By Julie Ellingson

As a social worker for a company providing nonmedical homecare for seniors, I have gay clients on my caseload and provide services for a handful of post-operative transgender people. What I have learned is that being open to and accepting of transgender elders does not necessarily mean one knows exactly how to care for this population properly and respectfully.

I started research for this article by calling two of my post-operative transgender clients and asking them to share insights. I found out how complicated the care issues surrounding this population are and how many issues there are to which I had given little or no thought. Because transgender people, like the rest of us, are each unique, those of us caring for this population cannot take a “one size fits all” approach.

The first step in providing care for an aging person who identifies as transgender is to understand what that means to him or her. The person needs to be addressed using their preferred pronoun. Sexual orientation needs to be understood as clearly as possible. Something as simple as showing a driver’s license for identification purposes can pose a threat to some pre-surgical transgender persons because they often have IDs that don’t match their physical sex or chosen names. Sexual status on common legal documents cannot be corrected until the person has had a sex reassignment surgery, which some never complete because of the cost or other reasons. They may have to carry with them letters certifying their transgender status in case of an emergency.

For both direct caregivers and for those in administration, extensive education needs to be a priority. It is possible and relatively easy to find information addressing the medical, surgical, and psychological issues of this population, but according to my clients, social issues are largely ignored. For instance, it is not uncommon for post-operative transgendered people to be totally estranged from their families of origin or to have ongoing conflict and misunderstandings surrounding the need for the surgical change in the first place. They may have abandoned their previous life, job and social circles. Many start a new life “from scratch” in a place where their gender history is not known.

From early preschool on, my clients told me, they were encouraged not to trust who they knew they really were at the core of their being. They could not be honest or open with others. They could not trust themselves or others. Therefore, confidentiality and privacy, which help to develop trust, though always important with any client population, are imperative with this population. Breaches of confidentiality, even to another co-worker, could have dire consequences for the client.

My post-operative female-to-male client told me that, should he ever need to go to a residential care facility, he would absolutely need a private room. Even though he is now male and looks like a male, he has never had a phalloplasty. He imagines the worst if a potential male roommate would happen to notice. In addition to private rooms, rooms with doors that can be locked by the resident are also preferred for added security and unintentional embarrassing incidents.

Care plans need to include regular urological and prostatic examinations for post-operative male- to- females because they may still posses the prostate gland and male “plumbing,” so to speak. Routine pap tests and gynecological care, including mammograms, are necessary for post-operative female- to- males. These precautions are in addition to the routine screenings that are performed on any female or male. Most are on lifelong hormone treatments, which affect the male and female sexual organs.

There are practical physical matters unique to this population that might otherwise be overlooked by caregivers. For example, for post-op male-to-females, particular attention to shaving (face, armpits, legs) and skin moisturizing is important. There may be allergic reactions from new makeup or hair spray. Fingernails and eyes might be prone to infections from the regular use of nail glues, false eyelashes, or mascara.

Easy access to quality mental health services is necessary, either on-site or contracted. There may be ongoing family-of-origin issues such as abandonment, relationship and marriage breakdowns, and loss of relationships with children or extended families. Those issues, coupled with prejudice, stereotyping, and discrimination, can cause isolation.

Supportive formal affiliations and collaborations with agencies outside the care facility or agency where the transgender person receives services are important. This is beneficial for ongoing staff education and support, as well as for the clients receiving care.

Social activities where transgendered people can be themselves completely need to be developed. These outside enterprises may help with the development and implementation of such programs. Outside affiliations can also provide contacts and help-lines for both caregivers and care recipients when issues, to which caregivers may not relate, arise.

These suggestions are merely the “tip of the iceberg” as far as issues to contemplate when planning for or providing care to transgender elders. Anyone who is in this position would be wise to consult directly with clients regarding their needs. My clients made it clear to me that post-surgical transgender persons are uniquely individual. From my experience, these people are eager to talk about their life and care experiences, both positive and negative, and they are the experts on identifying their needs and preferences.

Julie Ellingson, LSW, is a licensed social worker and has been employed with Right at Home, Bloomington, MN, since December of 2002. Prior to that, she worked admissions at a large inner-city skilled nursing facility in Minneapolis, and as manager of an older adults training and volunteer program with Lutheran Social Services in Minnesota.

This article was brought you by the editorial board of ASA’s LGBT Aging Issues Network (LAIN).