REVIEW URRENT C OPINION
Care of the elderly transgender patient Randi Ettner
Purpose of review This review examines recent developments regarding the care of the elderly transgender patient. There is scant clinical or other relevant information related to this topic, as the phenomenon of gender incongruity has been largely misunderstood and underreported. It is important that guidelines for appropriate and sensitive care be established, as this population is proliferating due to media attention and greater access to care. Recent findings A preponderance of evidence exists establishing that gender nonconforming elders are subject to discriminatory healthcare treatment. Agencies that serve the elderly are rife with policies and practices that resist acknowledging the needs of this population. Most heathcare and service providers have little experience with this group and limited understanding of non-normative gender identification. Barriers to treatment amplify the challenges of ageing for the transgender person and can lead to nondisclosure of clinically relevant personal information. Summary Increasing numbers of ageing transgender individuals will be interfacing with health and care providers. Many of these individuals will require medical and surgical interventions for gender dysphoria. Therefore, a concise enunciation of guidelines and standards of care applicable to these elderly, and training of primary care and specialists to provide such care are necessary. Education for nurses, social workers, administrators and others who comprise the comprehensive care system must be mandatory. Finally, institutions and agencies must adapt and become inclusive of the spectrum of diverse individuals found across the changing social landscape. Keywords ageing transsexual, elderly transgender, older gender dysphoria patient
INTRODUCTION
ISSUES OF AGEING
In 1953, Christine Jorgensen publicly disclosed her transition from male to female. By 1965, Harry Benjamin had seen 307 transsexual patients, who served as the basis for his 1966 publication, ‘The Transsexual Phenomenon’ [1]. Thus, a taboo area of human behaviour was reconstructed into a medical specialty. As treatment advanced and access to care eased, gender dysphoric individuals sought professional assistance in greater numbers. Even societies that forbade reassignment surgeries saw their citizens cross continents to secure much-needed treatment. The first exploration of the experiences of elderly gender dysphoric individuals appeared in 1979. Gerontologists and others have documented the failure of healthcare systems and providers to meet the needs of the ageing lesbian, gay, bisexual and transgender community. More and more people who identify as transgender, transsexual or gendernonconforming are now elderly, yet guidelines for the care of this unique population are nonexistent.
In most Western societies, the issues affecting ageing individuals are remarkably consistent. Health, social isolation and income are almost universally cited as the major concerns in the later years. For elderly adults who identify as gay, lesbian bisexual or transgender (LGBT), coping with these issues presents additional challenges [2].
www.co-endocrinology.com
INSTITUTIONAL AND HEALTHCARE BIAS Very few agencies that provide services to the aged understand the needs of older LGBT adults. In the USA, urban-based agencies are more likely to provide staff training regarding nonconforming elders New Health Foundation Worldwide, Evanston, Illinois, USA Correspondence to Randi Ettner, New Health Foundation Worldwide, 1214 Lake Street, Evanston, IL 60201, USA. Tel: +1 847 328 3433; e-mail: [email protected] Curr Opin Endocrinol Diabetes Obes 2013, 20:580–584 DOI:10.1097/01.med.0000436183.34931.a5 Volume 20 Number 6 December 2013
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Care of the elderly transgender patient Ettner
KEY POINTS The needs of the elderly transgender patient are ignored or dismissed in most healthcare settings. Transgender patients require and can safely receive medical and surgical interventions for gender dysphoria. Education and culturally sensitive training must be supplied to all who provide care for gender nonconforming elders.
ancillary healthcare professionals. Yet, compared with other healthcare disciplines, nursing education and training is sorely lacking in addressing healthcare disparities affecting the LGBT population [12 ]. Cultural sensitivity, issues of sexuality in the aged [13] and evidence-based best practices regarding these elders is not, but should be, incorporated into healthcare curricula. In addition, policy and practice in institutions must ultimately be reconfigured to match the diversity of the ageing population throughout the world and provide respectful and appropriate treatment [5 –7 ,9,10]. &
&
than nonurban-based agencies, but there is little in the way of outreach [3 ]. Some researchers have found service providers to be dismissive of the needs of this community and characterize the agencies as resistant to providing services to LGBT elders [4]. Similar findings emerged from a survey of retirement and residential care providers in Australia. There was little experience with, or understanding of, the issues facing this population. Indeed, many aged admitted to concealing their identity, bowing to the fear of insensitive treatment or frank discrimination [5 ,6 ]. Heteronormative bias and assumptions of binary gender conformity are found to pervade the organizational structure of healthcare facilities and are operative at every level of residential care settings. For example, in most of these environments, individuals are assigned to either male or female accommodations, and activities offered rely on time-worn gender stereotypes rather than the lived experience and self-proclaimed identity of residents [7 ]. A survey of LGBT individuals with speech and hearing impairments revealed that although they believed it was relevant to treatment to disclose their membership in the LGBT community, the majority did not do so. Previous experiences of bias in the healthcare system led to the conviction that such disclosure would result in inferior care [8]. HIVpositive older LGBT adults represent another challenge to existing healthcare infrastructure, which at present is ill-equipped to provide needed support and treatment [9]. Inadequate care for vulnerable populations often exacerbates medical conditions [10]. Moreover, LGBT physicians themselves experienced discrimination in their training. They report that medical schools and healthcare workplaces discriminate against both LGBT patients and physicians [11]. &
&
&
&
EDUCATION AND CULTURAL COMPETENCE As life expectancy increases, more seniors will be interfacing with healthcare providers and facilities. Most of this care will be provided by nurses and
&
ISSUES OF THE ELDERLY TRANSGENDER PERSON The elderly transgender individual constitutes a minority within a minority. Although subject to all of the aforementioned onerous issues of ageing, they face additional unique challenges. A study [14] of quality of life revealed significantly lower quality of life for transgender elderly persons. A review of end-of-life care for the LGBT population yielded no studies related to the transgender person’s care in hospice or similar situations [15 ]. Unlike sexual orientation, gender variance still remains a supremely misunderstood area of human behaviour. For the elderly transgender person, a lifetime accumulation of shame, guilt and subterfuge, so often encountered in the narratives of these individuals, is hard to shed. Although society may currently be more aware of gender variance due to enhanced media attention, one who has spent a lifetime suppressing one’s authentic gender and adopting a pseudo persona cannot easily dethrone the tyranny of the ‘public self’ in later years [16 ]. It is not surprising that evidence exists confirming the harm inflicted by decades of such secrecy and shame. In the 1960s, patients in the UK subjected to ‘treatments’ to ‘cure’ homosexuality or ‘transvestism’ reported experiencing lasting negative impact from those shame-inducing interventions. Male homosexuality remained illegal in England until 1967 and gender nonconformity and homosexuality were viewed as mental illnesses for several decades thereafter [17]. Thus, in Western society, gender nonconformity can require the repression of feelings and behaviours in an attempt to appear ‘normal’ and avoid social derision. This repression starts at an early age and, over time, creates an inner landscape of chronic secrecy and inhibition of expression. Inhibition of expression is a known risk factor for hypertension. An analysis of 195 gender dysphoric males seeking hormonal treatment revealed that they had a 45.1% greater rate of hypertension than a control group of cisgender males. It appears that the lifelong
1752-296X ß 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
&
&&
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Reproductive endocrinology
compensatory reactions to the threat of exposure of this socially volatile topic often result in extreme cardiovascular reactivity. Patients who fear disapproval are uncomfortable sharing personal information, even when the information is relevant to care [18 ]. The ageing transgender individual, unlike the gay or lesbian elder, may require medical or surgical interventions for gender dysphoria. In pursuit of those interventions, they are at the mercy of a system that they fear is, at best, ignorant of their needs, and, at worst, dismissive or derisive. &&
PSYCHOLOGICAL ISSUES IN THE TRANSGENDER AGED There is very little literature addressing the psychological issues faced by transgender persons as they age. In 1979, Lothstein [19] published the first article focusing on this cohort. He studied 10 elderly gender dysphoric individuals requesting sex reassignment surgery. Although Lothstein’s theory of the cause of the condition has long been discredited, his views on the issues and treatment of this group retain relevance. Lothstein [19] recognized that oestrogen treatment was beneficial for ageing male-to-female patients as a means of attenuating depression, and he acknowledged that surgery may be a viable treatment for some elderly patients [19]. In the ensuing decades, increasing numbers of transgender individuals have been presenting to clinicians for the first encounter at age 60, or older. Three forces converge that account for this late appeal for treatment.
SOCIAL FACTORS In late adulthood, social responsibilities decline. Child-rearing is over and work expectations have declined or ended. For many elderly people, friends and acquaintances have moved or died, and social networks have diminished. Deterioration of health, limitations on physical stamina and/or reduced income may cause a restriction of activities. The social networks that provided the impetus to hide one’s identity are no longer operative. These elderly individuals were born decades before there was a name for the puzzling feelings they have experienced throughout their lifetimes. For some, Christine Jorgensen’s bold emergence occurred during their childhood, and it is memorialized as the day hope for future relief burgeoned.
IDENTITY FACTORS Eric Erickson, the psychologist who studied development across the life cycle, coined the phrase ‘identity crisis’. He stated that those over 65 years of age must come to terms with the imminence of death. 582
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At this stage, one will review one’s life and feel either great accomplishment or, if adulthood was difficult, despair [20]. This is the phenomenological situation that can catapult the elderly transgender person into crisis: The question ‘Who am I?’ becomes a pressing inquiry that must be answered. The memories of a life ‘lived for others’ bring a profound sense of alienation. Such feelings threaten identity and kindle gender dysphoria.
HORMONAL FACTORS It is quite likely that the normal hormonal changes that accompany ageing can destabilize a gender dysphoric individual and intensify the dysphoria. Postmenopausal women produce approximately 90% less oestrogen and biological men begin to show a decrease in hypothylamic pituitary gonadal function at age 30, with free testosterone declining at a rate of 1% per year thereafter. The loss of testosterone in transsexuals and nontranssexuals alike can lead to depression, and is a threat to cardiovascular health. At age 70, adults have 10% of the dehydroepiandrosterone they had at age 20. The elderly produce more cortisol, which decreases the sex hormones. Although the interdependence of sex steroids and the brain is constant throughout life [21,22], deciphering the complexity of the relationship at a particular developmental epoch, and anchoring levels of circulating sex hormones to emotional and cognitive processing, remains challenging. Using postmortem hypothalamic brain tissue from women, men and male-to-female transsexuals from infancy, puberty and old age, researchers demonstrated that certain sex differences emerge at adulthood. They found a robust female-dominant sexual dimorphism in the infundibular nucleus (INF). Postmenopausal women showed increased neurokinin B (NKB) immunoreactivity compared with premenopausal women, indicating the likely involvement of infundibular NKB system in the feedback of oestrogen on GnRH secretion. Male-to-female transsexual individuals exhibit female-typical structural difference in the NKB system [23 ]. &&
MEDICAL CARE OF THE TRANSGENDER ELDERLY The medical care of the elderly transgender patient is largely identical to that of the elderly nontransgender patient. Primary care physicians routinely see older individuals and provide care to them in accordance with evidence-based recommendations. When such a patient requests contrary hormones, physicians should assess pre-existing conditions, but rarely do they absolutely serve to contraindicate administering hormones in this population. Volume 20 Number 6 December 2013
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Care of the elderly transgender patient Ettner
OESTROGEN FOR THE MALE-TO-FEMALE PATIENT A long-term follow-up study has documented greater morbidity (venous thromboembolism) in transgender patients taking oral oestrogens as opposed to transdermal or percutaneous oestrogens. Use of oral estradiol was associated with an independent three-fold increased risk of cardiovascular death [24,25]. Patients who have been prescribed oral conjugated oestrogens should be switched to transdermal or intramuscular administration of hormones. All elderly patients who commence or continue oestrogen protocols should be monitored carefully. It is worth noting that hormones metabolize more slowly in the aged. Although the patient may urge the physician to ‘expedite’ or maximize feminization, as they sense a foreshortened future, elderly biological women have undergone menopause and it may be biologically imprudent to induce the hormonal equivalent of puberty in an aged individual. If oestrogen is categorically contraindicated, the patient may benefit from antiandrogenic compounds.
TESTOSTERONE FOR THE FEMALE-TOMALE PATIENT As evidence accumulates for the benefits of supplemental testosterone in ageing natal men, it has seen wider use in the ageing population. Indeed, ‘low-testosterone clinics’ that aim to restore vigour and health to the adult male are cropping up in various parts of North America. Female-to-male patients who have been receiving testosterone, particularly if they have undergone hysterectomy and oophorectomy, will require exogenous androgens for life. For the elderly female-to-male patient commencing hormone therapy, testosterone, administered transdermally or by intramuscular injection, can attenuate dysphoria and depression. Fairly frequent initial monitoring of the patient’s self-reports, laboratory values and physical status will guide the physician going forward. In general, testosterone dosages used to treat hypogonadal men appear to be well tolerated [24].
SURGERY FOR THE TRANSSEXUAL PATIENT Gender-confirming surgeries for elderly patients are dependent on the overall health of the patient and the extensiveness of the procedure in question. Many surgeons who perform genital reconstruction (sex reassignment surgery) have age limits, for example 65, which they may adhere to for medico-legal reasons rather than clinical criteria. In the
USA, few insurance companies pay for gender confirmation surgeries, thus rendering these therapeutic interventions largely unaffordable. One surgical procedure that provides a viable option for the ageing male-to-female patient is orchiectomy. Removal of the testicles reduces the ongoing dosage of exogenous hormones necessary for management of the condition and effectively diminishes the dysphoria. It is performed as an outpatient procedure, and the individual can return home the same day.
CONCLUSION There is very little literature or investigation relevant to the care of ageing transgender persons. Yet, owing to increased life span, greater awareness and visibility, and the timing of the introduction of nomenclature, the ageing transgender population will proliferate. Existing agencies, structures and personnel that provide care for the aged are woefully lacking in knowledge, training and capacity to care for maturing transgender people. The ageing transgender person will likely encounter health disparities in the patient-provider relationship and no services addressing their unique needs in residential, palliative or end-of-life care settings. Acknowledgements None. Conflicts of interest The author is a director on the board of WPATH, the World Professional Association for Transgender Health. There are no conflicts of interest.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Ettner R. Gender loving care. New York: W.W. Norton; 1999. 2. VanWagenen A, Driskell J, Bradford J. I’m still raring to go: successful aging among lesbian, gay, bisexual, and transgender older adults. J Aging Stud 2013; 27:1–14. 3. Knochel KA, Croghan CF, Moone RP, Quam JK. Training, geography, and & provision of aging services to lesbian, gay, bisexual, and transgender older adults. J Gerontol SocWork 2012; 55:426–443. This study highlights the disparity in LGBT awareness and outreach in non-urban US areas. 4. Hughes AK, Harold RD, Boyer JM. Awareness of LGBT aging issues among aging services network providers. J Gerontol Soc Work 2011; 54:659–677. 5. Cartwright C, Hughes M, Lienert T. End-of-life care for gay, lesbian, bisexual & and transgender people. Cult Health Sex 2012; 14:537–548. The investigators found little understanding in Australia of the needs of this community amongst service providers, obstacles to care and discrimination in end-of-life care, which has not previously been addressed in the literature. 6. Horner B, McManus A, Comfort J, et al. How prepared is the retirement and & residential aged care sector in Western Australia for older nonheterosexual people? Qual Prim Care 2012; 20:263–274. This article underscores a ‘vicious cycle’; the elderly LGBT in Western Australia do not disclose their identities due to fear, and thus, there is little experience with this population and there are no policies to accommodate them.
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Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Reproductive endocrinology 7. McIntyre M, McDonald C. The limitations of partial citizenship: healthcare & institutions underpinned with heteronormative ideals. ANS Adv Nurs Sci 2012; 35:127–134. A unique proposal claiming that nothing less than dismantling the entire fabric of organizations serving the aged, and repudiating the bias and heteronormative assumptions that underlie them, can create an essential change. 8. Kelly R, Robinson G. Disclosure of membership in the lesbian, gay, bisexual, and transgender community by individuals with communication impairments: a preliminary web-based survey. Am J Speech Lang Pathol 2011; 20:86–94. 9. Cahill S, Valadez R. Growing older with HIV/AIDS: new public health challenges. Am J Public Health 2013; 103:e7–e15. 10. Waisel DB. Vulnerable populations in healthcare. Curr Opin Anaesthesiol 2013; 26:186–192. 11. Eliason MJ, Dibble SL, Robertson PA. Lesbian, gay, bisexual, and transgender (LGBT) physicians’ experiences in the workplace. J Homosex 2011; 58:1355–1371. 12. Lim FA, Bernstein I. Promoting awareness of LGBT issues in aging in a & baccalaureate nursing program. Nurs Educ Perspect 2012; 33:170– 175. A significant article in articulating the necessity of providing information about elderly LGBT people in nursing education, as nurses are poised to provide care to this growing population in many different venues. 13. Benbow SM, Beeston D. Sexuality, aging, and dementia. Int Psychogeriatr 2012; 24:1026–1033. 14. Motmans J, Meier P, Ponnet K, T’Sjoen G. Female and male transgender quality of life: socioeconomic and medical differences. J Sex Med 2012; 9:743–750. 15. Harding R, Epiphaniou E, Chidgey-Clark J. Needs, experiences and prefer& ences for end-of-life care and palliative care: a systematic review. J Palliat Med 2012; 15:602–614. A review of 133 articles establishes ample evidence to recommend that healthcare professionals require education to address the needs of this underserved community with regard to end-of-life issues.
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16. Ettner R, Wylie K. Psychological and social adjustment in older transsexual people. Maturitas 2013; 74:226–229. An exploration of the emotional and psychological challenges facing the ageing transsex individual, which is otherwise absent in the literature, with recommendations for delivery of mental health services. 17. Dickinson T, Cook M, Playle J, Hallett C. ‘Queer’ treatments: giving a voice to former patients who received treatments for their ‘sexual deviations.’. J Clin Nurs 2012; 21 (9–10):1345–1354. 18. Ettner R, Ettner F, White T. Secrecy and the pathogenesis of hypertension. Int && Jour Fam Med 2012; 2012:492718. The role of inhibition of emotion in the cause of essential hypertension in this population is documented and discussed, as well as implications for physicians treating sex nonconforming patients. 19. Lothstein L. Psychodynamics and sociodynamics of gender dysphoria. Am J Psychother 1979; 33:214–238. 20. Erickson E. Identity: youth crisis. W.W. Norton: New York; 1968. 21. Mendrek A. Sex steroid hormones and brain function associated with cognitive and emotional processing in schizophrenia. Expert Rev Endocrinol M 2013; 8:1–3. 22. Bao AM, Swaab DF. Sex differences in the brain, behavior, and neuropsychiatric disorders. Neuroscientist 2010; 16:550–565. 23. Taziaux M, Swaab DF, Bakker J. Sex differences in the neurokinin B system in && the human infundibular nucleus. J Clin Endocrinol Metab 2012; 97:2210– 2220. An innovative study using immunohisotochemical staining to document sexual dimorphic structural differences at different age epochs and a reversal in male-tofemale transsexual infundibular anatomy. 24. Asscheman H, Giltay EJ, Megens JA, et al. A long-term follow-up study of mortality in transsexuals receiving treatment with cross-sex hormones. Eur J Endocrinol 2011; 164:635–642. 25. Canonico M, Oger E, Plu-Bureau G, et al. Hormone therapy and venous thromboembolism among postmenopausal women. Circulation 2007; 115:840–845. &&
Volume 20 Number 6 December 2013
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Care of the elderly transgender patient Randi Ettner
Purpose of review This review examines recent developments regarding the care of the elderly transgender patient. There is scant clinical or other relevant information related to this topic, as the phenomenon of gender incongruity has been largely misunderstood and underreported. It is important that guidelines for appropriate and sensitive care be established, as this population is proliferating due to media attention and greater access to care. Recent findings A preponderance of evidence exists establishing that gender nonconforming elders are subject to discriminatory healthcare treatment. Agencies that serve the elderly are rife with policies and practices that resist acknowledging the needs of this population. Most heathcare and service providers have little experience with this group and limited understanding of non-normative gender identification. Barriers to treatment amplify the challenges of ageing for the transgender person and can lead to nondisclosure of clinically relevant personal information. Summary Increasing numbers of ageing transgender individuals will be interfacing with health and care providers. Many of these individuals will require medical and surgical interventions for gender dysphoria. Therefore, a concise enunciation of guidelines and standards of care applicable to these elderly, and training of primary care and specialists to provide such care are necessary. Education for nurses, social workers, administrators and others who comprise the comprehensive care system must be mandatory. Finally, institutions and agencies must adapt and become inclusive of the spectrum of diverse individuals found across the changing social landscape. Keywords ageing transsexual, elderly transgender, older gender dysphoria patient
INTRODUCTION
ISSUES OF AGEING
In 1953, Christine Jorgensen publicly disclosed her transition from male to female. By 1965, Harry Benjamin had seen 307 transsexual patients, who served as the basis for his 1966 publication, ‘The Transsexual Phenomenon’ [1]. Thus, a taboo area of human behaviour was reconstructed into a medical specialty. As treatment advanced and access to care eased, gender dysphoric individuals sought professional assistance in greater numbers. Even societies that forbade reassignment surgeries saw their citizens cross continents to secure much-needed treatment. The first exploration of the experiences of elderly gender dysphoric individuals appeared in 1979. Gerontologists and others have documented the failure of healthcare systems and providers to meet the needs of the ageing lesbian, gay, bisexual and transgender community. More and more people who identify as transgender, transsexual or gendernonconforming are now elderly, yet guidelines for the care of this unique population are nonexistent.
In most Western societies, the issues affecting ageing individuals are remarkably consistent. Health, social isolation and income are almost universally cited as the major concerns in the later years. For elderly adults who identify as gay, lesbian bisexual or transgender (LGBT), coping with these issues presents additional challenges [2].
www.co-endocrinology.com
INSTITUTIONAL AND HEALTHCARE BIAS Very few agencies that provide services to the aged understand the needs of older LGBT adults. In the USA, urban-based agencies are more likely to provide staff training regarding nonconforming elders New Health Foundation Worldwide, Evanston, Illinois, USA Correspondence to Randi Ettner, New Health Foundation Worldwide, 1214 Lake Street, Evanston, IL 60201, USA. Tel: +1 847 328 3433; e-mail: [email protected] Curr Opin Endocrinol Diabetes Obes 2013, 20:580–584 DOI:10.1097/01.med.0000436183.34931.a5 Volume 20 Number 6 December 2013
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Care of the elderly transgender patient Ettner
KEY POINTS The needs of the elderly transgender patient are ignored or dismissed in most healthcare settings. Transgender patients require and can safely receive medical and surgical interventions for gender dysphoria. Education and culturally sensitive training must be supplied to all who provide care for gender nonconforming elders.
ancillary healthcare professionals. Yet, compared with other healthcare disciplines, nursing education and training is sorely lacking in addressing healthcare disparities affecting the LGBT population [12 ]. Cultural sensitivity, issues of sexuality in the aged [13] and evidence-based best practices regarding these elders is not, but should be, incorporated into healthcare curricula. In addition, policy and practice in institutions must ultimately be reconfigured to match the diversity of the ageing population throughout the world and provide respectful and appropriate treatment [5 –7 ,9,10]. &
&
than nonurban-based agencies, but there is little in the way of outreach [3 ]. Some researchers have found service providers to be dismissive of the needs of this community and characterize the agencies as resistant to providing services to LGBT elders [4]. Similar findings emerged from a survey of retirement and residential care providers in Australia. There was little experience with, or understanding of, the issues facing this population. Indeed, many aged admitted to concealing their identity, bowing to the fear of insensitive treatment or frank discrimination [5 ,6 ]. Heteronormative bias and assumptions of binary gender conformity are found to pervade the organizational structure of healthcare facilities and are operative at every level of residential care settings. For example, in most of these environments, individuals are assigned to either male or female accommodations, and activities offered rely on time-worn gender stereotypes rather than the lived experience and self-proclaimed identity of residents [7 ]. A survey of LGBT individuals with speech and hearing impairments revealed that although they believed it was relevant to treatment to disclose their membership in the LGBT community, the majority did not do so. Previous experiences of bias in the healthcare system led to the conviction that such disclosure would result in inferior care [8]. HIVpositive older LGBT adults represent another challenge to existing healthcare infrastructure, which at present is ill-equipped to provide needed support and treatment [9]. Inadequate care for vulnerable populations often exacerbates medical conditions [10]. Moreover, LGBT physicians themselves experienced discrimination in their training. They report that medical schools and healthcare workplaces discriminate against both LGBT patients and physicians [11]. &
&
&
&
EDUCATION AND CULTURAL COMPETENCE As life expectancy increases, more seniors will be interfacing with healthcare providers and facilities. Most of this care will be provided by nurses and
&
ISSUES OF THE ELDERLY TRANSGENDER PERSON The elderly transgender individual constitutes a minority within a minority. Although subject to all of the aforementioned onerous issues of ageing, they face additional unique challenges. A study [14] of quality of life revealed significantly lower quality of life for transgender elderly persons. A review of end-of-life care for the LGBT population yielded no studies related to the transgender person’s care in hospice or similar situations [15 ]. Unlike sexual orientation, gender variance still remains a supremely misunderstood area of human behaviour. For the elderly transgender person, a lifetime accumulation of shame, guilt and subterfuge, so often encountered in the narratives of these individuals, is hard to shed. Although society may currently be more aware of gender variance due to enhanced media attention, one who has spent a lifetime suppressing one’s authentic gender and adopting a pseudo persona cannot easily dethrone the tyranny of the ‘public self’ in later years [16 ]. It is not surprising that evidence exists confirming the harm inflicted by decades of such secrecy and shame. In the 1960s, patients in the UK subjected to ‘treatments’ to ‘cure’ homosexuality or ‘transvestism’ reported experiencing lasting negative impact from those shame-inducing interventions. Male homosexuality remained illegal in England until 1967 and gender nonconformity and homosexuality were viewed as mental illnesses for several decades thereafter [17]. Thus, in Western society, gender nonconformity can require the repression of feelings and behaviours in an attempt to appear ‘normal’ and avoid social derision. This repression starts at an early age and, over time, creates an inner landscape of chronic secrecy and inhibition of expression. Inhibition of expression is a known risk factor for hypertension. An analysis of 195 gender dysphoric males seeking hormonal treatment revealed that they had a 45.1% greater rate of hypertension than a control group of cisgender males. It appears that the lifelong
1752-296X ß 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins
&
&&
www.co-endocrinology.com
581
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Reproductive endocrinology
compensatory reactions to the threat of exposure of this socially volatile topic often result in extreme cardiovascular reactivity. Patients who fear disapproval are uncomfortable sharing personal information, even when the information is relevant to care [18 ]. The ageing transgender individual, unlike the gay or lesbian elder, may require medical or surgical interventions for gender dysphoria. In pursuit of those interventions, they are at the mercy of a system that they fear is, at best, ignorant of their needs, and, at worst, dismissive or derisive. &&
PSYCHOLOGICAL ISSUES IN THE TRANSGENDER AGED There is very little literature addressing the psychological issues faced by transgender persons as they age. In 1979, Lothstein [19] published the first article focusing on this cohort. He studied 10 elderly gender dysphoric individuals requesting sex reassignment surgery. Although Lothstein’s theory of the cause of the condition has long been discredited, his views on the issues and treatment of this group retain relevance. Lothstein [19] recognized that oestrogen treatment was beneficial for ageing male-to-female patients as a means of attenuating depression, and he acknowledged that surgery may be a viable treatment for some elderly patients [19]. In the ensuing decades, increasing numbers of transgender individuals have been presenting to clinicians for the first encounter at age 60, or older. Three forces converge that account for this late appeal for treatment.
SOCIAL FACTORS In late adulthood, social responsibilities decline. Child-rearing is over and work expectations have declined or ended. For many elderly people, friends and acquaintances have moved or died, and social networks have diminished. Deterioration of health, limitations on physical stamina and/or reduced income may cause a restriction of activities. The social networks that provided the impetus to hide one’s identity are no longer operative. These elderly individuals were born decades before there was a name for the puzzling feelings they have experienced throughout their lifetimes. For some, Christine Jorgensen’s bold emergence occurred during their childhood, and it is memorialized as the day hope for future relief burgeoned.
IDENTITY FACTORS Eric Erickson, the psychologist who studied development across the life cycle, coined the phrase ‘identity crisis’. He stated that those over 65 years of age must come to terms with the imminence of death. 582
www.co-endocrinology.com
At this stage, one will review one’s life and feel either great accomplishment or, if adulthood was difficult, despair [20]. This is the phenomenological situation that can catapult the elderly transgender person into crisis: The question ‘Who am I?’ becomes a pressing inquiry that must be answered. The memories of a life ‘lived for others’ bring a profound sense of alienation. Such feelings threaten identity and kindle gender dysphoria.
HORMONAL FACTORS It is quite likely that the normal hormonal changes that accompany ageing can destabilize a gender dysphoric individual and intensify the dysphoria. Postmenopausal women produce approximately 90% less oestrogen and biological men begin to show a decrease in hypothylamic pituitary gonadal function at age 30, with free testosterone declining at a rate of 1% per year thereafter. The loss of testosterone in transsexuals and nontranssexuals alike can lead to depression, and is a threat to cardiovascular health. At age 70, adults have 10% of the dehydroepiandrosterone they had at age 20. The elderly produce more cortisol, which decreases the sex hormones. Although the interdependence of sex steroids and the brain is constant throughout life [21,22], deciphering the complexity of the relationship at a particular developmental epoch, and anchoring levels of circulating sex hormones to emotional and cognitive processing, remains challenging. Using postmortem hypothalamic brain tissue from women, men and male-to-female transsexuals from infancy, puberty and old age, researchers demonstrated that certain sex differences emerge at adulthood. They found a robust female-dominant sexual dimorphism in the infundibular nucleus (INF). Postmenopausal women showed increased neurokinin B (NKB) immunoreactivity compared with premenopausal women, indicating the likely involvement of infundibular NKB system in the feedback of oestrogen on GnRH secretion. Male-to-female transsexual individuals exhibit female-typical structural difference in the NKB system [23 ]. &&
MEDICAL CARE OF THE TRANSGENDER ELDERLY The medical care of the elderly transgender patient is largely identical to that of the elderly nontransgender patient. Primary care physicians routinely see older individuals and provide care to them in accordance with evidence-based recommendations. When such a patient requests contrary hormones, physicians should assess pre-existing conditions, but rarely do they absolutely serve to contraindicate administering hormones in this population. Volume 20 Number 6 December 2013
Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Care of the elderly transgender patient Ettner
OESTROGEN FOR THE MALE-TO-FEMALE PATIENT A long-term follow-up study has documented greater morbidity (venous thromboembolism) in transgender patients taking oral oestrogens as opposed to transdermal or percutaneous oestrogens. Use of oral estradiol was associated with an independent three-fold increased risk of cardiovascular death [24,25]. Patients who have been prescribed oral conjugated oestrogens should be switched to transdermal or intramuscular administration of hormones. All elderly patients who commence or continue oestrogen protocols should be monitored carefully. It is worth noting that hormones metabolize more slowly in the aged. Although the patient may urge the physician to ‘expedite’ or maximize feminization, as they sense a foreshortened future, elderly biological women have undergone menopause and it may be biologically imprudent to induce the hormonal equivalent of puberty in an aged individual. If oestrogen is categorically contraindicated, the patient may benefit from antiandrogenic compounds.
TESTOSTERONE FOR THE FEMALE-TOMALE PATIENT As evidence accumulates for the benefits of supplemental testosterone in ageing natal men, it has seen wider use in the ageing population. Indeed, ‘low-testosterone clinics’ that aim to restore vigour and health to the adult male are cropping up in various parts of North America. Female-to-male patients who have been receiving testosterone, particularly if they have undergone hysterectomy and oophorectomy, will require exogenous androgens for life. For the elderly female-to-male patient commencing hormone therapy, testosterone, administered transdermally or by intramuscular injection, can attenuate dysphoria and depression. Fairly frequent initial monitoring of the patient’s self-reports, laboratory values and physical status will guide the physician going forward. In general, testosterone dosages used to treat hypogonadal men appear to be well tolerated [24].
SURGERY FOR THE TRANSSEXUAL PATIENT Gender-confirming surgeries for elderly patients are dependent on the overall health of the patient and the extensiveness of the procedure in question. Many surgeons who perform genital reconstruction (sex reassignment surgery) have age limits, for example 65, which they may adhere to for medico-legal reasons rather than clinical criteria. In the
USA, few insurance companies pay for gender confirmation surgeries, thus rendering these therapeutic interventions largely unaffordable. One surgical procedure that provides a viable option for the ageing male-to-female patient is orchiectomy. Removal of the testicles reduces the ongoing dosage of exogenous hormones necessary for management of the condition and effectively diminishes the dysphoria. It is performed as an outpatient procedure, and the individual can return home the same day.
CONCLUSION There is very little literature or investigation relevant to the care of ageing transgender persons. Yet, owing to increased life span, greater awareness and visibility, and the timing of the introduction of nomenclature, the ageing transgender population will proliferate. Existing agencies, structures and personnel that provide care for the aged are woefully lacking in knowledge, training and capacity to care for maturing transgender people. The ageing transgender person will likely encounter health disparities in the patient-provider relationship and no services addressing their unique needs in residential, palliative or end-of-life care settings. Acknowledgements None. Conflicts of interest The author is a director on the board of WPATH, the World Professional Association for Transgender Health. There are no conflicts of interest.
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Reproductive endocrinology 7. McIntyre M, McDonald C. The limitations of partial citizenship: healthcare & institutions underpinned with heteronormative ideals. ANS Adv Nurs Sci 2012; 35:127–134. A unique proposal claiming that nothing less than dismantling the entire fabric of organizations serving the aged, and repudiating the bias and heteronormative assumptions that underlie them, can create an essential change. 8. Kelly R, Robinson G. Disclosure of membership in the lesbian, gay, bisexual, and transgender community by individuals with communication impairments: a preliminary web-based survey. Am J Speech Lang Pathol 2011; 20:86–94. 9. Cahill S, Valadez R. Growing older with HIV/AIDS: new public health challenges. Am J Public Health 2013; 103:e7–e15. 10. Waisel DB. Vulnerable populations in healthcare. Curr Opin Anaesthesiol 2013; 26:186–192. 11. Eliason MJ, Dibble SL, Robertson PA. Lesbian, gay, bisexual, and transgender (LGBT) physicians’ experiences in the workplace. J Homosex 2011; 58:1355–1371. 12. Lim FA, Bernstein I. Promoting awareness of LGBT issues in aging in a & baccalaureate nursing program. Nurs Educ Perspect 2012; 33:170– 175. A significant article in articulating the necessity of providing information about elderly LGBT people in nursing education, as nurses are poised to provide care to this growing population in many different venues. 13. Benbow SM, Beeston D. Sexuality, aging, and dementia. Int Psychogeriatr 2012; 24:1026–1033. 14. Motmans J, Meier P, Ponnet K, T’Sjoen G. Female and male transgender quality of life: socioeconomic and medical differences. J Sex Med 2012; 9:743–750. 15. Harding R, Epiphaniou E, Chidgey-Clark J. Needs, experiences and prefer& ences for end-of-life care and palliative care: a systematic review. J Palliat Med 2012; 15:602–614. A review of 133 articles establishes ample evidence to recommend that healthcare professionals require education to address the needs of this underserved community with regard to end-of-life issues.
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Volume 20 Number 6 December 2013
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