Original Research
Transgender Health
Sociodemographic Variables, Clinical Features, and the Role of Preassessment Cross-Sex Hormones in Older Trans People

https://doi.org/10.1016/j.jsxm.2016.01.009Get rights and content

Abstract

Introduction

As referrals to gender identity clinics have increased dramatically over the last few years, no studies focusing on older trans people seeking treatment are available.

Aims

The aim of this study was to investigate the sociodemographic and clinical characteristics of older trans people attending a national service and to investigate the influence of cross-sex hormones (CHT) on psychopathology.

Methods

Individuals over the age of 50 years old referred to a national gender identity clinic during a 30-month period were invited to complete a battery of questionnaires to measure psychopathology and clinical characteristics. Individuals on cross-sex hormones prior to the assessment were compared with those not on treatment for different variables measuring psychopathology.

Main Outcome Measures

Sociodemographic and clinical variables and measures of depression and anxiety (Hospital Anxiety and Depression Scale), self-esteem (Rosenberg Self-Esteem Scale), victimization (Experiences of Transphobia Scale), social support (Multidimensional Scale of Perceived Social Support), interpersonal functioning (Inventory of Interpersonal Problems), and nonsuicidal self-injury (Self-Injury Questionnaire).

Results

The sex ratio of trans females aged 50 years and older compared to trans males was 23.7:1. Trans males were removed for the analysis due to their small number (n = 3). Participants included 71 trans females over the age of 50, of whom the vast majority were white, employed or retired, and divorced and had children. Trans females on CHT who came out as trans and transitioned at an earlier age were significantly less anxious, reported higher levels of self-esteem, and presented with fewer socialization problems. When controlling for socialization problems, differences in levels of anxiety but not self-esteem remained.

Conclusion

The use of cross-sex hormones prior to seeking treatment is widespread among older trans females and appears to be associated with psychological benefits. Existing barriers to access CHT for older trans people may need to be re-examined.

Introduction

Trans people of all ages have been found to face a number of difficulties, including interpersonal challenges (such as disclosing their gender identity)1; discrimination and victimization2; low self-esteem3; body dissatisfaction4; rejection from family and loved ones5; and self-harming behavior.6, 7 Some of those difficulties may be more prevalent among older trans people as ageism, discrimination in employment, lack of affordable housing, and lack of social and family support often beset older trans people.8, 9, 10

In contemporary Western societies, it is not unusual for trans people to present to a gender identity clinic service (GICs) at age 50 or older. Trans older adults have been largely invisible in existing aging and health research.11 Generally subsumed under the broad umbrella of lesbian, gay, bisexual, and transgender (LGBT), there has been little information regarding how trans people differ from nontrans lesbian, gay, and bisexual people or how trans older adults differ from younger trans adults and cisgender (nontrans) older people.12 The literature that does exist deals mainly with the lack of adequate and appropriate services for older gender nonconforming and trans people.13 Barriers to health care are significant in this population due to shame, stigma, lack of educated caregivers, and lack of insurance.14, 15, 16 This may increase the difficulties accessing services, forcing older trans people to self-medicate.

Studies investigating the use of cross-sex hormone treatment (CHT) prior to attending gender identity clinic services among trans people of all ages found that they most commonly obtain hormones via the Internet, which leaves these individuals without the knowledge to minimize health risks.17, 18, 19 Trans people who self-prescribe cross-sex hormones tend to be predominantly trans women and older when they present to gender identity clinic services and generally have poor knowledge of the side effects and risks associated with CHT.17, 18, 19 On the positive side, there is evidence that trans people of all ages who are taking CHT experience improved quality of life and less social distress, anxiety, and depression when compared to a population not on CHT.20, 21, 22 However, most of the studies exploring the benefits of CHT are rarely controlled for other factors known to be associated with an increased psychopathology, such as social support8 and interpersonal difficulties.23

Section snippets

Aims

This study had 3 main aims. The first was to describe the sociodemographic and clinical features of trans people over the age of 50 years referred to a national gender identity clinic service during a 30-month period. The second aim was to collect and analyze the use and the source of CHT prior to referral to a gender identity clinic service and to compare trans people who were using CHT prior to referral with those who did not. Based on the literature regarding CHT and trans people, it was

Participants and Procedures

The sample consisted of all individuals over the age of 50 who were referred for an assessment to a national gender identity clinic service in the United Kingdom during a 30-month period between November 2012 and June 2015.

Prior to the clinical assessment, every patient was invited to complete a battery of questionnaires to aid the assessment and diagnostic procedure. The assessment at the clinic consists of 2 appointments with independent senior clinicians with experience in the field of

Main Outcome Measures

The Hospital Anxiety and Depression Scale (HADS)26 is a 14-item self-report screening scale originally developed to indicate the possible presence of anxiety and depression states in the setting of a medical nonpsychiatric outpatient clinic. HADS consists of 2 subscales, HAD-Anxiety (HAD-A) and HAD-Depression (HAD-D), each with seven items, rated on a 4-point Likert scale (ranging from [0], as much as I always do; [1] not quite so much; [2] definitely not so much; to [3] not at all), indicating

Sociodemographic and Clinical Characteristics

During the recruitment period of 30 months, 689 individuals were referred to the clinic, of whom 77 (11.2%) were aged 50 years and older. Three people did not attend their appointment. Hence, the total sample consisted of 71 (96.2%) trans females and 3 (3.8%) trans males. Table 1 describes the sociodemographic and clinical characteristics of the total sample.

The sex ratio of older trans females compared with trans males was 23.7:1.

The mean age at the time of the assessment of the participants

Discussion

There has not been any systematic information investigating sociodemographic and clinical characteristics of older trans people. There is no systematic collection of such data in this group other than case reports,36, 37 case series,38, 39 and population samples obtained via the Internet40 or postal questionnaires.12, 41 Similarly, there has been no research investigating the role of CHT in older trans people. This is the first study to exclusively focus on trans people aged 50 years and beyond

Conclusion

The majority of older people presenting at gender identity clinic services over the age of 50 years old are trans females. After coming out as trans older people take on average about a decade to fully transition, which may be related to employment or family responsibilities. More than a quarter of this older trans population had obtained hormone treatment via the Internet without medical advice. Older trans females who use cross-sex hormones were found to be significantly less anxious compared

Statement of authorship

Category 1

  1. (a)

    Conception and Design

    • Walter P. Bouman; Jon Arcelus; Gemma Witcomb

  2. (b)

    Acquisition of Data

    • Walter P. Bouman; Ellen Marshall; Victoria Maddox; Gemma Witcomb; Jon Arcelus

  3. (c)

    Analysis and Interpretation of Data

    • Walter P. Bouman; Laurence Claes; Jon Arcelus

Category 2
  1. (a)

    Drafting the Article

    • Walter P. Bouman; Laurence Claes; Gill Pinner; Julia Longworth; Jon Arcelus

  2. (b)

    Revising It for Intellectual Content

    • Walter P. Bouman; Laurence Claes; Ellen Marshall; Gill Pinner; Julia Longworth; Susana Jimenez-Murcia; Fernando

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  • Cited by (0)

    Conflict of Interest: The authors report no conflicts of interest.

    Funding: None.

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