To date the transitional process for transgender persons often starts at young age enabling better transition with less surgery. Parallel to this phenomenon a steadily growing group of transpersons reaches old age. Guidelines in transgender medicine are still sparse and hardly address issues of concern for elderly transpersons. As a rule but not substantiated cross-sex hormonal treatment is recommended to continue life-long, only adapted to an individual risk profile. Problably this recommendation emerged from the fear of recurrence of the hated characteristics of the former gender when cross-sex hormones would be ceased. Transgender persons have struggled for years to get recognized. Living with a body congruent with one´s identity is regarded more important than potential health risks. Moreover, the relationship between the transcommunity and medical professionals has been extremely problematic for decades as transpersons were either ignored or pathologized. A prosperous black purchasing market and selfmedication were the rule rather than the exemption. It is only in the last 15 years that transgender healthcare became recognized as a serious branch of medicine. Few data on morbidity and mortality with follow-up of over 20 years are available. These data clearly show that transgender persons do have an average life expectancy comparable to the general population. It is still unclear whether the hypothesis that life expectancy of transwomen gradually shifts towards the age of biological women will come true. At older age both man and women are more vulnerable for chronic diseases, and this also applies for transpersons. Cross-sex hormonal treatment should be adapted with respect to dosage and route of administration, and should substantially be reduced as virilisation or feminization at older age are unlikely. Anti-androgens at older age are no longer indicated. Also less potent estrogens as estriol (E3) or Estretol (E4) are under consideration for elderly transgender person. Transgender medicine for the elderly is in need for a well-balanced treatment concept, satisfying the needs of the individual person and with respect for the principles of responsible medicine.