Managing Risk Aversion & Loss Aversion in Later Life Gender Transitions

Abstract

Risk and loss aversion are key forms of behavioral decision-making describing how people weigh potential gains and losses. Although most of the literature on risk and loss aversion comes from the field of behavioral economics, these concepts are applicable to complex medical decision making, especially when those decisions are shaped by sociopolitical factors as in gender transitions. For clinicians providing gender-affirming care, discussions of risk and loss aversion can support the informed consent process by reducing “noise” that may obscure gender identity and embodiment goals and delay critical decisions. Using this framework and understanding the impact of oppositional sexism and the gender binary can help clinicians understand why their clients might be hesitant to transition and how they can help affirm their client’s gender identity while supporting their transition goals. This approach is especially helpful when working with individuals who undergo transition in later life who may be struggling to overcome tacit assumptions about sex and gender identity that stand in the way of pursuing gender-affirming care.

1. Introduction

Risk aversion and loss aversion are psychological terms used frequently in financial research to better understand investment choices (Kahneman and Tversky 2013; Rabin 2013; Tversky and Kahneman 1974; Tversky 1975). Risk aversion is tied to expected-utility theory, which is a way of analyzing decision making in the face of uncertainty (Tversky 1975). The basic idea here is that most people are averse to uncertainty when the stakes are high, and more open to uncertainty when the stakes are perceived as low (Rabin 2013). Loss aversion, a central part of prospect theory, is the tendency to overweigh small risks of loss when choosing between different options (Kahneman and Tversky 2013; Tversky and Kahneman 1974).

These concepts have a powerful psychological impact. For example, Schindler & Pfattheicher found that the pain of loss is about two times more powerful than the pleasure of gain (Schindler and Pfattheicher 2017). When people are making decisions, they will often take the sure gain over a riskier option, even when the riskier option has the potential for greater gain (Kahneman and Tversky 2013; Rabin 2013). While risk aversion disciplines the decisions that people make, loss aversion can inhibit people from making decisions. Loss aversion helps produce inertia, pressing people to maintain the status quo even when it is in their interests to pursue change (Thaler and Sunstein 2009).

In medicine, clinicians and patients also must regularly weigh risk and loss. This is often done through the informed consent model where clinicians discuss the pros, cons, and potential side effects of a treatment course or procedure, and the patient makes an informed decision based on this information (Bazzano et al. 2021). In most cases, the risks and potential gains/losses of taking no action must also be considered. For the patient, the task is complex. They must weigh the information provided to them by their medical providers, decide whether it is sufficient, and make a choice that aligns with their personal needs and goals. Patients may consider possible side effects to medicines and surgeries, the irreversibility of some interventions, and uncertainties about long-term outcomes and satisfaction with those outcomes. How patients weigh potential risks and losses verses gains will influence how they choose medical treatment options.

For transgender and gender-diverse (TGD) patients, transition-related medical decisions may involve complex internal calculations of risk and loss that are rarely captured in conventional discussions of informed consent. Transition-related decisions may affect social standing, financial status, relationships, sexuality, sexual intimacy, privileges, support, and safety. These considerations often become more complex and intertwined with age.

In modern society, people are interpellated to live healthy and authentic lives and, for transgender and gender diverse (TGD) people, this sits at odds with political projects that seek to erase and marginalize TGD people as part of an attack on “gender ideology” (Butler 2024). This offers a vivid demonstration of how the potential risks, losses, and gains of medical decisions can extend outside the body into the psychosocial domain.

Our approach recognizes that the decision to seek gender-affirming care currently takes place in a political environment that conflates gender-affirming healthcare with advocacy that extends beyond the evidence base and what has been termed “gender ideology” (Butler 2024). This political context creates issues for patients and health professionals as “uncertainty in the environment also increases risk aversion” (Leder et al. 2024). The goal of discussing the management of risk aversion and loss aversion is to help clinicians build a more supportive model of gender-affirming care that maintains informed consent as its centerpiece.

Individuals have different levels of loss and risk aversion, and while this is natural human variation, it can coalesce with mental health co-morbidities to create issues in the provision of healthcare. An extreme example would be someone whose mental health condition impacts their capacity to make medical decisions (Calcedo-Barba et al. 2020). Examples may include active psychosis, mania, or severe suicidal depression. However, the effects may be more subtle or insidious. For example, depressed patients have been found to have a heightened level of risk and loss aversion (Baek et al. 2017). For a transgender patient, this may result in not choosing or delaying a treatment path that may ultimately improve wellbeing, health, and psychosocial functioning. The informed consent model operates on the premise that patients have the capacity to understand the risks of pursuing or avoiding different forms of gender affirming care. Consent is key in a “partnership approach” to healthcare that “recognises both the patient’s autonomy and the healthcare professional’s role as healer” (Maclean 2009, p. 112). This model respects patient autonomy, empowers patients to make decisions, and has “advanced the rights of adult transgender people to obtain needed care without the stigma and obstacle of a mental health evaluation” (Drescher 2023, p. 104). The informed consent model of gender-affirming care is robust, with self-reported gender identity and embodiment goals sufficient for preventing regret (Ashley et al. 2024). However, it can be improved by acknowledging that the decision to seek gender-affirming care is “embedded in economic, cultural, and emotional structures” (Bessey 2026, p. 6) and not simply the exercise of personal autonomy.

Modern healthcare is characterized by a shift from paternalistic modes of biopower to those that privilege autonomy and seek to empower the patient (Devisch 2017). While the shift away from the medical gate-keeping of TGD people provides new avenues for the expression of agency, there is tension between a person’s self-knowledge and how a clinician can best support their patient to achieve gender congruence in a world where the pursuit of good health is increasingly seen as a personal responsibility (Hull 2017). While the clinician may have expertise in providing gender-affirming care, the patient has expertise in their own lived experience, and these parties must work together to find a discourse that allows for the mutual expression of power. As Spivak (2009) proposes, how things are expressed delineates the range of potential responses to what is expressed. This Foucauldian perspective emphasizes that discourse operates as a form of power that substantiates relations between people. Furthermore, this paradigm suggests that discourses that help patients to articulate and frame their experiences are important tools to empower patients.

In behavioral economics, the concept of ‘decision hygiene’ is used to describe processes, such as sequencing information and setting guidelines to “reduce noise in human judgments” (Kahneman et al. 2021, p. 222). Noise is a property that confounds prediction and makes judgment difficult, with medical decisions particularly prone to this issue (pp. 279–86). Establishing guidelines appears to help clinicians make more consistent diagnostic decisions, and while a patient might be confident in their self-reported gender identity, self-determination of embodiment goals intersects with biological, economic, and political constraints. Because the informed-consent model confers a degree of diagnostic power upon the self-reporting of the patient, the role of the clinician is to assist the patient in these broader decision-making processes so that together they act to manage tensions between self-determination and beneficence (King and Moulton 2006).

Informed consent is possible only when health communication allows patients to exercise their informed consent (Pilegaard 2016). Discussions of risk and loss aversion therefore are broadly relevant to the discussion of health communication and the study of bioethics. Clinicians need to consider not only the information that they present to their patients but also how this information is presented, and how this relates to the patient’s life experiences. In essence, the clinician must meet the patient’s information needs. Patients will have different relationships to the pillars of transition described above, and they are likely to have a diverse range of understandings of the self; knowledge of medical transition; awareness of other trans people, and notions of how gender intersects with other aspects of culture.

This commentary will discuss the ways risk and loss aversion affect a TGD person’s transition decisions, especially in later life, using a hypothetical case (Harper) derived from a synthesis of interviews and clinical encounters. It will touch on the impact of oppositional sexism and the gender binary on gender affirmation. Lastly, it will explore risk and loss aversion within the psychosocial framework, providing clinicians with a framework for supporting their patients on their transition journeys.

2. Discussion

2.1. Risk Aversion in Gender Transitions

Medical, social, and legal transition represents unique risks for the TGD person. The most obvious are the risks associated with gender affirming medical and surgical treatments. These interventions will have differing risks based on a person’s age, co-morbidities, and overall health status (Cheung et al. 2023). Let us consider our hypothetical patient, Harper.

Harper is a 64-year-old transwoman with a history of diabetes, coronary arterial disease (CAD), transient-ischemic attack (TIA), and prostate cancer, s/p orchiectomy and prostatectomy, who is also considering feminizing hormones for the first time. For Harper, the choice to initiate treatment will be made in part by her personal appraisal of the stakes. Specifically, she will consider whether the risk of adverse events are high or low, and the reversibility of those adverse events should they occur. The clinician’s role is to serve not only as expert, but also evaluator of the patient’s ability to understand the stakes and to make an informed decision. For example, in Harper’s case, a history of TIA may indicate an increased risk of blood clotting, which may be exacerbated by some formulations of estrogen. A stroke would be a high-stakes adverse event and would want to be avoided. In cases where abnormally high-risk aversion is present (i.e., in a patient with active depression or high anxiety), or a complete lack of risk concern exists (i.e., in a patient demonstrating mania, thought disorder, high impulsivity, or an unusual level of goal-directed behavior), further evaluation and support may be warranted.

Gender-affirming providers may support patients struggling with risk aversion by supporting autonomy, clarifying potential trade-offs, and reducing uncertainty. This may include discussing the risks of not acting or presenting both choices as having potential consequences. Clarifying reversible verses irreversible steps, and breaking down those steps into a series of smaller (possibly reversible) steps may also be helpful. A provider should also normalize caution as normal and not a sign of identity confusion, pathology, or avoidance.

Risk aversion may also impact social gender transition. Many countries and U.S. states have laws restricting access to gendered spaces including bathrooms, changing facilities, and other single-sex spaces (Murib 2020; Reed 2024). This legalized discrimination essentially criminalizes social transition and gender expression, raising the stakes for TGD people to safely and legally inhabit public spaces (Murib 2020). For the gender-affirming clinician, understanding regional laws and restrictions against TGD expression may help patients make accurate assessments of potential risks. Let us consider Harper again.

Harper has been socially transitioning for about 6 months. She introduces herself as Harper and uses she/her pronouns. Most days, she still likes to wear jeans and a blouse, but now that her hair has grown out, she feels more comfortable wearing a dress on occasion. Harper still has days where she presents in “boy mode.” This causes her significant dysphoria, and now she is considering the risks of a full social transition. Unfortunately, Harper lives in a state where discriminatory laws prevent her from using restrooms and gendered spaces in government buildings, public schools, and universities that align with her gender identity. Violating the law carries a fine.

Harper regularly visits state parks for exercise, which only have gendered bathrooms. Before her transition, she never thought much about using the bathroom. Now, gendered spaces make her very anxious, and she fears harassment, especially after someone recently told her she was “in the wrong restroom.” For Harper, assessing risks of harassment and loss of privilege against the potential emotional and physical benefits of full social transition will be important. Her clinician might recommend a web application like REFUGE Restrooms, which helps TGD and intersex people to locate safe, inclusive facilities.

In general, a clinician can help clients like Harper manage risk aversion to social transition by reducing the perceived stakes and decreasing uncertainty. Social transition means different things for different people based on their embodiment goals, so clarifying those goals is important. Breaking down social transition into a series of low-risk “experiments” may make social transition feel less like a series of irreversible commitments. Clinicians should help their clients weigh the costs of ongoing concealment and consider the risks of non-transition such as ongoing emotional distress. As risk aversion often preys on intangible fears, anticipating and planning for feared outcomes, while learning to differentiate between controllable and non-controllable risks is key.

Safety is another significant concern for many TGD people. Often associated with social and legal marginalization, gender-based violence has a prevalence rate of as high as 89% in some populations (Wirtz et al. 2020). Concerns for safety, both in the home and in the community, may lead some TGD persons to consider the stakes of social transition too high, and this may contribute to a person’s decision to defer or relinquish their transition (Turban et al. 2021). An older person that transitions their gender expression, even if they do not face outright marginalization or violence, is quite likely to become an “object of interest” (Kaplan 2017, p. 359) to people around them, and this may produce minority stress.

Minority stress is a form of chronic stress experienced by individuals from stigmatized or marginalized groups, which was first described by Dr. Winn Kelly Brooks (formerly Virginia Rae Brooks) in her 1981 work Minority Stress and Lesbian Women (Brooks 1981). Hendricks and Testa (2012) would later apply this concept to gender minorities, showing how discrimination, prejudice, and internalized transphobia could worsen mental health outcomes.

Similar to the effect of depression on increasing risk and loss aversion (Baek et al. 2017), minority stress may increase a TGD person’s anticipation of prejudice, resulting in feelings of unsafety in otherwise neutral settings (Aversa et al. 2021). In this way, minority stress may amplify risk aversion for gender transition. Clinicians can support patients by providing education on minority stress and by helping them develop resiliency factors, such as community connectedness, family and social support, and gender identity pride. Cultivating these resiliency factors may help mitigate both real and perceived safety concerns of social transition.

For transgender people, access to legal documents that align with their gender identity can improve wellbeing and reduce discrimination in employment, housing, and education systems (Gamarel et al. 2023; King and Gamarel 2021; Restar et al. 2020). Legal gender affirmation has also been associated with lower anxiety and depression (Restar et al. 2020). Requirements for legal recognition vary, with some regions blocking access completely and others requiring punitive measures such as sterilization or gender reassignment surgery (Hill et al. 2018; Restar et al. 2020). Legal restrictions such as these may prohibitively increase the stakes for social transition. For example, inability to update identity documents may “out” transgender people, placing them at an increased risk for harassment or violence (Herman and O’Neill 2021). Clinicians should know local and regional rules/laws for legal transition and support their patients through this process. Let us revisit Harper.

Harper has changed her legal name, but lives in a state that prevents her from updating her gender marker on her birth certificate or driver’s license. This makes her feel unsafe. She is considering a move to another state with less restrictive gender marker change requirements. The idea of moving makes Harper anxious. She has lived in the same place for 20 years. She worries about making new friends and whether or not she will find affirming providers. The more she thinks about it, the more stuck she feels.

To help Harper, clinicians may consider several approaches to reduce her risk aversion. They may recommend Harper write down explicit benefits and risks of staying or going. Writing it down makes it real and tangible. This may also help Harper explore how moving might reduce the risk of harm overall. It might also help to reframe moving as a series of steps rather than a single leap into uncertainty. For example, many aspects of the move can be planned ahead such as getting established with a new gender-affirming care team.

Many TGD people avoid the healthcare setting due to past negative experiences with healthcare professionals such as misgendering, a lack of knowledge, misdiagnosis, and mistreatment. This kind of minority stress can lead to healthcare avoidance (Thomas et al. 2024), which can impact a TGD person’s ability to medically transition. This should be differentiated from healthcare avoidance due to other causes such as lack of insurance, transportation, and other factors like fear of medical settings that may also disproportionately impact TGD people due to their low socioeconomic status (Seelman et al. 2017). Clinicians should be aware that patients are considering the risk of non-affirmation, rejection, and mistreatment at each visit. They should strive for culturally competent healthcare, ensuring staff education, welcoming settings, and TGD-friendly forms (Redfern and Sinclair 2014).

From the perspective of risk-aversion theory, transgender people like Harper may experience strong reluctance to change healthcare providers after finding an affirming care team. The perceived risk of losing a known, supportive provider may be felt to outweigh the potential benefits of transitioning to a new one, even when change may be necessary for safety or access. In addition, status quo bias (Thaler and Sunstein 2009, p. 37) may lead individuals to prefer maintaining an existing care relationship rather than confronting the uncertainty associated with unfamiliar providers, as well as concerns such as non-affirmation, rejection or mistreatment.

Clinicians can help mitigate this form of risk aversion by reducing uncertainty and reframing provider changes as a continuation of affirming care rather than a disruptive loss. Directing patients to vetted online resources such as the OutCare Provider Directory, the LGBTQ+ Healthcare Directory, and the World Professional Association for Transgender Health (WPATH) Provider Directory can increase predictability and trust in the transition process. By framing provider changes as opportunities for continuity and growth, rather than as starting over, clinicians can help patients recalibrate perceived risks and feel more confident engaging in necessary changes to their care.

2.2. Loss Aversion in Gender Transitions

For some TGD people, transition may represent a loss of social privilege, legal recognition, traditional gender roles, livelihood, and relationships with family & friends. These potential losses may feel monumental in the midst of early transition risks when many of the beneficial outcomes of gender transition feel elusive and far off. Therefore, helping TGD persons evaluate and navigate loss aversion is an important role of the gender-affirming clinician.

Individuals with elevated loss aversion due to minority stress factors may lack motivation to initiate change, even when such change has the potential for substantial benefit (Thaler and Sunstein 2009). Clinicians therefore play a critical role in addressing cognitive distortions and mental health comorbidities, such as depression, that may exacerbate loss aversion (Baek et al. 2017). At the same time, clinicians must develop a nuanced understanding of each patient’s unique psychosocial milieu, including their internal and external minority stressors, resilience factors, and the community and medical resources available to mitigate these stressors. To illustrate these concepts, we return to the hypothetical case of Harper.

As part of her social transition, Harper is considering telling her friends, coworkers and family members that she is transgender. Even though Harper only works part time, she gets a lot of enjoyment from her job and does not want to lose it. So far, Harper has only told a few close friends and family members about her gender identity. These are people who have been supportive of transgender people in the past. Harper is still worried that she might lose her job or be rejected by her two children if she comes out. Fear of damaging or losing her relationship with her children was one of the primary factors that led Harper to defer transition earlier in life.

These concerns reflect loss aversion, in which the anticipated losses associated with disclosure, such as strained family relationships, social rejection, or employment instability, are weighted more heavily than the potential psychological and relational benefits of living authentically. Loss of family and interpersonal relationships is a significant concern for many transgender and gender-diverse (TGD) individuals who pursue transition (Klein and Golub 2016). Family rejection has been shown to predict increased risk of suicide attempts and substance use among TGD adults, underscoring that these anticipated losses are not merely hypothetical (Klein and Golub 2016).

Fear of rejection may further intensify loss aversion for individuals considering gender transition later in life, who often must navigate complex, multigenerational family systems and relationships. In the case of Harper, her clinician can help her feel better by talking to her about her fears. For example, the clinician can help Harper think about what she might gain and what she might lose if she changes her gender. The clinician can also help Harper figure out if she is thinking about things in a way that is not totally realistic which can make her more afraid of losing something. When the perceived potential for loss is high, clinicians may also focus on strengthening resilience by fostering community connectedness, social support, and pride in one’s TGD identity. These protective factors can buffer the psychological impact of rejection and reduce the subjective weight of anticipated losses (Conn et al. 2023). Clinicians should consider actively promoting these resilience-building strategies with all TGD patients, particularly those facing high-stakes disclosure decisions.

Workplace discrimination represents a salient and highly weighted source of anticipated loss for transgender and gender-diverse (TGD) individuals (Boncori et al. 2019). From the perspective of loss aversion theory, threats to employment, income, and career stability are likely to be perceived as disproportionately costly, leading individuals to prioritize avoiding potential losses over pursuing the psychological and social benefits of gender transition. Because livelihood is closely tied to financial security, identity, and autonomy, even low-probability risks of workplace discrimination may exert a powerful deterrent effect on transition-related decisions (Köllen 2018).

Gender-affirming clinicians can help mitigate this form of loss aversion. They can help people feel more in control of what happens to them at work, by encouraging patients to consult with their organization’s Human Resources department to clarify existing nondiscrimination policies and workplace protections (Human Rights Campaign (HRC) Foundation 2024). In addition, clinicians should remain informed about relevant state and federal nondiscrimination laws that may protect TGD individuals in employment, as well as in related domains such as housing, public accommodations, and access to credit (MAP 2024). By making legal protections more visible and concrete, these interventions can reduce the subjective magnitude of anticipated losses and rebalance decision-making.

Loss aversion and sensitivity to risk are also thought to change with age (Guttman et al. 2021; Seaman et al. 2018). In this context, risk sensitivity describes the tendency of individuals to become more cautious when outcomes are uncertain. (Weber and Johnson 2009). Some evidence suggests that cortical thinning may cause increases in loss aversion with age (Kurnianingsih et al. 2015; Guttman et al. 2021). However, other research indicates a non-linear relationship between age and loss aversion (Seaman et al. 2018), which may reflect differences in neurobiological aging (Guttman et al. 2021), methodological differences in how loss aversion is assessed (Gächter et al. 2022), or differences in individual values, motivations, and life circumstances. For older TGD individuals, these factors may interact to amplify the perceived costs of workplace loss, further reinforcing loss-averse decision-making around gender transition.

In Harper’s case, the gender-affirming clinician might consider a number of strategies to help her overcome her loss aversion. Continuing to come out to people one at a time, and on her own terms, may shrink the size of potential losses. For example, the clinician may recommend Harper plan to have an affirming friend or family member to talk to if she experiences rejection following disclosure. Loss aversion lessens when there is someone or something to fall back on. It may also be helpful for Harper reframe some of her perceived losses as transformations or exchanges. For example, a change in employment, albeit scary, might lead to new connections with affirming individuals.

In Harper’s case, a gender-affirming clinician might employ several strategies to help mitigate her loss aversion. Continuing to disclose her gender identity gradually and coming out to people one at a time and on her own terms can reduce the perceived magnitude of potential losses. Smaller, staged disclosures help counter the tendency to experience anticipated losses as overwhelming or irreversible.

The clinician may also encourage Harper to identify affirming supports in advance, such as a trusted friend or family member she can turn to following disclosure. Loss aversion is reduced when individuals perceive that they have something or someone to fall back on, making potential losses feel more survivable rather than catastrophic.

Additionally, the clinician can support Harper in reframing certain anticipated losses as transformations or exchanges rather than absolute losses. For example, while a change in employment may feel threatening, it may also create opportunities for new professional connections and more affirming work environments. By reframing transition-related changes in this way, the clinician can help Harper rebalance her decision-making and reduce the disproportionate weight placed on feared losses.

2.3. Other Considerations

Among TGD elders, risk and loss aversion related to gender transition may be mitigated by a perceived sense of having “failed” to meet heteronormative expectations of gender (Fabbre 2015). Many report a sense of having “served their time” in fulfilling societal and familial roles, alongside an increased awareness that the time remaining to live as their authentic selves is finite (Fabbre 2017). For these individuals, gender transition may come to represent “success on new terms” (Fabbre 2015). Consistent with this perspective, quality-of-life outcomes are significantly higher among transgender elders (aged 60 and older) who initiate gender-affirming medical treatment compared with younger transgender adults (aged 18–59) (Cai et al. 2019). These themes may serve as valuable discussion points for clinicians working with elders who continue to struggle with risk and loss aversion related to gender transition.

Returning to Harper’s case, she has since relocated to a new state, where she has obtained a new part-time job and updated her identification to accurately reflect her gender. She made some friends and met new people. Harper says that transition has really helped her feel better and confident about herself. She thinks about how she spent a lot of her life doing what other people thought she should do. Now she wants to use her time left to be herself and do what she wants. Harper has expressed interest in pursuing shallow-depth vaginoplasty and reports feeling better than she ever has before. The fears of loss that once loomed large early in her transition now feel less imposing, as she experiences daily life as more aligned with her values and sense of self.

Tacit assumptions about sex and gender identity may also stand as additional barriers to pursuing gender-affirming care (Conn et al. 2023). Norms that conceptualize gender as opposing categories create oppositional sexism (Serano 2024). Oppositional sexism leverages a system of binary oppositions to generate stereotypes about men and women. These stereotypes harm all people because they stigmatize natural human variation and corral gender expression in the service of a symbolic dichotomy. However, oppositional sexism also intersects with traditional sexism, and this creates an additional issue for TGD people on the transfeminine spectrum. Traditional sexism is underpinned by the tacit acceptance of patriarchal norms. These values assume the superiority of masculinity, and see femininity in oppositional terms, and so generate stereotypes that emphasize its inferiority. From this perspective, transfeminine people will likely lose patriarchal privilege in the process of pursuing gender affirmation.

The gender binary might also pose an additional challenge for patients wanting to pursue gender affirmation. The default assumption that gender is a binary might be useful for some patients—the recognition that one does not identify with sex assigned at birth might help some people to recognize their transgender identity. However, the gender binary is a system that simplifies different aspects of a person, and some patients might find that this level of “noise reduction” (Kahneman et al. 2021) inhibits their recognition of themselves. In this case, patients might benefit from resources that seek to emphasize the diversity in sex and gender characteristics; identities; and expressions (Läuger 2022). Such resources can be useful for ensuring that patients maintain a clear sense of autonomy and a good sense of morale, and this gives patients a good basis for addressing their aversions to gender affirmation.

For a trans woman like Harper, oppositional sexism and rigid gender binaries may shape her experiences in different ways. Some may tell her she is “not feminine enough,” while others may accuse her of “trying too hard.” Trans women like Harper are essentially in a no-win situation. If they do not follow the rules they get in trouble. If they try to follow the rules they still get in trouble. As a result, Harper may feel pressure to conceal or suppress her authentic gender expression in order to avoid scrutiny or rejection. Failure to conform to oppositional sexist standards may also lead to tangible consequences, including the withholding of social privileges, increased marginalization, or the denial of her womanhood altogether.

Resources that help the patient to understand their own gender identity can introduce new paradigms of self-understanding that resolve persistent questions or doubts that foster “status quo bias” (Thaler and Sunstein 2009, p. 37) and help them to “map” (p. 220) their gender transition. While patients may benefit from seeing a gender therapist or counselor, these services might constitute a barrier for some patients. Some might find the cost prohibitive, or they might struggle to find a counselor with whom they feel comfortable building a relationship. Others might associate a therapist with conversion therapy, or other non-affirming practices, and have lived experiences consistent with this association. In these cases, workbooks invite patients to explore themselves by offering new perspectives while also respecting patient autonomy. Self-help workbooks on gender identity differ in their focus and tone with some addressing skills such as self-care (Triska 2021) or resilience (Singh 2018); others are notable for adopting a relatively serious (Hoffman-Fox 2017) or playful tone (Bornstein 2013). Other books might be particularly helpful for clients contemplating a non-binary identity (Läuger 2022; McDaniel 2023), and so clinicians should make recommendations that align with the patient’s needs and their attitude to their gender transition. Clinicians should also be versed in therapeutic strategies for addressing risk and loss aversion in their patients when they arise (see

Table 1. Clinical recommendations for addressing risk and loss aversion.

Clinical Recommendation	Description
Risk Aversion
Risk Appraisal	Clarify and process feared outcomes with evidence-informed discussions and realistic probabilities.
Reversible Steps	Consider starting with reversible steps that can be used to build identity confidence and contextualize embodiment goals. Reframe transition as gradual, individualized, and flexible.
Positive Gain Framing	Point out potential gains of transition to reduce dysphoria and improve alignment when the focus is only on risks.
Graded Exposure	Recommend gradual exposure to feared situations to cultivate confidence and reduce fear.
Loss Aversion
Cognitive Reframing	Reframe possible losses as evolution, transformation, or growth that represents a continuity of self rather that a loss.
Resources and Support	Identify and strengthen supports (e.g., family, community) and offer resources to mitigate possible losses (i.e., fertility preservation, emergency funds, community resources).
Visualization & Narrative Exercises	Use visualization and written exercises to help patients clarify and contextualize their authentic self in the clearest form possible.
Grief Processing	Acknowledge that all change represents a loss. Normalize the difficulty of change, even positive change. Offer support and assist in processing grief.

).

Thaler and Sunstein (2009) note that “it is particularly hard for people to make good decisions when they have trouble translating the choices they face into the experiences they will have” (p. 83). While a community or body of knowledge can never anticipate what experience an individual will have, because decisions and outcomes are invariably connected but separate, connecting with people and engaging in processes of self-education help people to make good decisions. Joining support groups and other collectives may operate as potential alternatives or supplements to workbooks on gender identity. Furthermore, actively seeking to build community may help to ameliorate the loss of patriarchal privilege, and to connect the patient with new groups of people unequivocally prepared to affirm the gender of the patient. This helps to offset any loss of social standing with people known to the patient prior to their gender transition. Frances Mulcahy is an Australian who transitioned later in life. She describes the value she found in connecting herself to a local feminist organization:

Early in my transition to an authentic life, I read voraciously about inclusive feminism. I attended a OWP [Gender Justice Project, formerly One Woman Project] seminar series and found a wonderfully diverse and committed group of (young) women. I was immediately included and at home.

(Gender Justice Project 2020)

Furthermore, in correspondence with the authors (Stapleton and Agapoff 2026), Mulcahy adds that this experience is ongoing and that becoming familiar with feminist theory and building social connections around feminist activism were necessary to provide her with the discourse and community to articulate the experience of losing male privilege. This example highlights that gender transitions later in life can be the impetus for forming new relationships with others and cultivating knowledge about hitherto unexplored aspects of the self. Furthermore, it also demonstrates that affirming connections can be made in contexts beyond the TGD community.

Some TGD people might find queer theory to be particularly useful for making sense of their experiences of gender diversity. Queer theory highlights “the awkwardness and imprecision of signifiers such as ‘straight,’ ‘gay,’ and ‘bisexual,’ which do not begin to address the complexity and subtleness of each individual situation” (Kaplan 2017, p. 366). Becoming better informed in this area not only provides people with paradigms and language to make sense of their experiences, but its veneration of diversity might help older TGD people. It might insulate them from a sense of personal frustration if they are unable to fully realize their embodiment ideals, or to comfort them when they suffer the marginalization that TGD people often face. This set of ideas can help them to instead find liberation beyond binary and normative understandings of sex and gender.

Consequently, patients should be encouraged to engage not only in traditional support groups for TGD people but to consider the parts of the broader culture invested in respecting TGD people. Engaging in these processes of learning and building relationships within and beyond the TGD community helps position people to engage with the world as trans elders. Let us check in with Harper.

Harper has begun attending a transfeminine support group at a local LGBT+ center. She no longer meets regularly with a gender therapist, noting, “I feel like I understand myself pretty well now.” Harper likes the sense of community she gets from the group. The group is a place where Harper can share her thoughts and feelings, and help others by sharing her life experiences. Her involvement at the LGBT+ center has strengthened her sense of community connectedness, which in turn makes it easier for her to filter out distressing news and media narratives that scapegoat transgender people. Harper has also observed that many younger transgender group members feel overwhelmed by the current sociopolitical climate. In response, she has shared workbooks and resources she has found particularly helpful for building resilience, allowing her to support others while cultivating her own sense of purpose and wellbeing.

Transitioning into the role of elder is associated with pursuits of deeper meaning and a reconciliation of past choices (Chen et al. 2021; Erikson 1993). Eric Erikson believed that mastery of this stage led to ego integrity, which he described as “the acceptance of one’s one and only life cycle as something that had to be” (Erikson 1993). Considerations of “time left” to live, and “time served” to society, may facilitate deeper explorations of identity and self-expression (Fabbre 2017). Gender transition may represent a path out of regret and toward ego integrity. As social circles become smaller, fears of rejection by family and friends may take on new meaning. While gender transition may evoke fears of isolation, loss of social familial standing, and a breakdown of ego integrity, concerns over social normativity may no longer take precedent, opening the door for true identity alignment and expression.

3. Conclusions

For gender-affirming clinicians, understanding behavioral decision-making can enhance their ability to support patients in pursuing their affirmation goals. Gender transition is a major life decision with significant emotional, social, and physical implications. In a time when political narratives are at odds with the alignment goals of transgender and gender-diverse (TGD) people, a careful examination of risk and loss aversion may support the informed consent process by helping patients navigate ambivalence, cognitive distortions, and decision-making biases. Clinicians should also be prepared to critically examine and challenge heteronormative expectations of aging, oppositional sexism, and rigid gender binaries, as these frameworks may contribute to resistance, blind spots, or an underestimation of the potential benefits of gender transition. By fostering greater tolerance for uncertainty and reframing perceived risks, clinicians can better support patients in making decisions aligned with their values and wellbeing.