A Fate Worse than Death? Being Transgender in Long-term Care
By Mark Brennan-Ing, PhD (Senior Research Scientist, Brookdale Center for Healthy Aging)
“I would kill myself.” This is what a 70 year-old transgender woman told me recently when I asked what she would do if she needed long-term care. While this sounds dramatic, it is a common sentiment among older transgender and gender nonconforming (TGNC) adults (Witten, 2014). Many TGNC older adults do not have family caregivers available to meet their needs for assistance in later life, having been rejected and ostracized by their families of origin according to a study by Grant and colleagues (2011), and long-term care services may be their only option.
Plans for concealing gender identities, suicide and euthanasia are one way for older TGNC adults to cope with the fears of entering long-term care (Bockting & Coleman, 2007; Ippolito & Witten, 2014). The National Senior Citizens Law Center (2011) reports that TGNC older adults, regardless of the degree of gender transitioning, are at risk for abuse, mistreatment, or violence in institutionalized settings, especially those needing assistance with activities of daily living such as showering, dressing, and toileting.
Accessing medically competent care may also be a problem for older TGNC adults in long-term care. Geriatric care for TGNC older adults requires special considerations. Due to potential drug interactions, contraindications, and polypharmacy, TGNC older adults using hormone therapy concurrent with other medications may require close monitoring (Grant et al., 2011; SAGE & NCTE, 2012; Witten & Eyler, 2015). Sometimes these problems may require stopping hormone therapy, which may be especially traumatic for those who have transitioned later in life and not yet achieved their goals for masculinizing or feminizing their appearance.
Since private rooms in long-term care facilities are not covered by insurance, older TGNC adults may be assigned shared rooms based on their birth sex instead of their gender identities, which is problematic for the TGNC person as well as their roommate. The Department of Veterans Affairs (2013) has issued a directive that rooms for TGNC veterans are assigned based upon self-identified gender without regard to physical presentation or surgical history. This policy should be a requirement in all long-term care facilities.
The Nursing Home Reform Act and the Fair Housing Act prohibit TGNC discrimination and mistreatment in long-term care. The Affordable Care Act (ACA) also prohibits discrimination on the basis of gender identity by health care organizations (NCTE, 2015), but this legal protection is at risk following the 2016 election with promises by those in power to repeal the ACA. If ACA repeal is successful, older TGNC people will lose safeguards around denial of services, access to facilities like restrooms that conform to their gender identities, isolation, deprivation, and harassment by staff.
For long-term care providers, there are a number of resources available for continuing education to better serve their TGNC clients. These include the National Resource Center on LGBT Aging, which offers a variety of in-person and on-line training options (http://www.lgbtagingcenter.org/training/index.cfm). Providers working with veterans can review training and education options in the VA system at http://www.patientcare.va.gov/LGBT/index.asp . And TRANSLINE provides on-line consultation for medical providers (http://project-health.org/transline/ ).
Sadly, we may soon witness a rollback of protections for TGNC individuals in long-term care. Therefore it is imperative that the TGNC community and their allies work harder than ever to insure that policies, legislation, and training programs are in place to guarantee that older TGNC people are treated with the dignity and respect they deserve in long-term care and other clinical settings.
Portions of this blog were drawn from “Providing competent and affirming services for transgender and gender nonconforming older adults” (Porter, Brennan-Ing et al., 2016), and “Guidelines for psychological practice with transgender and gender nonconforming people (American Psychological Association, 2015).
American Psychological Association (2015). Guidelines for psychological practice with transgender and gender nonconforming people. American Psychologist, 70(9), 832-864. http://dx.doi.org/10.1037/a0039906 .
Bockting, W. O., & Coleman, E. (2007). Developmental stages of the transgender coming‐out process. In R. Ettner, S. Monstrey, & A. Eyler (Eds.), Principles of transgender medicine and surgery (pp. 185‐208). New York, NY: Haworth.
Department of Veterans Affairs (VA; 2013). Providing health care for transgender and intersex veterans (VHA Directive 2013–003). Retrieved from http://www.va.gov/vhapublications/ViewPublication.asp?pub_ID=2863
Grant, J. M., Mottet, L. A., Tanis, J., Harrison, J., Herman, J. L., & Kiesling, M. (2011). Injustice at every turn: A report of the national transgender discrimination survey. Washington, DC: National Center for Transgender Equality & National Gay and Lesbian Task Force. Retrieved from http://endtransdiscrimination.org/PDFs/NTDS_Report.pdf
Ippolito, J., & Witten, T. M. (2014). Aging. In L. Erickson-Schroth (Ed.), Trans bodies, trans selves: A resource for the transgender community (pp. 476-497). New York, NY: Oxford University Press.
National Center for Transgender Equality (2015). Know your rights: Healthcare. Retrieved from http://www.transequality.org/know-your-rights/healthcare
National Senior Citizens Law Center (2011). LGBT Older Adults in Long-Term Care Facilities: Stories from the Field. Washington, DC: National Senior Citizens Law Center.
Porter, K. E., Brennan-Ing, M., Chang, S. C., dickey, l. m., Singh, A. A., Bower, K. L., & Witten, T. M. (2016). Providing competent and affirming services for transgender and gender nonconforming older adults. Clinical Gerontologist. http://dx.doi.org/10.1080/07317115.2016.1203383
Services and Advocacy for GLBT Elders (SAGE) & National Center for Transgender Equality (NCTE; 2012). Improving the lives of transgender older adults. New York, NY: Authors. Retrieved from http://transequality.org/Resources/TransAgingPolicyReportFull.pdf
Witten, T.M. (2014). End of life, chronic illness and trans-identities. J. Social Work in End-of-Life and Palliative Care, 10(1), 1-26. doi:10.1080/15524256.2013.988864
Witten, T.M. & Eyler, A.E. (2015). Care of aging transgender and gender non-conforming patients. In. R. Ettner, S. Monstrey and A.E. Eyler (Eds.), Principles of transgender medicine and surgery. New York, NY: Routledge Press.
Mark Brennan-Ing, PhD is the Senior Research Scientist, Brookdale Center for Healthy Aging at Hunter College, City University of New York. He was the 2016 Chair of the APA Committee on Sexual Orientation and Gender Diversity.