Transgender Elder Questionnaire

trans elder form

The ACLU LGBT & HIV Project is invested in supporting transgender people and fighting discrimination against transgender people in all forms, including discrimination against transgender elders. We have developed a questionnaire as part of our efforts to respond to the unique ways that discrimination impacts transgender elders in our community.We want to hear from transgender people above the age of 50 about any experiences of anti-trans discrimination by providers of elder-specific care, services or accommodations.

The questionnaire will seek information about the following topics:

(1) Background Information.

(2) Housing.

(3) Medical Care.

(4) End-of-Life Issues.

The most important thing we need right now is stories from transgender people who have experienced harassment, mistreatment, abuse, hostility or other form of discrimination in elder-centered spaces or while seeking aging-related services.

Your responses will also help the ACLU to better understand the needs of the transgender elder community so that we can shape our work to meet those needs.

Please answer the following questions in as much detail as possible. Any information you choose to share with us will remain confidential and be reviewed by ACLU legal staff. We will not share any of your information without your consent.

This is not an offer of legal assistance, just a request for information. We will contact you only if we need to follow up with you.

If you have any questions or concerns please contact Malita Picasso at mpicasso@aclu.org.

If you would prefer to complete a paper version of this questionnaire, you can find a PDF version for print here, and mail it to the ACLU national LGBT & HIV Project for review at:

ACLU

LGBT & HIV Project

125 Broad Street, 18th Floor

New York, NY 10004

Contact Information

Name: *

Telephone: *

Email: *

Background Information

Date of birth: *

Where do you live?

State

City

If other, please describe

If other, please describe

If other, please describe

Housing

This section seeks information about your experiences while seeking housing.

Examples of Housing Discrimination:

A 70 year old transgender woman visits a local nursing home she hopes to move into. While meeting with the manager she mentions that she is transgender. The manager tells her that if she decides to move in she will be assigned to a room on the Men’s floor, rather than the Women’s floor.
A 55 year old gender nonbinary person rents an apartment in a senior-specific apartment building. Since they arrived, another tenant has harassed them repeatedly. The gender nonbinary tenant asked the building management to help but the management has done nothing to address the harassment. Instead, management said, “Maybe you’ll be happier somewhere else.”

Questions:

If other, please describe

Have you ever been denied housing because of your gender identity or gender expression? *

Please explain.

Medical Care

This section seeks information about your experiences while seeking medical care. Medical care can include: physician visits, dental services, mental health services, pharmacy services, physical therapy services, at-home healthcare services, meals-on-wheels services, etc.

Examples of discrimination in medical care:

A 65 year old transgender woman goes to her doctor to discuss starting hormone therapy, but her doctor refuses to discuss it with her, saying he won’t prescribe hormones for her because of his religious beliefs.
An 80 year old transgender man has an at-home nurse. The nurse refuses to use the man’s correct name and pronouns while providing care, despite having been repeatedly asked to do so.

Questions:

Do you have a primary medical care provider? *

Yes

No

Have you spoken with your medical care provider about of your gender identity or gender expression? *

Yes

No

When was your last visit with a medical care provider?

Month and Year

During the last year, approximately how often did you visit a medical care provider? *

Month and Year

Do you currently have active health insurance? (Mark all that apply) *

If other, please describe

Have you ever been denied medical care because of your gender identity or gender expression? *

Please explain.

End-of-Life Arrangements

This section seeks information about your experiences with making end-of-life arrangements for yourself or your loved ones.

Definitions:

Funeral Directive (Disposition of Remains Directive): Lists your instructions for any funeral arrangements including who should make decisions and what should be done with your remains.
Health Care Proxy (Durable Power of Attorney for Health Care or Medical Power of Attorney): Empowers a person of your choice to make medical decisions on your behalf if you’re hospitalized or unable to make decisions yourself.
Living Will (Advanced Healthcare Directive): Specifies your wishes for what should happen if you need certain medical interventions to stay alive.
Visitation Directive: Directs health care providers to allow your loved ones to visit you, or to prevent certain individuals from visiting you in the hospital or long-term care facility.
Will: Specifies what should happen to your property after your death.

Questions:

Have you taken any of the following steps in making end-of-life arrangements for yourself? (Mark all that apply) *

Created a Living Will

Created a Will

Created a Funeral Directive or Disposition of Remains Directive

Created a Visitation Directive

Created a Health Care Proxy

None of the Above

Not Sure

Have you spoken with your loved ones about... (Mark all that apply.) *

Your wishes if you become unable to make medical decisions for yourself

Who should make medical decisions on your behalf in an emergency or if you are incapacitated

Who should or should not be permitted to visit you in the hospital or long-term care facility

Distributing your property after your death

Burial, cremation or similar arrangements

Cemetery plot or mausoleum space

Assisted suicide

None of the Above

Not Sure

Please indicate any of the following steps you have taken in making end-of-life arrangements for your loved one: (Mark all that apply.)

Created a Living Will

Created a Will

Created a Funeral Directive or Disposition of Remains Directive

Created a Visitation Directive

Created a Health Care Proxy

None of the Above

Not Sure

Final

Is there anything else you would like to tell us that we did not cover?

Please explain.

Thank you!

Thank you for sharing your story with us. Your answers to these questions will help us better understand how we can meet the most pressing needs of transgender elders. The information you have shared with us will be reviewed by ACLU legal staff and will remain confidential. This is not an offer of legal assistance, just a request for information. We will contact you only if we need to follow up with you.

Disclaimer and Notice

This questionnaire does not give legal advice, and you should not rely on it as legal advice. You should not rely on the information you get from this site and should speak with a lawyer to get advice on your specific situation. We also cannot promise that the information on this site is complete, accurate, or up-to-date.

This questionnaire is not a solicitation or an offer by the American Civil Liberties Union and its affiliates to represent you. We cannot promise you that the information you provide will lead to any specific action on the American Civil Liberties Union or its affiliates part. Once you complete the questionnaire, the American Civil Liberties Union may not do anything—including contact you—about your situation.

The American Civil Liberties Union will contact you if we are interested in using your information from this questionnaire for one or more of the following purposes: (1) legislative testimony, (2) litigation; (3) contacting a city, state or federal agency; or (4) telling your story to the public, including the media.

We will keep your name, address, telephone number and email confidential unless you give us permission to use it or unless we are ordered to turn it over by a court (although we will attempt to prevent any disclosure).

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