Long-Term Care Abuse and Neglect

Trans Specific Dynamics

Transgender LTC residents are vulnerable to types of institutional abuse and/or intimate partner violence that are trans-specific. Abusive behaviors towards trans people may include:

• Refusing to use the LTC resident’s correct name and pronoun;
• Calling the LTC resident pejorative names;
• Refusing to match the LTC resident with a roommate of their gender identity;
• Ridiculing the elder’s body;
• Refusing to allow the LTC resident to wear their preferred clothing;
• Ridiculing or belittling the resident’s identity, including declaring that the LTC resident is not a “real” man or woman;
• Eroticizing/fetishizing the LTC resident’s body against their will;
• Touching parts of the body the LTC resident deemed off-limits or calling body parts by names they know the LTC resident finds offensive;
• Refusing to touch the elder to perform supportive services such as help with bathing, toileting, or assistance with other activities of daily living;
• Threatening to “out” (disclose they are transgender) the LTC resident;
• Stating the LGBTQ+ community would be harmed if the abuse were revealed;
• Claiming no one would ever believe the LTC resident if they did reveal abuse;
• Telling the LTC resident no one will ever love them and/or that they could never find a better place to live;
• Denying the LTC resident access to hormones or medical treatment, prosthetics, or other trans-specific items.[ii]

People of any age may be in Long-Term Care Facilities, however, older trans/nonbinary people may have unique concerns. Trans elders who are now in a long-term care facility have likely experienced prior abuse or even decades of denigration, discrimination, and violence. This polyvictimization history has direct effects if they become a LTC abuse victim. Trans elders may be unable to recognize that what they are experiencing is abuse. For many, they may believe their experience is just normal based on history of how others have treated them.  They may also believe that abusive behavior is what they can expect as a trans person.  These beliefs may make them very reluctant to report abuse or consent to interventions since they don’t expect to ever find a better situation. They may be even more fearful of retaliation for reporting poor care or abuse than are other residents, given their history of discrimination and violence. They may also refuse interventions in order to protect themselves, in part due to the current anti-trans legislation aimed at reducing trans people’s rights.

Responses to Institutional/LTC Abuse

The systems set up to prevent and address LTC abuse are complex and overlapping. Nearly every nursing home accepts federal funding (such as Medicare and Medicaid), which means they are all covered by the federal Nursing Home Reform Act (NHRA).[iii] This law provides some broad standards of care. Nursing facilities must “protect and promote the rights of each resident…[including] reasonable accommodation of individual needs and preferences.” They must also provide care and services that help residents “attain or maintain highest practicable physical, mental, and psychosocial well-being.” The law also articulates a long list of resident rights, one of which is the right to be free from physical or mental abuse, corporal punishment, and involuntary seclusion. It set up a system of surprise inspections carried out by each state’s licensing and certification agency. In addition to the inspections, these state offices also accept and investigate complaints, which may include allegations of abuse or neglect. A directory of state survey agencies is available at https://www.cms.gov/medicare/health-safety-standards/quality-safety-oversight-general-information/contact-information.

The federal Older Americans Act (OAA)[iv] set up the long-term care ombudsman program (LTCOP),[v] which, among other things, is tasked with identifying, investigating, and resolving complaints made by or on behalf of LTC residents. Every state, by law, must have at least one state Ombudsman, but most have many regional and local ombudsmen, and many use volunteer ombudsmen, as well.

In 2023, the U.S. Supreme Court ruled that nursing home residents can also sue their nursing home for violations of their federal rights.[vi]

Assisted living facilities are regulated by each state, so care requirements and enforcement mechanisms vary. A great deal of information, including a guide to each state’s law, is available at https://www.aplaceformom.com/caregiver-resources/articles/assisted-living-violations

Note: Many federal laws and acts are going through administrative changes, with some guiding documents becoming less protective of transgender individuals, people with disabilities, people who are not white, and individuals who are undocumented.  Please check the law or act for clarification about any changes made about levels of protection and care recommendations.

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