Aging and Gender Diversity
Social Work Today
By Tarynn M. Witten, PhD, MSW, FGSA
Vol. 4 No. 4 p. 28

Transsexuals, transgenders, cross-dressers, and other persons whose gender expression or identification is other than the “traditional” male or female represent a substantial but epidemiologically invisible minority group within the worldwide older adult population.

In an era in which forecasting the health of elder populations is increasingly important, discussion of quality-of-life issues faced by older transsexuals and other gender minority persons should not be deferred. It is difficult, unfortunately, to provide data-based information about many of the health issues faced by elder transsexuals, as this group is particularly “epidemiologically invisible” (Witten and 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.” However, the number of transgender-, transsexual-, and intersex-identified elders is increasing worldwide (Witten, 2002, 2003).

Stages
The gender minority community includes numerous subgroups of importance. Many intersex-identified elder individuals will likely have had genital surgery forced upon them at early ages and may have been subjected to hormonal treatments as well. They may, consequently, be facing numerous psychological issues related to the undesired violation of their bodies and effects the undesired surgery has had on their lives. Others in the same group who may not have had the surgery are dealing with the consequences of their lifelong, nonnormative status.

For a given transidentified person, time of transition (hormonal and surgical modification) can be important to understanding the aging process. A person may be older when he or she chooses to transition, or the person may have made the transition earlier in life and is now older in the contragender identity and body, having dealt with a longer period of time in the transition state. Each of these individuals may or may not be hormonally or surgically modified. As such, their experience as elders will differ and requires understanding from the social worker, geriatric case manager, and/or caregiver.

Issues of long-term stress, negative life experience, long-term exposure to hormones, and transition in midlife can profoundly affect socioeconomic status for the transidentified person. While these factors can have numerous immediate effects, they also have long-term effects (Turrell, 2002; Kraaij, et al., 2002). Persons who undertake gender transition during midlife or the elder years are more likely than their younger peers to experience difficulties related to physical health. Ill health, especially cardiac or pulmonary dysfunction, may preclude eligibility for surgical procedures, including breast or genital reconstruction. In addition, persons with moderate or severe hypertension or other conditions of old age may be poor candidates for estrogen therapy. Androgen supplementation in female-to-male (FTM) transsexuals and transgenders may increase coronary artery disease risk and is also a risk factor for the development of polycythemia, a potentially life-threatening condition. Only recently has any significant work been done on the mortality and morbidity rates for transsexual and transgender clients on cross-hormonal treatment (Ascherman, et al., 1989).

Access to Services
For transgender-identified persons, healthcare and personal assistance services are more complex than for those who are transsexual and postoperative. Apparent mismatch between genital anatomy and gender of presentation can result in difficulty in obtaining medical services, practical nursing care, or even appropriate funeral arrangements. In the late 1990s, Tyra Hunter, a preoperative male-to-female (MTF) transsexual, was refused appropriate and timely medical care by Washington, DC paramedics who, when arriving on the scene of a hit-and-run car accident involving Hunter, discovered her transgenderism. Believing that her gender incongruity implied that she must also be homosexual, the paramedics refused to render treatment because they thought that she might have AIDS. The case of Leslie Feinberg (Feinberg, 1996), who was forced to leave an emergency department when his female anatomy was discovered, is also well-known in the gender minority community. Many healthcare personnel consider transgenderism (or transsexualism or cross-dressing) to be evidence of psychiatric pathology, and inappropriate psychiatric referrals may result. Similar issues are often experienced by intersex individuals (Witten, 2004).

Economic Status
The financial aspects of transsexual and transgender healthcare are also affected by gender discrimination. Many FTM transsexual and transgender adults begin gender transition after years of lesbian identification. Many of them have incomes well below the national average, most likely as a result of gender and antilesbian discrimination. Conversely, MTF transsexual and transgendered persons tend to be older at the time of transition and have enjoyed decades of male privilege and income. Nonetheless, attempts to transition in the workplace are at times met with dismissal; only one state and a handful of municipalities provide legal protection from employment discrimination based on gender presentation.

Physical Changes/Healthcare Issues
The physical realities of aging may serve to facilitate social gender transition. For example, women and men share more physical similarity during the elder years than at any time since childhood. Loss of facial skin tone produces a softer appearance for many genetic males, and the natural diminishment of circulating estrogens, accompanied by a shift toward andronization of the hair follicles, facilitates the production of new beard growth in FTM transsexuals. Loss of muscle mass and increased body fat content that is experienced by both male and female elders often results in men and women appearing more alike physically. These physiologic alterations are clearly advantageous to transsexual persons who begin the transition process later in life.

Although cross-dressers do not usually seek contragender hormonal services, middle-aged and elder cross-dressing persons often experience difficulty in obtaining appropriate healthcare services due to privacy concerns. For example, most MTF cross-dressers remove leg and body hair to appear as normal women while dressed as women. 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 instead to postpone services until the body hair has regrown. 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 (e.g., cardiac) or long-term care (e.g., nursing home, rehabilitative care) can be problematic for similar reasons.

Family and Social Support
Quality-of-life issues for older members of the gender minority community often center on the degree of social integration the individual has been able to achieve earlier in life, or on the personal flexibility and resilience available for the development of new relationships during the later years. Community resources and acceptance of persons with nontraditional life paths can also be crucial. These needs are similar to those of elder nontransgendered persons who benefit from social network support and community resources.

Family relationships may be altered following the older person’s “coming out” with regard to his or her gender identity. Fatherhood and motherhood, siblingships, grandparenthood, and other aspects of the family constellation may be reevaluated during the gender transition process. Children and young adults are usually (though not always) accepting of gender change. Young children may respond well to being offered an actual or fictitious reference to provide a “model” for transgenderism. Children aged 4 to 7 often still practice magical thinking to a higher degree than their older peers and frequently have the least difficulty in accepting cross-dressing, transgendered, and gender-transitioning adult relatives (Ettner, 1999). Therefore, concerns regarding the appropriateness of disclosing gender minority behaviors to grandchildren and other young relatives are unwarranted; however, young children are also vulnerable to their parents’ prejudicial attitudes and may react negatively if their parents reject a grandparent or older relative.

Marriage, Partnership, and Sexual Expression
Although gender transition among older adults within the context of a long-term marriage or partnership is still relatively rare, experience with middle-aged couples in which one partner is transgendered or transsexual suggest several possible patterns. Many spouses or long-term partners of transgenders or transsexuals will choose to maintain the relationship as a husband, wife, or lover changes gender presentation, genital sex, or both; however, many others will not. Couples who do maintain a marriage or partnership may need to “redefine” their relationship.

Gender transition later in life may enable the individual greater freedom of expression as his or her true self. Furthermore, the normal bodily changes of aging will be partially offset by hormonal and surgical therapies. Specifically, breasts that develop in midlife or the elder years due to cross-gender hormonal administration will not begin the ptotic process until very late in life. Genital (labial or scrotal) ptosis will also be greatly postponed for individuals who have experienced genital reconstruction during the elder years. Conversely, the other normal changes of aging (e.g., body habitus, dermal integrity) will be experienced equally by transsexuals and their gender-congruent peers, and the bodily changes associated with sex reassignment surgery, even if strongly desired, may be a positive stressor for the elder client. Geriatric care managers who are providing mental health services to older transsexuals are well-advised to prospectively address this potential with their clients and remain alert for more specific questions and complaints during (and especially after) the gender transition process.

The greatest obstacle to sexual expression among older adults (particularly heterosexual women) is the lack of availability of suitable partners. Consequently, a MTF transsexual person who undertakes gender transition later in life is more likely to experience sexual isolation or deprivation than would have been the case prior to this transformation (i.e., when the individual had been perceived as male). In addition, some older women have been primarily socialized to believe that female sexual behavior is acceptable only within the context of marriage and possibly for the exclusive purpose of procreation as well. However, persons who change gender later in life may share in these perceptions to a lesser degree than do their nontranssexual peers.

Sexual expression may be positively enhanced by the newfound congruence between the body and the psychological (true) self. With regard to the mechanics of sexual functioning following sex reassignment surgery, few generalizations can be made. Orgasmic capability is preserved in the majority of FTM genital reconstructive procedures and many MTF surgeries as well. However, the sexual response cycle usually requires a greater length of time among older adults than their young and middle-aged peers.

Despite the obstacles to sexual expression, most transindividuals experience a positive development of personal sensuality when they are able to live in congruence with their deepest self-perception. Patterns of sensual expression are usually present across the life span, with sexual behavior also serving as a vehicle for the basic human need of the sense of touch. When touch is absent, severe psychobiological stress and symptomatology can result. The increased sensuality experienced by transsexual and transgendered persons who are able to achieve a sense of bodily wholeness may serve to enhance physical and mental health by providing additional capability for healthy touch. Cross-dressing persons who are able to integrate temporary role change into healthy partnered or social relationships may similarly benefit.

Professional Response
Healthcare professionals can assist clients in this regard by validating the sensual expressions and potentials of their older clients, offering sexual counseling and education when needed and assisting other family members in accepting the gender presentation and sexual expression of their older relatives. Increased education for healthcare professionals serving these communities, regarding gender diversity and sexual expression among older adults, may also be needed for professionals in inpatient, chronic, and acute care settings to provide appropriate and compassionate care for their older clients and patients. Dispelling myths regarding elder sexuality, providing information regarding the usual physical changes of aging and the human sexual response cycle across the life span, and offering interventions that address sexual expression in cases of physical disability may also be particularly useful for social workers and other professionals who provide care to older adults.

The needs of older members of the gender minority community are similar to those of their nontransgendered peers with respect to the significant life transitions of the elder years. Loss of a spouse or significant other (and long-standing friendship group) due to death, decreased ability to maintain a private residence, loss of driving capability, and transition from an independent residence to an assisted-living environment (and ultimately to dependent nursing care) serve to erode personal control and are significant issues in the lives of all persons who survive to become the “oldest old.” In the case of transsexual-, transgendered-, and cross-dressing–identified elders, these challenges are compounded by issues regarding disclosure, privacy, isolation from transgendered peers, specialized healthcare needs, and the potential for ostracization and judgment by the healthcare professions and other care providers.

Within the gender minority community, transsexuals who have undertaken sex reassignment surgery at earlier life stages may not experience these difficulties due to congruence between gender presentation combined with elimination of historical ties to the pretransition life that occurs with the passage of time. However, transgenders, cross-dressers, and transsexuals who undertake transition during the elder years must make numerous decisions with regard to sharing confidential personal information with their caregivers. In addition, postoperative transsexuals must confide in their physicians and other healthcare professionals with regard to past medical history or risk later exposure.

Social workers and geriatric care managers can assist older gender minority clients by providing them with information regarding the importance of routine healthcare (including preventive services), arranging referrals to providers who are empathetic and supportive to members of the gender minority community, and educating others involved in the clients’ care with respect to the realities of human gender diversity.

Intergenerational dialogue must be established. The young transgendered must be made aware of the life course issues of aging. The additional stigma of being “old,” coupled with any sort of variance with respect to sexuality and/or sexual preference, significantly exacerbates the problems of elder transindividuals.

Invisibility
The intersex elder community remains invisible, and there is no literature available on elder issues and intersex. Attention to the needs of the gender and intersex communities with respect to biological, medical, psychological, and socio-cultural facets can be best served through a comprehensive and holistic approach, including family, provider, and community education and the development of appropriate professional and community networks. Health and social policy development on behalf of both the transgendered and intersex elder (including the assurance of nondiscrimination with regard to quality healthcare services, privacy, confidentiality, respectful treatment and caregiving, and personal safety) is also strongly needed.

— Tarynn M. Witten, PhD, MSW, FGSA, is the senior fellow and executive director of TranScience Research Institute, Richmond, VA. She can be reached at transcience@transcience.org or transcience@earthlink.net.

Due to space limitations, we were unable to include this article’s references. However, the references are available upon request by e-mailing SWTeditor@gvpub.com.