Q&A: Kylie Madhav, Senior Director of Diversity, Equity, and Inclusion at SAGE

For years, transgender individuals have been shown to be at greater risk for mental health concerns, with an alarming 40% of the nearly 28,000 respondents to the 2015 U.S. Transgender Survey (USTS)—the largest survey of the lives of transgender people in the United States—reporting that they had attempted suicide (2023 survey results from the National Center for Transgender Equality are forthcoming). More specifically, older transgender and gender nonbinary (TGNB) individuals have been shown to be at increased risk for depression, anxiety, substance use, and other mental health disorders, according to a 2018 report published in The American Journal of Geriatric Psychiatry.

We recently reached out to Kylie Madhav, MBA, LMSW, the Senior Director of Diversity, Equity, and Inclusion at SAGE, to share her insights on how counselors can gain a better understanding of the experiences and profound challenges faced by many TGNB elders and how to better support these marginalized and underserved clients.

Can you tell us a little bit about the mission of SAGE?

SAGE is the world’s largest and oldest organization dedicated to improving the lives of lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ+) older people. Founded in 1978 and headquartered in New York City, SAGE is a national organization that offers supportive services and consumer resources to LGBTQ+ older people and their caregivers. SAGE also advocates for public policy changes that address the needs of LGBTQ+ elders, provides education and technical assistance for aging providers and LGBTQ+ community organizations through its National Resource Center on LGBTQ+ Aging, and cultural competency training through SAGECare. People can learn more about us at sageusa.org. 

What are some of the unique challenges that TGNB elders typically face?

TGNB elders face pervasive discrimination and transphobia in various aspects of public and private life. They encounter more hurdles than non-TGNB members of the LGBTQ+ community, including being denied employment or access to housing based on their identity, leading to financial precarity and higher risks of homelessness. TGNB elders are also more likely to face physical violence, especially Black TGNB women. TGNB elders’ physical and mental health is at even greater risk with the rise of transphobic legislation and rhetoric from prominent politicians. The latter is especially true for TGNB elders of color who face systemic transphobia, racism, and colorism. At SAGE, we have heard this from our program participants and have seen the need for support from the explosion of calls to our National LGBTQ+ Elder Hotline.

How may these challenges affect their mental well-being?

TGNB elders are more likely to exhibit signs of depression and anxiety when compared to their LGBQ+ peers. TGNB elders are also more likely to live in relative social isolation as they are less likely than non-LGBTQ+ people to have children and are more likely to be estranged from their families. Because of the barriers TGNB people face in education and employment, they are more likely to have smaller professional and social networks, which only exacerbates the deleterious effects on their mental health brought about by living in a largely transphobic society.

What are the needs of older TGNB individuals, and how are they different from those in younger generations? What can counselors do to help address those needs?

While transphobia continues to be a scourge that TGNB people of all ages face, younger TGNB people are today, on average, more likely to be able to access avenues of affirmative support than older TGNB people were in decades past. This is, of course, a broad generalization. Still, one can reasonably posit that TGNB elders were more likely to encounter even more overtly transphobic attitudes as they led their lives in the past. This means that TGNB elders are more likely to experience chronic isolation and its concomitant physical and emotional effects.

Because of barriers to gainful employment and affirmative healthcare, TGNB elders may be more likely to have sought or seek medical care via unlicensed channels. This means that many TNGB elders, particularly transwomen, may have received injections of harmful substances. This often requires years of—often inaccessible—medical treatment, and the physical changes brought about by certain unlicensed substances may also intensify experiences of anxiety or bodily dysmorphia.

Counselors should bear these challenges in mind when working with TGNB elders, while also not overlooking the myriad effects that the current assault on trans personhood may have on the mental health of TGNB elders.

What do counselors need to better understand regarding the social challenges, including safety risks and other special considerations?

Perhaps the most crucial consideration to remember when working with TGNB elders is the truly pervasive nature of transphobia. Even within spaces built to welcome the LGBTQ+ community, TGNB people often find themselves and their voices sidelined, ridiculed, ignored, or actively shunned. Transphobia informs how non-LGBQ+ people relate to and perceive TGNB people and how LGBQ+ people interact with trans and nonbinary people. While specific enclaves scattered across the country are known to be enclaves of LGBQ+ inclusiveness, there is no neighborhood in the United States where transpeople can aspire to live safely among other members of the TGNB community. For TGNB elders, safety may only extend to the boundaries of their living space, and even that is not a guarantee.

Moreover, there is no country that TGNB people of any age can look to as a beacon of trans and nonbinary inclusivity. TGNB communities exist nearly universally on the margins of the societies they inhabit, and the lack of even the idea of a locale where they might live safely profoundly shapes the outlook of TGNB people throughout their lifetimes.

Counselors should therefore be careful not to assume that TGNB elders will feel at home in spaces geared toward the broader LGBTQ+ communities. Counselors must also not flatten the differences in trans identity when race and wealth are considered. The experiences of a wealthy, White transman in his 50s may be wholly unrelated to the experiences of an unhoused, undocumented hijra elder in their 70s, even if they both share a trans identity and live in the same city.

How can we support transgender people in our lives and become allies?

In 2023, TGNB elders need non-TGNB people to speak up and show up. Slogans and programs are helpful ways to draw attention to an issue, but what TGNB elders most need is for a critical mass of people (TGNB and otherwise) from across society to recognize the ongoing and worsening harm being inflicted on the TGNB community—right now—in pursuit of short-term political gain.

TGNB elders need their neighbors, friends, and people they may never know to speak up and condemn politicians who denigrate and demonize their community. They also need these same people not to be afraid to examine and challenge their assumptions about gender identity. The movement to roll back trans rights shows no sign of abating. Hence, TGNB elders need those who would like to work in solidarity to evince equal amounts of tenacity and resolve in pushing back against the worsening tide of transphobic legislation and rhetoric.

How can counselors improve their cultural competency and be more inclusive of transgender clients?

As counselors, it is essential to understand that TGNB clients embody a vast range of lived experiences and personalities. While common threats jeopardize the emotional, physical, and financial security of TGNB people, there is no unified TGNB experience. Socioeconomic status, country of birth, state of birth, race, religion, and other classifiers are all factors that influence how TGNB people interact with the broader world. It is imperative that counselors and therapists refrain from seeking to essentialize the identities and lived realities of their TGNB clients. Please do not assume you know them from the outset of therapy because they are TGNB. Allow your TGNB clients to be as complex and nuanced as anyone you work with.

What are changes that counselors can make to create a safe and welcoming therapeutic space for all clients?

In many instances, cost is a primary barrier to therapeutic services for TGNB people. This can be remedied by offering pro-bono or sliding-scale services to TGNB clients as counselors can.

Many TGNB people also experience a heightened risk of experiencing physical violence outside their residences, particularly those who take public transport. One possible solution may be to offer virtual services that allow TGNB people to engage in care in a safe way.

Again, it is crucial not to make assumptions about who TGNB people are or their presenting concerns based solely on their trans or non-binary identity. Gender may not be at the crux of what they want to process in therapy. TGNB people encounter difficulties in their relationships and at work just as non-TGNB people do, so do not assume that TGNB people are looking to process their feelings about their gender while they are in therapy.

Are there any trainings and resources you recommend for counselors who want to expand their competencies around working with transgender clients, especially the TGNB elder population?

Over the years, SAGE has amassed an expansive collection of resources about topics relevant to LGBTQ+ aging, including caregiving, LGBTQ+ inclusion and cultural competency, financial security, and retirement. This compendium has proven invaluable to providers looking to enhance their work on behalf of and in solidarity with TGNB and LGBTQ+ elders. These resources can be found within our National Resource Center on LGBTQ+ Aging.

In addition, our SAGECare team offers training for counselors and other providers entitled “Transgender Older Adults: Information and Suggestions for Providers.” This training covers best practices for providing transgender-affirming care and education regarding the unique needs of transgender older adults and addresses common questions about the transgender experience and transitioning. Interested providers can access this training by contacting our SAGECare team here.

The SAGE National LGBTQ+ Elder Hotline is also a great resource to share and people can access it 24/7 at 877-360-LGBT(5428).

How is SAGE handling the recent anti-transgender legislations?

To track and advocate against the spate of anti-trans legislation making its way through state legislatures, SAGE’s advocacy team has a tracker of anti-trans legislation across the country and is in contact with local groups. While many pieces of legislation are focused on youth, we have seen a creep that affects the care of older TGNB people. That’s why we work with organizations on the ground to elevate the voices of TGNB elders and allies across the country. I encourage anyone interested in our advocacy work to sign up for our Action Squad—a community of bold individuals energized for change.

How can counselors support the mission of SAGE?

The most impactful way that counselors can support our work at SAGE is by letting TGNB and LGBTQ+ elders know that we are here to support them. SAGE serves the community via a wide range of initiatives, including advocacy, direct service work, training development, counseling, case management, and economic empowerment. In addition to the many in-person events and programs we organize nationwide, we offer virtual programs allowing LGBTQ+ elders to connect with the community wherever they might be. I strongly encourage people to check out all of the different ways SAGE impacts LGBTQ+ elders by exploring our website and checking out our various social media accounts. You can find SAGE on Facebook, Instagram and Twitter.

Kylie Madhav, MBA, LMSW, is the Senior Director of Diversity, Equity, and Inclusion at SAGE, where she defines the strategic vision for SAGE’s external-facing DEI work and leads in designing the organization’s DEI action plans, goals, and benchmarks. Previously, she worked as the Clinical Support Services Manager at New York City’s Lesbian, Gay, Bisexual, and Transgender Community Center. Over her career, she has worked on behalf of immigrant and LGBT communities in New York, the Dominican Republic, and Mumbai, India. She holds an MBA from the Yale School of Management and an MSW and BA in Linguistics and Law & Society from New York University.