An aging population is still a population of unique individuals. Thus, to properly care for the individual patient, a medical practitioner must be aware of the many physical and emotional complexities and challenges that present not only as a result of aging but also as a result of all other factors, such as, for example, gender and sexuality.

No longer are sexuality and gender as black and white as heterosexual male and heterosexual female, nor were they ever. It just was not talked about. Today, patients have more opportunities to be more honest and open about who they truly are and to be who they truly are. These opportunities, however, do not negate the challenges and complexities that accompany them. This particularly applies to the transitioning and transgender community-a community that is aging with the rest of America and requires a level of care equal to that received by other aging communities. Unfortunately, that quality of care has not always been and still is not always the norm.

As a nurse, you can help change that by understanding not only the population of transgender older adults but also the obstacles these individuals face when seeking medical care.

The Population

Being transgender or wishing to transition may not initially appear to be a prevalent issue within the senior population. Most mainstream media images of transgender or transitioning individuals are images of young or middle-aged adults. However, these middle-aged adults continue to age and will soon be seniors. Furthermore, the transgender older adult community is not as small as it may seem; it is, quite simply, quieter.

"Transgender people are everywhere, and many must live an isolated and secretive life due to fear of stigma and mistreatment," explained Jae Sevelius, PhD, assistant professor, Center for AIDs Prevention Studies, the Center of Excellence for Transgender Health, and the Department of Medicine at the University of California, San Francisco. 

"As society becomes more aware of the needs of transgender people and societal transphobia decreases, more older people will come out as transgender, either as people who have transitioned or wish to transition," she finished.

The stigma associated with transgender individuals has led not only to secrecy but also to marginalization and discrimination. "The National Center for Transgender Equality (NCTE) estimates that between ¼% and 1% of the population are transgender. In their recent study, "Injustice at Every Turn, "NCTE found transgender individuals are four times as likely to live in poverty compared to the general population," stated Serena Worthington, director of community advocacy and capacity building for Services and Advocacy for Gay, Lesbian, Bisexual and Transgender Elders (SAGE).

She added, "41% of respondents [in the study] reported attempting suicide and that 'the combination of anti-transgender bias and persistent, structural racism was especially devastating with African-American transgender respondents faring far worse across the board.'"

Competent Care

Increased rates of attempted suicide and poverty are just two of the systemic and social challenges that present when providing medical care for older individuals who are transgender or transitioning. There are many others, and perhaps the most pressing is the need for recurrent quality care.

"Many transgender people lack primary care doctors," Worthington explained. "According to a report on transgender aging from SAGE and NCTE, one-third of the transgender population responding to a Philadelphia survey do not have a regular doctor."

This lack of regularity can be, at least to a degree, attributed to insensitive and unaware care. "Transgender people often find themselves having to educate their providers about their needs, and often face discrimination and stigma when seeking healthcare," Sevelius said. "Some transgender people may not feel safe disclosing their transgender status to a care provider until trust has been established.

"In addition," she continued, "although some older adults may have transitioned many years prior, their transgender status remains an issue to be disclosed or withheld from care providers throughout their lifetime, so older transgender people are constantly struggling with decisions about coming out as transgender to people who may or may not need to know in order to provide competent care."

Even if patients disclose they are transgender, they may be keeping other factors private. For example, "due to the high rates of interpersonal violence experienced by members of the transgender community, they may be being harassed, sexually assaulted or physically assaulted, in some cases by their intimate partner or by the very people we are trained to call for help, the police," Worthington stated. "There are multiple studies that have found that at least 50% [of transgender individuals] are survivors of sexual violence."

Additional social concerns include social isolation, which subsequently leaves transgendered patients without support networks.

Medical Care

Once trust has been established and the social/emotional factors are noted and at the forefront of delivery, medical care is more easily provided, but there are still obstacles. For example, "[Some] challenges may be directly related to the lack of research on transgender older adults, such as the potential risks of transitioning late in life. Screening for gender-related health risks, such as breast and prostate cancer, may require special attention and sensitivity with transgender patients," Sevelius offered.

"There is no established upper age limit for transitioning," she continued. "But older age may preclude some types of surgeries. Transgender men who are transitioning after age 40 may experience a slower rate of appearance of the desired results. 

"There is currently no evidence-based information about outcomes for older patients. Older transgender people considering surgery should consult with surgeons to determine what physical readiness requirements might be advisable to be medically eligible for surgery. Anticipated recovery times may be longer."

Worthington added to Sevelius' list of challenges, stating, "In terms of health outcomes, Injustice at Every Turn shows us that transgender people have significant, nearly insurmountable challenges. For one thing, they have higher rates of HIV infection (four times the national average), smoking, and drug and alcohol use.

"Astoundingly," she continued, "transgender people across the country are routinely denied medical care by providers, a fact that I find completely disheartening."

"I once received a call from a homeless transgender woman in her 60s," Worthington remembered. "She needed emergency brain surgery but the hospital would not admit her unless she had a discharge plan. She called nursing home after nursing home who all told her that they would not admit her. This is in Illinois where discrimination in public accommodation is against the law."

With so many challenges, the idea of treating and working with transgender older adults may seem overwhelming and frustrating. However, as Worthington and Sevelius would be the first to tell you, it can be extremely rewarding. The key, according to Sevelius, is to "Educate yourself. ... Be willing to learn, both on your own and from your patients, but do not expect your patients to teach you everything you need to know and do not ask inappropriate questions. Be sensitive to your patients' unique concerns and understand that transgender people are not all alike." Much like the aging population is not all alike.

Sue Coyle is a freelance writer.