The phenomenon of transsexualism or transgenderism, the belief that maintaining one's gender is not congruent with one's biological sex, has been recognized throughout history and across many cultures (Green, 1998). However, the case of Christine Jorgensen's 1952 sex-change surgery gave considerable impetus to contemporary transgender studies. In addition to initiating scholarly investigation, the landmark Jorgensen case led to an increased interest in surgical and hormonal management options for transgendered individuals (Denny, 1994).
The research on transgenderism has mainly focused on the psychopathology of transgenderism. Researchers have explored issues of diagnosis and medical or psychosexual adjustment (Midence & Hargreaves, 1997). Health care needs of transgendered individuals have received little scholarly attention. Furthermore, research on transgenderism has mainly included individuals between ages 20 and 40 (Hastings & Markland, 1978; Levine, Shaiova, & Mihailovic, 1975; Mate-Kole, Freschi, & Robin, 1990; Sadoughi, Jayararn, & Bush, 1978). The current body of research on transgenderism does not address the social and medical issues facing transgendered older adults. This article explores some of the social support, psychosocial, medical, and health care access challenges unique to transgendered individuals older than 65, and presents implications for nursing practice and research. Because of the dearth of research specific to this population, this article of necessity depends on research conducted with younger transgendered individuals and speculates the application to older adults. In addition to largely excluding the older adult, much of available research on social issues related to transgender is more than 20 years old.
Despite their low prevalence, issues salient to the transgendered population require exploration by nurse researchers and clinicians. Transgendered individuals are at risk for insensitive, prejudiced, and uninformed nursing care because of the lack of research concerning the needs of transgendered individuals. Although some references to the importance of sensitivity toward transgendered patients are made in the nursing literature, the articles are generally case studies or opinion pieces rather than research findings (Eastwood, 1992; Grimshaw, 1998; Rees, 1993; Thomas, 1993). This lack of research is especially evident in the care of older adults whose special needs in relation to transgenderism have rarely, if ever, been studied. Older transgendered adults are at an even greater risk for poor nursing care than their younger counterparts because they are more likely to have contact with health care professionals because of health problems associated with aging. Furthermore, although the body of research on sexuality in older adults is growing, studies have not explored the particular challenges faced by older transgendered adults (Russell, 1998).
A number of terms are used to describe individuals whose gender identity is completely or partially incongruent with the gender determined by their biological sex (Table 1). The term "gender dysphoria" was established by the American Psychiatric Association in 1980 when it first defined transsexualism as a mental illness (Midence & Hargreaves, 1997). Although there is considerable disagreement about these definitions, this article will use the term "transgendered" as an umbrella term for all individuals described in Table 1. It is important to recognize "gender identity" and "sexual orientation" as two different characteristics. "Sexual orientation" is defined as that gender or genders to whom someone is sexually attracted. "Gender identity" refers to whether individuals perceive themselves as being male, female, both, or neither (Cook-Daniels, 1997). Therefore, a transgendered person can be heterosexual, homosexual, bisexual, or asexual - this orientation is separate from their gender orientation.
The prevalence of transgenderism in the United States in the 1960s was estimated as 1 in 100,000 men and 1 in 400,000 women (Landen, Walinder, & Lundstrom, 1996). More recent data from Europe suggest the prevalence is 1 in 11,900 men and 1 in 30,400 women. Accurate data about the frequency of transgenderism is difficult to obtain because of the variety of diagnostic criteria used, differences in presenting symptoms, and social stigmatization leading to a reticence to selfidentify (Franzini & Casinelli, 1986). Although accurate estimations of rates vary and are difficult to obtain, it is clear that transgenderism is a relatively uncommon phenomenon.
In this exploration of issues related to aging in the transgendered population, it must be recognized that, although individuals may have faced issues of gender identity in their youth, some older adults may not recognize gender identity issues until later in life. For example, Docter (1985) published the case study of Mary Ann, a biological man who underwent sex reassignment surgery at the age of 74. Mary Ann waited until 10 years after her wife's death to explore her life-long belief that she wanted to be a woman. This case reflects that gender identity struggles are not solely the domain of young adults.
DEFINITION OF TERMS RELEVANT TO TRANSGENDERISM
RELATIONSHIPS WITH FAMILY AND COMMUNITY
In a 1975 study of the families of seven male-to-female transsexuals, Money, Clarke, and Mazur examined the families' response to their children' sex-reassignment surgery after 5 years. At the time of their sex-reassignment surgery, the study participants' ages ranged from 23 to 33. The researchers explored social stigmatization and how the families communicated their daughters' choice to others. Although none of the families abandoned or were abandoned by their children, there were numerous cases of concealment. In two families, younger siblings were not told of their older sibling's sex change. In one family, the parents told the younger sibling that they had a new older sister being adopted into the home and that their older brother lived too far away to visit. Participants frequently discontinued contact with their friends who knew them as men.
The Money et al. (1975) study is problematic for a variety of reasons. It is more than 20 years old, and has a very small sample size consisting of only male-to-female, post-surgical transsexuals. All the participants had their surgeries at a center where parental consent for sex-reassignment surgery was required. The study, therefore, is biased toward those families that had accepted their child's sex change. Because the subjects were all younger than 35 at the time of their surgery, and younger than 40 at the time of the study, the research does not address any of the challenges unique to transgendered older adults.
Despite these flaws, Money et al. (1975) offer one of the few explorations of families' response to their children's sex reassignment in terms of their choices of communication and concealment. Implications for older transgendered individuals are the importance of assessing their relationship with their family, especially their siblings. The transgendered adult may have been forced, or may have chosen, to sever ties with or lie to their siblings. Therefore, nurses working with transgendered individuals should be cautious when speaking to family members because the family may not be aware of the patient's transgendered status. Furthermore, the Money et al. (1975) study draws attention to the effect transgender may have on familial support systems. Siblings and other relatives who might have supported individuals as they cope with aging-related issues may not be available to the transgendered older adult.
Levine et al. (1975) explored the community relationships of 12 maleto-female transsexuals. The subjects in the study ranged in age from 25 to 33. The researchers found that, over time, the transsexual adults became socially isolated. They spent little time with other transsexual adults and felt separate from either the gay male or heterosexual community. These findings would suggest many transgendered individuals lack a clear community of support. Levine et al.'s small sample size, the ages of the subjects, and a focus on only male-to-female, postsurgical transsexuals may affect the relevance of findings for the older transgendered adult. However, the implication for older transgendered adults may be the lack a support system if they do not sense that they belong to either the homosexual or heterosexual community.
The detrimental effects of poor social support on health outcomes may be particularly noticeable among older adults. In a study on social networks, Bosworth, Hayden, Schaie, and Warner (1997) found that older adults with lower levels of social support had increased hospital visits and greater health care costs. Thus, potentially, transgendered older adults are at an increased risk for health problems. However, currently the goal for many transgendered individuals is to completely blend into heterosexual society (L. Cook-Daniels, personal communication, April 7, 1999). Therefore, many transgendered adults receive support from their new heterosexual community.
Another source of support is the transgendered community, which has become increasingly organized and vocal in the past 10 to 20 years (Blumenstein, Warren, & Walker, 1998). It is possible the isolation among transsexuals found by Levine et al. in 1975 has become less common as the transgendered community has grown and become more visible. Therefore, a careful assessment of all support systems is essential when caring for the older transgendered adult.
In a 1978 study, Hastings and Markland explored the post-operative adjustments of 25 male-to-female transsexuals. The average age of the participants at the time of their sexreassignment was 28 years. Two participants had surgery when they were in their 50s. Four of the patients in the study attempted suicide and one was shot and seriously injured by an acquaintance. Although this study is old and had a small sample, it points to the potential for violence that transgendered individuals face - both self-inflicted and from others.
In one of the few articles to address the issue of domestic violence among transgendered individuals, Courvant and Cook-Daniels (1998) present findings from the Gender, Violence, and Resource Access Survey of Trans and Intersex Individuals. They report that 50% of those surveyed had been assaulted or raped by a partner. The authors also found that transgendered individuals face multiple barriers to reporting the violence they experience. Low self-esteem is common among transgendered individuals who have, more than likely, grown up in a society prejudiced against their gender identity (Anderson, 1998). Among older adults, low self-esteem has been associated with increased rates of elder abuse (Kleinschmidt, 1997).
Legal and law enforcement agencies may be insensitive to the needs of transgendered individuals. Stories have circulated throughout the transgendered community about police and emergency room personnel who ignore the medical and legal needs of abused transgendered individuals (Cook-Daniels, 1997; Courvant & Cook-Daniels, 1998).
Estimates show that at least one third of transgendered individuals attempt suicide at some point (Midence & Hargreaves, 1997). Substance abuse is also noted as a major problem by therapists working with transgendered clients (Anderson, 1998). Suicide, substance abuse, and depression are believed to be common problems among those struggling with their gender identity. Depression stemming from prejudice and lack of support can lead transgendered individuals to react through suicide attempts and substance abuse (Anderson, 1998).
Fear of crime leads to social isolation and depression, which also have been identified as important and detrimental psychosocial issues of aging (Benson, 1997; France, 1989). From the literature reviewed in this article, transgendered older adults may be at considerably more risk for fear of crime, depression, and suicidal ideation than the general aging population. In addition, they are less likely to report crimes because of fears about discovery by the police (CookDaniels, 1997).
When working with transgendered older adults, health care professionals must be aware of these risks and assess whether any fear of crime or depression is affecting the older adult's social functioning. If it is suspected an older adult is transgendered and may be the victim of abuse or is a risk to his or her own safety, he or she should be put in contact with appropriate resources (see Sidebar). These resources should include health care providers who are sensitive to and educated about the unique situation of the transgendered older adult (Cook-Daniels, 1997).
Although it is beyond the scope of this article to consider all the medical challenges faced by transgendered individuals, a few particularly salient to the older adult will be addressed. Transgendered individuals who choose to have surgical or hormonal treatments face a variety of potential complications. Individuals who undergo male-to-female sex reassignment surgery are at risk for rectovaginal fistulas, urinary tract infections, and misdirection of the urinary stream secondary to granulation tissue (Beemer, 1996). Male-to-female transgendered individuals who take female hormones, either alone or to augment surgical treatment, are at a greater risk for breast cancer, deep vein thrombosis, pulmonary embolism, and osteoporosis (Beemer, 1996). Female-to-male transgendered individuals who take hormones, either alone or as adjunctive therapy to surgery, are at an increased risk for a variety of health conditions. Androgen use has been implicated in the development of cardiovascular disease, liver disease, and diabetes (Prior & Elliott, 1998).
The majority of the complications reviewed are conditions also more common among older adults. Although there has been no research into the cumulative effects of the surgical and hormonal complications and the normal aging process, it can be speculated that the aging transgendered patient's risk of developing these conditions is magnified because of the effects of both age and the treatments. For example, post-surgical male-to female transsexuals are at an increased risk for genitourinary complications (Beemer, 1996). Aging also increases the risk of genitourinary complications (e.g., urinary tract infections, urinary incontinence) (Yoshikawa, Nicolle, & Norman, 1996). Therefore, post-surgical male-to-female transsexuals may have an increased risk for genitourinary complications caused by the compounded effects of aging and post-surgical complications.
Female-to-male transgendered older adults taking androgens may increase their risk of common medical conditions. Androgens have been shown to cause cardiovascular disease and diabetes - common health conditions common among older adults (Centers for Disease Control and Prevention, 1999; McCredie et al., 1998; Prior & Elliot, 1998). Thus, the potential health risks associated with androgen use by transgendered older adults may be greater than that experienced by their younger counterparts.
Health care providers must be aware of the health risks and changes caused by surgical and hormonal treatments. For example, laboratory values are often altered by hormonal treatment and could be misinterpreted as being abnormal if the wrong norms are used (Beemer, 1996). Hormones might also need to be discontinued before a hospitalization or surgery to decrease the chances of complications or interactions with other treatments. Considering the number of medications taken by most older adults, drug-drug interactions and polypharmacy should be a serious concern when caring for older transgendered adults.
In caring for transgendered older adults in the outpatient setting, health care providers must be knowledgeable about those screening and preventive services necessary for this population. For instance, most female-to-male transgendered individuals will need a Pap smear and breast examination. Likewise, male-to-female patients will need to be screened for prostate cancer. Health care providers should base their choices about necessary screening tests on a combination of factors, including the patient's biological sex, surgical status, declared gender, and the use of any hormone therapies. To develop a therapeutic relationship with a transgendered patient, it is essential that health care providers refer to them by their chosen name and pronoun (Cook-Daniels, 1997). Therefore, when approaching a patient about a screening test that is based on their biological sex rather than their chosen gender, the provider should be sensitive to the issues this may raise for the transgendered patient and address these issues directly.
The Centers for Disease Control and Prevention (CDC) assert that access to adequate medical and dental care, including preventative services, can reduce premature morbidity and mortality among older adults (1999). Also, access to adequate health care services can preserve function and improve overall quality of life. Older adults without access to adequate health care will not receive appropriate preventative services important with increasing age (CDC, 1999). Specifically, screening for diseases common among older adults, such as cancer and cardiovascular disease, as well as providing vaccinations and dental care can decrease morbidity and mortality. Transgendered individuals are often reluctant to seek health care because providers may have treated them with ignorance and prejudice in the past (Cook-Daniels, 1997). Thus, transgendered older adults may not receive appropriate preventative screening, vaccinations, and dental care.
MAJOR ISSUES AND PREFERRED INTERVENTIONS IN APPROACHING TRANSGENDERED OLDER ADULTS
When transgendered individuals seek health care services, they may avoid sharing their transgendered status (Cook-Daniels, 1997). This is especially likely in older transgendered adults who may have sought treatment for their transgender at a time when it was common for providers to use very strict guidelines to determine who could and could not receive treatment. These guidelines led to a climate in which some who desired treatment were forced to Ue about themselves to be considered candidates (Anderson, 1998; Cook-Daniels 1997). For these reasons, it is especially important for health care providers to educate themselves and treat their transgendered patients with sensitivity (Table 2).
Transgendered individuals who choose to legally change their identifying sex may face a variety of legal and insurance challenges that can affect their ability to receive adequate health care. In one case, a male-to-female patient died of prostate cancer without receiving any treatment for the cancer because her insurance company refused to cover the treatments (M. Bourbonniere, personal communication, March 22, 1999). The insurance company stated that because the patient was legally a woman, she was not entitled to coverage for prostate cancer treatment. This case reflects the marginalization and discrimination transgendered individuals encounter when seeking health care.
Although the phenomenon of transgenderism has received scholarly attention in the past 40 years, much of the research has been based in a psychopathology framework focusing on issues of diagnosis and medical or psychosexual adjustment (Midence & Hargreaves, 1997). Because the research has not been patient-centered, it is difficult to understand the life experiences of transgendered individuals. This has been especially true of older transgendered adults, whose experiences have received little to no attention. In addition to being focused on psychopathology, existing research has generally explored only male-tofemale post-operative transsexuals. More research into the experiences of non-surgical and surgical transgendered individuals, both male-tofemale and female-to-male, is needed.
Nursing's holistic view of the individual and increasing efforts in qualitative research places nurses in an ideal position to investigate the life experiences of older transgendered adults (McCabe, 1988). Such research should explore the social and psychological experiences of older transgendered adults and seek to understand how these experiences affect their health. Research into psychosocial issues, such as transgendered older adults' support systems and their relationship with their families, is needed.
Another area in need of research is transgendered older adults' health concerns, such as how their surgical and pharmacological treatments affect and are affected by chronic health conditions. Investigations into transgendered older adults' access of health care are also needed. Understanding which actions taken by nurses and other health care providers encourage and discourage health care use would increase the ability to provide sensitive and appropriate care. Only through a research-based understanding of the unique challenges faced by the transgendered older adult can gerontological nurses hope to provide sensitive, non-prejudiced, and therapeutic care to this aging population.
- Anderson, B.E (1998). Therapeutic issues in working with transgendered clients. In D. Denny (Ed.), Current concepts in transgender identity (pp. 215-226). New York: Garland.
- Beemer, B.R. (1996). Gender dysphoria update. Journal of Psychosocial Nursing, 34(4), 12-19.
- Benson, S. (1997). The older adult and fear of crime. Journal of Gerontological Nursing, 23(10), 25-31.
- Blumenstein, R., Warren, B.E., & Walker, L.E. (1998). The empowerment of a community.
- In D. Denny (Ed.), Current concepts in transgender identity (pp. 427-430). New York: Garland.
- Bosworth, A., Hayden, B., Schaie, K., & Warner, A. (1997). Relationship of social environment, social networks and health outcomes in the Seattle longitudinal study. Journal of Gerontology, 52, P197-P205.
- Centers for Disease Control and Prevention. (1999). Surveillance for selected public health indicators affecting older adults - United States. Morbidity and Mortality Weekly Report, 4S(SS-S), 1-168.
- Cook-Daniels, L. (1997). Lesbian, gay male, bisexual and transgendered elders: Elder abuse and neglect issues. Journal of Elder Abuse & Neglect, 9(2), 35-49.
- Courvant, D., & Cook-Danieis, L. (1998) Trans and intersex survivors of domestic violence: Defining terms, barriers, and responsibilities. Paper presented at the Proceedings of the National Coalition Against Domestic Violence, Denver, CO.
- Denny, D. (1994). Gender dysphoria; A guide to research. New York: Garland.
- Docter, R.E (1985). Transsexual surgery at 74: A case report. Archives of Sexual Behavior, 14, 271-277.
- Eastwood, A. (1992). Return to gender. Nursing Times, 88(\5), 49-50.
- France, T.R. (1989). Treating depression in old age: Is it worth the effort? Psychiatric Journal of the University of Ottawa, 14, 367-369.
- Franzini, L.R., 8c Casinelli, D.L. (1986). Health professionals' factual knowledge and changing attitudes toward transsexuals. Social Science Medicine, 22, 535-539.
- Green, R. (1998). Mythological, historical, and cross-cultural aspects of transexualism. In D. Denny (Ed.), Current concepts in transgender identity (pp. 3-14). New York: Garland.
- Grimshaw, R. (1998). When two souls meet. Nursing Standard, 12(36), 26-27.
- Hastings, D., & Markland, C. (1978). Post-surgical adjustment of 25 transsexuals (maie-tof emale) in the University of Minnesota study. Archives of Sexual Behavior, 7, 327-336.
- Kleinschmidt, KX. (1997). Elder abuse: A review. Annals of Emergency Medicine, 30, 463-472.
- Landen, M., Walinder, J., & Lundstrom, B. (1996). Prevalence, incidence and sex ratio of transsexualism. Acta Psychiatrica Scandinavica, 93, 221-223.
- Levine, E.M., Shaiova, C.H., & Mihailovic, M. (1975). Male to female: The role transformation of transsexuals. Archives of Sexual Behavior, 4, 173-185.
- Mate-Kole, C, Freschi, M., & Robin, A. (1990). A controlled study of psychological and social change after surgical reassignment in selected male transsexuals. British Journal of Psychiatry, 157, 261-264.
- McCabe, S.V. (1988). Male-to-female transsexualism: A case for holistic nursing. Archives of Psychiatric Nursing 2(1), 48-53.
- McCredie, R., McCrohon, J., Turner, L., Griffiths, K.A., Handelsman, D.J., & Celermajer, D.S. (3998). Vascular reactivity is impaired in genetic females taking high-dose androgens. Journal of the American College of Cardiology, 32, 1331-1335.
- Midence, K., & Hargreaves, I. (1997). Psychosocial adjustment in male-to-female transsexuals: An overview of the research evidence. The Journal of Psychology, 131, 602-614.
- Money, J., Clarke, R, & Mazur, T. (1975). Families of seven male-to-female transsexuals after 5-7 years: Sociological sexology. Archives of Sexual Behavior, 4, 187-197.
- Prior, J.C., & Elliott, S. (1998). Hormonal therapy of gender dysphoria: The female-to-male transsexual. In D. Denny (Ed.), Current concepts in transgender identity (pp. 427-430). New York: Garland.
- Rees, M. (1993). He, she or it? Nursing Times, S9(10), 48-49.
- Russell, P. (1998). Sexuality in the lives of older people. Nursing Standard, 13(S), 49-53.
- Sadoughi, W, Jayaram, B., & Bush, I. (1978). Postoperative changes in the self concept of transsexuals as measured by die Tennessee self concept scale. Archives of Sexual Behavior, 7, 347-349.
- Thomas, B. (1993). Gender loving care. Nursing Times, 89( 10), 50-51.
- Yoshikawa, T.T., Nicolle, L.E., & Norman, D.C. (1996). Progress in geriatrics: Management of complicated urinary tract infection in older patients. Journal of the American Geriatrics Society, 44, 1235-1241.
DEFINITION OF TERMS RELEVANT TO TRANSGENDERISM
MAJOR ISSUES AND PREFERRED INTERVENTIONS IN APPROACHING TRANSGENDERED OLDER ADULTS