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Neither here nor there; unique challenges for LTC.

Age plays a cruel game on transgender transgender or transgendered
 individuals as they advance in years, leaving long term care facilities with unique challenges.

Tarynn Witten, executive director of the TransScience Research Institute in Richmond, Va., recalled a case of a female-to-male transsexual trans·sex·u·al
A person who strongly identifies with the opposite gender and who chooses to live as a member of the opposite gender or to become one by surgery.

1. Of or relating to such a person.

 nursing home resident. "John," formerly "Jane," remained anatomically female below the waist.

Now 85, John is in a nursing home after suffering a series of mini-strokes. He's also starting to develop senile dementia senile dementia
A progressive, abnormally accelerated deterioration of mental faculties and emotional stability in old age, occurring especially in Alzheimer's disease.

As a result, John--"who has been on hormones for so long that all you see is a bald little old man"--started walking around the nursing home claiming to be his former self, Jane. What do you do?

"You hope to God your staff is sensitive enough," Witten said. "And, you use what's known as 'validation.' You basically tell them what they think they are--that they're Jane--even though they may look like John. Otherwise, telling them that they're John is just going to make them upset and possibly violent."

Witten, said that "trans folk"--anyone who physically attempts to turn into the opposite sex by manner of dress or through medical procedures--are a caregiving challenge for various social and medical issues, The same goes for intersexed persons--individuals born with ambiguous genitalia ambiguous genitalia Endocrinology♂ or ♀ external genitalia that are undifferentiated, indistinct or discordant with the genotype. See Hermaphroditism, Intersexuality.  who don't always concretely fall into the traditional male or female genders.

While less common than the growing population of lesbians and gays in LTC LTC
lieutenant colonel
 facilities, there are an estimated 350,000 to 1 million trans gender persons in the United States United States, officially United States of America, republic (2005 est. pop. 295,734,000), 3,539,227 sq mi (9,166,598 sq km), North America. The United States is the world's third largest country in population and the fourth largest country in area.  aged 65 and older, according to according to
1. As stated or indicated by; on the authority of: according to historians.

2. In keeping with: according to instructions.

 Witten's 2002 study, Transgender and Aging Research Issues.

That represents approximately 1 to 3 percent of the American senior population.

Another 17,000 American elderly 65 or older are intersexed, or about 1 out of every 2,000 seniors. These numbers are expected to grow as the baby boomer baby boomer also ba·by-boom·er
A member of a baby-boom generation.

Noun 1. baby boomer - a member of the baby boom generation in the 1950s; "they expanded the schools for a generation of baby boomers"
 crowd ages and more Ts and Is acknowledge their existence.

As this aging group of TGIs migrates into long term care, facilities will face a greater task than they do from the already controversial lesbian, gay and bisexual (LGB Noun 1. LGB - a smart bomb that seeks the laser light reflected off of the target and uses it to correct its descent; "laser-guided bombs cannot be used in cloudy weather"
laser-guided bomb
) group. "Elder Ts and Is have all the stigmas and social problems of LGBs," Witten said. "But then they have another series of medical and non-medical psychological issues that pertain only to them."

Looks are everything.

Accommodating a gay or lesbian in your facility is often easier than transgender and intersex intersex /in·ter·sex/ (in´ter-seks)
1. hermaphrodite.

2. pseudohermaphrodite.

3. intersexuality.

female intersex  a female pseudohermaphrodite.
 residents because there's no physical difference to deal with, said Loree Cook Daniels, founder of the Transgender Aging Network in Glendale, Wis.

Yet, many elderly TGs are "pre-op"--persons who only underwent hormonal therapy Hormonal therapy
Use of hormone medications to inhibit menstruation and relieve the symptoms of endometriosis.

Mentioned in: Endometriosis
 but never had a below-the-waist sex change operation, she said. Even those that undergo the full treatment--the "post-ops"--have major scars and body incongruencies that make it "very unlikely that they're going to pass as their preferred gender when they're naked," Cook-Daniels said.

This can mean major trauma for Elder TGs, some of whom "went stealth" decades ago and have lived for years under their new identity, Cook-Daniels said. Now, because of health issues, their past is coming back to haunt them. "What they're afraid of is that they're automatically outed if they're in a position where someone has to provide intimate care," she said. "They are frightened to death of what the reaction might be and what (reprisals REPRISALS, war. The forcibly taking a thing by one nation which belonged to another, in return or satisfaction for a injury committed by the latter on the former. Vatt. B., 2, ch. 18, s. 342; 1 Bl. Com. ch. 7.
) they might face."

As a result, older trans folk are resistant to intimate care, Witten said. "(One facility) had a dying, extremely weak lady--a non-op male-to-female with AIDS--who refused to let nurses remove the thong she wore under two sets of underwear even though everything was wet," Witten said. "(They) ordered the inpatient nurse to give her adult pull-up diapers. She died comfortably a few hours later."

Medical question mark

The challenges are not merely social, however. Transgender persons are a medical question mark because the effects of long term adult hormone use remain largely unknown, Cook-Daniels said. Some details are emerging--for example, male-to-female TGs can suffer osteoporosis like biological women. And certain habits, such as smoking, can cause serious health issues in conjunction with androgen androgen (ăn`drəjən): see testosterone.

Any of a group of hormones that mainly influence the development of the male reproductive system.
 or testosterone use.

Experts stress that physicians must be made aware if a resident is transgender, because vital health care could otherwise be ignored or a wrong diagnosis made.

This can be tough because of how secretive TGs are about their bodies. "Many of them choose to ignore certain types of care for fear of how they'll be treated by the physician, or simply because they don't think they need it anymore now that they've changed genders," Cook-Daniels said.

Physicians and medical staff must also know how to identify and treat transsexual medical problems--something few are currently able or willing to do, Witten said. "Nursing homes and other facilities don't have training and sensitivity to these issues, much less sensitivity to this population," she said.

In one case, a doctor suspected a woman had developed cancer because of a large mass detected in her abdomen, Cook-Daniels said. The physician didn't know that the elderly woman was a post-op transsexual and that the mass in her abdomen was really a prostate gland.

In a second case, a transgender male died from ovarian cancer ovarian cancer

Malignant tumour of the ovaries. Risk factors include early age of first menstruation (before age 12), late onset of menopause (after age 52), absence of pregnancy, presence of specific genetic mutations, use of fertility drugs, and personal history of breast
 because he couldn't find anyone to treat him. "There's a standard rule: if you have the body part, it needs to be checked," Witten said.

"So even if he's now a woman, he's a woman with a prostate. She still has to undergo a prostate exam. (The person) can't ignore the body part just because (he or she doesn't) look like what (they) were born with,"

Policy shifts

As with LGBs, facilities will have to revamp their administrative policies to make transgender individuals feel more at home, Cook-Daniels said. Administrators must make sure the facility's program, policy and publications include "gender identity," as well as "sexual orientation sexual orientation
The direction of one's sexual interest toward members of the same, opposite, or both sexes, especially a direction seen to be dictated by physiologic rather than sociologic forces.

If there isn't a policy, "you send a message to transgender persons and their partners that they are only welcome if perceived as lesbians or gay males," Cook-Daniels said.

A checklist of transgender inclusion items can be found on the Transgender Aging Network's Web site at

Of course, the appropriate members of the nursing staff must be trained in validation and the methods associated with it, Witten added. "It also requires an environment of acceptance in the nursing home--namely that the other residents don't freak out freak out Substance abuse A verb, popularized in the US in the '60s–to experience nightmarish hallucinations including by LSD or a similar drug. See 'Bad trip.', Flashback. ," she said, "because otherwise, what are you going to do--isolate this person?"
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Title Annotation:Caregiving
Author:Naditz, Alan
Publication:Contemporary Long Term Care
Geographic Code:1USA
Date:Oct 1, 2004
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