Gender-Affirming Service and Supports Overview

This section is designed to familiarize long-term care communities with best practices to enhance care for transgender patients, who can face an exceptional degree of discrimination and harassment.

A 2011 report by the National Center for Transgender Equality and the National Gay and Lesbian Task Force documented discrimination toward transgender patients in care settings ranging from private doctors’ offices, to emergency rooms, to mental health clinics and drug treatment programs. Respondents reported being harassed by staff or other patients or even being physically abused while seeking care. Nearly one in four transgender women and one in five transgender men reported having been refused medical treatment because of they were transgender. Respondents who had lower incomes or were people of color reported higher rates of mistreatment.

Transgender older adults may feel they have particular reason to fear entering a nursing home because of potential discrimination, hostility, and violence from staff and other residents, and the possibility of receiving unequal care—yet health disparities and social isolation may put many at greater risk for requiring more intensive care. In a recent AARP report, 70% of transgender individuals were concerned they would need to hide their identity in long-term care and 75% were concerned that healthcare providers would not be sensitive to their needs.  These fears are exacerbated for transgender people of color who face higher levels of discrimination than their white counterparts.

The federal Nursing Home Reform Act guarantees rights of privacy, dignity, autonomy, and freedom from restraint and abuse in facilities that accept Medicaid and Medicare. Facilities violate these rights when they refuse to respect the identities of residents, such as by refusing to permit or assist them in wearing clothing consistent with that identity; when they deny hormone medication or refuse to provide personal care because staff are uncomfortable with a resident’s body; when they isolate transgender residents; and when they fail to prevent routine harassment by residents or staff. Facility managers and even state officials might not recognize that such practices are illegal. Again, regulators could help by revising federal nursing home guidelines to clarify these rights.

For transgender and gender expansive people, improving cultural competence for long-term care workers and administrators is a critical component of improving the services and supports they receive. The following section of questions targets key best practices designed to support transgender and gender expansive residents.

Does your community have a policy or policies that specifically outline procedures and practices ensuring appropriate, welcoming interactions with transgender residents (i.e. support one's gender identity and expression)?

Transgender and gender expansive people face enormous challenges when entering community settings.  They face elevated levels of discrimination and harassment, both from staff, volunteers, other residents and even the friends and family of staff, volunteers and other residents. It is critically important that all long-term care communities display a zero tolerance environment for any displays of transgender bias. Having policies that outline proper protocols creates conditions where transgender residents can feel safe and be supported in long-term care communities, while also setting clear expectations for staff, volunteers and other residents. 

There are a number of common practices and procedures, which when implemented, can greatly improve the quality of community for transgender and gender expansive people.  These include:

  • Using the resident’s name and pronoun(s), as indicated by them, in admitting and registration records and with interactions among residents.
  • Ensuring that all residents have the autonomy to present their gender as they would like and that they are not denied clothing, accessories, cosmetics and personal care items that align with their gender identity.
  • Ensuring access to gender-affirming restrooms
  • Preventing interruption to gender-affirming medical and behavioral healthcare such as hormone therapy
  • Assisting with potential insurance / billing claims
  • Compliance with privacy laws

For example: 

"Guidelines for Quality Care for Transgender Patients" by Woodland Pond at New Paltz includes policices and procedures related to pronoun usage and access to restrooms.

Does your community offer all-gender restrooms in public areas and/or have clear posted signage indicating a policy that allows individuals to use the restroom that aligns with their gender identity?

Bathroom safety is a paramount concern among transgender and gender expansive individuals. According to the National Center for Transgender Equality. A majority (53%) of transgender people report experiencing verbal harassment or disrespect in a place of public accommodation and 8% percent report being physically attacked or assaulted in places of public accommodation.

59% of transgender people say they have avoided bathrooms in the last year because they were afraid of problems, such as being confronted by others; 

12% of transgender people report that they have been harassed, attacked, or sexually assaulted in a bathroom in the last year 

And although some claim that expanded bathroom access will result in safety risks to women and girls, a 2018 study from the Williams Institute found no link between gender inclusive bathrooms and safety. The research showed that reports of these incidents are extremely rare.  The real risk is non-inclusive bathrooms.  Reports of attacks on transgender people in restrooms are much more highly prevalent and present a serious safety risk to transgender and gender expansive people.

Because of the growing recognition of this safety precaution, many organizations and businesses across the country have adopted gender inclusive bathroom policies and procedures.  

In example:

"All Gender" bathroom signage