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Risks, rewards increase for older transgender adults
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When Olympic gold medalist and reality star Bruce Jenner came out as transgender in a high-profile television interview, a national audience was able to put a well-known face with a long-misunderstood gender identity.
But with Jenner’s announcement — he told an interviewer that “for all intents and purposes, I’m a woman” — came a new focus on the needs of transgender adults. Jenner, who is 65, admitted he grapples with a number of health concerns, both physical and mental, including whether to undergo gender reassignment surgery and how to make the transition easier on his large family.
Jenner’s concerns are not unique. Older transgender adults often face challenges when transitioning that younger transgender individuals do not. Hormone therapy, for example, may be less effective and carry more risk of side effects in certain older transgender adults, and surgery brings increasing risk with age.
For many older transgender adults, simply making the decision to come forward to family and friends after decades identifying as a certain gender is a difficult and painful one, requiring the understanding and support of trained clinicians.
“These are people who often lived stealthily — not revealing their transgender status to a lot of people, not even to their loved ones, and built lives around themselves that are established on the gender identity associated with their sex,” Timothy Cavanaugh, MD, medical director of transgender health at Fenway Health in Boston, told Endocrine Today. “And then, all of a sudden, they’re coming to the realization that they need to affirm their gender identity … and they have to negotiate that in terms of relationships, marriages, children, jobs they’ve been in a long time. People, I think rightfully so, are concerned that the rest of their life will fall apart around them.”
Hormone therapy
Current clinical practice guidelines from the Endocrine Society recommend that a mental health professional make the initial diagnosis of gender identity disorder (GID) and that treating endocrinologists confirm both the diagnostic criteria for GID and the patient’s readiness for endocrine treatment. Once a patient decides to move forward with treatment, clinicians should monitor older transgender adults for specific risks associated with starting a hormone regimen, particularly in transgender women.
“The effectiveness of hormones … tend to be less satisfactory as patients become older and have gone through a long number of years with their own endogenous hormones,” Cavanaugh said. “So, absolutely the effectiveness is determined by the age of the patient, and also by genetics.”
In transgender women, estrogen brings an increased risk of blood clotting, pulmonary emboli and cardiovascular disease that must be monitored closely, Cavanaugh said. To reduce risk, Cavanaugh recommends a transdermal estrogen patch to patients so the hormone metabolizes before it reaches the liver.
Low bone density
Wylie C. Hembree, MD, chairman of the Endocrine Society’s Transgender Task Force, said there have been reports concerning bone density abnormalities and osteoporosis risk in older transgender adults. Problems related to bone health can arise, he said, when patients do not follow their prescribed hormone regimen.
“To my surprise, one study was in [transgender] women treated in Belgium,” Hembree said. “Estradiol levels were below the normal range for adult natal women. However, they were well above natal male estradiol levels. This may have something to do with withdrawal of testosterone, in the face of somewhat low estradiol levels found in natal women. Another study demonstrated low bone density in 33% of a group of [transgender] women. When women do not take the estrogen level, the pituitary hormones go up in an effort to stimulate production of the steroids. Therefore, it was presumed that the women had low bone [density] because they were not taking the estrogen regularly.”
Breast cancer
Cancer screenings among older transgender adults are also important. While study data currently show breast cancer rates among transgender women to be low, Cavanaugh recommended transgender women over age 50 on hormones for more than 5 years with a family history of breast cancer get mammograms. Likewise, transgender men who have not had their breasts removed should get mammograms on the same schedule as a natal female, Cavanaugh said.
“As long as there is breast tissue there, we want to be screening for breast cancer,” Cavanaugh said. “It’s not clear what the effect of testosterone is on breast cancer. There is some circumstantial evidence that it might actually decrease the risk of breast cancer, but that’s not at all clear.”
Surgical risks
Gender reassignment surgery, too, can bring added risk for an older adult, particularly if the person has a comorbid condition like cardiovascular disease or diabetes. Many transgender patients seeking gender reassignment surgery are older, Cavanaugh said, in part because the surgeries are costly.
“Many younger people can’t afford them,” Cavanaugh said. “Most of the patients, at least in my experience and in this country, undergoing gender-affirming surgeries tend to be older and generally really do quite well. Surgeons are very careful about trying to optimize patients’ health status — getting them to quit smoking, making sure their hormone levels are well managed. So, even though there is a greater concern with older patients, I would say most of the surgery we see done — even when patients are in their 60s — really tend to do well.”
Psychosocial issues
The biggest concerns among older transgender adults tend to be centered around the psychosocial. Hembree recalled an older transgender patient who was concerned about how hormone therapy would affect the person’s marriage.
“Someone once came to me — and we went round and round about this — they wanted just enough estrogen to know what it felt like to have some estrogen, but that brought about no obvious physical changes,” Hembree said. “They thought if their wife knew about it, there would be financial and social consequences. So I had to say to them, ‘I’m sorry, I do not know what that dose could possibly be that would change things.’”
Hembree ultimately prescribed progestin for his patient, he said, to help suppress testosterone without major physical side effects. For many transgender adults, Hembree said, that first step is the beginning of the journey.
“Many people … say after their testosterone has been suppressed, they feel better; they don’t have as much anxiety about it,” Hembree said. “Many people say, when they begin to move in that direction — not even necessarily bodily changes — that makes them feel enormously better about the changes that are going to happen.” — by Regina Schaffer
For more information:
Timothy Cavanaugh, MD, can be reached at Fenway Health, 1340 Boylston St., Ansin Building, Boston, MA, 02215; email Tcavanaugh@fenwayhealth.org.
Wylie C. Hembree, MD, can be reached at wch2@columbia.edu.
Disclosure: Cavanaugh and Hembree report no relevant financial disclosures.