Wednesday, June 12, 2013
Hospice and the Transgendered
by: Robert Killeen MD
Hospice is beset by many societal obstacles in its care of the transgendered patient. I saw a most recent example of this in our local community hospice. An elderly female (MTF) transgendered patient had developed metastatic cancer. Chemotherapy had failed and had left her profoundly weak and infirmed. Estranged from her family, she had only a few friends to rely on but then only intermittently so. Hospice admitted her to their IPU and, with supportive care, her overall status did improve. However, now she was in a dilemma. She was well enough to leave the unit but not well enough to go home. Too poor to afford a single room, the patient was unable to be placed. Chronic care facilities viewed her as if she were both male AND female. This prohibited her placement with a roommate. As she was physically female she wished to have a female roommate; the facilities saw her as originally 'male' and either could not or would not comply. In the end, she remained at the hospice center for the remainder of her life. While the hospice provided her with exemplary care, the obstacle of society's views on gender prevented her from ever leaving the unit.
The transgendered population confronts a myriad of difficulties which hospice must also address. Socially, transgendered folk, gentle folk, find themselves relegated to a near-netherworld existence. Forced to society's fringes they feel isolated, even abandoned, by family and friends. They may find their friendships restricted to a "gay-friendly" environment or to other 'T-girls'. Many T-girls succumb to a personal economic collapse with a loss of job, loss of insurance, and even a homeless existence. Their health can deteriorate with severe depression being a foremost finding. Impoverished and despondent, they may turn to alcohol or drug abuse. They may engage in risky behavior for hepatitis and AIDS. Many transgendered people would shun medical care until their health status has deteriorated to the extreme. In an era when patients can be nudists, "furries", or carry tattoos of violent causes (eg. Nazis), why must the transgendered have fear of disfavor from a medical staff corrupted by society? Their only supposed crime is gender. In the Virginia Transgender Health Initiative Study almost half of the transgendered patients felt that their doctor had little or no knowledge of transgendered health issues. Roughly half of patients surveyed felt uncomfortable discussing their transgendered issues with health care providers for reasons like fear of ridicule, hostility, insensitivity amongst personnel, and refusal of treatment. About a fourth of those surveyed had experienced discrimination by medical providers. As these patients avoid medical care their acutely treatable conditions may progress to chronic, or more terminal illnesses or be complicated by other maladies.
The transgendered population is often helpless to find support for their health care. Transgendered people are a 'minority of minorities', "society's most vulnerable population" as per the Reverend Stan Sloan of Chicago House, creator of the TransLife Center. The center offers a haven to a people who sometimes find themselves unwelcomed at homeless shelters, are ignored by charitable institutions, and report feeling forgotten by the gay community. While gay and lesbian awareness progresses, transgendered support appears stagnant. Hospices need more resources to draw on for the special problems of transgendered patients, perhaps something more than just sources adjunct to the gay and lesbian community.
Schaffer N. "Transgendered Patients: Implications for Emergency Department Policy and Practice". J Emerg Nurs 2005. 31:405-7
Xavier J, Honnold J, Bradford J. "The Health-related Needs and Lifecourse Experiences of Transgendered Virginians". Virginia Department of Health. 2007.