Neither here nor there; unique challenges for LTC.

Age plays a cruel game on transgender 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 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.

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 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 facilities, there are an estimated 350,000 to 1 million trans gender persons in the United States aged 65 and older, according to 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 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) 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 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 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) 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 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 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."

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 www.forge-forward.org/tan.

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," she said, "because otherwise, what are you going to do--isolate this person?"