Transgender Competence in Social Work with Older Adults in Sweden

Abstract

Despite a growing transgender aging population with differing needs and care preferences, professional knowledge on gender identity and expression is still limited. This study examines Swedish social workers’ knowledge, experiences, and prerequisites for working with older transgender adults in municipal social services. The study is based on qualitative semi-structured interviews with 16 social workers and the collected data were analyzed using the content analysis method. The analysis is presented through three themes: Heteronormative Discourse, Causes and Consequences of Invisibility, and Terminology and Pronouns. The results indicate that the challenges in social work with older transgender adults are related to invisible needs, a lack of knowledge, and social services organizations that do not prioritize issues related to gender identity and expression. Implications for social work are discussed as an increased reflective practice and a norm-critical approach, in order to grasp the older transgender individual’s specific experiences and needs, beyond stereotypical ideas and thoughts on sexual orientation. However, to be able to develop this reflective practice, institutional and organizational conditions for increased knowledge are required as well as an historical understanding of exclusion and a deeper attention to the meaning of equal treatment. Future research suggestions include examining the relevance of LGBTQ-certification.

Keywords:

• Transgender
• gender identity/gender expression
• older adults
• elderly care
• social workers
• social services

Introduction

Despite a professional mandate for social workers to understand the unique needs of older transgender adults, aging service providers are in general unprepared to meet the challenges of a growing lesbian, gay, bisexual, transgender and queer (LGBTQ) older population (Fredriksen-Goldsen et al., 2014; Knochel et al., 2012). Not only does a normative view on aging combined with a history of marginalization of transgender persons contribute to this ignorance, but so does a lack of research on gender identity and expression among older adults (Fredriksen-Goldsen & Muraco, 2010; Siverskog, 2014).

Many transgender people have undergone a process – mental, spiritual, social, and/or physical – to acknowledge their gender identity and expression, and for many it has meant navigating prejudices, hostility and discrimination. Jones and Willis (2016) argue this process is associated with fears and discomfort which may be triggered by the disclosure of the formerly assigned gender. A report from The Public Health Agency of Sweden (2015) shows many transgender individuals experience mental illness because of abusive treatment, discrimination, and violence: 36% state they have had thoughts of suicide, 65% have foregone activities due to fear of discrimination and 20% have been subjected to violence. Even though Sweden, together with other Nordic countries, tops the list of the world’s most equal countries (Equal Measures 2030, 2030, 2019), the experiences of transgender persons are basically neglected in Swedish gender equality policy (National Secretariat for Gender Research, 2015). This is especially true regarding to older transgender people. For example, in a national strategy for equal rights and opportunities irrespective of sexual orientation, gender identity or gender expression, six particularly important development areas are identified. Five out of the six areas are directed at the entire group of the LGBT community and one area concerns young adults. Although large parts of this strategy are relevant for older transgender adults, attention is not paid to the specific needs of elderly adults (Government Offices, 2014; SOU, 2017:92). For people who, through their physical bodies, challenge cisgender¹ normative assumptions and who have experiences of a process for confirming their gender identity, it can be particularly unpleasant to become recipients of (intimate) elderly care services (Jones & Willis, 2016; Siverskog, 2016).

Despite rights regulated in legislation, aging transgender people are worried about future care, and fear being exposed to transphobia from care providers in the elderly care sector (cf. Siverskog, 2014, 2016). Many older LGBTQ adults also experience a lack of knowledge among professionals and have low confidence in social institutions, such as healthcare and social services (Siverskog, 2014). This concern is partly due to previous negative experiences from their encounters with healthcare services, but also to the fact that transgender adults of this generation have lived at a time when repression against them was institutionalized (Swedish Federation for Lesbian, Gay, Bisexual, Transgender, Queer & Intersex Rights [RFSL], 2020). These insecurities are also apparently justified as shown by the fact social workers themselves report they experience uncertainties when meeting people whose gender expressions are difficult to interpret (Smolle, 2016; Swedish Government, 2016).

Although transgender issues are increasingly discussed in the mass media, the professional knowledge on LGBTQ issues within health and social care is still limited and rarely acknowledges older transgender adults (Löf & Olaison, 2020; Siverskog, 2014; SOU, 2017:92). As the transgender aging population grows and becomes more visible, there will be an increase in older adults with differing needs and preferences (Löf & Olaison, 2020; Vincent & Velkoff, 2010). This in turn will mean a diversity of care requests that call for competent social workers who understand the unique needs of older transgender individuals. However, research that reflects the conditions and prerequisites for professionals in elderly care to work with this group is still limited. This includes, for example, knowledge of how structural factors and legislation discriminate transgender people, familiarity with gender identity and expression, and its significance for older people’s experiences of treatment.

The aim of this article is to examine Swedish social workers’ knowledge, experiences, and prerequisites to work with older transgender adults in municipal social services. Key questions are:

1. How do social workers understand the needs of older transgender adults?

2. What are the knowledge gaps?

3. What are the conditions for working with a norm-critical approach that extends beyond the prevailing gender binary?

The Swedish Context

There are no reliable statistics in Sweden on the number of individuals who do not define themselves within the framework of the dichotomous gender division. However, in recent years there has been a large increase in young adults seeking help on gender dysphoria, and the State subsidizes gender-affirming care and treatment after a medically established gender dysphoria diagnosis (National Board of Health & Welfare, 2019). The referred care and treatment include medical help to transform the body with hormones and/or surgery. The transition process in Sweden is often, according to Bremer (2011), gender normative and aimed to materialize bodies to either female or male. That means for people whose gender identities do not fit into these two categories, their accessibility to appropriate types of transgender related care is jeopardized (cf. Linander, 2018; Siverskog, 2014).

The gender normative perspective means, for example, it is only possible to be assigned one of two legal genders, and this legal gender in turn affects the registered personal social security number of a person. All Swedish citizens have a gendered social security number (cf. Linander, 2018); however, after changing one’s legal gender, it is possible to apply for and obtain a new social security number (Transformering, 2019). The social security number is crucial because it is frequently used in Swedish bureaucracy and administration, which means regardless of a person’s gender identity and expression, a person’s gender is interpreted in accordance with the social security number.

Transgender identity and expression is a protected ground of discrimination as stipulated in the Swedish Discrimination Act (Diskrimineringslagen, SFS 2008:567). This act intends to counteract discrimination and promote rights and opportunities regardless of gender identity and expression (in addition to seven other grounds of discrimination, such as ethnicity and age). The Act encompasses direct discrimination, indirect discrimination, lack of accessibility and harassment. In 2018, the Swedish Parliament also decided to extend criminal justice protection to transgender people (Ministry of Justice, 2017) which means transgender people are today recognized in the Swedish Constitution (see Freedom of the Press Act 1949:105).

In a strategy for equal rights and opportunities, the Swedish government has highlighted several areas in which conditions to increase knowledge and equal treatment regarding sexual orientation, gender identity and gender expression can be created. Here, ambitions are expressed that are intended to reduce exposure to violence, discrimination, and violations and, moreover, to facilitate equal conditions to enable good health, and to strengthen civil society organizations that promote equal rights and opportunities. One of the areas highlighted as particularly important, is strengthening the LGBTQ perspective in the care of the elderly (SOU, 2017:92).

Support and care for the elderly is mainly provided within the social services at the municipal level (cf. SOU, 2008:51; Socialtjänstlag, SFS 2001:453) and it is usually social work professionals in the elderly care field who meet older adults when care, help and support is potentially needed. The social worker function includes assessing needs, taking decisions on support and assistance, and collaborating with healthcare agencies. Furthermore, older adults can also be put in touch with other professional social workers for financial assistance, substance abuse, other family matters, etc.

Despite the intentions of the Swedish Social Services Act (Socialtjänstlag, SFS 2001:453), that the care of elderly should protect and respect each individual’s privacy and bodily integrity, self-determination and participation, there is a fear among transgender people of being transphobically treated (Siverskog, 2016). A survey conducted by the National Board of Health and Welfare (2013) also confirms LGBTQ issues are often given low priority in social services, and there are no tools for dealing with people with a norm-critical approach. One way to address this lack of knowledge is to undergo LGBT certification, usually organized by The Swedish Federation for Lesbian, Gay, Bisexual, Transgender, Queer and Intersex Rights (RFSL). An LGBT certificate can be awarded after a workplace, group or team have completed knowledge- enhancing initiatives on the norms and consequences of standards for health and living conditions for LGBTQ people (RFSL, 2020b). Today, more than 400 workplaces have been awarded an LGBT certificate in Sweden (RFSL, 2020c). Overall, this certificate appears to have been awarded most frequently in the social services sector working with children and young people, for example in youth guidance (RFSL, 2020a).

Previous Research

Although the legal and civil rights of LGBTQ people have gradually been strengthened (Parliamentary Assembly of Council of Europe [PACE] 2015, 2017; UN Human Rights Council, 2011, 2015) many older LGBTQ adults report a high degree of discrimination, vulnerability and internalized stigma, as previously mentioned (Fredriksen-Goldsen et al., 2013; Siverskog, 2016). Discrimination and stigma, in turn, contribute to older LGBTQ adults having a disproportionately high risk of lower health status, psychological distress and poverty (Fredriksen-Goldsen et al., 2013; Grant et al., 2011). The vulnerable life situation also means older transgender people are overly concerned about what will happen when they no longer have the capacity and/or resources to take care of themselves and they become dependent on others. The older people’s fears and concerns about life’s final stages are thus largely about losing control and integrity (Witten, 2016). Therefore, it is important that potential care needs are understood in the light of a person’s life history and do not replicate people’s previous experiences of negative treatment (Jones & Willis, 2016).

Deficiencies in meeting transgender needs in public health and social services mean social support from close relatives is of great importance. Fortunately, in general, many LGBTQ individuals receive vital informal care and support within their social network (Chapman et al., 2012). However, the situation for Swedish LGBTQ people appears to be different. Research shows older transgender adults have small networks and less access to social support compared to cisgender persons in the same age group (Siverskog, 2014). This portends a critical situation considering the lack of potential support relationships in turn requires a greater need for social support provided by public institutions; and this at a time when there have been cutbacks in the Swedish welfare state. Consequently, there is a risk of unmet needs for older transgender adults who often belong to an array of family structures including families of choice (friends or former partners) where support exchanges are more a matter of negotiation rather than commitments and obligations (Espvall, 2008).

Transgender people’s confidence in social institutions in Sweden is, as in the rest of the world, extremely low (Wahl & Jonsson, 2017). In the survey by The Public Health Agency of Sweden (2015), a quarter of those who responded stated they had been subjected to physical violence by an on-duty police officer. Transgender people also find it particularly difficult in their encounter with the social services because social workers often lack knowledge on transgender-related issues and therefore act unprofessionally, i.e. by not knowing which questions can be asked and which questions can be perceived as offensive (SOU, 2017:92).

“They Just Don’t Have a Clue” is the title of Siverskog’s (2014) article, which summarizes the lack of knowledge on transgender issues that older transgender people experience in their contacts with Swedish social services. Overall, research on transgender living conditions in Sweden is limited, and the research that is available mostly focuses on conditions when people seek medical help because of gender incongruence (cf. Bremer, 2011; Linander, 2018; Zeluf et al., 2016), or emphasizes sexual orientation, which means issues related to gender identity and gender expression are partially neglected (SOU, 2017:92). An important exception is the research conducted by Siverskog (2014, 2016) and Löf and Olaison (2020). While Siverskog examines LGBTQ people’s experiences of living and aging as lesbian, gay, bisexual, transgender or queer, Löf and Olaison focus on LGBTQ people’s perceptions of future needs in elderly care. Notwithstanding, the unique conditions that apply to transgender people are still an overlooked field in Swedish research and applies in particular to the treatment and knowledge deficiencies in the social services.

Gender Identity, Expression, and Ageing

It is impossible to avoid the wide range of associations and norms that are a consequence of the gender assigned at birth as well as to the gender attributes present (cf. Connell & Pearse, 2015; van Anders, 2015). Gender identity is described by Fredriksen-Goldsen (2016) as a person’s own sense of gender, irrespective of the gender assigned at birth. The construction of gender identity could be interpreted as a result of becoming a gendered being, which includes what beliefs and conceptions about belonging to a specific gender mean (cf. Connell & Pearse, 2015). Gender expression can be defined as a person’s way of articulating gender through behavior, appearance, and symbols. Identity can therefore be understood as indefinite and not nature given, which consequently means it is possible to define oneself in several ways (Butler, 1990). In research on these issues, different concepts are used to clarify the complex systems that exist around gender and gender variations. Transgender (or in short “trans”) is an umbrella term for identities that do not, or partially do not, define themselves with the assigned biological or legal gender, or with the socially constructed gender binary or cisgender norms (Burdge, 2007; Jones & Willis, 2016). Both transgender and trans are used from hereon, but they refer to the same thing.

Central themes within queer theory are the questioning of fixed gender identities and normative expectations and beliefs (Butler, 1990; Cameron & Kulick, 2003). An awareness of gender norms is fundamental for understanding an identity that exceeds gender norms and, therefore, it is relevant to apply theories that question the meaning of normality/normativity, and performativity. Normality is used as a term for what is considered “normal” while normativity is a system of norms that affects beliefs of what is to be seen as normal. Performativity explains how well a person imitates and presents gender and identity based on hetero- and cisgender norms (cf. Butler, 1990). Because trans people (as well as intersex people) sometimes have bodies that exceed the two-gendered norms or expectations of how gender should be presented, the concepts around normativity and performativity are highly relevant. This relevance can be explained by the fact that normativity and performativity can act as factors as to who is considered acceptable or normal, according to normative assumptions of the gender binary (cf. Butler, 1990). However, they also interact and intersect with other categories, such as sexuality and age. The body is a central theme in relation to aging because of normative ideas on how age is supposed to be performed. At the same time, sexuality and gender identity or expression are not expected to be embodied or practiced by an older adult (cf. Butler, 1990; Siverskog, 2016). Older adults who perform their gender or age in a non-normative way are therefore likely to be seen as less “normal” and acceptable, in regard to the concepts on normativity and performativity (cf. Butler, 1990). These two terms are continuously used in this article.

Regarding aging, it is not possible to find an indisputable definition because the meaning of age and its attributes are socially and culturally constructed (Heaphy, 2007). The experience of aging will therefore differ markedly between individuals as well as between social groups (Heaphy, 2007). However, discourses on older age are intricately linked with assumptions about several aspects relating to social life and older bodies (Sandberg, 2008). Sandberg explains a reason to focus on higher age and aging in relation to queer theory is primarily advantageous because of the possibility to critically question normativity and power. Older adult is used in this article to describe a person who is 65 years of age or older while elderly is used in some parts of the article when referring to a specific group and area within social work (elderly care). However, it should be kept in mind that age, as well as gender, can be questioned through critical perspectives.

Studies that problematize and challenge gender dichotomy and norms, and discourses concerning gender in social work are often presented from a queer theoretical approach (Burdge, 2007; De Jong, 2014; 2015; Fabbre, 2015; MacKinnon, 2011; Ohnstad, 2009; Spivey, 2006; Tilsen & Grieves, 2007; Willis, 2007). Grounded in these types of earlier contributions, this study uses queer theory in similar ways, i.e. to question and problematize normativity and performativity, especially regarding gender identity/expression and age, as well as established normative beliefs and expectations. Further, queer theory acts as a critical lens when examining social work with older transgender adults, in addition to the theoretical insights gender theory contributes.

Method and Analysis

This study is a part of a larger project with the overall aim to examine Swedish social workers’ knowledge on transgender issues and their professional experiences of working with older trans adults in social services. The research project has been reviewed and approved by the Research Ethics Board in Umeå 2018 (doc. no. 2018/261-31).

This article is based on qualitative interviews with sixteen social workers, of which thirteen are cisgender women and three cisgender men, working in a medium-sized Swedish city (about 60,000 inhabitants) and a metropolitan area (about one million inhabitants). Fourteen of the interviewees have a degree in social work and two have a university degree in another care-related profession. The age of the interviewees differed significantly (between 25 and 65 years of age) as did their professional experience counted in years (from 1 to 20 years of experience in social work). Ten interviewees work specifically assessing older adults’ health and care needs, while six of the interviewees work within a wider spectrum of social services. Social workers with broader task assignments were interviewed because of an ambition to cover wider professional experiences with older transgender adults, not just within elderly care. Four of the interviewed social workers had completed some form of training to collectively receive a “LGBTQ diploma” at the workplace.

Initially, contact with managers and social workers was established in the municipalities. These, in turn, forwarded information about the project and a request for an interview to their employees and colleagues. Contact was then made with interested social workers, who were given further information about the project, and a time and place for an interview was agreed. All interviews were carried out at the social workers’ workplaces. Before the interview started, the respondents were again informed about the aim of the research project and confidentiality conditions, and they were reminded of their rights to decline participation at any time in the interview process. Participants were asked open, thematic questions about their professional experiences. The themes addressed were: Understanding and knowledge about the needs of older transgender adults and norm-critical approaches and perspectives. The interviews lasted between 40 and 80 min. All interviews were audio recorded and transcribed verbatim.

Analysis of data began by reading through the transcribed text to create an overall understanding of the collected material (cf. Hsieh & Shannon, 2005). The transcribed material was then read several times using the content analysis research tradition (cf. Krippendorff, 2013). Similarities and differences in the social workers’ experiences were noted, using the software program NVivo 12. Collected data were then interpreted with guidance of theory to find meaningful patterns and themes. This study did not seek to generalize statistically to the wider population but rather to develop a deeper understanding of social workers’ professional experiences of working with older transgender adults. Although the social workers are employed in different fields and municipalities and are of different gender and age, the informants in this study provided quite similar descriptions of their professional experiences, a factor that strengthens the validity of the study. All quotes have been translated with great care from Swedish to English.

Results

This section presents the interviewed social workers’ views, approaches, knowledge, experiences, and needs, in their work with older adults and issues related to gender identity and expression. The results are presented through the following three themes: Heteronormative Discourse, Causes and Consequences of Invisibility, and Terminology and Pronouns. In the results, the interviewed social workers have been given fictitious names for anonymity.

Heteronormative Discourse

In all interviews, the social workers emphasized the importance of equality and respect for individual rights in their work and underlined the significance of equal treatment for all regardless of gender identity, expression, sexual orientation, ethnicity and class. Although human rights and legal certainty were referred to as fundamental norms, a heteronormative discourse emerged as a central theme in the interviews. Several social workers stressed normative views on sexual orientation and gender were manifested, for example, through the choice of language in conversations conducted between colleagues at the workplace. One informant described:

There are almost only discussions derived from heterosexual norms. Sometimes there are discussions about same-sex relationships, but it does not really have to do with work but matters that are more private. There is a very strong heteronormative perspective here. Even when it comes to gender, there is a very normative view, I would say. (Lars)

The majority of the interviewees deliberated about how heteronormative structures form the basis of preconceived opinions and views that social workers, more or less intentionally, let influence their work. The heteronormative perspective described could be explained by a dichotomous approach, which assumes there are two kinds of human bodies – women and men – that are expected to perform their assigned gender. Relying on dichotomous beliefs in practice, whether deliberately or not, complicates the task of examining and assessing the need of care among trans individuals. To some extent, it is even possible that heteronormative discourses counteract human rights in social work with one consequence that principles, such as legal certainty, are difficult to achieve. Furthermore, in a heteronormative discourse expressed by the informants, a binary view on gender emerged. This included dichotomous and stereotypical images of what transgender means, where most of the informants focused on transsexualism or transvestism. For example, when asked about experiences of meeting people (clients) with trans identities or expressions, one informant (Sander) said “Have I ever met people that are transsexual? Not in this occupation. I might have, although I have not noticed it. But I have met gay persons.” Little attention was given to identities that do not define themselves according to the two-gendered norm or do not fit into the stereotypical image of a transgender person. Despite the interview’s focus on gender identity and expression, the informants included sexual orientation (illustrated in both examples above), which indicated that there was a discursive understanding of people who were not interpreted as, or did not consider themselves to be within, the heteronormative framework. In addition, terminology relating to sexual orientation and gender identity and expression, seemed to be mixed up by the social workers, which can be interpreted as lacking understanding of the distinction between gender identity/expression and sexual orientation. Such a lack of separation may contribute to the deviant group, viewed from a heteronormative perspective, being seen as homogeneous regardless of differences in orientation, identity, body, life experiences, age, and ethnicity, and so on, living under similar conditions.

Causes and Consequences of Invisibility

The matter of invisibility was another central theme in the interviews; and the social workers especially focused on the causes of invisibility as well as possible consequences when failing to recognize a group and its potential needs. Recognition of older trans adults did not appear to be a matter of certainty for the social workers in this study. As several informants touched on, they found it hard to determine when it was correct to acknowledge and, in addition, ask questions related to gender expression which might be considered a sensitive topic for some older adults. One informant said:

There are many [cisgender women] who wear pants and have short hair without having a transgender identity. It may not be as common for people that look like men and are cisgender to wear dresses. Therefore, recognizing them is much easier, while people who might have a particular purpose with their clothes and their hairstyles might be at risk of becoming invisible. (Zara)

This type of reflection disclosed some sorts of stereotypical ideas about gender attributes appeared to be a real dilemma for social workers. Transformed into action it could, on the one hand, contribute to discriminatory practices and, on the other, contribute to making individuals invisible. Invisibility emerges especially if the help-seeking older adult does not deviate much from expectations on how gender should be presented and performed. That means an older adult’s gender presentation and performativity in itself could act as a mechanism for invisibility with the consequence that the individual needs of people with non-normative or non-conforming gender identities and expressions are at risk of not being recognized.

One explanation for the social worker’s lack of experience is the invisibility of older trans adults, resulting in social workers assuming not to have met the target group (cf. Fredriksen-Goldsen, 2016). Siri noted “But I’ve never really been face-to-face with someone where you see that you need to talk a little bit more about identity. It has not really happened for me, or I might have been unaware in some way.” The quote illustrated if social workers do not reflect on and talk about gender identity and expression, the consequence is gender variety does not exist and older transgender adults remain invisible. Invisibility can be understood as a silence, from both parts – social workers as well as older trans adults. When needs are not expressed, they are not seen to exist, which underlines the importance of identifying silence and silencing within care settings. From this perspective, it also becomes clear that a person, already vulnerable because of their normative deviance and need of care, is in a particularly vulnerable position regarding invisibility. In addition to this, life experiences linked to stigma associated with gender identity and expression can also be a contributing factor to a person being vulnerable and having specific care needs. In addition, the notion of passing is also highly relevant to mention regarding invisibility. Passing can be defined as a person’s desire not to be identified as a person with trans experience (Engdahl, 2010); and the wish to pass is often closely linked to a person’s experiences of not being acknowledged as having the gender in which they identify (cf. Linander et al., 2019). Passing can therefore be understood as how a person is perceived by others, in a normative or non-normative way, which puts great pressure on an individual’s practice of gender normativity as well as gender performativity. Considering the quote above, when Siri mentioned “someone where you see…” this likely referred to a person who is not perceived to be normative regarding their gender performativity or is not considered (according to the social worker in this case) to be passing.

Furthermore, some informants described their experiences of how the ambience in the workplace changes when an individual does not “act as expected.” Lea explained:

I know that when there have been people who do not act as expected, the atmosphere has become a little bit non-serious. People easily joke about it. People get a little bit nervous. (Lea)

Firstly, the informant said “act as expected” which can be interpreted as a person’s gender normativity or non-normativity. Secondly, it is reasonable to assume professional uncertainty, rooted in lack of knowledge, and insufficient experience, contributed to this non-serious and nervous atmosphere. In this case, professional ignorance was expressed when the social workers met someone who challenged their expectations on gender normativity, which often become particularly visible when they are exceeded. The consequence is an invisibility of the older trans adults’ gender identity or expression as well as needs, which likely will have an impact on the care that is given.

Social workers’ experiences of insufficient knowledge as well as professional insecurities are therefore aspects that contribute to an understanding of both the causes and consequences of invisibility. The same applies to the notion of passing, which can also be seen as a significant aspect of invisibility. The social workers interviewed in this study all expressed good intentions, but great insecurity because they did not want to contribute to creating visibility in a negative way (outing) for people with trans experiences, or to make sensitive situations uncomfortable. These insecurities seemed to be especially related to concerns about the age of the people the social workers meet.

Terminology and Pronouns

How to speak about transgender issues and how to put questions to older adults was a central theme in the interviews, and much attention was given to terminology and pronouns. As mentioned in the previous theme, the limited knowledge of trans people and their possible needs seemed to be the main reason for the informants’ uncertainty about how to act and speak in a potential meeting with older trans adults. Ola described:

I don’t know much about the aging of transgender people. Other than there has been a demand for elderly care homes [with LGBTQ focus] and that this has been addressed in some places. Although I know people of my own age and younger, it doesn’t say much about those who were born in the 30s to 40s. (Ola)

The quote illustrated how knowledge about trans people is primarily centered on a younger generation. This was evident in all the social workers’ descriptions regardless of the typical ages of the client groups they met daily. Knowledge on transgender issues is often described as derived from general societal discourses and media, where a younger population are often the focus. Gender identity and expression as well as sexuality are rarely expected to be practiced or performed by an older person, and therefore a non-sexualized and cisgender normative discourse of older adults is likely influencing how needs are perceived. This contributes to an age-related understanding that neglects the special needs of older adults.

An overall central topic in the interviews was the demand for a deeper understanding of adequate terminology. The informants described the existence of many new terms, related to gender identity and expression, the meaning of which they did not understand. They also pointed out concerns about whether the older adults they meet would understand this terminology, as some words used today are new or have previously been used with negative connotations. For example, the term queer which, for a long period during the 1900s, was used as a derogatory word for LGBTQ people, by people outside the community. This is highlighted as a reason why some older adults might not want to be associated with concepts related to negative experiences earlier in life. Siri described further about pronouns:

I do not ask about pronouns, but I do label people when I refer to them as “she” or “he.” One way could be to write “they”² about everyone but I think that many of the older adults would not understand it. That is a prejudice of mine. (Siri)

In the quote, Siri was partly reflecting on the consequences of only using certain gendered pronouns as well as on the possibility of using a gender-neutral pronoun. However, Siri also pointed out that this might pose a risk of not being understood by older adults, or that prejudices and expectations about older adults and aging again are reproduced. In line with this, one informant further described how the social workers at the workplace talked about asking questions about preferred pronouns, to open up for self-definition. However, some colleagues were doubtful. Ida put it:

What we have been talking about is that we in our interview guide should start by asking a question about pronouns. We do not have that now and some social workers think “There are some that will not understand what we mean by that and then we must explain.” Yes, but maybe it is still better than not asking because we write “he” and “she” kind of a lot in the assessment material. (Ida)

The majority of the informants felt it would be beneficial to ask the people they meet for pronouns, but no one did this as they were concerned about potential reactions. This puts individuals in situations where they need to decide whether the possible benefits of discussing pronouns and using certain terminology outweigh the consequences of exposing someone to privacy violations. Most informants mentioned they work with an administrative system that collects names and social security numbers from the population register, which means that a person is presented in documentation as one of two genders even before the meeting takes place with that person. It is obvious that the administrative system as well as predetermined guidelines and documentation standards, such as forms, are challenges in the work toward achieving better treatment for older trans adults. However, some argued with more knowledge they could choose to work in a different way, such as asking questions differently, while also contributing to updating heteronormative forms and guidelines.

Regarding the complexity associated with asking questions correctly, the interviewees talked about opportunities, which involve increased insight and trust, but also risks, such as potential violation of older adults.

I am thinking about how to ask questions […] that you should ask the question in a way that includes all people. We have talked a little bit about that maybe we should ask: “Who do you consider to be your family?”, for example, instead of: “Do you have children?” […]. That way, people can mention other people who may not be, biologically speaking, family. (Lea)

Lea illustrated the relevance of using language – when questions were asked – as a link to respect and inclusion (cf. Fredriksen-Goldsen et al., 2014). In the proposed questions given by the informant, an approach emerged in which questions were asked to open up the possibility for the person to define the meaning of, in this case, family relations. The quote also touched on another central aspect of asking questions, where family acts as an example of how it is possible to gain increased transparency and understanding of the individual’s situation and possible needs. This can be relevant in the work with older trans adults where extended and alternative families and networks can be of importance.

Furthermore, most of the informants’ underlined their meetings with the older adults in the assessment process for needs and interventions are short and temporary, while more extensive support is provided by other caregivers, such as homecare and healthcare. Consequently, several professions need to work actively and together for a successful norm-critical practice in elderly care. In order to bring about a change through increased awareness, the informants suggested that all professionals (meeting older adults) should have insight into the problems that older transgender adults can experience, and some mentioned LGBTQ certification as a conceivable way forward.

Discussion and Implications

In this study, Swedish social workers’ knowledge of transgender issues and their professional experiences of working with older transgender adults, has been examined. The main results in this article, based on three key questions, addresses the social workers’ understanding of needs, the invisibility of older trans adults in social work practice, as well as certain dilemmas and knowledge gaps in regard to gender identity and expression.

Our first question was about social workers’ understanding of older trans adults’ needs. The results indicate a heteronormative discourse dominates social work practice and, paradoxically, contradicts central values relating to the importance of human rights and equal treatment, regardless of gender identity and expression. As social workers are part of general society, it is likely that normative ideas follow the social workers into the assignments and contribute to reproduction of stereotypes and, consequently, individual needs are overlooked. When LGBTQ issues are raised by the informants, primarily sexual orientation is noticed, and transgender is often described in terms of transsexualism or transvestism. Other trans definitions, such as those beyond the binary ideas of gender, are therefore rarely used among the social workers. In addition, questions or issues regarding gender identity/expression are raised primarily, if at all, when older adults do not perform gender and age in a normative way.

Our second question was about the existence of knowledge gaps. Knowledge gaps around trans issues also mean that the importance of visibility, recognition and meaning of passing is ignored. To pass is often intertwined with the longing of having the gender identity affirmed as well as not being questioned (Linander et al., 2019). Passing is about normativity and performativity, i.e. how and to what extent a person performs gender and age in normative ways. Lack of knowledge about these processes implies that some social workers face a dilemma when they want to acknowledge older trans people in order to counteract invisibility, but do not want to be disrespectful to either cisgender or trans people. Therefore, the social workers feel insecure when asking questions in an open manner. On the one hand, they wish to receive important information and recognize needs and, on the other, they do not want to risk violating people. These insecurities provide valuable insights as to why the social workers in this study avoid talking about gender identity and expression in their profession.

Finally, we examined the conditions for working with a norm-critical approach that extends beyond the prevailing gender binary. The Swedish Government has ambitions to create the conditions for a better response to LGBTQ persons in the social services and has set aside special funds for such an investment (SOU, 2017:92). Several municipalities have also developed strategies for this work, but it is still too early to assess the outcome of the government’s initiative. Further, there are increased prerequisites for LGBTQ certification. For a few years now it has been possible in Sweden to be awarded a LGBTQ certificate after completing training through an arrangement with the largest national LGBTQ organization (cf. RFSL, 2016). However, there is now a market even for these issues, and certificates are offered by a variety of organizations, businesses and municipalities, using different labels such as diplomas. The length and content, as well as the price, are often reduced compared to the original certificate (cf. RFSL, 2020b).

Conclusions

The study shows key challenges in the work with older transgender people relate to invisible needs, a lack of knowledge, and social services organizations that do not prioritize issues related to gender and identity. In other words, there is a gap between organizational prerequisites and professional ambitions which puts social workers in difficult situations and highlights the need for a norm-critical approach. Essential in such a norm-critical reflection is an historical understanding of exclusion and a deeper attention to the meaning of equal treatment.

An important part of norm-critical reflection is the insight into the consequences of cisgender- and heteronormative history, and how prevailing discourses exposed transgender persons to stigma, shame and invisibility (cf. Porter & Krinsky, 2014). Through a historical lens it becomes possible to understand why older trans adults nowadays are scared to talk openly about issues concerning gender identity and expression, why policy documents and manuals neglect the diverse needs of older trans persons, and why language and questions often manifest a heteronormative discourse. Without doubt, the social workers are striving for nondiscrimination and equal treatment. However, even if the equal treatment principle reflects good intentions, it can lead to discrimination in practice. Equal treatment is based on a vision to treat everyone equally, which means to treat everyone the same (cf. Fineman, 2010). Without acknowledging individual experiences and histories, the equal treatment principle can reproduce normative ideas while at the same time failing to recognize individuals who are not a part of the prevailing cisgender and hetero culture. This can be explained by the fact that this principle does not take into account background nor differences in positions, circumstances and contexts (cf. Fineman, 2010).

Parts of the knowledge gaps claimed in this article are on an individual level, but also reflect structural and institutional limitations. The social workers testify to the invisibility of trans people’s needs, lack of time and resources, and organizations that do not prioritize issues related to gender and identity. Social workers are organizational representatives who are in the intersection between organization and profession (Ponnert & Svensson, 2019). This means the organization is dependent on political factors and market logic while the social workers must meet individual needs and at the same time practice the established policies and regulations within the organization. The contradiction between organizational and political ambitions and practical prerequisites becomes evident when the informants repeatedly claim there is a lack of initiative and support for increased knowledge on the subject from management as well as politicians. In sum, Swedish social workers have good intentions to promote social justice and human rights for older transgender adults. In addition to an increased reflective practice to grasp a trans person’s specific experiences, needs and historical vulnerability beyond the topics of sexual orientation or stereotypical ideas, institutional and organizational conditions for increased knowledge are required.

Limitations and Future Research

The results of this study should be interpreted with some limitations in mind. One important aspect concerns the selection of informants and the general interest among social workers to discuss issues related to older adults’ gender identity and expression. The social workers who responded and wanted to participate in the study were mainly those that found these issues important and interesting to reflect on. From this it is possible to draw two conclusions. First, the lack of knowledge about these issues among the majority of social workers is likely to be greater than revealed by this study. Secondly, to obtain an idea of the state of knowledge in general, a strategic selection of informants, including social workers with a broader repertoire of interests and prior knowledge, would be preferred.

In regard to future research on social service competence on trans issues, one important area should be highlighted. In this article, four of the interviewed social workers had completed some form of training in order to collectively receive a “LGBTQ diploma” at the workplace. Some of the interviewees also spoke about the possibilities of certificates. No significant differences in knowledge nor experience could be identified in this study between the social workers who had received the diploma and those social workers who had not undergone training. However, the aim in this study was not to make a comparison, and it is highly likely that a study that focuses directly on these issues can contribute with greater insights into the relevance and possible value of certification.

Acknowledgements

We would like to thank all social workers who took the time to participate in the interviews. Also, we would like to thank PhD Anna Siverskog, Jönköping University, for contributing with valuable comments on the first draft of this article.

Disclosure Statement

No potential conflict of interest was reported by the author(s).

Additional information

Notes on contributors

Sofia Smolle

Sofia Smolle, Ph.D. Student in Social Work at the Department of Psychology and Social Work, Mid Sweden University. Smolle’s research focuses on acknowledgement of older transgender adults in social work as well as on norm-critical approaches. Other areas of interest are queer perspectives, intersectionality, empowerment and LGBTQ + related activism.

Majen Espvall

Majen Espvall, Professor of Social Work, at the Department of Psychology and Social Work, Mid-Sweden University. Espvall’s primary research interests center on how neoliberal changes in the Swedish welfare state affect the conditions for social work practice and support exchange in close relationships. Currently she is engaged in research that investigates social workers professional ambitions and organizational practices in social work.

Notes

1 Cisgender refers to a linear gender - where assigned gender, registered gender, gender identity and expression are aligned.

2 “They” can be used as a gender-neutral pronoun and is translated in this article from the Swedish word and pronoun “Hen.”