Hard-Won Trust & Strategic Healthcare Navigation In Later Life: Minority Stress, Community, and Aging Among Transgender Older Adults In Hawai'I

Background:
Transgender/māhū kūpuna (older adults) experience health inequities shaped by stigma, discrimination, and exclusion across the life course. In Hawaiʻi, these inequities unfold within a distinct social and geographic context marked by island-specific barriers to care, tight-knit communities, cultural complexity, and longstanding legacies of colonialism and social marginalization. Minority Stress Theory (MST) offers a useful framework for examining how external stressors, expectations of rejection, concealment, and internalized stigma shape healthcare experiences in later life. This qualitative study used MST to examine transgender/māhū kūpuna experiences with barriers to care, healthcare avoidance and navigation strategies, and community life to inform culturally responsive social work practices.

Methods:
Qualitative semi-structured in-depth interviews were conducted with transgender and māhū adults 55 years and older on Oʻahu, the most populous island in Hawaiʻi. Participants were recruited through community-based partnerships and were either currently accessing or may access elder care services. Interviews explored gender identity, lived experiences accessing healthcare as kūpuna, as well as wishes and worries for future healthcare. Data were audio recorded, transcribed, and analyzed using a transformative lens, inductive coding following MST with attention to how participants’ narratives reflected distal and proximal stressors, healthcare decision-making, and resilience within a Hawaiʻi context.

Results:
Findings (N=14) suggest that minority stress did not manifest primarily as broad disengagement from healthcare, but rather as selective navigation of systems based on trust, safety, and anticipated vulnerability. Most participants described being actively engaged in care and identified trusted primary care providers who offered affirming, respectful, and consistent support. Participants emphasized the importance of finding providers who understood them, treated them with dignity, and fostered long-term relationships, demonstrating access to gender-affirming and person-centered primary care was available, but hard-won.

At the same time, anticipatory healthcare avoidance emerged more in relation to long-term care, aging services, and future dependency. Participants worried about losing independence and needing in-home help or assisted living—concerns reflected more than cost alone. Participants described compounded uncertainty about whether future caregivers would be respectful of their gender identity, whether they would be safe in congregate aging settings, and whether they could afford supportive services that would allow them to age in place, reflecting both distal and proximal stressors. Three themes were especially salient: (1) trusted primary care relationships supported active healthcare engagement; (2) anticipatory avoidance was concentrated in long-term care and elder service contexts rather than routine medical care; (3) financial insecurity compounded fears about future care needs, particularly around affording in-home support; and (4) community and cultural roles plus intergenerational responsibility supported persistence, advocacy, and strategic help-seeking.

Conclusions:

MST helps illuminate how transgender/māhū kūpuna’s healthcare avoidance may reflect rational anticipation of harm rooted in structural and interpersonal stigma. In Hawaiʻi, these findings underscore the need for social work practice that is trauma-informed, gender-affirming, culturally grounded, and attentive to island-specific barriers to care. Implications include training providers to recognize anticipatory avoidance as adaptive, building trust through relationship-centered care, and designing services that honor the historical, cultural, and linguistic realities of transgender/māhū kūpuna in Hawaiʻi.