Title: Transgender Aging
Author:
Section/SPIG: Aging & Public Health
Issue Date:
Transgender Aging: The Graying of Transgender
Tarynn M. Witten*, PhD, MSW, FGSA
School of Social Work
Virginia Commonwealth University
Richmond, VA 23284
and
A. Evan Eyler, MD, MPH, FAFP
University of Vermont
School of Medicine
Burlington, VT
* Communications to this author at: T.M. Witten, PhD, MSW, FGSA, CSBC, Suite 111, Trani Life Sciences Bldg, 1000 West Cary Street, PO Box 842030, Richmond, VA 23284-2030
My friend John, a 64 year-old female-to-male transsexual, stared at a health care survey he had recently been asked to fill out. It asked his gender and then gave him the choices of male and female. John’s predicament illustrates the ongoing demographic invisibilization process transgender individuals undergo during the course of their journey (Witten & Eyler, 1999). Couple this with the typical marginalization suffered by the elderly in the United States, and you are faced with a growing population of persons (Witten, 2003) who suffer from significant degrees of health care (Witten & Eyler, 2004) and eco-socio-political injustice and inequity (Witten, 2004ab, Witten & Whittle, 2004).
Within the worldwide older adult population, transsexuals, transgenders, cross-dressers and other persons whose gender expression or identification is not seen as the “traditional” male or female represent a substantial minority group. Members of some Native American groups (i.e., Tewa Indians of New Mexico) might fall into this category, as would the Fa’afafine and Fa’afatama of Tonga and Samoa, the Hijra of India, Pakistan and Bangladesh, the Maori of New Zealand, the Mak Nyah of Malaysia, and the okama, gei bli, burˆbli and nyˆh#fu of Japan.
In an era in which forecasting the health of elder populations is increasingly more important and where issues of health care inequity (Institute of Medicine, 2003) are being touted as critical to address, discussion of quality of life issues faced by mid-to-late life transsexuals and other gender minority persons should not be deferred. It is difficult, unfortunately, to provide data-based information about many of the health care and related issues faced by elder transsexuals, as this group is particularly “epidemiologically invisible” (Witten & Eyler, 1999), with many of its members preferring not to reveal their natal sex due to perceived and real risks and stigma associated with being “out.”
Transgender elders face not only the normative problems of aging, but also, due to their contragender hormone use and other possible gender re-alignment surgeries, face problems evolving from the conflation of such alterations with the normative aging processes. Confounding these biomedical processes are a constellation of psycho-social and eco-legal-political factors that further exacerbate the biomedical condition due to numerous factors such as elevated stress, experiences of perceived and actual violence and abuse (Witten & Eyler, 1999; Lombardi et al., 2001; Witten, 2004ab), loss of social network support, loss of income, and divorce/loss of children (Witten, 2004b, Witten & Whittle, 2004).
Biomedically, little is known about long-term effects or morbidity/mortality risk changes from use of contragender hormones and genital or other surgery, as related to the canonical age-related diseases of osteoporosis, cancer (breast/prostate), stroke, cardiovascular and cerebro-vascular disease, and oral health. Additionally, good clinical judgment must be utilized when starting a gender journey later in life due to the potential consequences arising from normative aging processes. Here, smoking cessation programs should be emphasized due to elevated risks associated with hormone use and smoking.
Individuals who pursue gender transition later in life face different challenges than do their younger peers, and also possess certain advantages. Quality of life issues may be affected by a constellation of medical and social considerations. These issues are both similar and dissimilar to those encountered by non-transsexual elderly persons. In this section, we will briefly explore the realities influencing quality of life for older transsexual, transgendered and cross-dressing individuals.
Trans-individuals who have transitioned earlier in life and have experienced a significant portion of the adult lifespan as a contra-gendered individual must deal with questions relating to long-term stress, negative life experience, and long-term exposure to hormones that can profoundly affect socio-economic status for the transperson. While this can have numerous immediate effects, it also has long-term effects. For example, alterations of the oral environment, saliva production due to use of estrogen could have potential implications for long-term risk of cardiovascular disease. Persons who undertake gender transition during mid-life or the elder years are more likely than their younger peers to experience difficulties related to physical health status. Ill health, especially cardiac or pulmonary dysfunction, may preclude eligibility for surgical procedures including breast or genital reconstruction. Health care and personal assistance services are more complex for persons who are transgendered than for those who are transsexual and post-operative. Apparent mismatch between genital anatomy and gender of presentation can result in difficulty in obtaining medical services, practical nursing care, or even appropriate funereal arrangements. Many health care personnel consider transgenderism (or transsexualism or cross-dressing) to be evidence of psychiatric pathology, and inappropriate psychiatric referrals may result.
The financial aspects of transsexual and transgender health care are also affected by gender discrimination. Attempts to transition in the work place are at times met with dismissal; only one state and a handful or municipalities provide legal protection from employment discrimination based on gender presentation. This fact is significant in light of the truth that whether women are impoverished by adverse later-life events depends upon their economic resources just prior to the event; and that their financial resources in old age depends very much on their long-term economic status throughout their adult lives. While this has immediate relevance to the problem of financing health care costs, both short- and long-term, it is also pertinent to general long-term lifecycle issues such as housing and retirement.
Although cross-dressing individuals do not usually seek contragender hormonal services, middle-aged and elderly cross-dressing persons often experience difficulty in obtaining appropriate health care services due to privacy concerns. For example, most MTF cross-dressers remove leg and body hair in order to appear as normal women while dressed en femme. The need to seek medical care often forces the dilemma of whether to disclose one’s personal behavior to the physician or other practitioner, or whether instead to attempt to postpone services until the body hair has re-grown. In those cases, in which a chronic illness is present, avoidance of medical care for any length of time can have serious consequences. Situations in which the cross-dressing individual requires emergency (cardiac, for example) or long-term care (nursing home, rehabilitative care, for example) can be problematic for similar reasons.
Psychosocial issues pervade the life of a transgender-identified individual. Normative aging dynamics include decline of social responsibilities, end of child-rearing, reduced income due to retirement, normative deterioration of physical strength and health and a decline in social networks. These factors are magnified for trans-identified individuals as they risk loss of economic status, loss of access to qualified services – health care and other – and frequently see a decrease in the social support networks including loss of friends, family, significant others and as well as access to religious and spiritual organizations. Moreover, all of the negatives are further exacerbated by the stigma associated with being a transperson of color, race, ethnicity, immigrant and/or disability or having HIV/AIDS status. Caregivers must be acutely aware of the impact of these factors as related to increased depression, anxiety, alcohol/drug/substance abuse, suicidality and other related mental health issues, all of which are common in “normative” elders. Family relationships may be altered following the older person's “coming out” with regard to his or her gender identity. Family dynamics change as transgendered parents must now be taken care of by their children. Issues of elder maltreatment, abuse, neglect and self-neglect must be carefully monitored.
Public health officials and practitioners can best assist older transsexual, transgendered and cross-dressing clients by providing them with information regarding the importance of routine health care (including preventive services), arranging referrals to providers who are empathic and supportive to members of the gender community, and educating others involved in the clients’ care with respect to the realities of human gender diversity. In addition, facilitation of support group formation for older members of the gender community, education of leaders of existing groups and specific inclusion of transgendered persons in visible roles within retirement communities, health center sponsored programs and other service networks, may positively impact quality of life within the gender community.
Public health and social policy development on behalf of both the transgendered elder (including the assurance of nondiscrimination with regard to quality health care services, privacy, confidentiality, respectful treatment and care-giving, and personal safety) is also strongly needed. In addition, violence against members of the gender community shares many similarities with violence against genetic women, anti-homosexual (and other hate crime) attacks, and family violence which occurs when a child (or other family member) is “different.” It is often complicated by a lack of access to routine health care services and by inadequate response when victimization occurs. In addition, the current lack of comprehensive information about this aspect of family and social violence presents additional barriers to the design and implementation of both preventive and recovery services in this community. If society and the Public Health community is to respond adequately to the problem of social violence, and if the transgender community is to be able to protect itself from violent crime, accurate, scientifically reliable data on violence prevalence is needed, so that the necessary resources can be put in place to help the victims and to punish the perpetrators of violent acts. In order to improve gender-based violence prevention efforts, a better understanding of the etiologies of gender (and transgender) related violence must be obtained.
References
Institute of Medicine. (2003). Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, Washington, D.C.: National Academy Press.
Lombardi, E.L., Wilchins, R.A., Priestling, D., Malouf, D. (2001). Gender violence: transgender experiences with violence and discrimination. J. Homosexuality, 42(1): 89-101.
Witten, T.M. & Eyler, A.E. (1999). Hate crimes and violence against the transgendered, Peace Review, 11#3 (1999) 461-468.
Witten, T.M. (2002). Geriatric care and management issues for the transgender and intersex populations. Geriatric Care and Management Journal, 12(3): 20 – 24.
Witten, T.M. (2003). Transgender aging: An emerging population and an emerging need. Review Sexologies, XII (4): 15-20.
Witten, T.M. and Eyler, A.E. (2004). Healthcare Issues: Transsexuals, Transgenders, and Cross-Dressers. Healthcare and Aging, 11 (1): 4-5.
Witten, T.M. (2004). Aging and Gender Diversity. Social Work Today, 4 (4): 28-31
Witten, T.M. (2004). Life course analysis: The courage to search for something more: Middle adulthood issues in the transgender and intersex community. J. Human Behavior in a Social Environment. 8 (3-4), 189-224.
Witten, T.M. and Whittle, S.P. (2004). TransPanthers: The graying of transgender and the law. The Deakin Law Review, 9 (2): 503-522. Also available at http://www.deakinlawreview.org/currentIssue.php
All of the above papers are available as free pdf downloads at the TranScience Research Institute website http://www.transcience.org in the Research Archives section. The author can be contacted at twitten@vcu.edu. If you are interested in participating in the ongoing longitudinal research effort in support of transgender aging (as either a study participant or collaborator) or know of someone who might be, please contact the author for further details.