An Integrated Approach: Geriatric Transgender Mental Healthcare

For older individuals struggling with gender identity, mental healthcare providers are often a primary entry point into the healthcare system. New research suggests hidden strengths: integration of family-centered and interdisciplinary care teams.

In 2017, the American Association for Geriatric Psychiatry (AAGP) hosted, "A Multidisciplinary Approach to Transgender Aging." The session marked the 7th annual installment of the association's focus on aging LGBTQ Americans. In response to the session, a new paper in the American Journal of Geriatric Psychiatry describes the roles of mental healthcare providers in integrating family-centered and interdisciplinary approaches to geriatric transgender healthcare:

  1. Assessment of gender dysphoria

  2. Psychoeducation of patients and family members about diversity of gender identities and various options for alleviating gender dysphoria

  3. Referral to other professionals or collaboration with these professionals in an interdisciplinary manner

  4. Treatment of coexisting mental health concerns

  5. Advocacy for transgender patients and the transgender community

Assessment and Education

Discussing and diagnosing gender dysphoria is an incredibly sensitive issue. Additionally, the lack of standard screening tools introduces much more variability between service providers and healthcare settings, which can add to patient confusion, discomfort or emotional harm.

"Gender dysphoria was added to the DSM-5 in place of gender identity disorder in order to place more emphasis on the psychological distress associated with having a gender identity that does not match one’s sex while hoping to avoid labeling all transgender individuals as ill simply because of the incongruence between their sex and gender identities."

*Not all transgender people have experienced or are actively experiencing gender dysphoria and psychological distress directly attributed to their gender identity.*

In evaluating a transgender patient for gender dysphoria, it is critical to operate from a framework that is supportive and encouraging. The evaluative process is not meant to dissuade or discourage an individual from transitioning, it is to provide unbiased care and holistic commitment to the patient and their social supports.

It is also critical in the early stages of integrated healthcare from a mental health perspective to provide psychoeducation around the diversity of gender identities and ways to alleviate gender dysphoria.

"...it is very important to nurture a sense of hope for the patient and the members of their support network. A trans individual needs to be informed emphatically that simply being trans or [non-binary] is not a form of illness; however, it does increase the risk of mental health problems, at least in part, related to a spectrum of potentially toxic life experiences"

Regardless of service provider comfort of expectation of continuity of care, it is critically important to educate oneself about terminology, experiences and the transgender community to avoid re-traumatizing, shaming or marginalizing a transgender patient.

Referral and Treatment

Integration of other service providers through referrals is important in building an interdisciplinary care team. For older transgender people, these referrals might include: attorneys, vocal coaches, estheticians, primary medical care providers, surgeons, barbers or hair stylists, personal trainers, and others. Of note, it's estimated that over half of all transgender adults over the age of 65 have served in the military. This is an important consideration when making referrals and building a care team.

"The geriatric mental health professional is likely to be the best-qualified proessional to identify and treat the mental health impacts of stigma and minority stress, and to facilitate a coming out process. As noted earlier, the mental health provider can also play an integral role in educating family members and other members of the patient’s support system."

Advocacy

Advocacy for older transgender patients can come in many different forms. As previously mentioned, educating oneself and other members of the care team about terminology, experiences and the transgender community is one way to advocate. In the trans community, medical care providers have long been seen as gatekeepers, withholding hormones and other gender affirming resources until arbitrary medical standards are met. Advocacy and personal education can be the beginning of reconciling with this truth and demonstrating support for transgender patients.

Outside of the primary care team, it is important to work with other systems, such as hospitals, long-term care facilities and insurance companies, to advocate for patient needs surrounding medical care, social support and gender affirmation. With older adults, specifically, advocacy can also mean respecting and affirming end-of-life decisions that reflect the patient and their support system's wishes.

For continued reading and additional resources on the topic of geriatric-specific and general transgender healthcare, see the links below.


Resources

Read more of the article in the American Journal of Geriatric Psychiatry here: https://www.sciencedirect.com/science/article/pii/S1064748118302239

A copy of the Joint Commission's "Advancing Effective Communication, Cultural Competence, and Patient- and Family-Centered Care for the Lesbian, Gay, Bisexual, and Transgender (LGBT) Community" field guide can be found here: https://www.jointcommission.org/assets/1/18/LGBTFieldGuide.pdf

A copy of the World Professional Association for Transgender Health's Standards of Care can be found here: https://www.wpath.org/media/cms/Documents/Web%20Transfer/SOC/Standards%20of%20Care%20V7%20-%202011%20WPATH.pdf

A copy of the National Center for Transgender Equality's "Injustice at Every Turn: A Report of the National Transgender Discrimination Survey" can be found here: https://calculators.io/national-transgender-discrimination-survey/