have an important role of creating safe and secure spaces for healing for transgender clients, patients, family members, and friends.

To shed light on these important topics, I’m delighted to interview one of the nation’s leaders in Transgender aging, Loree Cook-Daniels, Founder of the Transgender Aging Network.


Here’s a peek inside the episode:

  • [05:27] Loree shares her personal story that inspired her to create the Transgender Aging Network.
  • [11:22] Discover the difference between transitioning early in life versus later in life, including the relationship and social factors that you need to be aware of.
  • [22:32] Mental health concerns and suicidal thoughts disproportionately affect transgender folks, learn more here.
  • [25:15] When we’re sick, we need to be cared for. Unfortunately, Transgender folks experience high rates of discrimination in the health care system, including being denied care or having to educate their medical providers about care.
  • [28:33] Family and partner relationships also go through an adjustment period when the transgender person transitions. Learn more about common relationship experiences.
  • [35:48] Mental health providers for years have been in the role as gatekeeper related to assessing a person’s ability to psychologically tolerate affirming hormone therapy or surgeries, but this can have the effect of setting up an imbalance in the mental health system.
  • [42:26] There is a lot providers CAN DO to create affirming spaces when working with Transgender older adults, learn what you can do here.
  • [55:00] As a national expert on Transgender Aging, Loree Cook-Daniels shares her top recommendations and resources for family, friends, mental health and medical providers, and senior care professionals.

About Loree Cook-Daniels

Loree Cook-Daniels has been working on both LGBT and aging issues since 1974. In the ‘90s she was a primary staff person for the National Center on Elder Abuse. She founded the Transgender Aging Network in 1998, and in 2000 became the Policy and Program Director for FORGE, a 26-year-old national transgender and SOFFA (Significant Others, Friends, Family, and Allies) organization that specializes in transgender aging and victims of violence. Formerly a contributing editor for the Victimization of the Elderly and Disabled, she has also authored numerous book chapters, articles and tip sheets on LGBT and trans aging issues. FORGE’s Transgender Aging Network was a founding partner in the National Resource Center on LGBT Aging and remains its primary transgender expert. She holds a B.A. in Women’s Studies and History, a M.S. in Conflict Management, and a Graduate Certificate in Trauma Counseling.

Resources on Transgender Aging

People Connections

  • Transgender Aging Network – listserv and Facebook page – for anyone interested in transgender aging issues. To subscribe, email [email protected]
  • ElderTG – a peer support listserv for transgender people age 50+ and partners and family members. To subscribe, email [email protected] or [email protected]

For Transgender Elders

For Service Providers

Leading general resources

Other Resources

World Professional Association for Transgender Health (WPATH)

Loree Cook-Daniels 0:00
And it has a lot to do, particularly for health care providers, and trans elders not wanting to access health care. Some figures for you - 19% of trans people across the lifetime have had medical care refused to them. Because they're transgender. And there are instances where insurance companies have said that broken arm is related to you being transgender, we're not going to cover it. So, there's been some really egregious stuff. 50% of trans people have had to train their medical providers on trans issues. So you're going in and saying, this is the problem. And this is what I've researched on the internet. And this is what I think you should do, which some people might think is really exciting, and exhilarating. And most of us, when we're not feeling well, want someone to take care of us, not be in a position of creating them. And in terms of trans people postponing medical care, 28% have postponed medical care at some point due to mistreatment. And 48% due to inability to afford treatment. No, that was before the Affordable Care Act picked up some of us. And we hope they will be returning to that soon. So there's lots of reasons why people resist even going to get health care.

Dr. Regina Koepp 3:03
I'm Dr. Regina Koepp. I'm a board certified clinical psychologist and I specialize with older adults and families. I created the psychology of aging podcast to answer some of the most common questions I get about aging. Questions about mental health and wellness, changes in the brain like with dementia, relationships and sex, caregiving, and even end of life. Like I say, in my therapy groups, no topic is off topic. We just have to have a healthy way of talking about it. So if you're an older adult, or caring for one, you're in the right place. Let's get started.

Dr. Regina Koepp 3:45
Did you know that by 2034, in less than 15 years, there will be more adults 65 and older than children under the age of 18. 20% of these older adults will have a mental health concern. And here's the thing. Mental health concerns are highly treatable. In older adults. There is a common misconception that depression is a normal part of aging. In fact, depression is not a normal part of aging. mental health providers need to be skilled and thoughtful around the mental health needs of older adults. And I offer training programs that address just that. There are three main training programs that I offer. One is on mental health care of older adults, it's great for mental health agencies or mental health providers. The next is on Sexual Health and Aging, but not just any sexual health. It's on sexual health in the context of dementia disorders. And what happens in the context of dementia disorders, when the person may have diminished capacity to make a decision around sexual interactions. That's great for senior care communities, and finally on equity and inclusion in senior care, and this is great for mental health or senior care communities. If you'd like to learn more about my training programs, head on over to my website that's I'll see you there and I hope that you check out some of the training opportunities.

Dr. Regina Koepp 5:27
This is transgender Awareness Week. Transgender Awareness Week is a week when transgender people and their allies, like me, take action to bring attention to the transgender community by educating the public. This education includes describing who transgender people are, sharing stories and experiences and advancing advocacy around the issues of prejudice, discrimination and violence that affects the transgender community. This week leads up to the Transgender Day of Remembrance on November 20. This day comes every year, and on this day, we honor the memory of transgender people whose lives were lost in acts of anti transgender violence. I hope that you join me on November 20 in taking a moment of silence and thinking about the lives lost over this past year. In honor of transgender Awareness Week, I am devoting today's episode to transgender aging, and I am so excited to introduce today's guest. Laurie Cook-Daniels has been working on both LGBT and aging issues since 1974. In the 90s, she was a primary staff person for the National Center on elder abuse. She founded the transgender aging network in 1998. And in 2000, became the policy and program director for Forge, a 26 year old national transgender and SOFFA that stands for significant others friends, family and allies -organization that specializes in transgender aging and victims of violence. Forge's transgender aging network was a founding partner in the National Resource Center on LGBT aging, and remains its primary transgender expert. If you all haven't seen or been to the website, the National Resource Center on LGBT aging, you have to go check it out. Lori Cook-Daniels, thank you so much for joining me on the psychology of aging podcast today. I am thrilled that you're here. I wonder if you would start by sharing about yourself in the trans aging network?

Loree Cook-Daniels 7:44
Thank you very much for inviting me here. I was a long time lesbian, with a partner that, when we first got together, she told me that she wanted to transition to male. But this was in the 80s. And because I was a lesbian activist, I said no way. So that's the way we left it for nine years. And then when I finally saw the light and said, you know, go for it. She did transition to male. And we did find some transgender community. Now, I had been doing LGBT aging work for 20-30 years at that point. And people began to ask me about transgender aging, because it made sense to them that I would know and I didn't know. So I founded the transgender aging network. This was in 1998. In order to try and network people who were doing research or of serving trans elders, or be interested in the topic so that we can begin to collect our cumulative knowledge and start figuring out what we knew and what we didn't know. The Listserv - because that's what we were doing in the 90s - the listserv was open, and we had a number of trans elders join, which was no surprise. But what they wanted was for the physicians and the mental health care providers and the other people on the network to answer questions about their transition, which of course is really important, but I didn't set up the listserv so that professionals have to provide free consultation. So, we quickly spun off elder teaching, which is another listserv that supports trans elders and we define that as 50 and up, and close partners and family members. So we've had some siblings, we certainly have had a number of partners. And that provides peer support so that people are sharing their knowledge based on what they've experienced and other people that they've talked to. And that also was started in 1998. And is still going and, in fact, during the COVID era is for some reason, we haven't figured out, attracting a lot of new members. So, that's where we are.

Dr. Regina Koepp 10:37
Wonderful. And then what is the difference between the transgender aging network and Forge?

Loree Cook-Daniels 10:41
So, the the transgender aging network and elder tg were both founded in 1998. And I moved to be with the co founder of Forge in 2000. So, at that point, we just pulled it under the Forge umbrella. Forge is a national transgender, anti violence organization.

Dr. Regina Koepp 11:07

Loree Cook-Daniels 11:07
So, it's mostly anti violence work, but we have the transgender age network, we've got a support group for parents of trans children in youth. So we're still dabbling in non victimization issues.

The Unique experiences of Transitioning Earlier in Life Versus Later in Life

Dr. Regina Koepp 11:22
When we were meeting to prepare for this interview, you shared with me two important experiences to be mindful of when thinking about working with older transgender folks. You were sharing with me the difference between transitioning later in life versus transitioning earlier in life?

Loree Cook-Daniels 11:39

Dr. Regina Koepp 11:39
And that's such... it really opened my eyes. And can you share a little bit about that with us now?

Loree Cook-Daniels 11:45
Yes, we are in a very kind of unique period of time, because of the discrimination, and, actually, the internet has a big part to do with this. In that trans elders, people who are elderly elders now, um, or grew up in some cases before even Christine Jorgensen. They didn't know about transgender people, they may have known that they didn't feel right. They may have called themselves of the other gender. But there was very little information and no social support for changing genders. So what happened was that when the internet came, started spreading, people had access to information that they had never had before. So many people found out about transgender people through the internet. The internet also spawned some other things or came at the same time of like the listservs. And the - what did we used to call them? Where people dialogued, on AOL, those sorts of things. And so there began to be a lot more information and support for transgender people. So what happens is that, for the people who are elders, now they lived a big chunk of their lives when there was no word for what they were, let alone support for what they were. And that's why we have a large percentage of trans people who are transitioning in their 50s 60s 70s. Because it's the first time in their lives, that they've really been able to do it. Now, there always were some really brave pioneers, who did transition decades ago, excuse me, and those people are now elders, too. So we've got two different kinds, I think two different general character groups of trans elders, the group that lived most of their lives, as the other gender, trying to... for instance, if they were born male, they often went into the military, or they went into really macho occupations in order to try and push themselves into masculinity. So, that's one of the reasons we have more trans vets than population. Um, and of course, then we've got the other group that lived most of their lives in their preferred gender. So they have two different issues or overlapping issues, but with different issues. Obviously, people who've been trans for decades have no need to be saying, "How do I come out to my family?" Or "where do I find a physician?" or that kind of stuff. So that's often what happens on elder teaching, is we get new people in and they're getting information on how do I start?

Dr. Regina Koepp 15:30
Yeah. And then the experience of, of transitioning earlier in life? How does that affect the aging process?

Loree Cook-Daniels 15:42
Well, um, some of the people that transitioned a long time ago, survived by going stealth, maybe even to the point of where even family members did not know that they're transgender. So, because almost none of those people have been able to surgically change their whole body, what that means is if they get ill, or they need intimate care, they're at risk of literal exposure, and being identified as being transgender. And that is very, very scary, it opens up the possibility of discrimination, which they've spent their lifetime trying to avoid by not telling people they're transgender. So, as a result, we get some people that just refuse to have any kind of care at all. And would quite literally, rather die than be in a position where their transgender identity might become known.

Dr. Regina Koepp 16:55
What a bind, I mean, what an emotional bind that you would... because the risk is you would be exposed and rejected or exposed and humiliated, or...

Loree Cook-Daniels 17:06
Um... it's rejected, humiliated, made fun of, depending on the caregiver, you might be exposed to religious expectations, you know, you're going to hell, your center. So there's a wide number of things that could happen.

Dr. Regina Koepp 17:33
Some moral judgment and spiritual persecution.

Loree Cook-Daniels 17:38
Right. Also, one of the things... one of the issues is if someone has been trying to keep their transgender history, or status secret, one of the big issues is, "are they going to out me?" If somebody finds out are they going to tell everybody else? So the potential for negative repercussions gets huge? Yes, not just one person.

Dr. Regina Koepp 18:08
I've also had the experience of working with older transgender folks where they have successfully transitioned to their gender identity, and have had affirming surgeries and have taken hormone replacement therapy. And then as they age, in combination with other medical problems and medications, have made the decision to stop hormone replacement therapy because of medical recommendations due to interaction effects and so on. And so then have the experience of some of the features changing, yes. Which can be very upsetting and requires adjustment, I think, to the physical changes that happen when you have to stop hormone replacement therapy, after you've worked so hard to have your appearance fit your inner world, your inner experience. And so, have you noticed that and how do you work with people on coming to terms with these transitions?

Loree Cook-Daniels 19:18
Um, yes. Now, anyone that has gone through menopause knows that hormones have a huge effect on people's emotions. Aside from all else, aside from how you're using the hormones, so yes, having to reduce or go off hormones, for medical reasons, can be really emotionally difficult. So yeah, that comes up on elder tg every once in a while. Yeah, it's an issue. We also need to be aware of, have a tendency of even healthcare professionals to believe that every problem a trans person has is related to their hormones. So we have to be careful when we work with people to ensure that, yes, this really is the hormones. Yeah, we've just recently... the community just recently lost a very beloved leader at age 58, to blood clots. And she used to smoke. And that's those two, the female hormones and smoking are really dangerous for blood clots. And yet, on the other hand, other people have died of like clots. So sometimes there's also a tendency to believe, "well, that had to be a hormone problem," when in fact, no, that's a human problem.

Dr. Regina Koepp 21:01
Yes, and she knows the risks, she gets to decide. And I think the other piece that I noticed in mental health work is that not all mental health problems are a result of gender identity, that people can have frustrations with their partner or their other issues. And that is not connected necessarily to gender identity that's connected to the relationship for all sorts of other things.

Loree Cook-Daniels 21:33
I have a common soapbox for quite a while about, just because you have depression and are transgender, settling into the gender you prefer is not necessarily going to take away the depression, because my concern was, we have such a high rate of suicide in our community. And I, you know, if you go to all the problems, all the work of changing your gender in some way, and then end up still depressed, I was afraid that that was adding too much. So we've done some work, trying to get people to recognize that depression and anxiety can be related to not being who you want to be, or who you think you are or who you are. They can be separate as well.

Mental Health Concerns among Transgender Older Adults

Dr. Regina Koepp 22:32
Yes. Since we're talking about mental health concerns, can you share a bit about some of the mental health concerns that older transgender folks do experience?

Loree Cook-Daniels 22:43
The big ones for the whole lifespan of trans people are depression and anxiety. And I haven't done the comparison to see how much more we have the general public, and it's going to be really different in covid, now. But depression and anxiety are big ones. And in fact, almost every youth where the parents are in my support group, almost every single one of them has depression or anxiety or both. The suicidality is very high. 41% of trans people have attempted suicide. And then the other note that I made for this call was people are not paranoid. They are worried. They have a real fear of what other people are going to do.

Dr. Regina Koepp 23:49
I'd say justifiable fear.

Loree Cook-Daniels 23:51
Yes. And that tension, we call it minority stress, but it's very wearing. It definitely can contribute to depression and anxiety. And I think I have begun to consider the possibility that the last four years, the number of official acts that were anti transgender, maybe pushing us up to something that I can't even, you know... so some level of feeling under siege, that we haven't seen before.

Dr. Regina Koepp 24:36
And the level of collective trauma is so high, right?

Loree Cook-Daniels 24:40
Yes. When your own government is very clearly against you.

Dr. Regina Koepp 24:46
Right. And potentially community and, I mean, it must be terrifying at some level, and it's not paranoia if it's true. Right? So Maybe it's at levels of intensity. And I'd say that's probably a fair response, given the level of trauma that transgender folks experience on a large scale.

Transgender Seniors' Experiences in the Health Care System

Loree Cook-Daniels 25:15
And it has a lot to do, particularly for health care providers, and trans elders not wanting to access health care. Some figures for you - 19% of trans people across the lifetime have had medical care refused to them. Because they're transgender. And there are instances where insurance companies have said that broken arm is related to you being transgender, we're not going to cover it. So, there's been some really egregious stuff. 50% of trans people have had to train their medical providers on trans issues. So you're going in and saying, this is the problem. And this is what I've researched on the internet. And this is what I think you should do, which some people might think is really exciting, and exhilarating. And most of us, when we're not feeling well, want someone to take care of us, not be in a position of creating them. And in terms of trans people postponing medical care, 28% have postponed medical care at some point due to mistreatment. And 48% due to inability to afford treatment. No, that was before the Affordable Care Act picked up some of us. And we hope they will be returning to that soon. So there's lots of reasons why people resist even going to get health care.

Dr. Regina Koepp 26:57
Yes. And then that I imagine increases rates of disability. In older adulthood, you'll be cut and then increases care need if you have higher levels of disability. And we know that preventive medicine and engaging in the healthcare system for medical treatment when we have medical needs, helps prevent disability. And so if there are all of these barriers for older transgender folks, to getting to the doctor, and then receiving, affirming care when you get there, and those are barriers, then there's the... you identified the socio economic factor, which is not being able to afford it, and there is a long literature describing discrimination in workplace for transgender folks. And so access to jobs and equitable access to jobs, even you were describing, as a lesbian woman, experiencing discrimination and rates of discrimination are higher for transgender folks. And then that affects, you know, income and income affects your ability to afford health care. And it's just a domino system. Now, family relationships are also really important when we talk about deepening our understanding of the experiences of older transgender folks. Can you share about older transitioners and common family dynamics?

Older transitioners and common family dynamics

Loree Cook-Daniels 28:33
Well, the big one is the partners. Because what happens with the partners, and this is not understood even by some trans people, is when, because our sexual orientation labels are so binary, just like the gender labels, when a partner transitions, genders go from one gender to the other binary. What that does to the partner is changes their public sexual orientation. So for instance, when my partner transitioned from female to male, we went from a visible lesbian couple, to one that looked heterosexual, right, which meant that I had to give up or constantly fight for my own identity. And that's a real issue, particularly for, let's say, it's a woman, a 55 year old woman whose husband transitions and she's always been brought up to think that gay people or some other species that weren't as good and now she's going to be as a lesbian out in the world, that's a big issue. And the irony of the transitioned person gets to be seen in the world the way they want to be seen, and the partner loses exactly the same thing. So there is a tension there that I think we don't talk about enough. Because often the spouse is told two binary things. One is you absolutely have to leave because obviously this marriage can't survive. Or they're told by those of us that are more socially advanced, maybe that you should be supporting your partner, you know, what's your problem. And there isn't enough awareness of the cost in my opinion. The other thing is that people really do have sexual orientations as in, this is the kind of body I want to be next to at night. And some of us can switch. And some of us can't. And, you know, that's not always given enough respect, either. Although they can change early on I was a peer with a lesbian woman whose partner transitioned to male, and I would get off my conversations with her and say, "This is never gonna survive such a pitch, you're not gonna make it," not judging it, but just not judging in a negative way. But judging like, oh, there's too much here. She's too settled in the lesbian mode. And she did make it. And they were very happy. So, you know, sometimes people, switch even when we think they're not going to.

Dr. Regina Koepp 32:18
This tension that you're talking about is so profound. I am just struck. I have heard those binaries, there's really nothing in between either you stay with the person or you don't, you come to terms with it, or you don't, and I appreciate that it's the transitioning partner moving into the identity that they identify with, and longed for, and feel most authentic in. And then the partner has to also shift the tension, I think, and friction is so important to hold space for, because I think if we don't hold space for it, it's less likely to succeed, it's less likely to help the partner to work through and sort of grieve some aspects of the partner's life and identity in support of their partner and in support of themselves. So there are lots of emotional and identity journeys that we're talking about. And then relational journeys that we're talking about. And I really, I thank you for sharing that with us because it's helping to deepen my own understanding and to hold space for people's unique experiences in the same relationship.

Loree Cook-Daniels 33:43
Right. And often, the transgender person believes that if I can convince you why I believe my gender, you know, then you'll go along. And there is a relationship issue here. That's far beyond that. Which does go to my second point about the adult children. When you're transitioning older, your children are often adults. And whether they accept the transition or not is kind of a toss up. We don't have the actual statistics, but some children get on board and some children do not. And we have not really studied about who is who but that's just like the general public. Some people can get their minds around it and some people cannot. But what does happen is if there are grandchildren, if the adult child does not approve of their parents transition, they may cut the grandchildren off and that is one of the worst heartbreaks that I see on elder tg is the grandparents that can't talk to their grandchildren that there is a level of pain in that, that seems to be incredibly high.

Dr. Regina Koepp 35:22
So much grief and loss of legacy and that, you know, parenting is hard. I think grandparenting is when you get the real... it's like the icing on the cake. You know, it's hard to make the cake, but then you just smear the icing on and yes, so much grief and loss and missed opportunity and loss of a legacy.

Loree Cook-Daniels 35:48

The complexity of having mental health providers in the role of gatekeeper for transitioning

Dr. Regina Koepp 35:48
Earlier, we talked about some of the barriers to engaging in mental health care and medical care. When we were preparing for this interview, you brought up such an important topic about the complexity of having mental health providers in the role of gatekeeper for transitioning. Can you talk a little bit about that?

Loree Cook-Daniels 36:07
For many years, what the standards of care for taking care of trans people were the Harry Benjamin standards of care, they're now known as the WPATH, and what wpath guidelines have required is, for many years, they required people to live a year as the gender that they are moving to, even before they could get such things as hormones and surgery, which, depending on your physical body, could be extremely difficult, and extremely opening people up to public problems, violence and discrimination. And what still remains is that in many cases, surgeons in particular, and sometimes the physicians that prescribe hormones, require their patients to basically have a letter from a mental health therapist who has treated them for some period of time. And the letter needs to say, essentially, um, this person believes they're of the opposite sex, but they're still saying it's, you know, the stamp of approval of it's okay to, to give hormones or do surgery, gender related surgery on this person. Sometimes people need those letters from two therapists, depending on what the surgeon or the physician requires. So what that means is that transgender people, this is truer in the past than it is now, have had to have relationships with therapists to even get the health care that they needed. Well, because the therapist had that gatekeeping to those important things that trans people wanted, that early literature from the the people that work with trans people said, they lied a lot. Well, they probably did, because they didn't want to jeopardize their chances of getting hormones and surgery. We know people because we will do so much work with people with trauma histories, that many trans people never tell their therapists about their trauma history, because of the possibility that the therapist would say, well, then you're not, you know, you're not a good candidate for hormones or surgery. Obviously, that means the therapy is less effective than it should be if you're hiding important things in order to present a facade to your therapist. But it also means that when we look at the statistics that the number of trans people that have been in therapy is incredibly high, really, really high. But when there is and when you're not going to therapy for your letter, it's called the letter like it had a big capital L. But you need a therapist for run of the mill depression or you got couples therapy that you need to do or something like that. There's all of this baggage. These were the people that held my identity and my history in their hands. So it's a really, it's a really skippy relationship.

Dr. Regina Koepp 40:12
Yes. The word that stands out to me is trust. And the nature of putting therapists in a role of determining if somebody has the psychological capacity to endure a transition sets this dynamic of mistrust and fear in the relationship that needs to be the most trusted. And so it would make sense to me that people would lie, who do you lie to? People you don't trust, and people who have power over you who could harm you. And so you'll do whatever it takes to keep safe and to get your needs met. And that might include lying. And then, so if you do need mental health care down the road, you carry with you, we call it in therapy and psychotherapy transference, you carry with you that experience, and you transfer it on to the new therapist, that mistrust, and the history of power imbalance and inequitable care, we don't put others through that same level of scrutiny, I can appreciate that there are so many barriers, and with a group of folks with high rates of trauma, and with high rates of mistrust, my hope is that mental health can begin to shift and provide affirming thoughtful, holistic care to trans folks, just as I would want for myself. But the gatekeeper role is not as standard. Is that what you were saying?

Loree Cook-Daniels 41:44
Well, there's now more physicians. And I think surgeons that are doing informed consent, which is the approach that the rest of us have, all the time in medical care, if the doctor says to you, "well, I think you ought to be on this drug. But these are the possible side effects," and you get to make the decision, are you going to accept those side effects? And that's what, that's what many people are moving to, with trans people is informed consent of, let's go over what these hormones will do and won't do and you know, what you can expect and what you're risking, then you decide.

What providers can do to create affirming spaces

Dr. Regina Koepp 42:26
Yes, you understand the risks and benefits and you make a decision that's consistent with what you need. So what can providers do to create affirming spaces? So what can mental health providers do to create affirming spaces? And begin to shift the tide, so to speak?

Loree Cook-Daniels 42:48
Well, I do have some ideas. The very first thing, the most basic thing, is you have got to get the name and pronouns correct. This is not an option, you have to get the name and pronouns correct. And amazingly, even though sometimes it seems difficult, it actually only requires what name and pronoun would you like me to use for you. And that's all it takes, except that you got to remember it, but that's critical. And then if you've got a lot of mental health professionals working alone, but if you've got a receptionist, or you work in a clinic, or whatever, everybody else has to get that too. I mean, I tell physicians, it doesn't matter how trans competent you get, if the receptionist makes a mistake, when the patient first walks in, because the patient won't sit in the waiting, they believe, you know, so you got to have everybody trained.

One of the things that we most emphasize with all kinds of healthcare professionals, including mental health professionals, is what we call "Know and tell why". trans people get subjected to the most obnoxious questions about their genitals. Partners get questions about their partner's genitals. Um, they get asked, you know, what was your real name, we get asked a lot of really strange questions. And as a result, we really get our backs up around questions. We're really nervous. So what providers can do is think through the questions they're asking And figure out, how are you going to use this information? And how is this information going to benefit the client? For example, for a non trans example you're doing your benefits and you're set, you say to someone, in order to figure out if you're eligible for this program, I need to know your income. So it's different, it's a different question than what's your income. And so that's what providers need to do with the questions that they asked trans people. The reason I'm asking this is, and men ask the question, because otherwise, trans people are going to be in general, I mean, it's a generality, but are going to have their backs up like, if it's not obvious why you're asking me this question. I'm going to worry that it's an inappropriate question, or you're just curious. And that happens a lot. I went in with my partner one time, when he had one of those colds, head colds that just you can see it. You can just see it. And we went into the physician, and the physician said, "Why are you on testosterone?" And my partner said, "Well, I'm transgender." And the physician said, "Well, have you had surgery? Do you have a penis?" And it's like, we're here for a head cold, you can see where...

Dr. Regina Koepp 46:44 penis does not influence my sinuses. Thank you.

Loree Cook-Daniels 46:50
You know, so when you get those kind of questions repeatedly, it really helps for providers to think through the question again, know and tell why. Why am I asking this question? And tell the client why. And that builds trust.

Privacy is even more important for most trans people than it is for non trans people. I mean, we were doing HIPAA and stuff, but it's much more important. And one of the things that I notice with a lot of service providers is that they think they have to tell other service providers that someone is trans. Well, that's personal medical information. And maybe you don't have to tell them that it definitely raises the exposure level of the trans person when people do that.

Another thing is to follow the lead, particularly around body part names, if you're talking about body parts, follow the client's lead. If I have what you think are large breasts, and I call it my chest, call it my chest. Trans people often use body part names, they can make up new body part names, they can use other body part names, it's a way of helping cope with the body dysphoria. And so you can really show respect and cut down on the trauma. Because if I said, this is my chest, and you said, "Well, you know, you're pretty big breasted." That can be traumatizing.

And the last thing that I wanted to mention is be an advocate. Find out if your trans client would like your help, it needs to be with informed consent. But if they would like your help with something because it is exhausting out there. I mean, and I think more people can get this now with COVID. It's exhausting out there. Well, it's been exhausting for trans people all along, because you're never navigating so much stuff. So, if service providers could be advocates with consent, that can be really helpful.

Dr. Regina Koepp 49:16
When you say advocates with consent, give us an example.

Loree Cook-Daniels 49:20
This is not exactly on point, but we had a trans man that we were working with that had gone through attempted gender conversion as a kid and it was really awful. And now he was having major, major depression issues. But he wouldn't go to a therapist because of his trauma history. And so we got his permission to talk with a therapist ahead of time. We got his permission to go with him to therapy. So that, you know, it's almost literal handholding?

Dr. Regina Koepp 50:10

Loree Cook-Daniels 50:10
That's the kind of thing I'm talking about of, of helping interface with other systems.

Dr. Regina Koepp 50:16
Thank you for that example. One of the things we talk about in mental health care as well, and in medical systems is a warm handoff. You use the trust that you've established with your client or patient, and by supporting them and moving into a new room, or if you're in the same medical system or supporting them. And starting with a new therapist, and maybe having a group zoom call, that you can help to transfer the trust that you and your client have established or you and the transgender individual have established, and then transfer that trust to the new relationship, just to help so much with the transitions of care. In fact, I was working with an older transgender adult, the therapist was leaving and the therapist had worked with the older transgender adult for many years, the therapist was leaving the system and transitioning the older person to me. And we had an overlap meeting where I came into her therapy room, the older transgender adult answered questions, I shared about myself who I am, what my style is, just so the older transgender person could know me a little bit, and it wouldn't just be so scary, wouldn't be so foreign, unfamiliar. And then she was her preferred pronoun, would know where to go, would know who to look for, would have a sense of security when she got there. And it really helped. And then I worked with her for years. And then after that time, she didn't need as consistent therapy. So, we didn't have the same warm handoff, because it wasn't needed anymore. But I would have done the same thing. And I had done the same thing with other folks. So thank you for saying that. So that is an act of advocacy. And it's an act of consideration for people with higher levels of trauma, higher levels of mistrust in the system. And just ways to build some bridges. Thank you for that, Loree, I really appreciate it.

Loree Cook-Daniels 52:33
It does remind me of something that I didn't say about providers that really is important - know who your referral is. Make sure when you refer someone that they are trans competent. We, we recently had an experience and I'm just telling you this because we're a trans organization, and you think we had it all together. We had a psychiatrist recommended to us. And we wanted to have a zoom meeting where the psychiatrist addressed medications with trans people. And so many of us are on medications, not just hormones, but for our trauma stuff. Plus the normal things like high blood pressure and that sort of thing. And he said horrible things he wasn't intending to but he said horrible things. Like he said, "Well, you're gonna," he said to someone who asked a question, "well, you're gonna have to educate your psychiatrist." And we're like, "No, you know, by the time someone's going to a psychiatrist, they are not in a position to be educating their psychiatrist," and he said a number of things like that. And we were just, we were beside ourselves, because we had some really fragile people on the zoom. And we had to do a lot of work afterwards. And we went back to the person who recommended him. And he says, "Well, I I thought it was really good." Well, maybe in general, but he hadn't had a clue about trans people and he didn't do any of his homework and he did damage. So make sure your referrals are good. And it can damage not only, you know, it not only can a failed relationship with a new person, but it could blow back on you.

Dr. Regina Koepp 54:44
Yeah, and folks' trust with the system as a whole... if the response is you have to educate your provider, that's saying providers are not educated.

Loree Cook-Daniels 54:54
Yeah, well...

Dr. Regina Koepp 54:57
....and are not going to be.

Loree Cook-Daniels 55:00
Yeah, and aren't going to do their homework.

Resources for learning more about Transgender Aging

Dr. Regina Koepp 55:01
Right. So, say we have a listener who is a family member, and wants to learn more about creating an affirming space for their loved one, what would you recommend?

Loree Cook-Daniels 55:13
We have a self help guide for partners of transsexual assault providers, which does talk a little bit about relationship issues. And I think any of the basic transgender aging publications that I sent to you might be helpful. The one resource that I particularly wanted to call attention to was, I have a new transgender client. Now what this one was written with a home health aide, or a nursing home aide in mind of answering the basic questions that tend to come up - what do I call my patient? Who should they room with? What am I going to see when their clothes are off? I mean, you know, we went to some of those, those questions. What happens if my religion tells me, you know, that this is not a good thing? So that particular...

Dr. Regina Koepp 56:25
Can I stop you? That sounds like an incredible resource. I'm going to have a podcast just on that.

Loree Cook-Daniels 56:33
I'm very proud of that resource. Because I didn't find anything out there that was like that. And I think we need to provide that kind of assistance to the people that are taking care. Because we don't think very much about training home health aides on this kind of stuff. We're training nursing home aides, and yet, that's the kind of stuff they're going to think about. So that there's some basic stuff in there that family members might be able to use. But otherwise, I think we're, again, talking about the use of pronoun and names and some of the the basic respect issues.

Dr. Regina Koepp 57:24
And for partners, you were talking earlier about the tension between identity, that identity tension?

Loree Cook-Daniels 57:31
Yeah, I really recommend that partners find at least an online group that supports partners of transgender people. Because I think, first of all, the very first thing of transitioning the partner of a transitioning person needs to know is some marriages make it. It is possible, because oftentimes, people think, well, I have to divorce. It's like, No, you don't. And we'll show you some marriages that survived. And then there needs to be a place to work through. You know, does this mean I'm a lesbian? Do I have to identify as bisexual? What if I don't like their body when they're on hormones? This is the kind of thing that really needs to be worked through. A few couples can work through it together. A lot of couples, it seems, cannot work through it together, they need, they need a separate place. So I would really recommend that. Partners find places online where they can talk to other partners. And of course, we do always recommend therapy. But even then, it's, you know, we've heard horror stories of the therapists that, in fact, I went to early conference where a therapist came in and it was a partner's caucus and she came in and said, get with it. You're supposed to support your partner. He's like, "No, I don't... I did feminists work for a long time. You don't come in and tell me what to do."

Dr. Regina Koepp 59:28
First of all, I decide Second of all, hold space for me. Earlier you mentioned Christine Jordan?

Loree Cook-Daniels 59:43

Dr. Regina Koepp 59:43
Jorgeson. Yeah, tell us who she is.

Loree Cook-Daniels 59:47
I thank you for having me do that. She was a former GI that transitioned and had a surgery in Europe, and was the first really public transgender person when she came back to the US. So, it's Christine Jorgensen. She was physically very beautiful. And she really caught a lot of people's attention. Because her transfer, her transition, made her look so different, and she was public about it. So that's the first time for most people. If you're old enough, that was probably the first transexual you heard about.

Dr. Regina Koepp 1:00:32
Christine Jorgensen.

Loree Cook-Daniels 1:00:34
Mm hmm.

Dr. Regina Koepp 1:00:36
You also shared with us, shared with me, that I will be sharing with our listeners a lot of resources that are so important. I'm just going to review a few of them because I really want our listeners to go and check them out. And these will all be available in the show notes on the trans aging network, elder tg, for transgender elders themselves, creating end of life documents, Medicare changes, transgender elder SOFFA round table, what is that?

Loree Cook-Daniels 1:01:08
SOFFA is significant others, friends, family and allies. It was coined in 95. And it was basically an attempt to open the trans community, which, at that time, defined itself as just trans people. And we were trying to, you know, make people understand that no, the family members were also affected.

Dr. Regina Koepp 1:01:37
Okay. And then for service providers, the guide that you we talked about earlier, which I can't wait to read, I have a new transgender client now, then creating equal access to quality health care for transgender patients, transgender affirming hospital prep policies, that sounds fantastic, inclusive services for LGBT older adults, a practical guide to creating welcoming agencies, quick tips for caregivers of transgender clients, wow, that and then, because I will be airing this right around Transgender Day of Remembrance, there are also really important guides and resources around improving the lives of older transgender adults, abuse and violence directed at transgender elders, and sexual violence, elder abuse and sexuality of transgender adults aged 50 and older results of three surveys. I cannot thank you enough for deepening my understanding and helping to reinforce the things that I do that are affirming and also sharing with me other things that I can do, like holding space for the partner. You know, I have shared this throughout this interview, but my hope is that, as mental health providers, as senior care providers, that we will do a better job for our older transgender adults, that we will begin to dismantle some of the stigma that plagues all of our systems, and keeps people out of care, and increases disability as a result and increases poverty as a result. And I just thank you so much for the work that you do and for educating us today. And I can't wait to read all of these resources and to share them on the show notes page. Thank you so much.

Loree Cook-Daniels 1:03:37
All right. Well, thank you. This has been a lovely interview.

Dr. Regina Koepp 1:03:41
If you have not yet seen the new my new website, I really encourage you to check it out. There are tons of great resources and information there for you. I have a great new guide called the memory loss and mental health guide. In that guide, I share signs and symptoms of dementia, I share signs and symptoms of depression and mental health concerns and what to do if you're concerned about your older loved one. If you're noticing signs of memory loss or mental health concerns, download that free guide as well. I'll link to that in the show notes too.

Oh, and if you haven't yet subscribed to this podcast, please please please subscribe. It really helps other people to find this show. I really want people to feel less alone in their caregiving journey. I want older adults to feel less alone in their mental health journey in their dementia journey if they have that. So please subscribe and leave a review. It really does help. Alright, I'll see you next week. Same time, same place. Bye for now.

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