Transgender and Age

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Unique Challenges of Transgender Aging: Implications From the Literature Diane I. Persson a a School of Nursing, Center on Aging, University of Texas, Houston, Texas, USA Online Publication Date: 01 August 2009

To cite this Article Persson, Diane I.(2009)'Unique Challenges of Transgender Aging: Implications From the Literature',Journal of

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Journal of Gerontological Social Work, 52:633–646, 2009 Copyright © Taylor & Francis Group, LLC ISSN: 0163-4372 print/1540-4048 online DOI: 10.1080/01634370802609056

Unique Challenges of Transgender Aging: Implications From the Literature

1540-4048 0163-4372 WGER Journal of Gerontological Social Work, Work Vol. 52, No. 6, jun 2009: pp. 0–0

Challenges D. I. Persson of Transgender Aging

DIANE I. PERSSON

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School of Nursing, Center on Aging, University of Texas, Houston, Texas, USA

Transgender elders are both underserved and understudied. Neither the etiology nor prevalence of transgender is well understood.

Because sex, gender, and sexuality are at the very core of individual identity, it is difficult to dislodge one’s ideas and feelings about them. Unlike biological sex and sexual orientation, gender has several aspects: gender identity, gender expression, and gender classification. A discussion of the terminology of transgender is presented, and the issues facing aging transgender individuals are identified. Although the challenges of adequate healthcare, social support, and legal obstacles are faced by many elderly individuals, the way they are presented and managed are unique to this often invisible group.

KEYWORDS Transgender, aging, transsexual, gender identity disorder

INTRODUCTION Over 50 years ago, the news of Christine Jorgensen’s sex change galvanized the press, introducing the notion that gender was not immutable, but open to change. As cultural norms change, gender expression has become more varied, both within the transgender community and in the population at large. And transgendered individuals have aged. This article clarifies the Received 14 December 2006; 1 July 2007.

This article would not have been possible without the encouragement and dedication of the late Brenda Thomas. It was supported, in part, by the City of Houston acting as the Harris County Area Agency on Aging and the Texas Department of Aging and Disability Services.

Address correspondence to Diane I. Persson, School of Nursing, Center on Aging, University of Texas, 6901 Bertner Avenue, SON 611, Houston, TX 77030. E-mail: diane.persson@ uth.tmc.edu 633

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terminology of transgender, reviews the literature of transgender and aging, and identifies issues and barriers facing this often invisible minority.

TERMINOLOGY, ETIOLOGY, AND PREVALENCE

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Although public health research on lesbian, gay, bisexual, and transgender (LGBT) groups has increased with time, English-language articles on this population published between 1980 and 1999 in MEDLINE were only 0.1% of all articles, and research attention to specifically transgender persons actually decreased by 21% (Boehmer, 2002). Although the American Public Health Association adopted a policy statement in 1999 on the need for acknowledging transgender individuals within research and clinical practice, transgender is often the silent T in LGBT.

Terminology Transgender includes a community of individuals whose biological sex is not entirely congruent with their gender identity. For the purpose of this discussion, individuals under the transgender umbrella include transsexuals, transvestites or cross-dressers, male/female impersonators or drag kings/ queens, and intersex or hermaphrodites. Transsexuals are individuals whose gender identity is that of the opposite sex. A transsexual may be pre-, post-, or nonoperative regarding sex reassignment surgery. The terms transvestite and cross-dresser describe people (primarily men) who dress in clothing of the opposite sex for personal or erotic pleasure. Individuals who perform as the opposite sex in a public setting and may or may not identify as transgendered are male and female impersonators or drag kings and queens. Intersex or hermaphrodites are born with a sexual anatomy that mixes male and female characteristics in ways that make it difficult to label the individual as male or female. Terminology describing the gender community is very dynamic, and there is increasing usage of transmen (female-to- male), transwomen (male-to-female), and queer, as in queer aging or aging in a queer world (Minter, 2006; Rachlin, Green, & Lombardi, 2008).

Etiology The likelihood of identifying a specific etiology of transgender is not promising, although a great deal of effort has been devoted to explain transgender identity and behavior. Some (Bailey & Triea, 2007; Lawrence, 2007) have proposed two types of male-to-female transsexuals: those sexually attracted exclusively to men (homosexual) or those motivated by the erotic desire to become women (autogynephilia). Aside from purely scientific

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Challenges of Transgender Aging Male

Female Biological Sex

(external genitalia, internal reproductive systems, chromosomes, hormones, secondary sex characteristics)

Male

Intersex/Hermaphrodite

Female

Gender Identity (person’s sense of self as being either male or female; gender identity does not always match biological sex)

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Man/Boy

Both/Neither/Other

Woman/Girl

Gender Expression (display of gender traits, e.g. clothing, hair, mannerisms, speech, roles) Masculine

Androgynous

Feminine

Sexual Orientation (person’s erotic and affectional response to another with respect to gender) Attracted to Women

Bisexual/Asexual

Attracted to Men

FIGURE 1 Model of sex and gender.

motivations, there are strong political reasons behind the desire to explain the phenomena of both gender identity and sexual orientation (Currah, 2006).

Sex and gender may be thought of as multidimensional (Bushong, 1994) and occupying a continuum; see Figure 1. Biological sex characteristics are objective in that they can be clinically observed. Although most people exist somewhere near one end or the other, the middle is occupied by intersex people who have combinations of characteristics typical of males and females. Gender identity refers to one’s subjective sense of being either male or female. Unlike biological sex, gender identity cannot be observed or measured, only reported by the individual. Gender expression, or gender roles, refers to those behaviors, attitudes, and personality traits that a society designates as masculine or feminine, including occupational and recreational interests and traits such as aggressiveness and nurturance.

Transsexuals are deeply convinced that they were born in the wrong biological sex and experience a discordance between gender identity and biological sex. Sexual orientation indicates erotic attraction. The ends of this

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sexual orientation continuum may be thought of as being homosexual and heterosexual, gay or straight. However, this may be confusing, given the variability in sexual orientation among transgender persons. Some may base their definition of sexual orientation on their gender identity; others may identify their sexual orientation based on their anatomy (Kenagy, 2002).

The model of transsexualism in current usage was established by Harry Benjamin, an endocrinologist who defined gender identity disorder (GID) and established standards of care (Benjamin 1966). These standards require that specific medical interventions or hormone therapy and sex reassignment surgery be recommended by a mental health provider after a thorough psychological evaluation and, in most cases, a period of psychotherapy. The classification of GID as a mental disorder (American Psychiatric Association, 2000) included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) may allow for insurance reimbursement and treatment for transgender persons seeking psychiatric therapy or hormonal treatment.

However, opinions on the classification of GID as a mental disorder are mixed, especially if GID is seen as a precursor or risk factor for homosexuality (Blanchard, 2005; Cole, Denny, Eyler, & Samons, 2000). Most people do not consider homosexuality a mental illness, and the American Psychiatric Association removed it from the DSM in 1980. There is current debate as to whether the diagnosis GID should remain in the next revision of DSM.

Prevalence Research did not uncover any formal epidemiological studies of the prevalence or incidence of GID, and estimates vary on the prevalence of transgenderism. The DSM-IV (American Psychiatric Association, 2000) stated that 1 per 30,000 adult men and 1 per 100,000 adult women in the United States seek sex reassignment surgery. The prevalence of transsexualism in the Netherlands appears relatively high (1:11,900 for men and 1:30,400 for women) and is attributed to the accepting social climate (Bakker, van Kesteren, Gooren, & Bezemer, 1993; Landen, Walinder, & Lundstrom, 1996). Male-tofemale transsexuality is 1.5 to 3 times more prevalent than female-to-male transsexuality (American Psychological Association, 2008).

Although the number of people obtaining sex reassignment surgery in the United States has increased since the 1960s, more of these procedures are performed abroad. Furthermore, these figures do not include individuals who are preoperative or nonoperative. One author estimated three to five times as many male-to-females are pre- or nonoperative, suggesting between 100,000 and 200,000 untreated cases (Conway, 2001). Another writer estimated 3 to 9 million potential postoperative transsexuals in the United States, and as many as 20 million if the broader definition of transgender is used (Witten, 2003). Estimates on cross-dressing are equally difficult to come by, although one study found almost 3% of men and 0.4% of women

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reported at least one episode of sexual arousal from cross-dressing or transvestic fetishism (Langstrom & Zucker, 2005). The prevalence of intersex is also difficult to estimate, although one study (Sax, 2002) has suggested that it might be as high as 1.7 per 100 live births.

Much of the transgender literature focuses on sex, drugs, and HIV status (Docter & Fleming, 2001; Nemoto, Operario, Keatley, Nguyen, & Sugano, 2005) and the aging literature for lesbian, gay, and bisexuals often excludes transgender. Qualitative research suggests that transgender individuals experience severe unemployment, housing, and health care discrimination, and many engage in behaviors that put them at risk for HIV (Clements-Nolle, Marx, Guzman & Katz, 2001). Literature on transgender aging is scant and often focuses on healthcare, social support, and institutionalized barriers.

Although these issues also affect nontransgendered individuals, their impact on this particular community is significant.

ISSUES FOR TRANSGENDER SENIORS The areas of concern for aging transgender individuals are primarily the same ones as for most aging adults: loneliness, health, and income.

However, transgender men and women find other layers of concern for the future—fear of rejection by family and adult children, transphobia, and marginalization from gay and lesbian communities, as well as from heterosexual communities and providers. In many instances, transgender individuals may be regarded as pathological or unhealthy, per se (Dean et al., 2000).

Health-Related Issues Because of stigma and prejudice, and because transgender people represent a minority of the population, clinical and public health studies and program evaluation have been scarce in all sectors of health delivery and research.

Unemployment and underemployment result in no or inadequate health insurance, and thus many transgender persons are unable to afford basic medical and mental health services.

Although it is beyond the scope of this article to consider all the medical challenges faced by older transgender persons, a few particularly salient issues are addressed. Those who choose to have surgical or hormonal treatments face a variety of potential complications; for example, individuals who undergo male-to-female sex reassignment surgery are at risk for rectovaginal fistulas and urinary tract infections. Those individuals who take female hormones, either alone or to augment surgical treatment, are at a greater risk for breast cancer, deep vein thrombosis, pulmonary embolism, and osteoporosis. Female-to-male transgender individuals who take hormones, either alone or as adjunctive therapy to surgery, are at an

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increased risk for a variety of health conditions, for example, cardiovascular disease, liver disease, and diabetes. Those who use hormone therapy but decide not to undergo surgery are at risk for endometrial cancer (female-tomale) and prostate cancer (male-to-female; Lee, 2000). Although there has been no research into the cumulative effects of the surgical and hormonal complications and the normal aging process, one writer has speculated that the aging transgender person’s risk of developing these conditions is magnified because of the effects of both age and the treatments (Berreth, 2003).

One of the most significant barriers to care is that most health professionals lack the knowledge about transgender identity and sexuality necessary for them to respond adequately to their patients (Gay and Lesbian Medical Association, 2001). As a result, patients with transgender concerns are usually required to educate health care providers (McMahon, 2003).

Many transgender persons are seen in the emergency room with the genital characteristics of their birth sex, although they may pass in everyday life as the sex to which they have transitioned. Many transgender people remain invisible until a health crisis occurs (Shaffer, 2005). One researcher has suggested that transgender individuals frequently have two different sets of health care providers: one for gender transition and one for regular health care (Lombardi, 2001).

Professionals in health and human service organizations need to recognize that older transgender persons present unique needs and challenges (see Table 1). In caring for transgender older adults in the outpatient setting, health care providers must be knowledgeable about those services necessary for this population, such as preventive screening, vaccinations, and dental care. For instance, most female-to-male transgender individuals TABLE 1 Strategies for Health Care Professionals Category Program/Policy Operative status Hormone use Time of transition Documentation Social support Language Publications Training

Approach Include gender identity, as well as sexual orientation, and establish policies to address transgender needs.

Acknowledge the different needs of pre- or nonoperative from postoperative individuals.

Recognize that although hormone use is usually life long, not all hormones are legally prescribed.

Individuals transitioning earlier in life versus later in life have different concerns regarding employment, family, health, and legal issues.

Name and gender designations both need change, and some documents have service implications (e.g., social security, employment/Veterans Administration/health records.

Ask specifically what you need to know, such as “Do you have a caregiver?” “What provides your emotional support?”

Clarify what name and pronoun the transgender individual uses.

Include trans-specific information and brochures.

Provide staff with necessary training, materials, and support they need to understand transgender aging issues.

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will need a Pap smear and breast examination. Likewise, male-to-female patients will need to be screened for prostate cancer. Health care providers should base their choices about necessary screening tests on a combination of factors, including the patient’s biological sex, surgical status, declared gender, and use of any hormone therapies. When transgender individuals seek health care services, they may avoid sharing their transgender status (Cook-Daniels, 1997). This is especially likely in older persons who may have sought hormonal or surgical interventions at a time when it was common for providers to use very strict guidelines to determine who could and could not receive treatment. It is essential that health care providers refer to transgender patients by their chosen name and pronoun, be sensitive to concerns gender transitioning raises, and address these issues directly (Feldman & Bockting, 2003). Mental health problems for transgender people are more likely to include adjustment disorders, anxiety disorders, and depression, and some studies indicate that they do not receive necessary services because they feel their gender identity will be judged negatively (Cahill, South, & Spade, 2000).

The likelihood of most older transgender individuals advocating for themselves is rare, because they are often not open about their gender identity. The lack of sensitivity, and particularly a homosexual orientation, often puts these seniors in vulnerable and uncomfortable circumstances, reinforcing social isolation and placing them at high risk for self-neglect (Cahill & South, 2002). Whereas lesbian and gay elders entering assisted living and nursing facilities are often presumed to be heterosexual, they may feel compelled to hide their sexual identity, resulting in long-term relationships being unrecognized or devalued. This is particularly difficult for the transgender elder who may have genitals, and perhaps other physical features, that are not congruent with their sense of who they are. Institutional caregivers need to be trained to be competent addressing residents’ issues concerning sexuality and gender.

Social Support Transgender life experiences are not always easy. Social stigma is a major feature in areas of employment, personal relationships, health care, and personal safety. Transgender adults may have been forced, or may have chosen, to sever ties with parents, siblings, spouses, or children. Crossdressers represent a unique group, because they often need to accept limits in their cross-dressing behavior if relationships are to survive (Bullough & Bullough, 1993). An implication for older transgender adults may be the absence of a support system if they do not sense that they belong to either the homosexual or heterosexual community. One study (McFarland & Sanders, 2003) found that homosexual elders obtain more support from friends, whereas heterosexual elders find their support from family members. The

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potential isolation of LGBT seniors who do not have strong friendships may contribute to limited social support. The more people within a transgender person’s network that they can talk to about their transgender issues, the higher level of social activity and their participation in broader political and social arenas (Lombardi, 1999). The age of gender transition poses challenges as well, because individuals who transition later in life face different issues than do their younger peers in terms of health and socio-economic concerns (Cook-Daniels, 2002).

Many transgender individuals seek to completely blend into the larger society. Because they are more at risk, they are less likely to report crimes because of fear about discovery (Berreth, 2003). One study of transgender individuals showed that approximately 60% had experienced some form of harassment or violence, and 37% had experienced some form of economic discrimination (Lombardi, 2001). Another study reported that over half had experienced harassment or violence, with the most common experience being verbal abuse, and workplace discrimination is so common that it is the norm among transgender people (Lombardi, Wilchins, Priesing, & Malouf, 2001). Transgender victims of domestic violence are the least likely to leave an abusive partner because they often believe their abuser’s taunts that no one else will ever love and accept them as they are, and there is transphobia in areas of law, enforcement as well as with health care professionals (CookDaniels, 1997). People who transgress gender roles appear to remain at the low end of the hierarchy of acceptability, and the literature suggests that this situation does not improve over time, resulting in limited social support and self neglect for the aging transgender person (Witten, 2003).

One study asked transgender individuals: What is it that you worry about now that you are in the middle part of your lives? The answers were financial stability, social isolation, safety, healthcare, independence, and living environment (Witten, 2004). A large number of transgender individuals use Web chat rooms as a place in which to derive a sense of community, kinship, friendship, and social support. Many questions related to social support remain unanswered. Most care-giving is provided by biological children and, because transgender people are less likely to have supportive children and appear more likely to live alone in old age, the issue of who will care for these elders is of concern. What does it mean for the former Dad to now be a woman, and how does the adult child create an adult relationship with that person? How does the aging transgender person deal with elderly parents who may or may not be accepting of changes and who may now need help?

Institutionalized Obstacles Transgender persons face several official barriers including discrimination in areas of employment, health care, and law enforcement. Legal issues can be

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complex, such as one’s legal status as a man or a woman, marriage, divorce, child custody, and identity papers and records. Traditional income support mechanisms such as Social Security and pension plans may also pose problems for the transgender senior.

In principle, discrimination against transgendered people could be covered under laws that prohibit discrimination on the basis of sex and/or sexual orientation, and discrimination against transsexual people in particular could be protected under laws that protect persons with disabilities. In practice, however, most courts have interpreted laws that prohibit discrimination on those bases to exclude transgender people (Frye & Rose, 2003; Levi & Klein, 2006). Between 2000 and 2006, the percentage of the US population in jurisdictions with explicitly transgender-inclusive antidiscrimination laws grew from 4% to 31% (National Gay and Lesbian Task Force, 2006). Ensuring legal protection of transgender people as they age remains a challenge.

As transgender people grow older and rely increasingly on public programs and social services for care and assistance, they face particular problems. Transitioning after marriage, with the result that spouses are now both men or both women, may invalidate the marriage. Transgender elders may not be eligible for Social Security survivor and spousal benefits. The tax implications of pension plans and 401(k) plans provide unequal treatment for same-sex couples, whether they are gay, lesbian, or transgender (Cahill & South, 2002). Neither Medicaid nor Medicare covers hormone therapy or sex reassignment surgery for transsexuals.

One study (Cahill, South, & Spade, 2000) noted that every civil rights movement has a bathroom movement, and legislation that addresses those situations may be necessary to ensure that transgender individuals have access to safe and dignified restroom facilities. Transgenders have little to no legal protection in the area of employment, and they have no standing for equal protection claims, no right to insurance coverage or government medical assistance, no housing protection, and no right to continue their medical service (Frye, 2000). Most courts have not found that laws prohibiting sexual orientation or gender discrimination apply to transgender people.

The protection of human rights for the transgendered has lagged behind the medical innovations that began over half a century ago (Green, 2008).

CONCLUSION Transgender persons face a number of particular concerns as they age. They often do not access adequate health care, affordable housing, and other social services that they need. Social isolation, ageism, transphobia, homophobia, and existing regulations act as barriers to further segregate this often invisible minority. As they grow older, they enter a world of

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services that may not be familiar with transgendered people. Although there are some specific service organizations such as Senior Action in a Gay Environment, Gay & Lesbian Outreach to Elders, Pride Senior Network, and a few others, these types of programs are not available in all parts of the country and cannot provide all the services needed (Cahill et al., 2000).

Little is known about transgender elders. The need to make broad assumptions about the size of this population underscores one of the major problems in understanding the needs of this group. Transgender elders are not only underserved, they are also understudied. There is a need for continued efforts in the areas of research, education, service, and advocacy.

Transsexuals, cross-dressers, intersex, and other persons whose gender expression or identification is other than traditional represent an invisible minority within the worldwide elderly population.

Research is needed on hormonal and surgical treatment and their longterm effects, combined with the normal aging process. The identification and prevention of abuse, neglect, and financial exploitation in this population needs to be better understood, as does mental health and substance abuse. The role and impact of family and social networks needs to be included in a transgender research agenda, as well as the history of gender variance. Agencies charged with serving the needs of older Americans must fund and actively initiate research on LGBT seniors.

Education programs to train and sensitize social service and health care providers to transgender needs are necessary. For example, those offered

by For Ourselves: Reworking Gender Expression can provide training, materials, and support to understand transgender elders and significant others, friends, family, and allies (Cook-Daniels, 2002). Public health education, including HIV/AIDS prevention education designed for, and specifically directed at, older individuals is needed, as are community and social support services.

Services are required that are sensitive to the needs of older transgender men and women in a variety of living situations. Because transgender medical care has shifted largely to the private sector, service provider information based on price, reputation, services offered, and location needs to be available. The range of long-term care services, including information and referral, housing and community support, geriatric care management, adult day programs, and residential care facilities needs to be identified. The individual elder as their own care manager combined with health care providers limited experience with gender identity issues presents unique challenges.

Advocacy for nondiscrimination state laws deserves special mention because the violence against transgender people tends to be particularly violent and brutal. Despite the seriousness of this problem, this group is excluded from any protection under the vast majority of state hate crimes statutes, and violent crimes against transgender people are often neither investigated nor prosecuted (Currah & Minter, 2000). Family law is an area

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in which sex distinctions and gender-role stereotyping appear to be the most intractable and adversely impact transgender parents and their children (Flynn, 2006). The impact of municipal, state, and federal legislation on transgender rights needs to be reexamined.

An International Bill of Gender Rights was proposed over 10 years ago to express fundamental human and civil rights from a gender perspective (Frye, 2006). This includes: (a) the right to define gender identity; (b) the right to free expression of gender identity; (c) the right to secure and retain employment and to receive just compensation; (d) the right of access to gendered space and participation in gendered activity; (e) the right to control and change one’s own body; (f) the right to competent medical and professional care; (g) the right to freedom from involuntary psychiatric diagnosis and treatment; (h) the right to sexual expression; (i) the right to form committed, loving relationships and enter into martial contracts; and (j) the right to conceive, bear, or adopt children, the right to nurture and have custody of children and to exercise parental capacity.

Gender transition at any age requires physical, legal, and social adaptation. The majority of aging programs, publications, and policies have not recognized transgender people. Although what causes a person to be transgendered is unknown, this population is often devalued and excluded.

Professionals in the field of aging can help improve the quality of life of older members of the gender community by understanding the unique challenges faced by this population.

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