Original ResearchTransgender HealthSociodemographic Variables, Clinical Features, and the Role of Preassessment Cross-Sex Hormones in Older Trans People
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 Conception and Design Walter P. Bouman; Jon Arcelus; Gemma Witcomb
Acquisition of Data
Walter P. Bouman; Ellen Marshall; Victoria Maddox; Gemma Witcomb; Jon Arcelus
Analysis and Interpretation of Data
Walter P. Bouman; Laurence Claes; Jon Arcelus
- (a)
Drafting the Article
Walter P. Bouman; Laurence Claes; Gill Pinner; Julia Longworth; Jon Arcelus
- (b)
Revising It for Intellectual Content
Walter P. Bouman; Laurence Claes; Ellen Marshall; Gill Pinner; Julia Longworth; Susana Jimenez-Murcia; Fernando
References (50)
- et al.
Non-suicidal self injury in transsexualism: associations with psychological symptoms, victimization, interpersonal functioning and perceived social support
J Sex Med
(2015) - et al.
Social support and psychological wellbeing: A comparison of patients with gender dysphoria and matched controls
J Sex Med
(2014) - et al.
People with gender dysphoria who self prescribe cross sex hormones: prevalence, sources and side effects knowledge
J Sex Med
(2014) - et al.
A European network for the investigation of gender incongruence: The ENIGI initiative
Eur Psychiatry
(2012) - et al.
Sociodemographic study of Danish individuals diagnosed with transsexualism
Sex Med
(2015) - et al.
Hormone-treated transsexuals report less social distress, anxiety, and depression
Psychoneuroendocrinology
(2012) - et al.
Is hormonal therapy associated with better quality of life in transsexuals? A cross-sectional study
J Sex Med
(2012) - et al.
Partial gender request and underlying motives of applicants for gender affirming interventions
J Sex Med
(2015) - et al.
The validity of the Hospital Anxiety and Depression Scale. An updated literature review
J Psychosom Res
(2002) - et al.
Psychiatric comorbidity in gender identity disorder
J Psychosom Res
(2005)
Attachment styles, interpersonal relationships and psychotic phenomena in a non-clinical student sample
Pers Indiv Differences
Long-term evaluation of cross-sex hormone treatment in transsexual persons
J Sex Med
Evidence for an altered sex ratio in clinic-referred adolescents with gender dysphoria
J Sex Med
Aesthetic and functional outcomes of neovaginoplasty using penile skin in male-to-female transsexuals
J Sex Med
Developmental stages of the transgender coming-out process
Gender Violence
J Homosex
An examination and comparison of transsexuals of color and their white counterparts regarding personal well-being and support networks
J GLBT Family Studies
Body image and eating disorders psychopathology in trans individuals: A matched control study of trans individuals, eating disorders clinical cases and a control group
Eur Eat Disord Rev
Experiences of familial acceptance-rejection among trans women of color
J Family Psychol
Non-suicidal self-injury and suicidality in trans people: a systematic review of the literature
Internat Rev Psychiatry
Trans mental health and emotional wellbeing study
Investigating the needs and concerns of lesbian, gay, bisexual, and transgender older adults: the use of qualitative and quantitative methodology
J Homosex
Sexuality in later life. Chapter 54
Physical and mental health of transgender older adults: an at-risk and underserved population
The Gerontologist
Lesbian, gay, bisexual, and transgender aging: Challenges in research, practice, and policy
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Conflict of Interest: The authors report no conflicts of interest.
Funding: None.