Obstacles to obtaining care are augmented by limited services that are culturally competent.6 For transgender and gender nonconforming individuals, it is not uncommon for them to seek out care to transition from 1 gender to another in mid- or later life.33

Older transgender adults have lower levels of self-acceptance: 48% of transgender older adults face depression compared with 30% of LGB older adults and 5% of older heterosexual populations.34 More than 50% of transgender adults aged 55 years and older state they have lost close friends because of their gender identity.35

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Forty percent of transgender adults aged 55 years and older state that their gender identity is the reason their children do not have contact with them.35 Moreover, 44% of transgender older adults live alone34 compared with 18% of the population.17 Transgender individuals have said that being old increases their risk of experiencing hate crimes because they have to deal with prejudice and discrimination, in addition to ageism.26

Transgender individuals are fearful that their gender identity will not be respected in long-term care and hospice facilities.36 Moreover, they are concerned that their gravestones and death certificates will not display their correct names or gender identities.17 

According to 1 study of 24 countries, older transgender adults have completed few end-of-life decisions. Of transgender adults aged 51 to 60 years, 15.2% had completed a will, and of transgender adults aged 61 years and older, only 8.1% had completed a will.17 

Only 8.1% of transgender adults aged 51 to 60 years and 7.4% of transgender adults aged 61 years and older had a durable power of attorney.17 There was a significant increase in those who had a will for transgender adults living with a chronic illness.

End-of-Life Issues: Hospice/Palliative Care

In general, it can be difficult for those in hospice or palliative care to focus both on disease and end-of-life care, as well as sexual health and sexuality. Sex and sexuality are connected to self-esteem, mood, pleasure, social role, and other factors that affect quality of life.37,38 

Because the majority of society views significant illness, dying, and sexuality as taboo topics, it is the role of the healthcare provider to bring up these topics.38,439 Because many LGBTQ individuals face discrimination and stigmatization by society, those in palliative care may voluntarily omit information such as HIV status, sexual orientation, or other possibly stigmatizing information from their healthcare providers.38 

In addition, for older LGBTQ individuals, there may be generational differences in terms of comfort in sharing information about one’s sexual orientation in healthcare settings.38,40 This is partially because of the heteronormative outlook, or the assumption that people are heterosexual, held by most of society, as well as most healthcare providers.38 

Older LGBTQ adults may feel less comfortable disclosing information regarding their sexuality to healthcare providers because they may have experienced a significant amount of discrimination regarding their sexuality throughout their lives.38 Transgender individuals fear that lack of understanding or appropriate responses regarding their gender identity or expression can lead to trouble in accessing palliative care.38,41

Palliative care should include all aspects of one’s life, including sexuality, and sexuality should be a part of the “personal side of dying.”42,43 Providing palliative care for the LGBTQ population has evolved over time; the current palliative care framework for LGBTQ patients is not 1 in which HIV/AIDS is at the forefront.38 

It is necessary that healthcare providers inquire about sexual identity, avoid assumptions about one’s sexual orientation (specifically that the patient is heterosexual), and ensure that partners are included in decision-making.38,44

This article originally appeared on Psychiatry Advisor