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June 16, 2012

Aging Transgenders: Quality of Life

Daily Kos
By Robyn Serven
A new publication announcement hit my in-box during the days this week when I was having to deal with some health issues.

Transgender older adults face profound challenges and experience striking disparities in areas such as health and health care access, physical and mental health, employment, housing and more.

Services and Advocacy for GLBT Elders (SAGE) and the National Center for Transgender Equality (NCTE) have worked together to produce a new report on aging transpeople: Improving the Lives of Transgender Older Adults: Recommendations for Policy and Practice. That's a pdf. I read them so you don't have to.This is a subject that has been rarely studied. Perhaps the assumption is that most of us will either be murdered or commit suicide long before this issue comes up.

Transgender older adults face profound challenges and experience striking disparities in areas such as health and health care access, physical and mental health, employment, housing and more. Research and experience also reveal that many transgender elders routinely encounter both a health care system and a national aging network that are ill-prepared to provide culturally competent care and services and create residential environments that affirm the gender identities and expressions of transgender older people.

Many transgender elders delay necessary care and are subjected to ignorance, prejudice, discrimination, hostility and even violence in the settings meant to support their successful aging. Policies and programs meant to support older people and other vulnerable populations often present significant barriers for transgender people, while initiatives that could address many of the disparities and challenges they face (such as elder abuse and housing costs) are neglected or underfunded.

This report is the result of the Transgender Aging Advocacy Initiative which was designed to identify the barriers faced by older transpeople and outline a roadmap to aid in eliminating those barriers.The report begins by assembling the current knowledge base on Trans Aging, and moves through stating the challenges we face, before making over 60 detailed policy recommendations.

The Knowledge Base

The research is limited, but there is some. The NCTE's National Transgender Discrimination Survey of 6450 gender variant adults included 110 transpeople over the age of 65. Unfortunately the demographic diversity of this sample was not great. Most members of this subsample were white transwomen who transitioned later in life and had relatively high incomes. While the report states that the reasons for this are not clear, I can offer some common sense observations: those older transpeople who participated in the survey would have been still in contact with the trans community, which means they are less likely to have transitioned more than a decade earlier, more likely to be computer savvy, which means they are more likely to be on the white side of the digital divide and more likely to have a higher disposable income. As for them mostly identifying as transwomen, one only has to note that in the early days of our community, transmen were nearly invisible.

The fact that the samples include people with a likely higher income is counterbalanced by the fact that transitioning later in life means that individuals are less likely to conform visibly to their gender (i.e. "pass") and therefore suffer more negative mental health outcomes.

Other surveys consulted, including the Transgender Law Center's State of Transgender California, suffer from the same bias.

It stands to reason that the population in general would be more vulnerable to abuse and neglect than the study samples.

SAGE attempts to smooth out some of the data by looking at their research into the general population of LGBT elders.

Both the general LGBT research and the trans-specific research document the routine exhibitions of ignorance, indifference, and discrimination in mainstream healthcare venues (hospital emergency rooms, mental health clinics, doctor's offices and drug treatment programs). When we are not outright refused care or harassed and/or abused, we most often encounter a lack of basic cultural and clinical knowledge possessed by our supposed healthcare providers. For elders that often translates to a higher than normal distrust of providers and possible disregard of their advice which often manifests itself in increased social isolation, delay in care-seeking and poor health.

The data indicate that the probability of mistreatment in medical settings is greater for transpeople of color, with Latin@ respondents reporting the highest rate of unequal care and African American respondents reporting the highest incidences of physical assault in doctor's offices and hospitals.

Without the support of healthcare providers and in order to avoid the stress of dealing with incompetent service providers, many transpeople do not seek healthcare until we are experiencing an emergency, which increases the likelihood of poor outcome, including death from the absence of medical care. 17% of African American respondents and 8% of Latin@ respondents to the NTDS listed emergency rooms as their primary source of medical care. Both of those sub-communities experience much higher incidences of poor health than the general population, including higher rates of HIV infection, smoking, drug and alcohol abuse, and suicide attempts.

A 2005 Philadelphia study found that 1/3 of transpeople had no primary care physician. The University of Washington's The Aging And Health Report surveyed 2500 LGBT older adults (50-95) and found that 1/3 of transgender elders report being in poor health and 22% needed to see a doctor but did not because they could not afford to do so. The UW repot also revealed that while 47% of LGBT elders were disabled, 62% of transgender elders reported having a disability.

A 2006 study revealed providers of aging services were even more intolerant towards LGBT elders than mainstream health providers. Providers of aging services were unlikely to be cultural competent on LGBT issues and were unlikely to have received any professional training in regard to the needs of LGBT older adults.

No current research reveals any unified effort to increase the cultural competency of staff or residents about issues of relevance to transgender clients. Indeed only 1/3 offered any training at all at the general LGBT level…and most of that training was part of a larger effort to address nondiscrimination.

Those agencies which did conduct training specifically on transgender issues (there were 101 of them across the nation…which was 7.2% of respondents) were likely to have done so only because they had received a request to help a transgender elder in the previous year.

lack of training maintains an atmosphere of ignorance regarding transgender people in aging settings,can enable neglect and abuse, and establishes an environment where older adults feel unsafe to speak openly and honestly about their gender identities and expressions. In a recent survey on LGBT older adults in long-term care facilities, 80 individuals (more than 10 percent of respondents) said that they,a loved one or a client had experienced staff refusal to call a transgender resident by his or her preferred name or pronoun.

The Aging and Health Report revealed that transgender people aged 50+ were more than twice as likely to have experienced physical or verbal violence in their domestic situation than their LGB peers over the preceding year. We are also less likely to report that abuse since we are more likely to have had negative interactions with law enforcement officials previously.

Transgender and intersex persons must go through a great deal to survive. Those that manage to live long lives as transgendered or intersexed persons must have developed coping and survival strategies that were highly effective in the face of all that is against them.
--Tarynn M. Witten

The general lack of professional training on transgender health compounded by discrimination in employment, education and housing, as well as the lack of social support systems, contribute to the chronic stress experienced by many transgender older adults. This amplified level of anxiety, common to groups who experience regular discrimination and violence, can lead to high-risk behaviors and poor health outcomes.

Then there are the problems associated with being HIV+. The rate of HIV diagnoses among transpeople is 6.3%, which is 50% higher than that of men who have sex with men. Not surprisingly the most vulnerable are transwomen of color.

The Transgender Aging Network (TAN) writes that transgender women who transition in mid-to late life may experience additional challenges in negotiating safe sex practices: “Frequently these MTFs [male-to-female persons] have been in heterosexual marriages for several decades, and may not have paid attention to safer sex messages because they felt the messages pertained only to gay men and/or younger people who were actively dating.

TAN also speculates that the neovaginas of post-operative transwomen may be unusually susceptible to HIV transmission, but there is no research on that.  On the other hand...

The risk for developing certain cancers can be more acute among transgender people and worsened by the lack of insurance coverage for transition-related screenings and procedures. For example, some research suggests that transgender men have an increased risk of endometrial and ovarian cancers; this heightened risk is due in part to the lower rates of regular Pap tests and pelvic exams among transgender males who may be denied care from providers, may feel uncomfortable requesting these examinations or who might also be denied insurance coverage for these gender-specific screenings.

And then there are the side effects possibly related to our treatment:

Whether obtained on the street or under professional medical supervision, the health implications, if any, of prolonged hormone usage is unknown. Further, there is no research that illustrates the potential consequences for older adults who use hormones at a point in their lives when hormone levels usually drop off. One known outcome is a heightened likelihood of developing osteoporosis for those transgender elders who discontinue hormone use and are no longer able to produce their bodies’ "native hormones.”

The long-term care associated with transition is likely not to be covered by health insurance.

Health insurance companies often systematically exclude transition-related care even while covering similar or identical treatments for other indications, and in many cases these exclusions are used to deny coverage for a wide range of care for transgender people that may or may not have any connection to gender transition.

As we age, having in many cases suffered years of employment discrimination and unstable access to private insurance, Medicare and Medicaid may become our only insurance options.

However, these programs frequently place arbitrary and discriminatory limits on coverage for transition-related and preventive care, requiring transgender elders to pay out-of-pocket for many expenses.

Also, although only 10% of the general population have engaged in military service, 41% of transgender seniors are veterans. As such, the VA is a primary point of healthcare access. Unfortunately the Transgender American Veterans Association has found

organizational discrimination at the VA in a lack of clear and consistent practice, with little support for gender transitions…there were many reports of interpersonal discrimination, via lack of respect from VA doctors, non-medical staff, and nurses.

No uniform policy had mandated fair treatment of transpeople prior to the VA Directive of 6/9/11, which emphasized that respectful healthcare services should be delivered to us "without discrimination" and that all medically necessary care, including sex-specific care such as mammograms, is covered. On the other hand, the VA does not cover sex reassignment surgery, a position which is at odds with current medical science.The remainder of the document consists of many recommendations. I'll not include them here since I have already used up more space than I probably should have.

Click here to read the original article.

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