Reprinted from 'Outword', the newsletter of the Lesbian and Gay Aging Issues Network of the American Society on Aging

Although they are often invisible to professionals in the field of aging - and indeed to society in general - transgender (TG) and transsexual (TS) individuals clearly form a more than negligible percentage of the U.S. population. These elders not only require the same care as all older adults, they also need care - and face obstacles - specifically related to their gender status.

Female-to-male (FTM) transsexuals and transgenders usually self-identify during their teens, 20s or 30s, often following a long period of self-identifying as a lesbian. By contrast, male-tofemale (MTF) transsexuals and transgenders more often attempt to suppress their gender identity for years or decades, first expressing their variance socially or seeking sex-reassignment services during midlife or older age.

Quality-of-life issues for all TG/TS individuals at midlife and in old age may be affected by a range of medical and social considerations. These issues in some cases are similar to those encountered by all older adults, and in many other cases are distinctive to those who are making or have made a gender transition.l The following overview briefly outlines a number of such issues that should be of concern to service providers in aging.

Medical Issues

People who undertake gender transition through hormone therapy or full sex-reassignment surgery during midlife or the older years are more likely than their younger peers to face obstacles related to physical health. Aging-related conditions, especially cardiac or pulmonary dysfunction, may make an individual ineligible for surgical procedures - including breast or genital reconstruction - that medical professionals deem elective.

In addition, genetic males seeking transition to the female gender may be poor candidates for estrogen therapy if their medical history incloudes various conditions more common in older adults: moderate or severe hypertension, pathologic hypercoagulable states or thromboembolic disease, or uncontrolled diabetes mellitus. Those receiving medical treatment involving unusually comlicated pharmacological regimens also may be ruled out. Conversely, MTF individuals with prostate disease may experience medically beneficial side effects from gender related estrogen treatment.

In FTMs, androgen supplementation does not cause problems with hypercoagulability, but it does increase the risk of coronary artery disease and may exacerbate dyslipidemias such as depressed HDL cholesterol. Androgen supplementation also is a risk factor for the development of polycthemia (increased red blood cell count), a potentially life-threatening condition. At the same time, it may have medically therapeutic value for FTMs with preexisting anemia or loss of bone mineralization.

Healthcare and Personal Assistance

Because of prejudice and rigid gender expectations on the part of service providers, TG/TS elders can encounter problems in gaining access to healthcare and personal assistance services. Older postoperative transsexuals who can "pass," even when nude, have the least difficulty. (Due to the current differences in the outcomes of reconstructive surgery for female vs. male genitals, this advantage is overwhelmingly experienced by MTF individuals.)

For TG/TS older adults who face varying degress of difficulty in passing, the apparent mismatch between their genital anatomy and their social gender can result in difficulty in obtaining medical care, practical nursing assistance and even mortuary services. In addition, many medical personnel consider transgenderism, transsexualism, and cross-dressing tobe evidence of psychiatric pathology. As a result of such mistaken notions, healthcare professionals may make inappropriate psychiatric referrals.

Middle-aged and older cross-dressers often experience difficulty in obtaining healthcare services due to privacy concerns. For example, most MTF cross-dressers remove leg and body hair in order to appear as normal women while dressed as women. When they need medical assistance, they face the dilemma of either disclosing their cross-dressing behavior or attempting to postpone services until the body hair has regrown. Such delays in obtaining medical care can have serious health consequences.

HIV and AIDS

HIV and AIDS have been of increasing concern in the TG/TS and cross-dressing populations. Those who have suppressed their gender identity during adolescence or early adulthood at times enjoy a "second adolescence" when they begin to socialize in their true psychological gender, adopting behaviors that may include risky dating and sexual acting out. Such behaviors may increase the risk of HIV infection, a situation that challenges service providers to create effective and culturally appropriate risk-reduction strategies for this population.

HIV infection in later life also presents special financial comlications for TG/TS older adults: They may face the burden of paying for contragender hormone therapy or transsexual surgical services as well as treatments for chronic conditions that accompany aging, while at the same time taking on the expense of HIV antivirals. in addition to the cost, elders in this situation may find it difficult to comply with required drug regimens; the "pill burden" may be very difficult to maintainon a daily basis.

Oral Health

Oral health is a particular concern for older MTFs who are receiving a hormone regimen. They face not only the risks of oral disease that generally come with aging, but also compounding problems specifically associated with estrogen therapy, among them bone loss in the jaw and increased likelihood of tooth decay. In addition, estrogen therapy is associated with bacterial changes in the mouth and with lower salive production. Both of these effects increase the risk of periodontal disease, which recent studies have shown to be a factor in the development of coronary heart disease and cerebrovascular disease.

Personal Finances

TG/TS older adults often experience the cumulative effects of discrimination on personal finances. Unpublished data from A. Evan Eyler and T.M. Witten indicate that incomes well below the U.S. national average are common among FTMs. Because many FTMs begin their transition only after years of lesbian identification, this is most likely a result of discrimination they experienced as women and lesbians. Conversely, MTFs who tend to be older at the time of transition, may have enjoyed higher income during a long period of male privilege before assuming their female gender.

Workplace discrimination also harms the financial stability of the TG/TS older adults. Attempts at gender transition on the job are at times met with dismissal; only one state and a handful of municipalities provider protection from employment discrimination based on gender presentation. Because financial resources in old age depend very much on what people have earned throughout their lives, TG/TS individuals who have experiences such discrimination may face difficulties in covering their expenses in retirement.

Physical Transition

The physical phenomenon of aging may facilitate social gender transition for TG/TS older adults. WOmen and men share more physical similarity during elder years than at any other time after childhood. For example, loss of facial skin tone produces a softer appearance for many genetic males - a change that helps MTF elders appear more female. Similarly, genetic females experience a shift toward andrognization of the hair follicles as they age. For FTM transsexuals, this encourage beard growth that produces a more male appearance.

Furthermore, the loss of muscle mass and the increase in body fat experiences by all elders often results in women and men appearing more similar. These physiological alterations are clearly advantagous for TG/TS individuals who begin the transition process later in life, as they may obviate the need for weight reduction for genetic males, body building for genetic females and minor cosmetic procedures for both.

Family Relationships

Longstanding family relationships are frequently altered when an older person reveals his or her gender identity. Most family roles are gender-based; parenthood;, brother and sister roles, grandparenthood, and other aspects of the family constellation must shift to accomodate the new gender role. Young children frequently have the least difficulty accepting cross-dressing, transgendered, and gender-transitioning relatives, yet their parents' distress and prejudicial attitudes may cause upheavals in even the youngest generation's relationship with a TG/TS older relative.

Long-time spouses or partners of transitioning elders must cope not only with their partner's changing identity, but also with the threats it poses to their own sexual orientation, social standing and sense of familial security. Some choose to continue their existing relationship, but many do not. Those who do stay together often redefine their relationships.

More versatile couples can maintain a sexual partnership, which may or may not include a change in the non-transgendered partner's sexual identity. Others choose to adopt new roles, defining their connection, for example, as that of friends or siblings. Even when the families are supportive, such adjustments take time and effort and maybe wrenching for everyone.

Sexuality and Intimacy

The greatest obstacle to sexual expression among older adults, particularly heterosexual women, is the lack of suitable partners. A single MTF transsexual who undertakes gender transition later in life is more likely to experience sexual deprivation than would have been the case had the individual continued to be perceived as male. And because the genitals of few FTMs look and function the way genetic men's do, FTMs face the daunting prospect of having to come out to potentially rejecting or hostile new sexual partners.

On the other hand, most transsexualsexperience a positive development of personal sensuality when they finally are able to live in congruence with their deepest perceptions of their own gender. Professionals can assist in this regard by validating the sexual potential of their older clients, offering counseling and education when needed, and assisting family members to accept their older relative's gender presentation and sexuality.

Professional Responsibilities

In the case of TG/TS and cross-dressing individuals, the typical life transitions of the elder years are compounded by a number of issues: disclosure and privacy; isolation from peers; specialized healthcare needs; and the potential of ostracism and negative judgements from healthcare professionals and other care providers.

Service providers can best assist these clients by providing them with information regarding the importance of routine healthcare, including preventive services; by arranging referrals to supportive providers; and by educating others involved in the client's care about gender diversity. this last endeaver must include medical, nursing and social work colleagues, as well as unskilled and semiskilled assistants.

In addition, professionals in the field of aging can help improve the quality of life of older members of the gender community by facilitating formation of support groups; educating leaders of existing groups, such as those operated by religious organizations, and gay, lesbian, and bisexual networks; and specifically including transgendered people in visible roles withing retirement communities, healthcare programs and other service networks.

T.M. Witten is director of the International Longitudinal Transgender and Transsexual Aging Research (ILTTAR) Institute in San Antonio, Texas

A. Evan Eyler is a family physician who has worked extensively with transgendred patients. She practices in Ann Abor, Mich.

Cathy Weigel works in the Comprehensive Gender Services Program of the University of Michigan Medical Center, Ann Arbor

This article is available in a longer version with citations. Contact T.M. Witten, ILTTAR Institute, 12846 Maple Park Drive, San Antonio, TX, 78249