This chapter examines how older nyah or Malaysian trans women negotiate ageing, health, and gender presentation within a restrictive religio-political and sociocultural context shaped by cisheteronormativity and political Islam. Challenging assumptions that trans identities are contingent upon youth or continuous medical transition, it argues that embodied gender identity does not expire in later life but evolves through pragmatic adaptation. Drawing on queer cultural gerontology, life course perspectives, and queer temporalities, the study employs the River of Life visual narrative method alongside semi-structured interviews with thirty nyah aged 40 and above. The findings highlight how later life transitions, such as discontinuing hormones, revising gender-affirming surgeries, and recalibrating visibility, reflect agency, resilience, and shifting priorities around health, safety, and survival. By centering non-Western later life trans experiences, this chapter contributes to more culturally situated and inclusive understandings of trans ageing.