The inflow of transgender persons in care settings is expected to continue to increase in the near future. The share of older people among those referred to the Gender Wellbeing Clinic has been minimal and the figures from the public registry show that of those who have accessed legal gender recognition only one was over 60 years of age. However, this does not mean that there are presently no or few trans people in this age group when compared to younger age cohorts, but that they most likely found little to no information or support in their youth and adult life, may have feared stigmatisation and exclusion or may not have had the means to access such procedures, among others.

It is therefore possible and probable that older (65+) clients will register for a request for transition-related care. Children becoming adults and leaving the family home, a social network that has changed due to retirement and the departure of family and friends, may trigger a situation in which the older trans person ends up questioning their gender identity and they wonder “who am I anyway?” (Ettner, 2013). The memory of a life ‘lived for others’ can bring a feeling of alienation, and possibly put the questions of identity back in the foreground.

To seek care, they must overcome many barriers related to stigma, anxiety and shame, as well as the lack of knowledge among care providers (Shires & Jaffee, 2015; Wylie et al., 2014). These barriers can also partly account for the frequency of self-medication in older trans populations – i.e. the use of hormones purchased over the internet. Research shows that in Europe, trans persons who buy hormones on their own are mostly trans women and the elderly, and that there is increased chance that they will have less knowledge about the effects and risks associated with HRT (Kreukels et al., 2012; Mepham et al., 2014; Simonsen et al., 2015).

In general, treatment options for older (healthy) trans persons remain the same, and they can also receive gender affirming hormonal treatment and surgery if desired, although the increased risks associated with these treatments must be clearly discussed with them so that they can make an informed decision (Bouman et al., 2016). Care providers should therefore pay attention to ‘ageism’ and protect themselves from a belief that it is ‘too late for treatment’. In general, treatment depends on the current state of health of the individual, and the stability and control on any relevant health conditions.

Follow-up care of older transpersons

To date, there has been little or no systematic research into the socio-demographic and clinical characteristics of older trans persons (Bouman et al., 2016). In addition, in general research on the elderly, LGBs and trans elderly people are often overlooked. The research that does exist mostly deals with the lack of suitable services for older non-binary and trans persons (Witten & Eyler, 2012). A major review of end-of-life care revealed that there are no studies specifically available which dwell on the experiences of transgender elderly people in rest and care homes (Harding, Epiphaniou, & Chidgey-Clark, 2012). However, some case reports do indicate that trans elderly people have concerns about their end of life care (their desire to die with dignity).

Health aspects linked to aging naturally also apply to older trans persons. Research shows that trans persons smoke more and use more drugs and alcohol. The problem of suicidal thoughts, commonly known in the elderly, is also an increased point of attention in trans persons. In terms of quality of life, it is generally known that elderly people often exhibit a reduced quality of life compared to young people, and this was confirmed in a Belgian study for trans elderly people (Motmans et al., 2012).

The research by Bouman et al. (2016) which investigated a group of trans women aged 50+ shows that also in this age group the positive correlation of gender affirming hormonal therapy with psychological and psychosocial well-being was noticeable, just as is the case with younger trans persons. There is no definite answer to date about the effects of long-term hormone use, due to a lack of long-term data. In the medium term, the studies do indicate that hormone use is a safe therapy.

Trans elderly in need of care

Many trans people (will in the future) stay in residential care centers, but they are often invisible. Transgender-sensitive care and responding to the specific needs of this target group is necessary. Health aspects linked to aging naturally also apply to older trans people. Research shows that older people smoke more and use more substances. The problem of suicidal thoughts and feelings of loneliness, well known among the elderly, is also an increased concern among trans elderly (Motmans et al., 2012).

Transgender seniors often have specific concerns about their end-of-life – for example, their wish to die with dignity or be buried under the correct name/gender. There is also concern about their possible admissions to residential care centers, for example when dealing with care staff or co-residents. Trans elderly people who receive care at home through an informal caregiver are sometimes afraid of losing it.

Trans seniors may be less mobile and may not handle multimedia very well. In a world where trans people often make contact and date online, they can quickly end up in social isolation. Some trans elderly people no longer have contact with family and friends and have to fall back on another social network where people are accepted. As they get older it is less and less obvious to find (younger) people who want to take on this responsibility and care.

Aging trans people also have specific health needs. Just think of a correct and lifelong application of hormonal treatment, or frequent dilation for trans women. They may need help with this and it is advisable as a care provider to be aware of the effect of the hormonal products. Finally, the life path taken in old age can be very confronting and psychological counseling may be desirable. Given the high rates of depression and anxiety disorder among trans seniors, it is especially important to focus on positive coping strategies and the development of a warm social network (Henderson & Almack, 2016). Another challenge is tackling possible financial instability due to past events: job losses, a complex divorce or high medical costs.

References:

  • Bouman, WP, Claes, L., Marshall, E., Pinner, GT, Longworth, J., Maddox, V.,. . . Arcelus, J. (2016). Sociodemographic Variables, Clinical Features, and the Role of Preassessment Cross-Sex Hormones in Older Trans People. The Journal of Sexual Medicine, 13 (4), 711-719. doi: https://doi.org/10.1016/j.jsxm.2016.01.009
  • Ettner, R. (2013). Care of the elderly transgender patient. Current Opinion in Endocrinology, Diabetes & Obesity, 20 (6), 580-584.
  • Harding, R., Epiphaniou, E., & Chidgey-Clark, J. (2012). Needs, Experiences, and Preferences of Sexual Minorities for End-of-Life Care and Palliative Care: A Systematic Review. Journal of Palliative Medicine, 15 (5), 602-611. doi: 10.1089 / jpm.2011.0279
  • Kreukels, BPC, Haraldsen, IR, De Cuypere, G., Richter-Appelt, H., Gijs, L., & Cohen-Kettenis, PT (2012). A European network for the investigation of gender incongruence: The ENIGI initiative. European Psychiatry, 27 (6), 445-450. doi: 10.1016 / j.eurpsy.2010.04.009
  • Mepham, N., Bouman, WP, Arcelus, J., Hayter, M., & Wylie, KR (2014). People with Gender Dysphoria Who Self ‐ Prescribe Cross ‐ Sex Hormones: Prevalence, Sources, and Side Effects Knowledge. The Journal of Sexual Medicine, 11 (12), 2995-3001. doi: https://doi.org/10.1111/jsm.12691
  • Motmans, J., Meier, P., Ponnet, K., & T’Sjoen, G. (2012). Female and Male Transgender Quality of Life: Socioeconomic and Medical Differences. The Journal of Sexual Medicine, 9 (3), 743-750. doi: 10.1111 / j.1743-6109.2011.02569.x
  • Shires, DA, & Jaffee, K. (2015). Factors associated with health care discrimination experiences among a national sample of female-to-male transgender individuals. Health and Social Work, 40 (2), 134-141. doi: 10.1093 / hsw / hlv025
  • Simonsen, R., Hald, GM, Giraldi, A., & Kristensen, E. (2015). Sociodemographic Study of Danish Individuals Diagnosed with Transsexualism. Sexual Medicine, 3 (2), 109-117. doi: https://doi.org/10.1002/sm2.48
  • Witten, TM, & Eyler, AE (2012). Lesbian, gay, bisexual, and transgender aging: Challenges in research, practice, and policy . Baltimore, MD: Johns Hopkins University Press.
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