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IDENTITE

SEXUELLE

IDENTITE SEXUELLE T.M. WITTEN RÉSUMÉ : Le vieillissement est un processus inévitable. Vieillir nous concerne tous.

T.M. WITTEN

RÉSUMÉ : Le vieillissement est un processus inévitable. Vieillir nous concerne tous. Cela est indépendant du contexte chromosomique, du comportement psychosocial, de la race, de la classe sociale, de l’identité de genre, de son expression et de sa perception, de l’appartenance ethnique, du statut socio- économique, ou des frontières géographiques. Dans cet article, j’aborderai certaines questions concernant le vieillissement dans les communautés transgenres. Pour commencer, j’essaierai d’estimer le nombre de personnes transgenres âgées à la fois aux États-Unis et dans le monde entier. Dans ce contexte, j’aborderai brièvement le problème posé par le fait de devoir catégoriser une communauté dans le but de la recenser. Je discuterai aussi de la question de la fiabilité des évaluations de la prévalence du transgenre dans la population. Je clôturerai par une discussion portant sur certains problèmes du vieillissement des transgenres.

MOTS-CLEFS :

• Transgenres

• Transsexuels

• Vieillissement

• Gériatrie

• Gérontologie

1 1
1 1

Le transgenre âgé ; une population et des besoins en progression

L a mort est un point final univer- sel dont le vieillissement est une sorte de « normalisation ». Le

vieillissement nous unit comme aucun autre processus. Il est indépendant des catégories, des préjudices, ou des craintes et des passions. Il est universel et inévitable.

Brève démographie du vieillissement

La démographie du vieillissement est un sujet complexe. Les différences entre les pays, à travers leurs structures sociales, représentations linguistiques, développement économique, système de santé, et autres facteurs, interagissent pour modifier la pyramide des âges d’une population particulière d’un pays. Il est impossible ici d’aborder toutes les complexités liées au vieillissement aux États-Unis ou dans le monde entier. Le Tableau 1 montre la répartition des populations âgées par classes d’âge aux États-Unis et dans le monde pour les plus de 65 ans. Etats-Unis En 1999, aux États-Unis, la population de plus de 65 ans était de 34,7 millions d’individus. Ce chiffre représente approximativement 13 % de la popu- lation totale des États-Unis. Il y avait 4,2 millions de personnes âgées de plus de 85 ans. Les gens âgés de 65 ans et plus atteindront plus de 70 millions

d’individus pendant les trois décen- nies prochaines. Les centenaires font partie du secteur de la population âgée qui croît le plus rapidement, suivi par les plus de 85 ans. Pour les centenaires, l’évaluation actuelle est de 50 000 à 75 000 individus. On s’attend à ce que ce groupe atteigne 834 000 individus vers 2050. 90 % des centenaires sont des femmes et 10 % sont des hommes. Ce taux de prévalence est approxima- tivement le même ou légèrement plus élevé que celui des autres pays indus- trialisés. Population mondiale En 1998 le World Population Profile mon- trait que, pour chaque pays, l’âge moyen était en forte augmentation, tandis que de grandes tranches de population attei- gnent des classes d’âges moyennes et plus âgées. « Durant les 25 prochaines années, le nombre de personnes âgées vivant dans les pays les moins dévelop- pés aura plus que doublé. » L’évaluation mondiale des individus de plus de 65 ans approche 409702000 per- sonnes (Tableau I).

Transgenres:

définition et démographie

La terminologie décrivant la commu- nauté transgenre est extrêmement mou- vante, non seulement du fait des élé-

   

Table I : Estimation du taux de population transgenre de plus de 65 ans aux Etats-Unis et dans le monde

 

Classe d’âge

Importance de la population

Estimation de la population transgenre (1 % — 3 %)

Estimation de la population transgenre (1 % — 3 %)
(en années) (Estimation 1999)

(en années)

(Estimation 1999)

65 + (Etats-Unis) 34,7 million 347.000 – 1.041.000

65

+ (Etats-Unis)

34,7 million

347.000 – 1.041.000

347.000 – 1.041.000
85 + (Etats-Unis) 4,2 million 42.000 – 126.000

85

+ (Etats-Unis)

4,2 million

42.000 – 126.000

42.000 – 126.000
100 + (Etats-Unis) 50.000-75.000 500-700 – 1.500-2.100

100

+ (Etats-Unis)

50.000-75.000

500-700 – 1.500-2.100

500-700 – 1.500-2.100
65 + (Etats-Unis) 70 million 700.000 – 2.100.000

65

+ (Etats-Unis)

70 million

700.000 – 2.100.000

700.000 – 2.100.000
85 + (US-projection) Indisponible au moment de la publication

85

+ (US-projection)

Indisponible au moment de la publication

Indisponible au moment de la publication
100 + (US-projection) 834.000 8.340 – 25.020

100

+ (US-projection)

834.000

8.340 – 25.020

8.340 – 25.020
65-79 (Monde) 334.003.000 3.340.030 – 10.020.090

65-79 (Monde)

334.003.000

3.340.030 – 10.020.090

3.340.030 – 10.020.090
80 + (Monde) 66.699.000 666.990 – 2.000.970

80

+ (Monde)

66.699.000

666.990 – 2.000.970

666.990 – 2.000.970
 

Total (Monde)

409.702.000

4.097.020 – 12.291.060

 
 

1 2

ments constituant l’identité de genre, mais également du fait de la terminolo- gie corps-sexe-sexualité liée à une identité de genre donnée. Cela, ajouté au fait qu’il s’agit d’une population peu disposée à se faire « marquer » ou classer par caté- gorie, rend extrêmement difficile un recensement précis. Bien qu’ils soient paradoxalement peu voyants, alors que, par ailleurs, ils sont stigmatisés dans notre société (protection légale, etc.), la population des transgenre est loin d’être négligeable aux États-Unis. Witten et Eyler (1999) définissent dans la commu- nauté de genre; les travestis (hommes et femmes qui prennent l’aspect de l’autre genre, souvent lors d’une activité sociale ou bien à certains moments), les trans- genres (ceux dont l’identification psy- chologique est celle de l’autre sexe, et qui changent leur comportement et leur aspect pour se conformer à cette per- ception interne, parfois à l’aide d’hor- mones), et les transsexuels, hommes vers femmes (MTF) et femmes vers hommes (FTM), qui entreprennent des thérapies hormonales et/ou chirurgicales de réas- signement sexuel. En outre, ils en incluent d’autres qui ont des perceptions individuelles de genre moins tranchées, s’éloignant de la dichotomie des sexes (Langevin, 1983; Godlewski, 1988; Hoe- nig et Kenna, 1974 ; Sigusch, 1991 ; Tsoi, 1988 ; van Kesteren et coll. 1996 ; Walin- der, 1971, 1972; Weitze et Osburg, 1996).

Estimation de la prévalence du « transgendérisme »

Concernant les évaluations de la popu- lation des transsexuels, Tsoi (1988) a noté qu’il y avait un problème d’estimation épidémiologique lié à ce que les trans- sexuels tendent à se rassembler dans les villes et dans certaines parties de ces villes et, de plus, que la plupart d’entre eux ne veulent pas être identifiés. Néan- moins, Tsoi a également noté que, à Sin- gapour, (où la chirurgie de réassigne- ment sexuel [SRS] est bien établie et les transsexuels bien intégrés), le diagnos- tic de transsexualisme est plus de huit fois plus important que dans n’importe quel autre pays où des évaluations ont été faites. Witten a précisé que l’évalua- tion du nombre d’individus prétendant avoir des identités alternatives de genre

aux États-Unis, aussi bien que dans d’autres pays, était faussée par le manque de « groupe contrôle ». Néan- moins, dans une enquête internationale aléatoire réalisée par cet auteur et son équipe, environ 8 % des 300 répondeurs qualifiaient leur perception de genre dif- féremment de 100 % masculin ou fémi- nin (publication en préparation). Si on prend seulement comme base les trans- sexuels opérés, au niveau international (1 %-3 %; Langevin, 1983 ; Godlewski, 1988 ; Hoenig et Kenna, 1974 ; Sigusch, 1991 ; Tsoi, 1988 ; van Kesteren et coll., 1996 ; Walinder, 1971, 1972 ; Weitze et Osburg, 1996), et si on considère que la population des États-Unis est de 300 mil- lions d’individus, ceci implique qu’il y a potentiellement 3 à 9 millions de trans- sexuels pouvant être opérés aux États- Unis. Cette évaluation semble surpre- nante. Certains chirurgiens internationaux impliqués dans cette pratique de réassi- gnement disent faire deux interventions par jour, 4 à 5 jours par semaine, 48 semaines par an. Les listes d’attente peu- vent aller jusqu’à 2 ans ou plus. Si on prend en compte une interprétation plus large de la communauté transgenre, incluant ceux qui ne se font pas opérer et les travestis, les estimations croissent jusqu’à environ 20 millions d’individus. Ces personnes impliquent leur entou- rage et de nombreuses structures dans leur problématique, rendant nécessaires des procédures de soutien plus impor- tantes que ne le voudrait le taux propre de la population transgenre. Dans la suite de cet article le mot trans- genre désignera l’ensemble de la com- munauté de genre au sens large.

Problèmes de stigmatisation et de violence dans la communauté transgenre

La stigmatisation de ces sujets, l’absence de source officielle de recensement, ainsi que l’importance de sous-populations épi- démiologiquement invisibles (court-cir- cuit des réseaux de soins), rend l’estima- tion de cette communauté très difficile. Witten et Eyler en 1999 décrivent dans un échantillon de 174 individus (âgés entre 22 et 79 ans) qui avaient souffert d’un haut

 

Table II : Type de violence chez les répondeurs de l’étude TLARS

T ype de violence n = %

Type de violence

n =

%

T ype de violence n = %
Physique 62 25 %

Physique

62

25 %

Physique 62 25 %
Morale 91 37 %

Morale

91

37 %

Morale 91 37 %
Sexuelle 26 11 %

Sexuelle

26

11 %

Sexuelle 26 11 %
Négligence 35 14 %

Négligence

35

14 %

Négligence 35 14 %
Exploitation 11 5 %

Exploitation

11

5 %

Exploitation 11 5 %
 

Non applicable

22

9 %

degré de violence et d’abus (135 répon- deurs pouvant donner des réponses mul- tiples) les résultats suivants (Tableau II). Sur n = 121, à la question de savoir s’ils avaient parlé de leur mauvais traitement et violences subies ou abus à d’autres, 93 (77 %) ont répondu oui, 28 (23 %) non. En ce qui concerne les raisons du silence, sur 132 (réponses multiples autorisées), 28 (21 %) ont indiqué qu’ils avaient peur de représailles, 14 (11 %) craignaient des problèmes médico-légaux, 5 (4 %) étaient incapables de verbaliser, 38 (29 %) ont estimé que cela ne changerait rien de rapporter l’incident ou les incidents, 10 (8 %) voulaient protéger l’agresseur, et 22 (17 %) avaient d’autres raisons. En outre, plusieurs thèmes inclus concernaient des actes d’abus, de mauvais traitement ou de violence, qui s’étaient produits dans au cours d’événements sociaux. Typi- quement, de tels actes ont lieu sur le lieu de travail, dans la rue, dans les bars, ou dans n’importe quelle autre scène publique et interpersonnelle. Des éta- blissements religieux, les systèmes édu- catifs, d’autres institutions. À la ques- tion de mauvais traitements dans des situations sociales, les participants ont répondu : oui (= 89 ; 66 %), non (= 42 ; 31 %), et pas de réponse (= 4 ; 3 % ;

n = 135). Problèmes du vieillissement de la population transgenre

Les transgenres âgés exigent non seule- ment le même soin que tous les adultes plus âgés, mais ils ont besoin également de soins spécifiques à leur statut de genre. Witten, Eyler, et Weigel (2000, 2002) ont enquêté avec précision sur la plupart des besoins sanitaires de cette population, (lesquels peuvent être consultés sur : asaging. org/LGAIN). C’est un fait bien connu que les condi-

tions sociales (Kubzamsky, Berkman et Seeman, 2000), les aides sociales (Eve- rard et autres, 2000 ; Pinquart et Soren- son, 2000 ; Grossman, D’Augelli et Her- shberger, 2000), le statut socio- économique (Rautio, Heikkinen et Heik- kinen, 2001; Pinquart et Sorenson, 2000), et même le rôle social (Krause et Shaw, 2000) peuvent tous avoir un impact signi- ficatif, positif ou négatif, sur la morta- lité, la morbidité, l’état de santé, la pré- valence de la dépression (bien-être psychologique global, Zhang et Hay- ward, 2001), sur l’harmonie du vieillis- sement, et sur de nombreux autres aspects de la qualité de la vie. Les résul- tats de ces études peuvent être synthéti- sés ainsi ; plus le revenu est bas, moins l’appui social est important (amis, acti- vité spirituelle, organismes de soutien, les voisins sur qui on peut compter, par exemple), plus les conditions d’héber- gement sont mauvaises (isolement, envi- ronnement médiocre), plus l’éducation est faible, plus le risque de dysfonction- nement psychologique est élevé, la qua- lité de la vie inférieure à long terme, la santé faible. Les auteurs insistent sur l’importance de l’accès à des soins de qualité pour élimi- ner les disparités de l’état de santé et augmenter l’espérance de vie. Dans le projet Healthy People 2010 project, chapitre I sous le titre : Access to Quality Healthcare, of the Healthy People 2010 Pro- ject (2000) : http://www.health. gov/heal- thypeople/Document/tableofcontents. htm. Il faut noter que les difficultés liées au modèle biomédical de classification éli- minent l’accès aux soins de toute la population transgenre au sens large, qui ne s’y plie pas ou n’en dépend pas, en les privant ainsi de l’accès à leurs besoins spécifiques. La stigmatisation financière gêne égale- ment l’accès aux besoins médicaux néces- saires pour commencer et maintenir la transformation. Le Washington Transgender Needs Assess- ment study (WTNAS) signale des niveaux d’éducation significativement

plus bas, 42 % de chômage, des revenus significativement plus bas (48 % ne pou- vaient pas assumer des soins et 29,6 % n’avaient soit pas d’assurance ou une assurance qui ne couvrait pas les soins relatifs au transgenre) et rapporte que 37 % des actifs étaient des ouvriers industriels, 14,5 % des employés de bureau, 5,5 % des travailleurs dans l’in- dustrie du sexe. Seuls 9 % avaient un emploi libéral. 19 % des participants au WTNAS ont signalé qu’ils avaient été expulsés pendant leur vie et 64 % ont déclaré qu’ils l’avaient été pour non- paiement du loyer. Il est important de noter que la popu- lation de plus de 50 ans croît propor- tionnellement le plus, et que le sida est un problème d’une importance signifi- cative dans la population des trans- genres, étant donné le succès croissant des cocktails de drogues qui prolongent la vie des victimes de sida, il n’est pas déraisonnable de supposer que la popu- lation de transgenres sous prescriptions sera de plus en plus importante, pres- criptions liées à l’âge telles l’hyperten- sion, les problèmes cardio-vasculaires et/ou pulmonaires, simultanément avec les hormones et les polythérapies de sida. Comme il existe un manque d’as- surances médicales selon les enquêtes WTNAS et TLARS, et comme il y a une grande proportion de personnes sans revenu, étant donné la stigmatisation de la position transgenre, comme nous l’avons déjà vu plus haut, il n’est pas déraisonnable de supposer que la qua- lité de vie à long terme et la réalisation des objectifs du projet HP2010 seront marginales à inexistantes, compte tenu de la politique fédérale actuelle vis-à- vis de la population transgenre en géné- ral et des plus âgés en particulier. La combinaison de facteur socio-éco- nomique influe à tous les niveaux de la vie quotidienne de la population trans- genre. La vie insalubre contribue à la mise en place de facteurs de risques psy- chologiques et de comportements à risques sexuels

1 3

Conclusion

La littérature gérontologique est riche d’une documentation soulignant l’im- portance des réseaux d’aide sociale (famille, amis, communautés spiri- tuelles, etc.) sur les taux de morbidité et de mortalité des hétérosexuels âgés. Il n’y a pas de raison de penser que ces résultats ne s’appliquent pas aux troubles de l’identité de genre non spécifiques. Le TLARS montre que près de 50 % des répondeurs vivent seul, ce qui est un fac- teur de risque significatif de la personne âgée. 10 % seulement déclarent vivre avec des enfants ou ont des enfants (fac- teurs délétères potentiels indiquant un soutien social faible). Parmi la popula- tion transgenre, il est raisonnable d’af- firmer que la spiritualité peut être un composant important de leur vie, mais il y a très peu de support religieux, étant donné que ces situations sont fortement stigmatisées dans les religions musul- mane, juive et chrétienne. L’absence d’ac- cès au soutien religieux, physique ou autre, est également un facteur de risque pour la personne âgée. Le divorce est très élevé parmi les trans- genres. Dans l’étude TLARS, 20 % étaient séparés, 10 % divorcés, d’où un manque ultérieur de soutien par les structures sociales encore plus important, ce qui est critique en fin de vie. L’inégalité de la répartition des soins, constatée dans la population en général, donne une idée de la carence de la prise en charge sanitaire et sociale dans les populations transgenre, compte tenu de la stigmatisation dont elles sont l’objet. Étant donné l’importance croissante de la composante transgenre dans la popula- tion américaine et mondiale, son exis- tence et ses besoins ne doivent plus être ignorés. T.M. Witten, Ph.D., FGSA, MSW (c) TranScience Research Institute PO-Box, 28089 Richmond, VA 23228-28089 transcience@earthlink.net

 

GENDER

1 5

T.M. WITTEN

T.M. WITTEN

Transgender aging :

 

an emerging population and an emerging need

 
 
 

SUMMARY : Aging is an inevitable process. Aging binds us all together. It does not see chromosomal context, psychosocial expression, race, class, gender identity, gender expression, gender perception, ethnicity, socio-economic status, or geographic boundary. In this paper, I will address some of the issues surrounding aging in the transgender communities. Initially,

Tarynn M. Witten, MS, MS, PhD (MSW, LCSW, DSW in progress), is a Fellow of the Gerontological Society of America and holder of the Inaugural Nathan W. Shock New Investigator Award from the Gerontological Society of America. She is a member of the consulting consortium of the Healthy People 2010 Project. Furthermore, Dr Witten serves as the Executive Director of the TranScience Research Institute; the only research insti- tute focused on scientific research on behalf of the aging transgender community and is founder and director of the International Longitudinal Transgender Aging Research Project. In addition, she serves on the Board of Directors of the National AIDS and HIV Over Fifty Association (NAHOF) and on the NGLTF Task Force on Aging. She is a Pro- fessor of Biostatistics at Virginia Commonwealth University-Medical College of Virginia Campus, Visiting Professor of Sociology and Anthropology at Virginia Commonwealth University-Main Campus, and has presented over 150 international scientific talks, panels and training sessions on transgender aging issues. Along with her colleague Dr. A. Evan Eyler, she published the first scientific research publication on violence in the transgender community, bringing to light the public health issues of violence against the trans-community. She is listed in Who’s Who In International Science, 1989/90, Who’s Who In Computing – 1989/90, Who’s Who In Health & Medicine – 1990/91, Who’s Who Worldwide – 1990/93/94, Who’s Who In Science And Engineering – 1992/93/94, Who’s Who In The South And Southwest – 1992/94/97, Who’s Who In American Edu- cation – 1993/94, International Who’s Who of Information Technology, 1996/1997, Who’s Who In the World 2000, International Who’s Who of Professionals 2000, and as one of the Top 2000 Women Scientists in the World 2001. She is also the author of the soon to be released book, The Tao of Gender (Humanics Press).

I

will address the question of estimating

the numbers of elderly transgendered both

in the US and worldwide. Within this context,

will briefly address the issue of labeling a community for the purposes of census taking.

I

I

will then discuss some of the problems

surrounding obtaining reliable estimates for the prevalence of transgender in the population. I will close with a discussion of some of the issues of transgender aging.

 

D eath is a universal endpoint. Aging is a universal norma- lizing process. Aging binds

way that no other process can. It does not see categories, prejudices,

or fears and hatred. It is universal and

us, as humans, across chromosomal context, psychosocial expression, across race, class, gender identity, gender expression, gender percep- tion, ethnicity, socio-economic status, geographic boundary, linguistic construction, and symbolic valuation. By definition, aging is a process, the- reby implying a temporal dynamic and removing the implicitly assumed embodied norm of temporal stasis of body, sex, gender, and sexuality. And, as a consequence of this fact, it sub- sequently demands that we see each other as «flow» in the context of per- sonal history, socio-cultural embed- ding, and both biomedical and envi- ronmental risk, vulnerability, and resilience. No gender identity, no body form, no sex/sexuality triad is neces- sarily fixed in time and no triad is invulnerable to the ongoing pro- cesses of aging. Aging unites us in a

it

is inevitable.

Brief demography of aging

 

The demography of aging is a com- plex subject. The simple question of estimating minority population sizes

is

non-trivial. Variations between coun-

tries, across social structures, through linguistic representations, across eco- nomic development, within healthcare delivery, and numerous other factors all interact to affect the age-structure of

a

particular country’s population. It is

 

KEY WORDS :

impossible, within the scope of this discussion, to discuss all of the com- plexities associated with understan- ding aging in the USA or worldwide. United States In 1999, in the United States, the size of the age 65 years and older popu- lation was 34.7 million individuals. This

• Transgender

• Transsexual

• Aging

• Geriatrics

• Gerontology

 
  - VOL.XII, N°44

- VOL.XII, N°44

1 6

1 6   Ta ble I : Estimation, in 1999, of the over 65 years old
1 6   Ta ble I : Estimation, in 1999, of the over 65 years old
 

Table I : Estimation, in 1999, of the over 65 years old population, and of the over 65 years old transgender population in the United States and Worldwide

 

Age Range

Population Size

Hypothetical Transgender Population Size (1 % — 3 %)

 

(in years)

(1999 Estimates)

(in years) (1999 Estimates)

65

+ (United States)

34.7 million

347,000 – 1,041,000

65 + (United States) 34.7 million 347,000 – 1,041,000

85

+ (United States)

4.2 million

42,000 – 126,000

85 + (United States) 4.2 million 42,000 – 126,000

100

+ (United States)

50,000-75,000

500-700 – 1,500-2,100

100 + (United States) 50,000-75,000 500-700 – 1,500-2,100

65

+ (US-projected)

70 million

700,000 – 2,100,000

65 + (US-projected) 70 million 700,000 – 2,100,000
 

+ (US-projected)

Unavailable

Unavailable

 

85

at publication

85 at publication

100

+ (US-projected)

834,000

8,340 – 25,020

100 + (US-projected) 834,000 8,340 – 25,020

65-79 (Worldwide)

334,003,000

3,340,030 – 10,020,090

65-79 (Worldwide) 334,003,000 3,340,030 – 10,020,090

80

+ (Worldwide)

66,699,000

666,990 – 2,000,970

80 + (Worldwide) 66,699,000 666,990 – 2,000,970

Total (Worldwide)

409,702,000

4,097,020 – 12,291,060

sub-population represents approxi- mately 13 % of the total population of the United States. There were 4.2 mil- lion people who were over age 85 years. The age 65 years and older population is projected to reach over 70 million individuals over the next three decades. Centenarians, indivi- duals 100 years old or more, repre- sent a special component of the aging population. They are the fastest gro- wing segment of the aging population. The second fastest being the 85 plus year old population segment. For cen- tenarians, the current estimate is 50,000 – 75,000 individuals. This group is expected to reach 834,000 by the year 2050. Moreover, 90 % of the cen- tenarians are women and 10 % are men. This prevalence rate is approxi- mately the same or a little higher than that of other industrialized countries. International The 1998 World Population Profile points out that, «every nation is aging. That is, in every country, the average age of the population is increasing as greater proportions of population reach middle and elderly age-groups.» They further point out that during the next 25 years, «the number of elderly living in less developed countries will more than double.» Lastly, the report points out that the size of the population of 65 years of age and older in the US and more industrialized nations, in 25 years, will be about 50 % larger than the total number of people alive in 1998. US Bureau of Census estimates (1999), for the total world population of individuals aged 65-79 years is 334,003,000 – with an additional 66,699,000 individuals in the 80 years

and over range. Hence, the worldwide estimate of individuals in the 65 + years of age group is approaching 409,702,000 people (Table I).

Defining transgender and the demography of transgender

The terminology describing the «gen- der» community is extremely dynamic, not just in the descriptors of gender, but also in the body/sex/sexuality ter- minology associated with a given gen- der identity. This, along with certain components of the population being unwilling to allow themselves to be labeled or categorized by labels fixed by someone else, it extremely difficult to obtain an accurate census of this population. Although they are frequently invisible and highly stigmatized within our society (i.e., marginal legal protection, non-inclusion in hate crimes legisla- tion, Witten and Eyler, 1999 ; Currah and Minter, 2000), transgender indivi- duals form more than a negligible per- centage of the U.S. population. Understanding that there are labeling and power concerns of importance that surround any issue of subdividing a population, Witten and Eyler (1999) address the definition of transgender stating that «The gender community includes cross-dressers (men and women who take on the appearance of the other gender, often on a social or part-time basis), transgenders (people whose psychological self-iden- tification is as the other sex and who alter behavior and appearance to

conform with this internal perception, sometimes with the assistance of hor- monal preparations), and transsexuals,

both male-to-female (MTF) and

female-to-male (FTM), who undertake

hormonal and/or surgical sex reassi-

gnment therapies. In addition, it

includes others with gender self-per-

ceptions other than the traditional

(Western) dichotomous gender world-

view (i.e., including only male and

female), such as persons with «non-

Western» gender identities (Langevin,

1983 ; Godlewski, 1988 ; Hoenig and Kenna, 1974 ; Sigusch, 1991 ; Tsoi, 1988; van Kesteren et al., 1996; Walin- der, 1971, 1972 ; Weitze and Osburg, 1996). (Table 1)Population size esti- mates, in 1999, of the over 65 years old transgender population in the Uni- ted States and Worldwide.

Estimating the prevalence of transgenderism

With regard to population estimates of transsexuality, Tsoi (1988) has noted that, «A… problem confounding an epidemiological survey is that trans- sexuals tend to congregate in cities and in certain parts of cities, and most of them do not want to be identified.» Much of our own research work has further substantiated this phenome- non. Nonetheless, Tsoi has also noted that, in Singapore, (where SRS is well established and transsexuals are not «suppressed,») diagnosed trans- sexualism is more than eight times more prevalent than in any other coun- try for which estimates exist. Witten has pointed out that estimates of the number of individuals claiming to have «alternative gender identities» in the U.S., as well as in other countries, are confounded by the lack of a control group by which to test prevalence and incidence estimates. Even so, in an international random survey perfor- med by this author and her collabora- tor, approximately 8 % of the 300 respondents identified their gender self-perceptions as something other than 100 % male or 100 % female (publication in preparation). Taking only the international estimates for post- operative transsexuality as a basis (1 %-3 %; Langevin, 1983; Godlewski,

- VOL.XII, N°44only the international estimates for post- operative transsexuality as a basis (1 %-3 %; Langevin, 1983;

1988 ; Hoenig and Kenna, 1974 ; Sigusch, 1991 ; Tsoi, 1988 ; van Kes-

1988 ; Hoenig and Kenna, 1974 ; Sigusch, 1991 ; Tsoi, 1988 ; van Kes- teren et al., 1996 ; Walinder, 1971, 1972; Weitze and Osburg, 1996), and using the approximate estimate of 300 million people for the US popula- tion, this would imply that there are potentially 3-9 million potential post- operative transsexuals in the US. While this estimate seems overly surprising, I have discussed the rate of gender re-assignment surgeries currently per- formed in the US and Europe, with a number of the more prominent sur- geons worldwide. A number of these surgeons indicate that they are per- forming 2 surgeries per day, 48 weeks per year, 4-5 days per week. Some of these surgeons state that they have waiting lists upwards of 2 years. If we allow for the more broad interpreta- tion of transgender as including non- surgical and cross-dressing individuals, the estimates increase to approxima- tely 20 million people, depending upon definitional criteria. It is also important to recognize that each of these indi- viduals touches numerous others in his or her life, family, friends, employers, employees, acquaintances, and random individuals on the street. Consequently, support services may well be necessary for many other indi- viduals other than just the actual trans- gendered persons. This insight identi- fies the impact of the transgendered population and its needs as being significantly larger than the immediate population of the transgendered alone. For brevity, in the upcoming discus- sion, the term «transgenders» will be used to signify the entire gender com- munity, unless otherwise specified. I would also like to point out that many indigenous peoples recognize genders other than male and female. (For example, Tewa adults identify as women, men, and ‘kwido’, although their New Mexico birth records reco-

 

Table II :Prevalence of violence types among respondents of the TLARS Study

Violence Type n = %

Violence Type

n =

%

Violence Type n = %
Physical 62 25 %

Physical

62

25 %

Physical 62 25 %
Emotional 91 37 %

Emotional

91

37 %

Emotional 91 37 %
Sexual 26 11 %

Sexual

26

11 %

Sexual 26 11 %
Neglect 35 14 %

Neglect

35

14 %

Neglect 35 14 %
Exploitation 11 5 %

Exploitation

11

5 %

Exploitation 11 5 %
 

Not Applicable

22

9 %

gnize only females and males (Jacobs and Cromwell, 1992). Persons with such « non-Western» gender identi- ties will also be considered as belon- ging to the gender community.

Problems with population estimates for the transgender community

The problem of stigma and violence Population estimates for the gender community are difficult to obtain and verify, due principally to the currently highly stigmatized nature of trans- sexualism, transgenderism and cross- dressing identifications and behavior, as well as the lack of available resources for the gender community in many geographic regions. (The lat- ter phenomenon leads to the choice of private solutions, such as «passing» as the other sex without medical or mental health assistance, and there-

fore to «epidemiological invisibility».)» By means of example, Witten and Eyler (1999) state that in a sample of 174 individuals (sample biased towards middle to upper-class indivi- duals and having age range 22-79 years) there was a high degree of vio- lence and abuse suffered. With regard to the definitions of abuse that most accurately described these situations (respondents n = 135 ; multiple ans- wers permitted), results were as fol- lows (Table II). Respondents were also asked to iden- tify whether or not they had ever told another person about the violence, abuse, or mistreatment that they had received, and to whom these events had been reported. Of the n = 121 par- ticipants who answered this question,

n = 93, (77 %) indicated that they had

told others of their abuse experiences, and n = 28, (23 %) stated that they had not. With respect to reasons for

non-reporting, (n = 132 ; multiple res-

ponses permitted) n = 28 (21 %) indi-

cated that they were afraid to report

for fear of reprisal by the perpetrator,

n = 14 (11 %) feared abuse by the

medical/legal system, n = 5 (4 %) were

unable to report, n = 38 (29 %) felt that

it would not make a difference if they

had reported the incident or incidents,

n = 10 (8 %) wanted to protect the per-

petrator, and n = 22 (17 %) indicated that there had been reasons other than those listed. In addition, several items were inclu- ded which pertained any acts of abuse, mistreatment or violence that had occurred in social settings. Typi- cally, such acts take place in the work- place, on the street, in bars, or in any other public, interpersonal scene. Reli- gious institutions, educational settings, other public environments, organiza- tions, or institutions were also inclu- ded in this section. When asked whe- ther or not the respondent had had any acts of mistreatment, abuse, or violence perpetrated against them in social settings, survey participants responded as follows : Yes (= 89; 66%), No (= 42; 31%), and Not Appli- cable (= 4; 3%; n = 135). Issues of Transgender Aging

Transgender elders not only require the same care as all older adults, they also need care – and face obstacles –

specifically related to their gender sta- tus. Witten, Eyler, and Weigel (2000) address much of the healthcare needs of this population in some detail. These needs are further addressed in Witten, Eyler, and Weigel (2002) and in (http://www.asaging.org/LGAIN).

It is a well-documented fact that social

conditions (Kubzamsky, Berkman, and Seeman, 2000), social network sup- port (Everard et al., 2000; Pinquart and Sorenson, 2000; Grossman, D’Augelli, and Hershberger, 2000), socio-eco- nomic status (Rautio, Heikkinen and Heikkinen, 2001; Pinquart and Soren- son, 2000), and even social role (Krause and Shaw, 2000) can all have significant impact, positively or nega- tively, on mortality, morbidity, health status, depression prevalence (overall psychological well-being, Zhang and Hayward, 2001), successful aging, and numerous other life course outcomes that are of current importance in the Healthy People 2010 Project. The results of these studies can be sum- marized as follows, the lower the income, the less social support (friends, spiritual activity, supporting organizations, neighbors upon whom one can depend, for example), the less habitable to social conditions (isola-

- VOL.XII, N°44

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1 7

neighbors upon whom one can depend, for example), the less habitable to social conditions (isola- -

1 8

 
 

tion, poor environment), the less edu- cation, the higher the risk for psycho- logical dysfunction, long-term poor quality of life, poor health status, increased morbidity and mortality, and

lence and stigma against the trans- gender community. However, the stigma extends into other areas as well. In particular, it has profound impact on the financial and medical well-being of this population. While the sample population from our lon- gitudinal study was both reasonably

well-off financially, it was only through this success that they were able to pay for the necessary drugs and other medical interventions necessary to both begin and subsequently main- tain the transition. The wave 1 TranS- cience Longitudinal Aging Research Study (TLARS) respondents replied as follows : Of the n = 175 individuals who answered the employment ques- tion, responses were as follows : n

impact on the later life issues, not only of regular aging, but of transgender related aging as well. For those who are elders on a fixed income, transgender medicines and interventions can be problematic at best, as they are not covered under Medicare. Additionally, current esti- mates (Crystal et al., 2000) show that expenditures averaged 19.0 % of income, for full-year Medicare bene- ficiaries alive during all of 1995. Higher burden subgroups, included those in poor health (28.5 % of income), older than age 85 (22.4 %), and with income in the lowest quintile (31.5 %). Finan- cial breakdowns for the TLARS show that for female-to-male transsexuals (n = 32 in the first wave of the study), the bulk of the respondents made less than $30,000/year with a significant amount making less than $20,000/year. This is true, despite the fact that the population is not under educated. The overall study popula- tion is similarly educated and more well off due to the preponderance of executive males in the population. The fact that Wave 1 of the TLARS study is a best-case scenario is again born out by the results of the WTNAS study showing that only 6 % of the WTNAS respondents had college degrees and another 6 % had gra- duate or professional degrees. Results of the WTNAS study are similar to the TLARS female-to-male transgender component. However, the WTNAS reports additional critical information in that 19 % of all of the WTNAS partici- pants reported that they had been evicted during their lifetimes and 64 % stated that they were evicted for non- payment of rent. To put the impact of the additional medical (pharmaceutical) treatment into perspective, the post-operative male-to-female transsexual is typically taking at least one gender-related medication. Typically, this medication is not covered under insurance. The average charge for this hormonal medication can range from between $40 and $100 dollars/month. Given the already meager fixed income avai- lable to a large portion of the trans- gender population, this additional medical burden can be oppressive. Pre-operative or peri-operative trans-

the less likely to be «a successful ager» in the sense of the MacArthur Foun- dation’s Successful Aging Project. The importance of healthcare in the US is clearly stated in the govern- ment’s push for the implementation of the goals of the Healthy People 2010 project, Chapter 1 entitled «Access to Quality Healthcare, » of the Healthy People 2010 Project (2000,

http://www.health.gov/healthy-

people/Document/tableofcontents.htm) states that a primary goal of the HP 2010 Project is to «improve access to comprehensive, high-quality care ser- vices.» In particular, the chapter authors go on to state «Access to qua- lity care is important to eliminate health disparities and increase the quality and years of healthy life for all persons in the United States.» While the stated goals are admirable and are well docu- mented, unfortunately the HP 2010 document does not address «all per- sons in the United States.» Page 1-13 of the 2010 document states, as its goal in clinical preventive care, «to increase the proportion of persons with health insurance.» It then illustrates data from the 1997 National Health Interview Survey (NHIS), CDC, and NCHS showing the percentages of individuals under the age of 65 years having health insurance. The table incorrectly identifies «sex» as «gen- der» and lists only the options of male or female as data collected. Later on in the same table, it indicates that sexual orientation data was not col- lected. This tacit assumption of the Western biomedical model of gender automatically dooms the HP 2010 pro- ject to failure in that it cannot possi- bly address the needs of those who could be generally classified as alter- natively gendered as it not only does not include collection of data relevant to the transgender population, but it does not address the specialized needs of that population. In the preceding discussion, my research colleague and I have demonstrated the profound public health hazard associated with the vio-

=

15 unemployed, n = 12 employed

part-time, n = 131 employed full-time, n = 10 retired, and n = 7 receiving disa- bility. Individuals were also asked to describe their most recent employ- ment, with the following results : n = 9 corporate executives, n = 85 mana- gerial or professional positions (e.g., accountant, engineer, scientist, lawyer, etc.), n = 19 service occupations (e.g., cook, child care worker, police, fire- fighter, etc.), n = 0 farming/forestry/ fishing related employment, n = 14 precision production, craft, and repair (e.g., mechanics, phone repair, locks- mith, etc.), n = 16 operator, fabricator, or laborer (e.g., typesetter, assembly

worker, crane operator, taxi driver, etc.),

n

= 10 independent freelancer or

consultant, n = 7 students, n = 3 recei- ving alternative income, and n = 19 «other». Results from the Washington Transgender Needs Assessment Study (2000) document significantly lower educational levels, 42 % unemploy- ment, and significantly lower income earning levels (48 % of the WTNAS respondents state that they could not afford care, 29.6 % state that they have either no insurance or insurance that does not cover the transgender healthcare related needs). Additionally,

in

the WTNAS study, 37 % of those

employed worked as service industry workers, 14.5 % as private sector office workers, 5.5 % as sex industry

workers, and the rest in other catego- ries, with only 9 % working as private sector professionals). Clearly, the type

of

employment will have significant

- VOL.XII, N°44

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genders are typically taking upwards of two prescriptions per month, increa- sing their fiscal burden proportionally more. In addition to the medication charges, there are additional gender- related medical charges including psy- chological evaluations, ongoing phy- siological tests for liver damage or other hormonally mediated damage, medical intervention due to unexpec- ted medical interactions of hormones with other age-related medications, interactions with current HIV/AIDS medications, and other unforeseen medical complications. It is of parti- cular importance to note that the por- tion of the population of age greater than fifty years old is the fastest gro- wing portion of the population with respect to incurring AIDS/HIV. Given that HIV/AIDS is a significant problem in the transgender population, given the increasing success of drug cock- tails that prolong the lives of HIV/AIDS victims, it is not unreasonable to assume that the transgender popula- tion will have a growing number of indi- viduals who are on age-related pres- criptions such as high blood pressure medicines, cardiac related medicines and/or pulmonary medicines, simul- taneously on hormones, and in need of HIV/AIDS drugs all at the same time. Given the demonstrated preponde- rance of the lack of medical coverage in both the WTNAS and TLARS sur- veys, given the large proportions of the population with marginal to no income, and given the stigma asso- ciated with being transgendered – as seen by the data on violence, abuse, and hate crimes presented earlier – it is not unreasonable to project (based upon the cited research references with respect to social support net- works, socio-economic status, etc.) that the long-term quality of life and the success at meeting the HP2010 goals will be marginal to non-existent given the current federal policies with respect to the transgender population in general and the elders of that popu- lation in particular. This combination of socio-economic factors negatively impacts all facets of the transgender population’s daily lives. It is clear that there is increased stress due to violence/abuse, fiscal impoverishment, healthcare delivery

stress, lack of insurance stress, and stigma associated with self-identifying with the transgender population. The scientific literature in Gerontology and Geriatrics has repeatedly demonstra- ted that these factors have a signifi- cant negative impact on health, qua- lity of life, functional capacity, mental status, etc. Low income levels lead to inability to purchase necessary hor- mones, increasing the likelihood of ille- gal hormone purchase and use of dirty needles that can lead to HIV/AIDS. Concomitant low income levels lead to poor housing and subsequent increased risk for substance abuse, depression, suicidal behavior patterns, and risky sexual behaviors such as participating in sex industry work. Moreover, the stigma of transgender makes access to assisted living and nursing home facilities beyond the reach of many and is certainly a fear- ful situation for most. This further dimi- nishes the potential elder care facili- ties available to the aged of the transgender population.

Closing thoughts on aging in the transgender community

The Gerontological literature is replete with documentation supporting the importance of social network struc- ture (family, spirituality, friends, to name a few items) on the morbidity and mor- tality rates of heterosexual elders. There is no reason to believe that these results do not apply to non-traditional gender identities, gender expressions, sexualities, sexes, and body forms. TLARS research indicates that nearly 50 % of the respondents are living alone (a significant risk factor for the elderly), and only 10 % of the respon- dents indicate that they are either living with or have children (a potentially deleterious factor indicating dimini- shed social support networks). Among the transgendered populations, it is reasonable to assume that while spi- rituality may or may not be an impor- tant component of their lives, there is little formal outlet for religious inter- action and support, as transsexuality in particular, and transgenderism in

1 9

general, are highly stigmatized within the traditional Judeo-Christian-Islamic religions. Lack of access to religious support, emotional, physical or other- wise, is also a significant risk factor for the elderly). Among transgenders, divorce is very high (estimates are not available, however TLARS results indi- cate that 20 % of the respondents were separated and another 10 % were divorced). This further exacer- bates the diminished social support network structures well known to be critical in the later life.

Conclusion

There are numerous questions that remain to be addressed, and which will be the subject of further white papers from this organization. Among them are questions of multicultural impacts on health, within the aging population of the transgendered and the intersexed. Certainly, the AHRQ has, along with other NIH and HHS components, documented the inequity of healthcare treatment both by race and by sex, among today’s healthcare service agencies. It is clearly worse, as we have seen in the previous dis- cussion, among the transgender and intersex populations. The profound effect of inequitable healthcare among the normative populations serves as a least upper bound for how bad it is among the non-normative LGBTI populations in general and the trans- gender and intersex populations in particular. Reports from both the TLARS study and the WTNAS study indicate that the situation is far worse than that seen in the normative popu- lations. Given the increasing size of the transgender and intersex compo- nents of the aging US and worldwide population, it is clear that these popu- lation components can no longer be denied either their existence or their needs.

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