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Transgender
and Gender
Nonconforming
Health and Aging
Cecilia Hardacker
Kelly Ducheny
Magda Houlberg
Editors
123
Transgender and Gender Nonconforming
Health and Aging
Cecilia Hardacker • Kelly Ducheny
Magda Houlberg
Editors
Transgender and Gender

Nonconforming Health
and Aging
Editors
Cecilia Hardacker Kelly Ducheny
Howard Brown Health Centre Howard Brown Health Center
Chicago, IL Chicago, IL
USA USA
Magda Houlberg
Rush University College of Nursing
Howard Brown Health Centre
Chicago, IL
USA
ISBN 978-3-319-95030-3 ISBN 978-3-319-95031-0 (eBook)

https://doi.org/10.1007/978-3-319-95031-0
Library of Congress Control Number: 2018959627
© Springer International Publishing AG, part of Springer Nature 2019

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
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broadcasting, reproduction on microfilms or in any other physical way, and transmission or information
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The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication
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To all the fierce TGNC people we have lost,
too soon and too many.
To those resilient TGNC pioneers who

endeavor to live respected, authentic, and
fulfilled lives and who provide resources and
support for generations that follow.
To all TGNC people who choose to live

privately or cannot live publicly for any
reason.
To all the TGNC communities that advocate

for, support, and elevate their members.
To the reader whose desire to deepen the

affirmative care provided to the TGNC
community will surely help improve the
quality of their lives.
Foreword
This book was created to offer providers and health-care teams better knowledge
and insight needed to provide affirmative, respectful, and personalized care to trans-
gender and gender non-conforming (TGNC) older adults. Specialized skills and
awareness are required to partner with TGNC older adults to best support their
holistic health, given the unique needs of this remarkably diverse and growing pop-
ulation. The ability to provide such affirmative and informed care is a national
imperative and a matter of life and death.
The editors worked hard to bring together a wide range of contributing authors
with diverse identities to speak to the provision of holistic, community-driven care
for older TGNC people from multidisciplinary perspectives. The authors come from
a range of gender identities, races, sexual orientations, ages, lived experiences, and
socioeconomic (SES), geographic, and professional backgrounds. For the culminat-
ing chapter of the book entitled VOICES, TGNC older adults were invited to share
their stories and speak directly to the provider and care team readers, offering their
personal perspectives on the care they have received and the guidance they would
like to offer their caregivers. The insight they offer is broad and distinct, in their own
words and stemming from their individual experiences.
We begin the book with the Essentials chapter that explores concepts that are
critical to understanding the experience of TGNC people, useful terminology, and
culturally sensitive skills for care provision. The Essentials chapter helps readers
begin a process of personal introspection and knowledge acquisition to develop a
framework for intentional, affirming communication with TGNC older adults.
Reading the Essentials chapter before moving deeper into the book is strongly rec-
ommended, since it allows the reader to anchor knowledge learned in the later chap-
ters upon Essentials frameworks.
The editors asked that the authors strive to integrate their experience and knowl-
edge with the existing literature and research, offering best practices and insight for
providing care to TGNC older adults. It is our hope that readers will take this infor-
mation, apply it, and share it widely. It is also our hope that this book will inspire
innovation and future models of care, progressively improving the affirmative, com-
munity-driven care provided to and with the TGNC older adult community. Readers
are reminded that while this book offers potential patterns, treatment approaches,
health-care needs, barriers, and resiliencies, TGNC older adults do not share a
vii
viii Foreword
universal narrative or life experience, but instead should be treated as unique, vibrant
individuals.
TGNC aging presents us with a spectrum of lived experiences. Some older adults
socially and/or medically transition in older adulthood, while others enter older
adulthood having transitioned earlier in life. No two journeys are the same. Years of
experiencing discrimination presents a different struggle than delaying one’s transi-
tion. Both deserve affirming care and attention, and we have made space in this
anthology for as many stories from TGNC older adults as possible.
Throughout the book we asked authors to use the term “TGNC” to include all
people whose gender identity does not align with their sex assigned at birth, includ-
ing gender queer, gender fluid, non-binary, third gender, two spirit, gender fabulous,
gender questioning, gender non-conforming, and transgender people. There are
some exceptions where specific reported research made use of other terminology.
“TGNC” was used to maintain consistency within the book, understanding that not
everyone would use this term to describe themselves. We intend its use respectfully
to include a wide variety of identities and lived experiences under its umbrella.
TGNC older adults have long sought affirming care from community health cen-
ters like Howard Brown Health and others, primarily in urban areas. The search for
comprehensive care across the lifespan motivates TGNC people to pursue centers of
excellence, sometimes traveling long distances and across the nation to urban cen-
ters, seeking evidence-based, gender affirming care. Howard Brown is deeply com-
mitted to providing affirmative, respectful, and personalized care to the TGNC
community. We are honored by the choice of many TGNC people to receive their
care at our health center and feel an urgent sense of responsibility and obligation to
share what we have learned to create a wider range of competent healthcare options
for the community.
Howard Brown envisions a future where the health and wellness of TGNC peo-
ple is affirmed with health care as a human right, where progressive social policy
and enlightened societal norms uplift the lives of TGNC people and their families,
and where affordable, accessible, and culturally competent care from non-judgmen-
tal healthcare professionals is available and provided to all who seek it. This book is
part of our contribution to furthering that vision.
Contents
1 The Essentials: Foundational Knowledge to Support

Affirmative Care for Transgender and Gender
Nonconforming (TGNC) Older Adults�� 1
Kelly Ducheny, Cecilia T. Hardacker, K. Tajhi Claybren,
and Channyn Parker
2 Endocrinology, Hormone Replacement Therapy (HRT),
and Aging�� 21
Magda Houlberg
3 Transgender Physiology, Anatomy, and Aging: A Provider’s
Guide to Gender-Affirming Surgeries�� 37
Cecilia T. Hardacker, Jules Chyten-Brennan, and Alix Komar
4 The Intersection of Transgender Identities, HIV, and Aging�� 61
Kristen E. Porter and Mark Brennan-Ing
5 Transgender Intimate Partner Violence and Aging�� 79
Adam M. Messinger and Jennifer Roark
6 Substance Use and Recovery in the Transgender and
Gender Nonconforming (TGNC) Older Adult Community�� 97
Stacy Agosto, Kristin Reitz, Kelly Ducheny, and Tatyana Moaton
7 Trauma and Aging �� 113
Loree Cook-Daniels
8 Religion, Spirituality, and Health Behaviors:
Intersections with Gender Diversity and Aging�� 131
Ruben A. Hopwood
9 Integrating Intersectionality when Working with Trans
Older Adults �� 151
Anneliese A. Singh, Natalia Truszczynski, Lindsay White, Sand
Chang, and Zyer Beatty
ix
x Contents
10 Evolving Aging Service Networks: Meeting the Demands

for Inclusive and Comprehensive Older Transgender
Adult Services�� 161
Kelly Rice, Claire Niemet, and Katt Ross
11 Aging in Place, Caregiving, and Long-Term Care for
Transgender Adults�� 175
Jacqueline Boyd
12 End of Life: Honor and Celebration of TGNC Individuals�� 191
Hector Torres, Greg Storms, and Vanessa Sheridan
13 Transitioning and Generational Cohort: Retirement�� 203
D. L. Wilke
14 Voices: Stories of Resilience�� 217
Cecilia T. Hardacker, Laura Kelly, Rachael Booth, Johnny
Simonello, Estelle Martin, Jesse Harris, Gina Eilers, Jolie Theall,
Stefanie Clark, Cornelia Kost, Kelly Ducheny, and Magda Houlberg
Index�� 233
Contributors
Stacy Agosto, LCSW Behavioral Health Services, Howard Brown Health Center,
Chicago, IL, USA
Zyer Beatty, M.Ed Department of Counseling and Human Development Services,
University of Georgia, Atlanta, GA, USA
Mark Brennan-Ing, PhD Brookdale Center for Healthy Aging, Hunter College,
The City University of New York, New York, NY, USA
Rory Meyers College of Nursing, New York University, New York, NY, USA
Sand Chang, PhD Department of Health Promotion and Behavior, University of
Georgia, Atlanta, GA, USA
Jules Chyten-Brennan, DO Montefiore Medical Center, Bronx, NY, USA
Claire Niemet, MPH Parkinson’s Disease and Movement Disorders Program,
Rush University Medical Center, Chicago, IL, USA
Loree Cook-Daniels, MS FORGE, Inc., Milwaukee, WI, USA
Kelly Ducheny, PsyD Behavioral Health Services, Howard Brown Health Center,
Chicago, IL, USA
Cecilia T. Hardacker, MSN, RN, CNL Howard Brown Health Center, Chicago,
IL, USA
Ruben A. Hopwood, MDiv, PhD The Danielsen Institute, Boston University,
Medical Department, Fenway Health, Boston, MA, USA
Magda Houlberg, MD, AAHIVS, CMO Medical Services, Howard Brown
Health Center, Chicago, IL, USA
Jacqueline Boyd, BS, CEO The Care Plan, Chicago, IL, USA
Katt Ross, LSW Social Services, Howard Brown Health Center, Chicago, IL, USA
Kelly Rice, MPH Social Services, Howard Brown Health Center, Chicago, IL, USA
Alix Komar, MD, FACOG Weiss Hospital, Chicago, IL, USA
Adam M. Messinger, PhD Justice Studies Department, Northeastern Illinois
University, Chicago, IL, USA
xi
xii Contributors
Tatyana Moaton, MBA-HRM Human Resources, Howard Brown Health Center,

Chicago, IL, USA
Channyn Parker Youth Development, Howard Brown Health-Broadway Youth
Center, Chicago, IL, USA
Kristen E. Porter, PhD, Mac, Lac Zen Executive LLC, Boston, MA, USA
Kristin Reitz, LCSW Behavioral Health Services, Howard Brown Health Center,
Chicago, IL, USA
Jennifer Roark, PhD, MSW Department of Sociology, Social Work, and
Anthropology, Utah State University, Logan, UT, USA
Vanessa Sheridan, BA Center on Halsted, Chicago, IL, USA
Anneliese A. Singh, PhD Department of Counseling and Human Development
Services, University of Georgia, Atlanta, GA, USA
Greg Storms, MA Center on Halsted, Chicago, IL, USA
K. Tajhi Claybren, A.M Behavioral Health Services, Howard Brown Health-
Broadway Youth Center, Chicago, IL, USA
Hector Torres, PsyD Center on Halsted, Chicago, IL, USA
Natalia Truszczynski, MPH Department of Health Promotion and Behavior,
University of Georgia, Atlanta, GA, USA
Lindsay White, MPH Department of Health Promotion and Behavior, University
of Georgia, Atlanta, GA, USA
The Essentials: Foundational Knowledge
to Support Affirmative Care 1
for Transgender and Gender
Nonconforming (TGNC) Older Adults
Kelly Ducheny, Cecilia T. Hardacker, K. Tajhi Claybren,

and Channyn Parker
1.1 Introduction
Long before the word “transgender” was introduced into our vocabulary, there
existed a constellation of individuals who have always been a foundational part of
what is known today as the lesbian, gay, bisexual, transgender, and queer (LGBTQ)
community. This unique set of soldiers, both known and unknown, spanning oceans
and time, have been erased and unwritten throughout history by the patriarchal pen.
Transgender and gender nonconforming (TGNC) people have long stood at the
forefront of battles for liberation and equality. With this book, we pay homage to
and salute our community’s most valuable resource, our TGNC elders.
In the last 15 years, there has been an explosion of research [3], literature, media,
and publication about TGNC identities, TGNC people, and the new frontier of affir-
mative health care [41, 72]. TGNC voices and identities have reached mainstream
society and professional networks in new ways, with TGNC voices amplified and
role models visible. Much of the exposure has highlighted TGNC people as an
“emerging” population, with deep focus on youth who are exploring TGNC
K. Ducheny (*)
Behavioral Health Services, Howard Brown Health Center, Chicago, IL, USA
e-mail: kellyd@howardbrown.org
C. T. Hardacker
Howard Brown Health Center, Chicago, IL, USA
e-mail: ceciliah@howardbrown.org
K. Tajhi Claybren
Behavioral Health Services, Howard Brown Health-Broadway Youth Center,
Chicago, IL, USA
e-mail: kTajhiC@howardbrown.org
C. Parker
Youth Development, Howard Brown Health-Broadway Youth Center, Chicago, IL, USA
e-mail: channynp@howardbrown.org
© Springer International Publishing AG, part of Springer Nature 2019 1

M. Houlberg et al. (eds.), Transgender and Gender Nonconforming Health and Aging,
https://doi.org/10.1007/978-3-319-95031-0_1
2 K. Ducheny et al.
identities [63] and TGNC adults in their 20s or 30s. Much less attention has been
focused on TGNC older adults’ unique life experiences, resiliency, and challenges.
Less attention has been focused on TGNC older adults because of ageist invisi-
bility and the rarity of a TGNC person surviving into older adulthood. It is fre-
quently stated by members of the TGNC community that TGNC people have an
average lifespan of 30–35 years [62], although no demographic evidence can be
cited. TGNC community members are accorded elder status in their 30s and 40s. To
emerge into their 50s, 60s, or 70s as older adults, TGNC people must have survived
hate, violence, and attempted murder, suicide and depression, limited access to edu-
cation, housing, and employment, systematic oppression, a profound lack of health
care, and constant risk of exposure and expulsion in a transphobic world [71].
Survival of TGNC older adults is a testament to their resilience, creativity, determi-
nation, resourcefulness, and perseverance [32].
TGNC people make up 0.53% of the US population, of those a greater number
are transwomen (0.28%) compared to transmen (0.16%) or gender nonconforming
people (0.08%) [20]. Other research estimates the percentage of TGNC people as
low as 0.3% in North Dakota and as high as 0.8% in Hawaii with only 0.5% of the
total over the age of 65 [26]. Data collection is limited by survey question inconsis-
tency and lack of viewing gender on a continuum [34] or gender spectrum that
includes queer and non-binary identities.
With an increase in culturally adept, affirmative health care, and a broadening
awareness and acceptance in mainstream society, more TGNC people will have the
opportunity to grow into older adulthood. Increasing the number of TGNC older
adults and improving their quality of life will evolve the essence and depth of TGNC
communities, preserving knowledge and connection, and intergenerational net-
works and support, interrupting the erasure and silencing of the TGNC community.
TGNC communities themselves are learning how to age and what it means to be an
older adult, since many TGNC people have never seen living into older adulthood
as a possibility. While most care systems are unprepared to provide affirmative,
respectful health care to TGNC elders [41], the need is extremely high given TGNC
people’s low access to affirmative care for decades of their lives and their under-
standable hesitance to approach health care, given previous, consistent experiences
in transphobic and damaging care systems [36].
An understanding of the compelling need for affirmative care is necessary but
not sufficient for the provision of affirming, adept, and effective care for TGNC
people. In addition to an understanding of need, health-care professionals must
develop knowledge, skills, and attitudes that support affirmative service provision
[36]. Such knowledge, skills, and attitudes are created in progressive layers, with a
foundational infrastructure of cultural sensitivity providing a frame upon which
more specialized intervention skills are built across time. This chapter is designed
to offer the foundational knowledge a reader will need to understand and apply
information found in the following chapters. The following chapters in this book are
written at an intermediate or advanced level and presume that the reader has inten-
tionally digested and learned the essential information presented below.
1 The Essentials: Foundational Knowledge to Support Affirmative Care 3
To understand and apply the content of this book, health-care professionals must
take initiative to gather, digest, and incorporate learning that isn’t taught in most
training programs or available in most care settings [36]. Without this learning, even
well-intentioned care professionals will do damage, interrupt affirmative care, and
fail to establish trust with TGNC older adults that is pivotal to their engagement and
participation in health care [3, 36]. While this learning can be personally challeng-
ing, it will deepen the care you can provide for TGNC people and for all people you
serve by extension. The information in this chapter is an introduction; it is not
exhaustive, but it is a critical starting point. Thank you for taking the next steps to
deepen your understanding about TGNC people and improve the care you can offer
to the TGNC older adult community.
1.2 Learning the Basics
This section will offer basic constructs and terminology that are pivotal when work-
ing with TGNC older adults. The goal is to provide the reader with foundational
understanding of gender identity, gender expression, and sexual orientation and
offer valuable insight into TGNC people’s lives that is essential to providing care to
TGNC older adults.
1.2.1 Gender Identity and Gender Expression
When born, children are assigned a sex of either male (M) or female (F) based on
observed reproductive anatomy. Children who are born with a penis receive a male
gender marker of “M”; children born with a vagina receive a female gender marker
of “F” [3]. That gender marker is listed on the child’s birth certificate. Children who
are intersexed (born with ambiguous physical characteristics of both sexes) are
assigned either a male or female sex and then may undergo unnecessary surgery to
align body parts with the assigned sex [36, 47]. The government, society, health-
care and school systems, and the child’s parents have traditionally assumed that all
children with a female sex assigned at birth will grow up to be women and all chil-
dren with a male sex assigned at birth will grow up to be men. It has been assumed
that people are cisgender, in other words, that people’s sex assigned at birth was
automatically identical to their gender identity – which is their personal felt experi-
ence of gender, of being male, female, a combination of male and female, or a
unique blend of those genders [3]. It was also assumed that gender was binary [3]
and that there are only two ways to experience gender either as a girl/woman or as
a boy/man.
These assumptions have been proven wrong. Research has demonstrated that a
significant number of people are transgender or gender nonconforming (TGNC)
[20], an umbrella term to describe people whose sex assigned at birth is not aligned
with their gender identity [3]. In addition, research has shown that people
4 K. Ducheny et al.
experience a wide range of gender identities, with gender identity being a spectrum
[33, 52] rather than a binary option of either boy/man or girl/woman [3, 5, 41]. How
a person externally expresses their gender identity is called their gender expression
[3]. Each person has a unique way of expressing their gender identity which can
include, but is not limited to, how people dress, their hair length/style, wearing jew-
elry or make up, chosen names and pronouns, self-portraits, gender markers on
identification and birth certificate, the way a person moves, acts or speaks, and other
aspects of physical presentation. A person’s gender expression can evolve and
change across time. A person’s gender identity can never be predicted based on
outward appearance [3]. Some TGNC people may select not to express their true
gender identity due to comfort level, issues of safety, or ongoing identity evolution
and development. Regardless of outward expression, a person’s gender identity
should always be honored and respected.
1.2.2 Sexual Orientation and Gender Identity
The “LGBT” acronym implies that lesbian, gay, bisexual, and transgender people
are the same, grouped for affinity and identity [36]. This is not accurate. Sexual
orientation refers to a person’s openness to or desire for emotionally, romantically,
and sexually intimate relationships with different types of other people [2, 3]. A
person’s sexual orientation can be lesbian, gay, bisexual, heterosexual, queer, pan-
sexual, or asexual [3]. Gender identity, in turn, refers to an individual’s internal felt
sense of gender [3]. TGNC people can have any sexual orientation. This can be
confusing because, in the past, sexual orientation was identified based on each per-
son’s sex assigned at birth. Given our evolving knowledge of gender, best practice
is to use each person’s gender identity (not sex assigned at birth) to describe sexual
orientation. For example, a transgender man (assigned female sex at birth, male
gender identity) who is only attracted to men would be gay, while a transgender
woman (assigned male sex at birth, female gender identity) who is only attracted to
men would be heterosexual. To best support TGNC people, allow them to share
important information pertaining to sexual partners and sexual behaviors as TGNC
communities include all sexual orientations.
1.2.3 Transition
Transition is the process of aligning a TGNC person’s gender expression with their
self-identified gender identity [3]. The process of transitioning can include medical,
social, and legal changes that support a TGNC person to actualize and share their
gender identity. Medical transition can include hormone therapy, surgery, and a
range of medical procedures that physically alter the body to align it more closely
with a person’s gender identity [16]. Social transitioning can include sharing a
TGNC identity with family, friends, and people in community, asking others to use
gender pronouns or a chosen name that align with gender identity, and dressing/
grooming in ways that align with gender identity [49]. Legal transition can include
changing a person’s legal name or gender marker and revising the gender marker or
name on legal documents (social security card, birth certificate, passport, insurance
card, state ID or driver’s license, credit cards, life insurance policies, etc.) [25]. It is
critical to understand that there is no right way to transition; there is no correct
sequence or combination of choices [73]. Transition choices may change across
time as gender identity evolves [73]. If someone chooses to pursue certain forms of
transitioning and/or does not medically, socially, or legally transition, their gender
identity still has great integrity and value; they are no less TGNC than someone who
chooses a more traditional pathway. Each person’s transition, whether visible to
other people or not, is deeply personal and individualized to the needs and desires
of that person.
1.2.4 Disclosure
Disclosing a TGNC identity, or coming out, can be intimately connected to a per-

son’s access to support and resources, sense of agency, and issues of safety and
control [3]. Before sharing their identity with others, TGNC people go through a
process of self-awareness and discovery, first understanding their own gender iden-
tity and then deciding whether and when to disclose to others. This includes family,
friends, loved ones, colleagues, and care providers. A person can develop self-
awareness of a TGNC identity at any age; some TGNC older adults may have known
since childhood, while others discover it in the later stages of their life after parents
have passed and they are free to explore their own identity [3, 41]. The age at which
someone identifies that they may be TGNC should not impact the validity and value
of that identity.
Coming out is never “finished,” with TGNC people having to make daily deci-
sions about what to share throughout their lives [74]. If and how someone decides
to disclose their identity is a personal choice; others should never impose that choice
or thoughtlessly share information about someone’s gender identity without permis-
sion. If and how a TGNC person decides to disclose their identity can change across
their lifespan [7]. Choices may change or evolve as a person’s control over living
conditions and care provision change, as resources and support shift, as their iden-
tity evolves, and as circumstances that could increase the danger of rejection, vio-
lence, loss of employment, injury, or discrimination develop. Some people choose
not to disclose that they are TGNC and instead make efforts to pass or to be consis-
tently perceived to be cisgender by others [30]. For TGNC people who select to live
a stealth life [3], their ability to pass and not be clocked (identified as TGNC) is
paramount. The more a TGNC person’s gender expression and behavior align with
cultural expectations of either masculinity or femininity, the increased possibility
the TGNC person will pass and will not be outed or identified as TGNC by others.
Worries about being clocked and outed by others can create intense social anxiety
and worry, making public interaction self-conscious and vulnerable [30]. Some
TGNC people may only seek to pass in specific situations or locations to increase
6 K. Ducheny et al.
safety and comfort, since falling out of narrow cultural expectations of gender and
being clocked as TGNC can result in violence, discrimination, and even death,
depending on who does the clocking. However, not every TGNC person is inter-
ested in passing [3]. Some TGNC people are not concerned with passing because
their gender identity and/or gender expression fall outside of cultural expectations
of masculine and feminine identities, such as a non-binary gender identity or a gen-
der nonconforming identity (identities that do not exclusively align with either mas-
culine or feminine) [3, 41]. For them, passing may not be of interest; instead they
may pursue a more robust understanding of gender identity and expression that
allows for and honors gender nonconformity and gender expansiveness. Other
TGNC people may realize that based on physical, financial, or health reasons, the
ability to pass is not an option. The ability to pass should not be pressed, prioritized,
or diminished by others. Instead, TGNC people’s experiences and choices should be
valued, with a focus on helping the TGNC person actualize their gender presenta-
tion goals.
1.2.5 Resilience
Despite the many adversities that TGNC people navigate to access basic human
rights such as education, employment, housing, social services, and affirming health
care, TGNC people demonstrate deep resilience, creativity, and resourcefulness
[64]. Resilience is an essential component of the livelihood of TGNC people and a
strength of TGNC communities [3, 55, 70]. TGNC people make passionate and
valuable contributions to their surrounding communities and around the world. For
many TGNC people, their resilience is rooted in their community connection and
chosen families [48] rather than biological families (family you were born into).
Some TGNC people develop a chosen family that is a group of individuals who
select one another to serve significant roles in each other’s lives, resembling a “fam-
ily structure” even though individuals are not biologically or legally related. Chosen
families can be essential when a TGNC person is rejected or unable to access sup-
port or resources from their biological family or mainstream society. Chosen family
members have few legal rights and are often unrecognized by hospitals for visitation
and medical decision-making and by legal systems (i.e., wills, deeds, shared homes,
intended inheritance), unless legal documentation is specifically created to establish
those rights [4]. The resilience of TGNC people can be awe-inspiring, with TGNC
people creating networks of supports, economic opportunities, services, celebra-
tions, and resources that are outside of official economic systems and mainstream
society and that are shared by word-of-mouth and community networking [4]. Due
to the structural oppression that TGNC communities experience, many TGNC peo-
ple, particularly those with multiple marginalized intersecting identities, find their
livelihood and overall well-being connected to work and earning opportunities out-
side of official economic systems that are based on street economies and sex work
([38], [75], [66]).
1.2.6 Gender-Affirming Communication
When communicating with TGNC people, there are several components of gender-
affirming communication that are critical to practice and apply. These include name
preference, gender pronouns, and how TGNC anatomy is understood and discussed.
TGNC people may prefer to use a name that is not the same as the name on their
legal documents, such as state ID, social security card, or insurance card (legal
name) [25]. Preferred names are chosen by TGNC people to represent their identity
and personality; names may change across time as identity evolves or may remain
steady. For various reasons, not everyone is able to legally change their name. Some
TGNC people choose to and are able to legally change their name. Upon completing
a name change process, the legal name of the person is no longer the name given to
them at birth but is the name they selected for themselves. Regardless of whether a
TGNC person has completed a legal name change, their preferred name should
always be respected and used. When first meeting any person, ask the name that
person would like you to use while working with them. It is important to use a per-
son’s preferred name regardless of whether that person is there to hear it [36].
Consistent use of preferred names with health teams and colleagues reinforces the
person’s choice, communicates respect, and offers the team practice at using the
correct name even when it might be counterintuitive by a person’s appearance (i.e.,
a person with long hair and makeup with a preferred name of Peter). As TGNC
people align legal documentation with their gender identity, they may change the
gender marker on their state ID, social security card, passport, or birth certificate.
Similar to state-based name change requirements, different states have different
requirements to change the gender marker on any of these documents [25]. Having
documentation that aligns with a TGNC person’s gender identity further supports
efforts to socially, legally, and medically transition.
Another critical component to respectful communication is the use of gender
pronouns (he, him, his; she, her, hers; they, them, theirs; ze, zir, zirs) chosen by
the TGNC person [22]. Gender pronouns should never be assumed based on
appearance. Instead, every person should be asked what gender pronouns they
use. Just like the range of gender identities and expressions, there are a range of
gender pronouns outside of she/her/hers and he/him/his. Some people with non-
binary or gender nonconforming identities use they/them/theirs to refer to them-
selves [3]. While using “they” as a singular pronoun (Amilie said they would meet
us in their office) may feel initially awkward, it is a common usage in TGNC
communities and in professions and care systems that serve TGNC people that
should be learned and integrated into daily practice [3]. If a mistake is made and
a TGNC person is misgendered (spoken to or about using the wrong pronouns)
[56], best practice is to acknowledge the error, genuinely apologize for the mis-
take, and then take action to avoid repeating the error. Mistakes are inevitable, but
an authentic apology and an intentional process that holds the system and health-
care team accountable for improvements communicate value and build true trust
with the TGNC community [36].
8 K. Ducheny et al.
1.2.7 Bathrooms
Bathroom use is a complex, persistent issue for TGNC people. Binary bathroom
designations (women’s room and men’s room) can place a TGNC person in uncom-
fortable and potentially dangerous situations. Forced choice bathrooms require
TGNC people to publicly declare an identity that may or may not match who they
are or how they present. Forced choice bathrooms also require TGNC people to
anticipate and manage the potentially aggressive, frightening, or demeaning reac-
tion of others using the bathrooms they choose [35]. To avoid this choice and these
situations, many TGNC people avoid using public bathrooms, even to the detriment
of their health [35]. Best practice is to offer gender-neutral single stall bathrooms
that can be used by anyone with any gender identity in privacy. A men’s room or
women’s room can be converted to a gender-neutral bathroom, and when that does
not occur, TGNC people should be able to use the bathroom that aligns with their
gender identity without questioning from others.
The section above offers a range of concepts and vocabulary. Like all aspects of
society and communication, word choice and language used by the TGNC and
health-care communities will continue to evolve. Language and vocabulary in this
area change at a fast rate, requiring regular refreshment and awareness [3]. While
language used by the TGNC community can change quickly, it is important to listen
to and reflect the preferred terminology of TGNC older adults as they discuss their
lives and identities. While some TGNC older adults will incorporate the newest
vernacular, some may prefer to use language that existed at defining times of their
lives, even if language in community and the profession has changed. It is critical to
respect TGNC older adults’ language choices while still introducing new terms and
concepts that deepen their awareness of options and self-determination. The
American Psychological Association [3] offers an excellent resource to explore
these concepts in greater depth that includes an informative glossary of terms.
1.3 Cultural Context and Generational Cohort
In understanding TGNC older adults, it is critical to examine the lives they have led
and the social, historical, and cultural contexts they have experienced. At this point
in time, TGNC older adults were born in the early 1960s and before. Though many
TGNC older adults will not self-identify as gender nonconforming or non-binary,
some will identify as transsexual [19], a term that is used less frequently in contem-
porary culture. TGNC older adults lived their younger years in stigmatizing and
dangerous environments, and they have endured medical practices that pathologized
transgender identities [50, 68, 69]. The approach to care for TGNC people has
evolved deeply since they came of age.
Historically in the United States, TGNC people have had few resources avail-
able to them. Affirming health care has been limited in the United States until
recently and was more established in European countries and in Thailand [21]
between 1940 and 1990. To be openly TGNC during these decades in the United
States was fraught with peril. In the 1940s, during the Second World War, approxi-
mately 15,000 gay men and transgender people were exterminated in German con-
centration camps [14]. In the 1950s, there was no cultural, legal, or medical safe
space for TGNC people who were often committed to psychiatric institutions for
reparative therapy or forced to live lives in isolation or seclusion [18]. Even in the
1960s, a time widely recognized as the beginning of civil rights for gays and
lesbians, TGNC people were largely excluded despite their active involvement in
the early movement [18]. TGNC people have borne decades of lack of care and
absolute danger to their lives.
Care for TGNC individuals in the 1960s focused solely on psychiatric care for
gender identity disorder [43]. Medical care for TGNC people, as we understand it
today, with affirming treatment with hormones, behavioral health, and surgical
options, was not available. Additionally, treatment in the 1960s through the 1990s
was isolating and rigid, requiring that TGNC people adhere to a narrow, specific,
and binary narrative or the limited care available to them was blocked [3]. Currently
in the United States, older adults are seeing a dramatic shift in care options and vis-
ibility. In the last 15–20 years, with much of the growth and activity in the last
5 years, older TGNC adults have growing access to care that they have not been able
to experience for most of their lives. Changes in access to services covered by insur-
ance, specifically Medicare, have made available long-denied services [15].
When working with TGNC older adults, it is imperative to consider each indi-
vidual and their life experience as the foundation of their care. Consider TGNC
older adults’ age of self-awareness of their own identity as TGNC and how that
played out in their lives. Be mindful of their age of coming out to others, if they are
out, and the generational assumptions of their younger years [3]. The experience of
coming out at 18 years old in 1960 will be very different from coming out at 70 years
old in 2015. For each individual, there will be a unique personal narrative, important
for the provider to appreciate and respect.
1.4 TGNC Health Disparities
As previously mentioned, the current and emerging generations of TGNC older

adults came of age between the 1960s and 1980s when homosexuality was illegal
and criminalized, and a TGNC identity was pathologized by the medical commu-
nity and mainstream society [24]. The onset of the HIV/AIDS epidemic in the 1980s
created further barriers to societal acceptance, positive health outcomes, and equal
access to physical and mental health services for many TGNC people [34]. The
discrimination and victimization TGNC older adults experienced in their formative
adult years created layers of trauma, caution, and well-founded mistrust of health-
care systems and mainstream society, reified by continued experiences of poor care,
discrimination, and mistreatment [36]. This trauma can result in caution disclosing
gender identity or personal details to health-care providers, worries about the loss of
existing services should their TGNC identity be discovered, and a distrust of health
service staff and systems by TGNC older adults [36].
10 K. Ducheny et al.
Little information is available on the number of TGNC older adults and the health
disparities they experience. Several factors appear to contribute to this gap of informa-
tion including, but not limited to, the low number of TGNC people living to older
ages, TGNC community concern about how collected information would be used by
researchers and health systems [39], the invisibility of TGNC people in current
research [3], inability to collect gender identity demographic data in electronic health
records, low national priority and lack of research funding, and the need for some
TGNC older adults to de-transition when moved into unsupportive care facilities [40].
Given a potentially higher mortality rate, fewer TGNC people may survive to older
ages compared to the general population, creating complex challenges in finding
TGNC older adult populations and studying their lives and health. Given the long his-
tory of non-affirmative and harmful health care and the past use of data to pathologize
TGNC identities, the TGNC community is appropriately cautious about engaging in
research [37, 54]. In addition, most research ignores gender identity as a demographic
variable, making the TGNC community invisible [34]. Available research on the
health disparities and specific needs of TGNC older adults has historically been lim-
ited, frequently considered a taboo subject of governmental and academically funded
research. Data on gender identity is not routinely collected by the US Census Bureau
[12], the greater medical community, or through federally funded demographic
research. Prior to 2015, there was no national directive to collect sexual orientation
and gender identity (SOGI) data in research or through patient information [41]. In
addition, TGNC older adults may choose to or be forced to “de-transition” (deny their
TGNC gender identity and shift gender presentation back to sex assigned at birth)
when shifting into assisted living systems or nursing homes [40].
Since 2015, as part of Meaningful Use Guidelines Stage 3 [13], electronic
health record (EHR) systems across the United States have been adding capacity
to collect sexual orientation and gender identity data. This critical information
collection allows TGNC communities to be visible in significant ways [12].
Without data collection, health inequities that exist for these vulnerable popula-
tions had minimal opportunity to be discovered and therefore were not addressed.
Now that these groups, especially TGNC communities, can be addressed in a
meaningful way in terms of research, the impact on specific subgroups can be
illuminated and studied [13].
In the past, research and data collection regarding the health needs of TGNC
people has largely focused on transition-related care and HIV/AIDS health dispari-
ties [9]. The limited amount of research completed on these topics has been con-
ducted with small and often ineffective convenience samples or samples obtained in
nonsystematic ways [44]. As the number of TGNC older adults increase, there is a
critical need to better understand the specific health needs of this growing, and
oftentimes vulnerable, population. TGNC older adults will not only have health
conditions that are customarily associated with aging, including hypertension, dia-
betes, heart disease, and degenerative memory disorders, but could also face uncer-
tain health conditions that are not yet fully understood. These uncertainties include
the long-term effects of the use of hormones and silicone injections, long-term
surgical complications, older adult HIV disease management, and the overall men-
tal and social health of aging TGNC individuals.
TGNC people are habitually subjected to various forms of discrimination
including social stress, violence, prejudice, workplace hostility, and institutional
and systematic barriers to care [41]. The impact of social stress, including vio-
lence, transphobia, and stigma, is significantly felt by TGNC people, and even
more so by aging persons within this population. This social stress can result in
depressive symptoms, suicidal ideation, interpersonal trauma exposure, substance
abuse disorders, and anxiety [67]. TGNC people are also disproportionately vic-
timized through physical and verbal abuse, sexual assault, property damage, and
denial of access to health-care services. One study found that 40% of transgender
individuals reported being denied health care or were provided inferior care based
on their gender identity [42]. Additionally, another study of over 27,000 TGNC
people published in 2016 found that 46% of respondents reported verbal harass-
ment; 24% were physically threatened; 58% reported being mistreated by law
enforcement officials; 19% were not hired for a job, fired, or not promoted; 54%
experienced intimate partner violence; and 47% were sexually assaulted. These
incidence rates are frequently found to be higher among TGNC populations com-
pared to cisgender peers [41].
The workforce can be a particularly challenging environment for TGNC people.
There are significant links between workplace hostility and suffering psychological
distress [8]. Nearly 50% of transgender individuals report workplace discrimination
based on their gender identity [46]. This discrimination can take the form of hostil-
ity, isolation, lack of collaboration, lower pay, and lack of advancement opportuni-
ties. The ability to advocate for one’s self can also be significantly altered by past
and current victimization and discrimination based on gender identity [11]. Realized
and perceived discrimination within the workplace can also affect a TGNC person’s
ability to maintain long-term employment, sustain a positive career advancement
trajectory, and attain occupational gratification and aspirations [10, 51]. In turn, it
adversely affects an individual’s lifetime earning potential, ability to financially
plan for retirement, maintain health insurance, and achieve an overall sense of finan-
cial security [17]. TGNC people may enter the workforce later than cisgender peers,
may have been held at entry level positions for longer periods of time, and are more
likely to have been involved in street economies that provide less reliable income
and financial safety. TGNC older adults find themselves moving into their older age
having earned consistently less than their cisgender peers [46] and rarely having had
the opportunity to plan or save for retirement or for a time in their lives when they
are no longer able to work. This financial insecurity impacts the individual’s ability
to access health care [27] and can increase feelings of depression, hopelessness, and
fear. According to the 2013 Aging with Pride: National Health, Aging, Sexuality
and Gender Study, 50% of all transgender adults aged 50 or older live at or below
200% of the federal poverty level, compared to only 30% of their LGB counterparts,
and 25% of transgender adults experience financial barriers to health services com-
pared to only 6.4% of non-transgender individuals [28].
Within many institutions and social service operations, supportive resources

available to older adults are not systematically inclusive of TGNC people’s life
experiences and needs. Many social programs and services within senior centers,
long-term care facilities, and in-home health services operate under the assumption
that all individuals served are heterosexual [44] and cisgender. Institutional provid-
ers of these services and programs must utilize culturally competent care delivery
systems, respectful and affirming language, informed intake procedures, and inclu-
sive operating procedures. The absence of these practices may cause TGNC indi-
viduals to be excluded, shamed, misunderstood, and forgotten.
Access to gender-affirming services remains a significant problem within the
health-care system. TGNC individuals are found to have lower rates of insurance
coverage, reduced social support, lack a primary care provider, delay seeking medi-
cal care, and experience harassment within health-care settings [41]. These factors
can lead to higher rates of mental stress/illness, emergency room visits, and hospi-
talizations [58]. A significant institutional deterrent to positive health outcomes for
TGNC older adults is the inequities that exist within the private and public insur-
ance systems. While it has been found that TGNC people with private insurance are
subjected to less discrimination within health-care settings, there are still exclusions
for TGNC affirmative care within many private insurance plans [42]. The exclu-
sions make it difficult or impossible for consumers to receive gender affirmative
surgery and hormone prescriptions. While Medicare has formally removed such
exclusions [57], other changes within the Medicare system and a lack of providers
willing to accept Medicare payment rates for gender affirmation surgery may make
it difficult to access a full continuum of affordable health care through public assis-
tance plans. Exclusion policies for Medicaid and private insurance plans vary state
by state, making the continued advocacy for TGNC patients’ rights to accessible
and affirmative health-care coverage essential.
Beyond the difficulties and trauma of navigating health and societal systems,
TGNC people frequently experience family rejection, stress, and oppression [3].
In lieu of unsupportive biological family relationships, many TGNC people create
support systems through a chosen family. A chosen family provides a TGNC older
adult with a personal safety net of friends, neighbors, and loved ones who provide
meaningful support to each other over time. A chosen family is a community- and
individual-level coping mechanism that aids in mitigating stress and establishing
meaningful, affirming relationships that can replace nonsupportive biological
family members [31]. One study has shown that some aging TGNC people with
close relationships to their biological families can actually show more depressive
symptoms than those that do not maintain these relationships [43], although some
TGNC people experience supportive, caring relationships with their biological
families. For TGNC older adults who remain connected to their families of origin,
it can be stressful to wonder whether relationships will remain strong across time
to rely upon family members when support and advocacy are needed to ensure the
TGNC older adult receives affirmative care and respect through older adulthood
and death.
1.5 Affirmative Care
Central to serving aging TGNC people is the provision of gender-affirming care,

defined as “care that is sensitive, responsive, and affirming to trans patients’ gender
identities and/or expressions” and “health care that holistically attends to transgen-
der people’s physical, mental, and social health needs and well-being while respect-
fully affirming their gender identity” [61]. Research has consistently shown that
TGNC people are more likely to experience positive life and health outcomes when
they receive social support and affirmative care [3, 65]. Affirmative, patient-centered
care must recognize and support each individual; there is no “one-size-fits-all”
approach [61]. In practice, this means that all health care providers will need to not
only educate themselves but also their care teams to provide this life-saving and
life-affirming care. To begin, providers should immerse themselves in the available
literature and develop a skill set that they can share with their teams. Development
of day-to-day practices, including appropriate use of terminology and recognition
of chosen name and pronouns, elimination of stigma, use of evidence-based proto-
cols, and a consistent commitment to personal introspection, are all essential to
creating a safe and welcoming space for TGNC people [3].
A foundational component of affirmative care is the recognition that TGNC
identities can be healthy and self-affirming and are not inherently pathological [16].
While a person’s identity is healthy, chronic exposure to societal stigma and dis-
crimination can result in persistent distress associated with discordance between a
person’s gender identity and body or sex assigned at birth [3, 9, 16], defined as
gender dysphoria in the Diagnostic and Statistical Manual of Mental Disorders,
Fifth Edition (DSM-5) [1]. Not every TGNC person experiences gender dysphoria,
but supporting those who do is a critical health-care need. The World Professional
Association for Transgender Health (WPATH) has a comprehensive resource avail-
able that describes standards of care for TGNC individuals [16]. The Center of
Excellence for Transgender Health at the University of California San Francisco
(UCSF) has similar guidelines for the “Primary and Gender-Affirming Care of
Transgender and Gender Non-binary People” [23], and multiple progressive LGBT
community health centers across the country utilize these care protocols [59].
It is critically important that TGNC people have agency in all aspects of their
health and wellness. As with many people who are aging, TGNC older adults may
experience loss of power and agency, especially as others involve themselves in
their care. An adult child or caregiver may invalidate a TGNC person’s identity by
not using correct pronouns or telling the provider that it doesn’t matter, referring to
their transfeminine parent as “my dad” or “him,” giving the provider permission to
do the same. Providers will demonstrate advocacy for their patient by adhering to
the patient’s chosen name and pronoun in spite of what family and outside systems
may suggest, and will ultimately be of more benefit to the patient.
Self-determination of the TGNC person regarding their identity, choices in care,
and plans for transition is the heart of patient-centered, affirmative care. Health-care
providers must place the TGNC older adult in the guiding role and, working in
concert, offer affirming pathways of care [60]. During the 1990s, Howard Brown
Health, an LGBT-centric federally qualified health center in Chicago, along with
Callen-Lorde Community Health Center in New York City, began developing an
informed consent model for hormone use that excluded the need for psychotherapy,
a mental health letter, and “proof” of having a “real” TGNC identity [59]. Community
and patient feedback, in addition to clinical data, led to the adoption of this model
of care. This pioneering approach eliminated required lengthy mental health evalu-
ations and the requirement that an individual prove real-life experience (RLE) (liv-
ing as their intended gender for a year) prior to acquiring a prescription for hormones.
The informed consent model, simply stated, provides that if the patient is of age of
consent, has no unmanaged medical conditions, and has the capacity to consent,
they will be able to gain a prescription of hormones, many times in their first
appointment [25].
The role of the health care provider in providing affirmative care for TGNC older
adults is multifaceted and, most importantly, demands interdisciplinary communi-
cation [25]. Support for older TGNC people will require the provider and the care
team to provide more patient navigation and support than usual, coordinating com-
munications between other health specialists and making best efforts to carve affir-
mative pathways to needed services. In affirmative interdisciplinary care, the role of
the care team expands to link patients to other affirmative care systems and, when
possible, to protect TGNC people from or prepare them to interact with systems that
are unsupportive or damaging [25]. For instance, a health care provider may call
ahead after referring a patient to a hospital for mammography, to advise the clinic
on providing respectful care to a transgender man who has breasts. In addition,
health care providers often write letters for TGNC people to change their gender
markers on a driver’s license and state identification documents; requirements to
change gender markers vary from state to state, but these all-important letters are
required to navigate these government offices [76].
In all encounters with TGNC people, there may be an understandable issue of
distrust on the part of the patient. The establishment of a successful relationship
begins the moment a provider and health care team meet a new patient. A best prac-
tice to utilize in the first patient encounter is for the provider to introduce themselves
with their name and pronoun, ask for the same from the patient, and, throughout the
interview, always ask permission to discuss sensitive topics and explain the intent of
questions. In cases when a physical exam is needed, be sure to ask for shared lan-
guage to describe body parts as the patient may use different terminology. Allow for
time to discuss any procedure, even allowing for the procedure to be done another
day if the prospect of an exam causes a patient distress [45]. Be mindful to screen
and treat body parts the patient has as it pertains to the purpose of the visit [23]. It
may be that an older transwoman may need a screening for prostate cancer and an
older transman may need a hysterectomy. Inspection of genitalia is not indicated
when a patient is visiting for a physical injury or illness that does not involve those
body parts.
Multiple challenges exist within institutional spaces that create barriers to care.
For example, most EHRs do not support the ability to use a name other than the
name used for billing in documentation and offer inadequate support in creating
affirmative documentation for referrals [76]. In terms of documentation, it is impor-
tant to use a patient’s preferred name and pronouns regardless of who reads it,
unless it is unsafe for the patient or if the patient has requested that different pro-
nouns be used in the medical records [13].
To actualize affirmative care, an interdisciplinary method must be employed to
support TGNC patients. An interdisciplinary collaborative care (ICC) team is
defined as a team that “aspires to a more profound level of collaboration (than a
multidisciplinary team), in which constituents of different backgrounds combining
their knowledge mutually complete different levels of planned care” [6]. This col-
laboration moves beyond traditional institutions of health care [25]. Consider a
team supporting a person transitioning as an older adult – this team may include a
primary care provider, behavioral health provider, spiritual adviser, and legal advo-
cate, with referrals to electrolysis, and case management or social service to aid
with housing, nursing home entry, or hospice care. This coordinated symphony of
care is needed for the unique challenges older TGNC people experience.
Many care systems do not have mechanisms in place to support ICC teams, which
can involve unbillable collaborative time; however, such collaboration and interdis-
ciplinary communication is pivotal in supporting TGNC people [25]. When work-
ing to build affirmative care pathways, team members who are more familiar with
TGNC resources and affirmative care will facilitate the learning of colleagues and
will maximize their colleagues’ effectiveness working with TGNC patients. A pro-
vider new to TGNC care will find this framework an invaluable support. If leading
this team building process, it is important to do this in a manner that solidifies the
team rather than disrupts it and, ultimately, amplifies and supports the voice of the
TGNC person to involve them in active participation as a care team member. Some
TGNC individuals who have not had their voices heard or respected in previous
health-care experiences, or who have learned from their community to expect disre-
spectful and damaging treatment, may present to the care team as less willing to
tolerate delay or more assertive about their health-care choices than other patients.
This behavior can sometimes be interpreted by care systems as insistent, entitled, or
even resistant. Care teams are encouraged to reframe their understanding of this
behavior, recognizing that this behavior has enabled TGNC people to protect them-
selves in often uninformed and damaging care systems, supporting them in their
fight to ensure body integrity and access medically necessary care. It is fueled by
resilience and has supported the survival of TGNC elders. Providers are encouraged
to work with the patient as the center of the care team and make every attempt to
support TGNC people in establishing agency and authentic equal participation in
care decisions [36].
As a provider and advocate to aging TGNC patients, it is critical that organiza-
tions move to establish safe, welcoming, and knowledgeable health care spaces.
Moving this work forward will require exerting the power and privilege inherent
in the role of provider and health care team to create safe and affirmative care
systems and laws, with every step toward affirmation building improved health
outcomes.
1.6 Ongoing Learning and Closing Thoughts
When providing care for TGNC older adults, it is important that health-care provid-
ers and all care team members are aware of the depth and limitations of their current
knowledge and skill base and continuously work to deepen them to support TGNC
people [25, 55]. A lack of knowledge or skill, or unexamined beliefs about gender
identity and gender expression on the part of a provider, can impact a TGNC per-
son’s willingness to trust them and their care team’s ability to offer affirmative care
[28]. The topics and guidance covered in this book are not exhaustive but offer some
necessary tools to offer affirmative care to TGNC patients. As such, it is imperative
that health-care providers and care teams continue to educate themselves through
training, mentorship, and authentic digestion of TGNC patient and community
feedback. It is not the responsibility of the patient to inform health-care providers of
best practices for offering affirmative care. TGNC patients can and will share impor-
tant details specific to their individualized care. However, it is the health-care pro-
fessional’s responsibility to deepen their education and the knowledge and skills of
their team and to consistently improve the system in which they provide care [25].
While the development of knowledge and skills are critical to the provision of
affirmative care, so is the introspection required to understand one’s unexamined
beliefs about gender identity and expression. Societal learning has embedded trans-
phobic beliefs, judgments, stereotypes, and assumptions about gender identity and
gender presentation in all people and systems [53]. Unexamined beliefs of this
nature will be obvious in language and behavior; even if they are actualized in subtle
ways, these beliefs will impact the care of the patient and their trust in the care team
[29]. As providers and care teams work to educate themselves, it is important to
devote time to the examination of beliefs, judgments, stereotypes, and assumptions
as they relate to patients, to the necessity and perceived value of care, and to the
possibility of best health for TGNC older adults. This examination may be exciting
and simultaneously uncomfortable as care team members work to learn more,
evolve understanding, and take critical steps to provide consistent and progressively
stronger affirmative care. We truly thank each person for reading this book and for
the affirmative care that will be provided to TGNC communities as a result.
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Another random document with
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212.3 Thureau-Dangin, Les cylindres de Goudéa, p. 57: Les héros
morts leur bouche auprès d’une fontaine il plaça.
212.4 Winckler, op. cit., p. 41.
212.5 Jeremias, op. cit., p. 15.
213.1 E.g. Peiser, Sketch of Babylonian Society, in the Smithsonian
Institute, 1898, p. 586, speaks as if it was ancestor-worship that held

the Babylonian family together.
213.2 Vide my article on “Hero-worship” in Hibbert Journal, 1909, p.
417.
214.1 V. Landau, Phönizische Inschr., p. 15.
214.2 Jeremias, Hölle u. Paradies, p. 37.
215.1 It would be idle for my purpose to distinguish between the so-
called “Achaean” and “Pelasgian” elements in the Homeric Νέκυια;
even if the latter ethnic term was of any present value for Greek
religion.
215.2 Hesiod, Ἔργ. 110-170 (the men of the golden and the silver
ages and the heroes).
216.1 Vide Zimmern in K.A.T.3, pp. 636-639; Jeremias, Hölle u.
Paradies, p. 25; cf. his Die Babyl. Assyr. Vorstellungen rom. Leben
nach dem Tode.
216.2 Vide supra, p. 160.
216.3 Zimmern, op. cit., p. 520; King, op. cit., p. 188.
217.1 King, op. cit., p. 138.
217.2 Lagrange, Études sur les religions sémitiques, p. 493.
218.1 Cf. Keil. Bibl., ii. 109; Jeremias, Hölle u. Paradies, pp. 13-14.
219.1 Jastrow, op. cit., pp. 472-473.
219.2 Ib., p. 473.
219.3 Ib., p. 472.
219.4 Zimmern in Sitzungsber. d. Kön. Sächs. Gesell. Wiss. 1907,
“Sumerisch-Babylonische Tanzlieder,” p. 220.

219.5 Vide Jeremias in his article on “Nergal” in Roscher’s Lexikon,
iii. p. 251.
219.6 It is doubtful if any argument can be based on the name
Ningzu, occasionally found as the name of the consort of Ereshkigal
(Zimmern, K.A.T.3, p. 637) and said to mean “Lord of Healing,” in
reference, probably, to the waters of life.
219.7 Only in the story of Adapa he appears as one of the warders
of the gates of heaven (Zimmern, K.A.T.3, p. 521).

220.1 The story of Aphrodite descending into Hades to seek Adonis
is much later than the period with which we are dealing. Nergal’s
descent to satisfy the wrath of Allatu and his subsequent marriage
with her (Jeremias, Hölle und Paradies, p. 22) is a story of entirely
different motive to the Rape of Kore.
CHAPTER XIII NOTES
223.1 Cook, The Religion of Ancient Palestine, p. 17.
223.2 Researches in Sinai, p. 72, etc., 186: he would carry back the
foundation to the fourth millennium B.C.
223.3 Vide Arch. Anzeig., 1909, p. 498.
223.4 Vide Cults, iii. p. 299.
224.1 Vide Hogarth’s evidence for the date of the earliest
Artemision, Excavations at Ephesus, p. 244.

224.2 Il., i. 38.
224.3 Ib., vi. 269, 299-300.
224.4 Ib., ii. 550.
224.5 Ib., ix. 405.
224.6 Vide Stengel, Griechische Sacral-Altertümer, p. 17.
224.7 Vide Athen. Mittheil., 1911, pp. 27, 192.
225.1 Vide Jeremias in Roscher, Lexikon, ii. p. 2347, s.v. “Marduk.”
225.2 Something near to it would be found in the cult-phrase Ζεὺς
Νᾶος of Dodona, which is a form commoner in the inscriptions than
Ζεὺς Νάϊος, if, with M. Reinach (Rev. Archéol., 1905, p. 97), we
regarded this as the original title and interpreted it as “Zeus-Temple.”
But the interpretation is hazardous.
225.3 A disk on the top of a pole, vide Jastrow, Rel. Bab. Assyr.,
vol. i. p. 203.
226.1 Cook, op. cit., p. 28.
226.2 Religion of the Semites, pp. 185-195; “Mycenaean Tree and
Pillar Cult,” Hell. Journ., 1901. It is interesting to note that Baitylos, a
name derived from the Semitic description of the sacred stone as the
“House of God,” is given as the name of a divine king in the
cosmogony of Philo Byblius, Müller, Frag. Hist. Graec., iii. p. 567; cf.
the baitylos with human head found at Tegea inscribed Διὸς
Στορπάω (fifth century B.C.), “Zeus of the lightning” (Eph. Arch.,
1906, p. 64).
227.1 Vide Evans, op. cit., and Annual of British School, 1908,
1909.
227.2 Vide my Cults, i. pp. 13-18, 102; ii. pp. 520, 670; iv. pp. 4,
149, 307; v. pp. 7, 240, 444.
227.3 For the evidence of a pillar-cult of Apollo Agyieus and
Karneios coming from the north, vide Cults, vol. iv. pp. 307-308.
227.4 The pillars known as “Kudurru,” with emblems of the various
divinities upon them, served merely as boundary-stones (vide
Jastrow, op. cit., i. p. 191; Hilprecht in Babylonian Expedition of
University of Pennsylvania, vol. iv.).
228.1 6, 269.
228.2 Cults, ii. 445.
228.3 Op. cit., vol. v. p. 8.
229.1 Arnob. Adv. Gent., 5, 19 (in the mysteries of the Cyprian
Venus), “referunt phallos propitii numinis signa donatos.”
229.2 Cook, Religion of Ancient Palestine, p. 28; cf. Corp. Inscr.
Sem., i. 11. 6, inscription found in cave, dedicated perhaps by the
hierodulai, “pudenda muliebria” carved on the wall.
229.3 Rel. of Sem., pp. 437-438.
229.4 De Dea Syria, c. 16 and c. 28.
229.5 Histoire de l’Art, iv. pl. viii, D.
230.1 Jeremias, in his articles on “Izdubar” and “Nebo” in Roscher’s
Lexikon, ii. p. 792 and iii. p. 65, concludes that a phallic emblem was
employed in the ritual of Ishtar; but he bases his view on the
translation of the word ibattu in the Gilgamesh Epic, which is
differently rendered by King, Babylonian Religion, p. 163, and
Zimmern, K.A.T.3, p. 572.
230.2 Thureau-Dangin, Les Cylindres de Goudéa, p. 69.
231.1 This may explain the double phrase, used concerning the
institution and endowment of temple-rites in an inscription of the time
of Tiglath-Pileser III., which Zimmern translates by “Opfer-
Mahlzeiten,” Keil. Bibl., iv. p. 103; cf. especially K.B., iii. p. 179 (inscr.
of ninth century); Zimmern, Beiträge zur Kenntniss der Babyl. Relig.,
ii. p. 99 (sacred loaves offered before consultation of divinity).
231.2 Vide Robertson Smith, op. cit., p. 200.
231.3 Vide Cults, i. p. 88; v. p. 199.
232.1 Judges ix. 13; cf. Robertson Smith, op. cit., p. 203.
232.2 Lagrange, Études sur les religions sémitiques, p. 506. This
seems to agree with the statement in Diodorus (19, 94) that the
Nabataeans tabooed wine; yet Dusares, the Arabian counterpart of
Dionysos, was a Nabataean god.
232.3 Gray, Shamash Religious Texts, p. 21.
232.4 Dhorme, Choix, etc., p. 41, l. 136.
232.5 Vide Cults, iii. p. 390, R. 57h.
232.6 Ib., ii. p. 646.
234.1 Robertson Smith, op. cit., pp. 272-273.
234.2 Athenae. 376a (Cults, i. p. 141).
234.3 Cults, ii. pp. 646-647.
234.4 O. Weber, Dämonenbeschwörung, p. 29; his note on the
passage “that the unclean beast is offered as a substitute for an
unclean man” is not supported by any evidence.
234.5 Zimmern, K.A.T.3, pp. 409-410.
235.1 Robertson Smith’s theory that the gift-sacrifice was a later
degeneracy from the communion-type is unconvincing; vide specially
an article by Ada Thomsen, “Der Trug von Prometheus,” Arch. Relig.
Wissensch., 1909, p. 460.
236.1 “Sacrificial Communion in Greek Religion,” in Hibbert Journal,
1904.
236.2 E.g. Il., 1, 457-474; Od., 3, 1-41; 14, 426.
236.3 Cf. Schol. Od., 3, 441 (who defines οὐλοχύται as barley and
salt mixed with water or wine… καὶ ἔθυον αὐτὰ πρὸ τοῦ ἱερείου…
κριθὰς δὲ ἐνέβαλον τοῖς θύμασι χάριν εὐφορίας); Schol. Arist. Equ.,
1167, τοῖς θύμασιν ἐπιβαλλόμεναι [κριφαί]. Vide Fritz. Hermes, 32,
235; for another theory, vide Stoll, “Alte Taufgebraüche,” in Arch.
Relig. Wissensch., 1905, Beiheft, p. 33.
237.1 Vide Evans, “Mycenaean Tree and Pillar Cult,” Hell. Journ.,
1901, pp. 114-115.
237.2 Od., 14, 426; cf. the custom reported from Arabia of mingling
hair from the head of a worshipper with the paste from which an idol
is made.
237.3 Aristoph. Pax., 956.
237.4 Athenae, p. 419, B.
237.5 Vide Arch. Rel. Wiss., 1909, p. 467; Thomsen there explains
it wholly from the idea of tabu.
237.6 The common meal of the thiasotaï is often represented on
later reliefs, vide Perdriyet, “Reliefs Mysiens,” Bull. Corr. Hell., 1899,
p. 592.
238.1 Vide Cults, i. pp. 56-58, 88-92.
239.1 In my article on “Sacrificial Communion in Greek Religion,”
Hibbert Journal, 1904, p. 320, I have been myself guilty of this, in
quoting the story told by Polynaenus (Strategem. 8, 43), about the
devouring of the mad bull with golden horns by the Erythraean host,
as containing an example of a true sacrament.
239.2 Vide Cults, vol. i. p. 145.
239.3 See Crusius’ article in Roscher’s Lexikon, s.v. “Harpalyke.”
240.1 Vide Cults, v. pp. 161-172.
240.2 Ib., v. p. 165.
241.1 K.A.T.3, p. 596.
241.2 Jeremias, Die Cultus-Tafel von Sippar, p. 26.
241.3 Zimmern, Beiträge zur Kennt. Bab. Rel., p. 15.
242.1 Vide Frazer, Adonis-Attis-Osiris, p. 189; cf. “Communion in
Greek Religion,” Hibbert Journ., 1904, p. 317.
242.2 Jeremias, Die Cultus-Tafel von Sippar, p. 28.
243.1 Weber, Dämonenbeschwörung, etc., p. 29.
243.2 iv. R2, pl. 26, No. 6; this is the inscription quoted by Prof.
Sayce (vide infra, p. 182, n.) as a document proving human sacrifice.

I owe the above translation to the kindness of Dr. Langdon; it differs
very slightly from Zimmern’s in K.A.T.3, p. 597.
243.3 Jeremias, op. cit., p. 29.
243.4 Renan’s thesis (C. I. Sem., i. p. 229) that the idea of sin, so
dominant in the Hebrew and Phoenician sacrifice, was entirely
lacking in the Hellenic, cannot be maintained; he quotes Porph. De
Abstin., 1, 2, 24, a passage which contains an incomplete theory of
Greek sacrifice. The sin-offering is indicated by Homer, and is
recognised frequently in Greek literature and legend; only no
technical term was invented to distinguish it from the ordinary
cheerful sacrifice.
244.1 Cults, ii. p. 441.
244.2 Vide K.A.T.3, pp. 434, 599, where Zimmern refers to the
monuments published by Ménant, Pierres gravées, i. figs. 94, 95, 97,
as possibly showing a scene of human sacrifice. But Ménant’s
interpretation of them is wrong; vide Langdon, Babyloniaca, Tome iii.
p. 236, “two Babylonian seals”; the kneeling figure is the owner of
the seal; the personage behind him is no executioner, but Ramman
or Teschub holding, not a knife, but his usual club. The inscriptions
published by Prof. Sayce (Trans. Soc. Bibl. Arch., iv. pp. 25-29) are
translated differently by Dr. Langdon, so that the first one (iv. R2, pl.
26, No. 6) refers to the sacrifice of a kid, not of an infant. The
misinterpretation of the inscription has misled Trumbull (Blood
Covenant, p. 166). The statement in 2 Kings xvii. 31 about the
Sepharvites in Samaria does not necessarily point to a genuine
Babylonian ritual, even if we are sure that the Sepharvites were
Babylonians.
245.1 Babylonian and Assyrian Laws, p. 95.
245.2 The excavations at Gezer have revealed almost certain
evidence of the early practice of human sacrifice; a number of
skeletons, one of a girl sawn in half, were found buried under the
foundation of houses (vide Cook, op. cit., pp. 38-39).
246.1 Stengel, Die griechischen Kultusaltertümer, p. 89.
246.2 K.A.T.3, p. 599.
246.3 Jastrow, op. cit., i. p. 500.
246.4 Might this be the meaning of a line in a hymn translated by
Jastrow, op. cit., p. 549, “I turn myself to thee (O Goddess Gula), I
have grasped thy cord as the cord of my god and goddess” (vide
King, Babyl. Magic, No. 6, No. 71-94); or of the phrase in the
Apocrypha (Epist. Jerem., 43), “The women also with cords about
them sit in the ways”?
246.5 Zimmern’s Beiträge, etc., p. 99.
247.1 On the famous bronze plaque of the Louvre (Jeremias, Hölle
und Paradies, p. 28, Abb. 6) we see two representatives of Ea in the
fish-skin of the god; and on a frieze of Assur-nasir-pal in the British
Museum (Hell. Journ., 1894, p. 115, fig. 10; Layard, Monuments of
Nineveh, 1, pl. 30), two men in lions’ skins; but these are not skins of
animals of sacrifice.
247.2 Vide my Evolution of Religion, pp. 118-120.
248.1 K.A.T.3, p. 49.
248.2 3, 300; 19, 265-267.
248.3 Polybius, 3, 25, ἐγὼ μόνος ἐκπέσοιμι οὕτως ὡς ὅδε λίθος
νῦν.
248.4 Op. cit., ii. p. 217.
250.1 According to Dr. Langdon (op. cit., p. xvi.), the wailing for
Tammuz was developed in the early Sumerian period of the fourth
millennium.
251.1 Langdon, op. cit., 300-341; cf. Zimmern, “Sumerisch-
Babylonische Tamuzlieder,” in Sitzungsber. König. Sächs. Gesell.
Wissen., 1907, pp. 201-252, and his discussion, “Der Babylonische
Gott Tamuz,” in Abhandl. König. Sächs. Gesell. Wissen., 1909.
251.3 Vide Langdon, op. cit., p. 501.
251.4 Antiqu., 8, 5, 3; cf. Clem. Recogn., 10, 24; Baudissin in his
Eschmun-Asklepios (Oriental. Stud. zu Nöldeke gewidmet, p. 752)
thinks that the Healer-god, Marduk Asclepios Eschmun, is himself
one who died and rose again in Assyrian and Phoenician theology.
For Asklepios of Berytos we have the almost useless story of
Damascius in Phot. Bibl., 573 H.; the uncritical legend in Ktesias (c.
21) and Ael. Var. Hist., 13, 3, about the grave of Belitana at Babylon
(to which Strabo also alludes, p. 740), does not justify the view that
the death of Marduk was ever a Babylonian dogma.
252.1 Perrot-Chipiez, Histoire de l’Art, iv. pl. viii.
253.1 Rev. de Philol., 1893, p. 195.
253.2 Vide Frazer, op. cit., pp. 98-99.
253.3 K. O. Müller, Kleine Schriften, vol. ii. pp. 102-103.
253.4 Journ. Roy. Asiat. Soc., 1909, pp. 966, 971; the information
about the true meaning of the ideogram I owe to Dr. Langdon.
254.1 Vide supra, p. 91; cf. Cults, ii. pp. 644-649; iii. pp. 300-305.
254.2 The Babylonian myths of Etana and Adapa, and their ascent
to heaven, may have given the cue to the Phrygian stories of
Ganymede and Tantalos.
256.1 Dr. Frazer, in Magic Art and the Evolution of Kings (G. B., vol.
ii. p. 45), quotes from N. Tsackni (La Russie Sectaire, p. 74) an
example of a fanatic Christian sect in modern Russia practising
castration. I have not been able to find this treatise.
257.1 Vide Cults, iii. pp. 300-301. Dr. Frazer’s theory is that the act
of castration was performed in order to maintain the fruitfulness of
the earth (op. cit., pp. 224-237). But this is against the countless
examples which he himself has adduced of the character and
function of the priest or priest-king as one whose virile strength
maintains the strength of the earth; the sexual act performed in the
field by the owner increases the fruitfulness of the field (Frazer, GB2,
ii. p. 205). Why should the priest make himself impotent so as to
improve the crops? The only grounds of his belief appear to be that
the priest’s testicles were committed to the earth or to an
underground shrine of Kybele (Arnob. Adv. Gent., v. 14, and Schol.
Nikand. Alexipharm., 7; vide Cults, 3; Kybele Ref. 54a); but such
consecration of them to Kybele would be natural on any hypothesis,
and Arnobius’ words do not prove that they were buried in the bare
earth.
259.1 Vide Cults, i. pp. 36-38.
259.2 Vide Evolution of Religion, p. 62.
260.1 Porph. Vit. Pyth., 17; cf. Callim. H. ad. Jov., 8; Diod. Sic., 3,
61; vide Cults, i. pp. 36-37.
260.2 Vide A. Evans in Hell. Journ., xvii. 350.
261.1 Vide Cults, vol. ii. p. 651; cf. Clem. Recogn., 10, 24,
“sepulcrum Cypriae Veneris apud Cyprum.”

261.2 Ib., pp. 651-652.
261.3 Vide Cults, vol. ii. pp. 447, n. c., 478, 638, n. a.
261.4 Aristot. Rhet., 2, 23.
262.1 Athenae, p. 620 A (ζητεῖν αὐτὸν τοὺς ἀπὸ τῆς χώρας μετά
τινος μεμελῳδημένου θρήνου καὶ ἀνακλήσεως); Pollux., 4, 54.

262.2 Frazer, GB2, vol. ii. p. 106.
263.1 Vide Thureau-Dangin, Vorderasiatische Bibliothek, i. p. 77.
263.2 Weber, Arabien vor dem Islam, p. 19.
264.1 Vide Evans in Hell. Journ., 1901, p. 176.
264.2 Cults, i. pp. 184-191.
264.3 Ib., iii. pp. 123-124.
264.4 Ib., iii. p. 176; cf. vol. iv. p. 34 n. b.
264.5 Ib., i. pp. 189-190.
265.1 1, 181.
265.2 Vide, for instance, Dr. Langdon in the Expositor, 1909, p. 143.
265.3 Winckler, Die Gesetze Hammurabi, p. 182.
266.1 Vide Dieterich, Mithras-Liturgie, pp. 126-127; Reizenstein,
Die hellenistischen Mysterien-religionen.

266.2 Vide Herzog’s Real-Encyclop., s.v. “Montanismus.”
266.3 Jourdanet et Siméon transl. of Sahagun, pp. 147-148.
266.4 Golther, Handbuch der Germanischen Mythologie, p. 229; cf.
Mannhardt, Baumkultus, p. 589.
267.1 Pausan., 2, 33, 3; 9, 27, 6; cf. my article in Archiv. für
Religionswiss., 1904, p. 74; E. Fehrle, Die Kultische Keuschheit im
Alterthum, p. 223, gives other examples which appear to me more
doubtful.
267.2 Paus., 3, 16, 1.
267.3 Cults, v. pp. 217-219.
268.1 Vide Cults, v. p. 109.
268.2 Winckler, op. cit., p. 110; Johns, op. cit., p. 54.
269.1 Code, § 182.
269.2 Jastrow, op. cit., ii. 157.
269.3 Vide Winckler’s interpretation of §§ 178, 180, 181; cf. also
Zimmern in K.A.T.3, 423.

269.4 1, 199.
270.1 E.g. Zimmern in K.A.T.3, p. 423.
270.2 Verse 43.
271.1 The first to insist emphatically on the necessity of their
distinction was Mr. Hartland, in Anthropological Essays presented to
E. B. Tylor, pp. 190-191; but he has there, I think, wrongly classified
—through a misunderstanding of a phrase in Aelian—the Lydian
custom that Herodotus (1, 93) and Aelian (Var. Hist., iv. 1) refer to;
both these writers mention the custom of the women of Lydia
practising prostitution before marriage. Aelian does not mention the
motive that Herodotus assigns, the collection of a dowry; neither
associates it with religion. Aelian merely adds that when once
married the Lydian women were virtuous; this need have nothing to
do with the Mylitta-rite.
272.1 E.g. Hosea iv. 13; Deut. xxiii. 18; 1 Kings xiv. 24.
272.2 Weber, Arabien vor dem Islam, p. 18.
272.3 C. I. Sem., 1, 263.
272.4 Strab., 272.
272.5 Strab., 559.
272.6 Pind. Frag., 87; Strab., 378; (Cults, ii. p. 746, R. 99g).
273.1 Cities and Bishoprics, i. 94. In his comment he rightly points
out that the woman is Lydian, as her name is not genuine Roman;
but he is wrong in speaking of her service as performed to a god
(Frazer, Adonis, etc., p. 34, follows him). This would be a unique
fact, for the service in Asia Minor is always to a goddess; but the
inscription neither mentions nor implies a god. The bride of Zeus at
Egyptian Thebes was also a temple-harlot, if we could believe
Strabo, p. 816; but on this point he contradicts Herodotus, 1, 182.
273.2 Et. Mag., s.v. Ἱκόνιον.
274.1 De Dea Syr., 6; cf. Aug. De Civ. Dei, 4, 10: “cui (Veneri) etiam
Phoenices donum dabant de prostitutione filiarum, antequam eas
jungerent viris”: religious prostitution before marriage prevailed
among the Carthaginians in the worship of Astarte (Valer. Max., 2,
ch. 1, sub. fin.: these vague statements may refer either to
defloration of virgins or prolonged service in the temple).
274.2 See Frazer, op. cit., p. 33, n. 1, quoting Sozomen. Hist.
Eccles., 5, 10, 7; Sokrates, Hist. Eccles., 1, 18, 7-9; Euseb. Vita
Constantin., 3, 58. Eusebius only vaguely alludes to it. Sokrates
merely says that the wives were in common, and that the people had
the habit of giving over the virgins to strangers to violate.
Sozomenos is the only voucher for the religious aspect of the
practice; from Sokrates we gather that the rule about strangers was
observed in the rite.
274.3 18, 5.
274.4 This is confirmed by the legend given by Apollodoros (Bibl., 3,
14, 3) that the daughters of Kinyras, owing to the wrath of Aphrodite,
had sexual intercourse with strangers.
275.1 Justin, 21, 3; Athenaeus, 516 A, speaks vaguely, as if the
women of the Lokri Epizephyrii were promiscuous prostitutes.
275.2 Pp. 532-533.
275.3 The lovers, Melanippos and Komaitho, sin in the temple of
Artemis Triklaria of the Ionians in Achaia; the whole community is
visited with the divine wrath, and the sinners are offered up as a
piacular sacrifice (Paus., 7, 19, 3); according to Euphorion,
Laokoon’s fate was due to a similar trespass committed with his wife
before the statue of Apollo (Serv. Aen., 2, 201). It may be that such
legends faintly reflect a very early ἱερὸς γάμος once performed in
temples by the priest and priestess: if so, they also express the
repugnance of the later Hellene to the idea of it; and in any case this
is not the institution that is being discussed.
276.1 Antike Wald u. Feld Kulte, p. 285, etc.
277.1 Why should not the priestess rather play the part of the
goddess, and why, if we trust Plutarch (Vit. Artaxerx., 27), was the
priestess of Anaitis at Ekbatana, to whose temple harlots were
attached, obliged to observe chastity after election?
277.2 Vol. i. pp. 94-96.
277.3 Op. cit., p. 35, etc.
277.4 Op. cit., p. 44.
278.1 I pointed out this objection in an article in the Archiv. f. Relig.
Wissensch., 1904, p. 81; Mr. S. Hartland has also, independently,
developed it (op. cit., p. 191).
278.2 Vol. ii. p. 446.
278.3 Origin of Civilisation, pp. 535-537.
279.1 Vide Westermarck, History of Human Marriage, p. 76.
279.2 Mr. Hartland objects (loc. cit., p. 200) to this explanation on
the ground that the stranger would dislike the danger as much as
any one else; but the rite may have arisen among a Semitic tribe
who were peculiarly sensitive to that feeling of peril, while they found
that the usual stranger was sceptical and more venturesome: when
once the rule was established, it could become a stereotyped
convention. His own suggestion (p. 201) that a stranger was alone
privileged, lest the solemn act should become a mere love-affair with
a native lover, does not seem to me so reasonable; to prevent that,
the act might as well have been performed by a priest. Dr. Frazer in
his new edition of Adonis, etc. (pp. 50-54), criticises my explanation,
which I first put forth—but with insufficient clearness—in the Archiv.
für Religionswissenschaft (1904, p. 88), mainly on the ground that it
does not naturally apply to general temple-prostitution nor to the
prostitution of married women. But it was never meant to apply to
these, but only to the defloration of virgins before marriage. Dr.
Frazer also argues that the account of Herodotus does not show that
the Babylonian rite was limited to virgins. Explicitly it does not, but
implicitly it does; for Herodotus declares that it was an isolated act,
and therefore to be distinguished from temple-prostitution of
indefinite duration; and he adds that the same rite was performed in
Cyprus, which, as the other record clearly attests, was the
defloration of virgins by strangers. Sozomenos and Sokrates attest
the same of the Baalbec rite, and Eusebius’s vague words are not
sufficient to contradict them. One rite might easily pass into the
other; but our theories as to the original meaning of different rites
should observe the difference.
280.1 But vide Gennep, Les Rites de passage, p. 100.
280.2 Cf. Arnob. Adv. Gent., 5, 19, with Firmic. Matern. De Error.,
10, and Clemens, Protrept., c. 2, p. 12, Pott.
281.1 1, 199.
281.2 The lady who there boasts of her prostitute-ancestresses
describes them also as “of unwashed feet”; and this is a point of
asceticism and holiness.
282.1 Op. cit., p. 199.
282.2 K.A.T.3, p. 423.
283.1 Vide supra, p. 163. The writer of the late apocryphal
document, “The Epistle of Jeremy,” makes it a reproach to the
Babylonian cult that “women set meat before the gods” (v. 30), and
“the menstruous woman and the woman in child-bed touch their
sacrifices” (v. 29), meaning, perhaps, that there was nothing to
prevent the Babylonian priestess being in that condition. But we
cannot trust him for exact knowledge of these matters. Being a Jew,
he objects to the ministration of women. The Babylonian and Hellene
were wiser, and admitted them to the higher functions of religion.
283.2 Vide Cults, iv. p. 301.
283.3 Vide Inscription of Sippar in British Museum, concerning the
re-establishment of cult of Shamash by King Nabupaladdin, 884-860
B.C. (Jeremias, Die Cultus-Tafel von Sippar).
284.1 Sumerian and Babylonian Psalms, p. 75.
284.2 Vide Langdon in Transactions of Congress for the History of
Religions (1908), vol. i. p. 250.
284.3 Vide Zeitung für Assyriologie, 1910, p. 157.
284.4 Formula for driving out the demon of sickness, “Bread at his
head place, rain-water at his feet place” (Langdon, ib. p. 252).

284.5 Delitsch, Wörterbuch, i. 79-80.
284.6 Zeit. für Assyr., 1910, p. 157.
284.7 Vide Hippocrates (Littré), vi. 362; Stengel, Griechischer
Kultusaltertümer (Iwan Müller’s Handbuch, p. 110).
285.1 Referred to in the comedy of Eupolis called the “Baptai.”
285.2 Jastrow, op. cit., p. 500.
285.3 Op. cit., p. 297, 487; the priest-exorciser, the Ashipu, uses a
brazier in the expulsion of demons.
285.4 Vide Golther, Handbuch der Germanischen Mythologie, p.
580; cf. my Cults, v. p. 196.
285.5 Cults, vol. v. pp. 383-384; cf. iv. p. 301.
286.1 Cults, v. p. 356; cf. p. 363 (the purifying animal carried round
the hearth).
286.2 Eur. Herc. Fur., 928.
286.3 Dio Chrys. Or., 48 (Dind., vol. ii. p. 144), περικαθήραντες τὴν
πόλιν μὴ σκίλλῃ μηδὲ δαδί, πολὺ δὲ καθαρωτέρῳ χρήματι τῷ λόγῳ
(cf. Lucian, Menipp., c. 7, use of squills and torches in “katharsis,” (?)
Babylonian or Hellenic); Serv. ad Aen., 6, 741, “in sacris omnibus
tres sunt istae purgationes, nam aut taeda purgant aut sulphure aut
aqua abluunt aut aere ventilant.”
286.4 “To take fire and swear by God” is a formula that occurs in the
third tablet of Surpu; vide Zimmern, Beiträge zur Kenntniss Babyl.
Relig., p. 13; cf. Soph. Antig., 264.
286.5 Salt used as a means of exorcism in Babylonia as early as
the third millennium (vide Langdon, Transactions of Congress Hist.
Relig., 1908, vol. i. p. 251); the fell “of the great ox” used to purify the
palace of the king (vide Zimmern, Beiträge, p. 123; compare the Διὸς
κῴδιον in Greek ritual).
287.1 Vide Thureau-Dangin, Cylindres de Goudéa, pp. 29, 93.
287.2 Vide Evolution of Religion, pp. 113, 114, 117; Cults, v. p. 322
(Schol. Demosth., 22, p. 68).
287.3 5, 13, 6.
287.4 Vide Cults, iii. pp. 303-304; Evolution of Religion, p. 121.
288.2 Vide Cults, iii. p. 167.
288.3 Published in Zimmern’s Beiträge, p. 123; cf. Weber,
Dämonenbeschwörung, pp. 17-19.
289.1 Il., xvi. 228.
289.2 Od., ii. 261.
289.3 Il., i. 313.
290.1 Od., xxii. 481: In the passage referred to above, Achilles uses
sulphur to purify the cups.
290.2 Od., xiii. 256-281: This is rightly pointed out by Stengel in his
Griechische Kultusaltertümer, p. 107.
290.3 Evolution of Religion, pp. 139-152; Cults, iv. pp. 295-306.
291.1 Vide Cults, iv. pp. 144-147, 300: To suppose that Hellas learnt
its cathartic rites from Lydia, because Herodotus (i. 35) tells us that
in his time the Lydians had the Hellenic system of purification from
homicide, is less natural. Lydia may well have learnt it from Delphi in
the time of Alyattes or Croesus. Or it may have survived in Lydia as
a tradition of the early “Minoan” period; and, similarly, it may have
survived in Crete.
291.2 Vide supra, pp. 176-178.
292.1 Vide Cults, iv. pp. 268-284.
292.2 For similar practices, vide Cults, pp. 415-417.
292.3 Clem. Alex. Strom., p. 755, Pott.
293.1 Paus., 9, 33, 4.
293.2 For the facts vide Zimmern, K.A.T.3, p. 592.
294.1 Works and Days, l. 824.
294.2 Ib., l. 804.
294.3 Expositor, 1909, p. 156.
294.4 Vide Photius and Hesych., s.v. Μιαραὶ ἡμέραι.
295.1 Hell., 1, 4, 12.
295.2 Vide Cults, v. pp. 215-216.
295.3 Cults, iv. p. 259.
295.4 Vide supra, pp. 176-177.
296.1 Sumerian and Babylonian Psalms, p. 196.
296.2 King, Babylonian Religion, p. 196.
296.3 Vide Fossey, La Magie Assyrienne, p. 96.
297.1 Knudtzon, Assyrische Gebete an den Sonnengott, p. 78
(texts belonging to period of Asarhaddon, circ. 681).
297.2 Zimmern, Beiträge, etc., p. 161.
298.1 Zimmern, Beiträge, etc., p. 163.
298.2 Fossey, op. cit., p. 399.
298.3 iv. R. 56, 12; Fossey, op. cit., p. 401.
298.4 Expositor, 1909, p. 150, giving text from iv. R. 40.
299.1 Fossey, op. cit., p. 209.
299.2 Zimmern, Beiträge, p. 173.
299.3 Supra, p. 176.
299.4 Zimmern, op. cit., p. 169.
300.1 Zimmern, Beiträge, pp. 30-31; he mentions also the similar
practice of tying up a sheepskin or a fillet of wool and throwing it into
the fire.
300.2 Zimmern, op. cit., p. 33: note magic use of knots in general,
vide Frazer, G.B.2, vol. i. pp. 392-403; Archiv. für Religionsw., 1908,
pp. 128, 383, 405. The superstition may have prevailed in Minoan
Crete (see A. Evans, Annual British School, 1902-1903, pp. 7-9) and
was in vogue in ancient Greece.
300.3 W. Warde Fowler, The Religious Experiences of the Roman
People, Gifford Lectures, p. 49.
301.1 Vide supra, pp. 248-249; Cults, iv. p. 191.
301.2 For the main facts relating to the Babylonian system and the
“baru”-priests, vide Zimmern, Beiträge, etc., pp. 82-92; for the

Hellenic, vide Cults, iv. 190-192, 224-231; also vol. iii. 9-12.
301.3 The documentary evidence, from a very early period, is given
by Zimmern, Beiträge, etc., pp. 85-97.
301.4 L. 322: Clytemnestra speaks of pouring oil and vinegar into
the same vessel and reproaching them for their unsociable
behaviour.
302.1 We have also one example of an oracle of Ishtar (in plain
prose), Keil. Bibl., ii. p. 179.
303.1 Zimmern, op. cit., p. 89.
303.2 Cults, iii. p. 297.
303.3 Lucian, De Dea Syr., 43.
303.4 Cults, iii. p. 297.
303.5 Vide Cults, iv. pp. 191-192; iii. p. 11.
TRANSCRIBER’S NOTES.
Page numbers are given in {curly} brackets.
Plain text version only: endnote markers are given in [square]
brackets.
Minor spelling inconsistencies (e.g. coexist/co-exist, temple-
ritual/temple ritual, etc.) have been preserved.
Add title, subtitle, and author’s name to cover image.
Alterations to the text:
Convert footnotes to endnotes, relabel note markers (append the
original note number to the page number), and add a corresponding
entry to the TOC.
[Title page]
Add commas to author’s bibliography.
[Chapter I]
Change “from the tyranny of a morbid ascetism” to asceticism.
[Chapter III]
“In his Historie des anciennes Religions, Tiele classifies” to
Histoire.
“and their aboriginal god was Possidon” to Poseidon.
[Chapter IV]
“and expecially the powers of the lower world” to especially.
“Even Allat, the goddess of Hell, she who” to Allatu.
“the great Assyrian god Ahshur is quaintly expressed” to Asshur.
“the idea that Istar is the compeer in power” to Ishtar.
“between the Hittites and the Assyrian Babylonian kingdom” to
Assyrian-Babylonian.
“no clear trace of theriomophism either in the” to theriomorphism.
“how far the Minaon religion was purely anthropomorphic” to
Minoan.
[Chapter V]
“I formerly developed in the second volume of my cults” capitalize
and italicize cults.
[Chapter VI]
“Still less is Allalu, the monstrous and grim Queen” to Allatu.
[Chapter VII]
(Alalkomenai, “the places of Athena Alalkomene; Nemea, “the…)
add right double quotation mark after Alalkomene.
[Chapter VII]
“about whom he is particulurly thoughtful” to particularly.
[Chapter IX]
“and regards this Hititte goddess as the ancestress” to Hittite.
[Chapter XIII]
“modern savagery and the history of ascetism” to asceticism.
(and bewail her”: “If you regard her as a deity, do) delete right
double quotation mark.
[Index]
“Hell, Babylonian conception of, 205-206” add period at end of
line.
[Endnotes]
(Page 17, note 1) “Archiv fur Religionswissenschaft, 1904.” to für.
(Page 42, note 1) “that the idiogram of Enlil, the god of” to
ideogram.
(Page 84, note 3) “last of the Babylonian kings, Nabuna ’id, who
prays” to Nabuna’id.
(Page 124, note 1) “Die Phoenizischen Imschriften,” to
Phönizischen Inschriften.
(Page 148, note 1) “Weber, Dämonenbeschworung bei den
Babyloniern…” to Dämonenbeschwörung.
(Page 183, note 3) “pp. 502 503, n. 2” add comma after 502.
(Page 232, note 2) “Lagranges, Études sur les religions
sémitiques” to Lagrange.
(Page 246, note 1) “Stengel, Die griechischen Kultusalterthümer,
p. 89” to Kultusaltertümer.
(Page 286, note 5) “vide Zimmern, Beitrage, p. 123;” to Beiträge.
[End of text]
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Transgender and Gender

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Gender Ambiguity in the Workplace Transgender and

Aging and mental health Qualls

Sporting Gender The History Science and Stories of

Transgender Mental Health 1st Edition Eric Yarbrough

Voice and Communication Therapy for the Transgender

Aligning Perspectives in Gender Mainstreaming: Gender,

Alcohol and Aging Clinical and Public Health

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© Springer International Publishing AG, part of Springer Nature 2019

To those resilient TGNC pioneers who

To all TGNC people who choose to live

To all the TGNC communities that advocate

To the reader whose desire to deepen the

1 The Essentials: Foundational Knowledge to Support

10 Evolving Aging Service Networks: Meeting the Demands

Tatyana Moaton, MBA-HRM Human Resources, Howard Brown Health Center,

Kelly Ducheny, Cecilia T. Hardacker, K. Tajhi Claybren,

© Springer International Publishing AG, part of Springer Nature 2019 1

1.2 Learning the Basics

1.2.1 Gender Identity and Gender Expression

1.2.2 Sexual Orientation and Gender Identity

Disclosing a TGNC identity, or coming out, can be intimately connected to a per-

1.2.6 Gender-Affirming Communication

1.3 Cultural Context and Generational Cohort

1.4 TGNC Health Disparities

As previously mentioned, the current and emerging generations of TGNC older

Within many institutions and social service operations, supportive resources

1.5 Affirmative Care

Central to serving aging TGNC people is the provision of gender-affirming care,

1.6 Ongoing Learning and Closing Thoughts

Institute, 1898, p. 586, speaks as if it was ancestor-worship that held

“Sumerisch-Babylonische Tanzlieder,” p. 220.

of the gates of heaven (Zimmern, K.A.T.3, p. 521).

Artemision, Excavations at Ephesus, p. 244.

Sayce (vide infra, p. 182, n.) as a document proving human sacrifice.

“sepulcrum Cypriae Veneris apud Cyprum.”

τινος μεμελῳδημένου θρήνου καὶ ἀνακλήσεως); Pollux., 4, 54.

Die hellenistischen Mysterien-religionen.

Zimmern in K.A.T.3, 423.

head place, rain-water at his feet place” (Langdon, ib. p. 252).

“baru”-priests, vide Zimmern, Beiträge, etc., pp. 82-92; for the

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1 The Essentials: Foundational Knowledge to Support

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1.2 Learning the Basics

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