Skip to main content

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.



Comments

Joanne Tanner said…
This comment has been removed by the author.
Joanne Tanner said…
Thank you for posting this! While at the Geriatric Round Table on Tuesday at EVMS, we learned that the 89 year-old patient hesitantly revealed to his doctors he was depressed because of losing his "friend" of 52 years. It was obvious the "friend" was his partner, but at his age, he was still struggling with admitting his orientation. The kind, caring doctors treating him were seeking ways to help him flourish and part of that is an attempt to find a support group for LBGT elders that he can be a part of. It is so important to recognize that this is an issue that is going growing and it is our responsibility as healthcare professionals to ensure we are part of the solution, not the problem.
Sabrina Samone said…
Thank you for this. I'm a Trangender female who has worked in the nursing home and home health settings for nearly 14 years. I've had transgender patients and with LGBT people growing older this is a concern, because their is still a huge amount of bigotry, even towards the weakest in our care.

Popular posts from this blog

The Dangers of Fleet Enemas

The dangers of oral sodium phosphate preparations are fairly well known in the medical community. In 2006 the FDA issued it’s first warning that patients taking oral sodium phosphate preparations are at risk for potential for acute kidney injury. Two years later, over-the-counter preparations of these drugs were voluntarily withdrawn by the manufacturers.  Those agents still available by prescription were given black box warnings mainly due to acute phosphate nephropathy that can result in renal failure, especially in older adults. Despite all this talk of oral preparations, little was mentioned about a sodium phosphate preparation that is still available over-the-counter – the Fleet enema.

Why Oral Sodium Phosphate Preparations Are Dangerous 

Before we go into the risks of Fleet enemas, lets spend just a couple sentences on why oral sodium phosphate preparations carry significant risks. First, oral sodium phosphate preparations can cause significant fluid shifts within the colon …

Dying without Dialysis

There is a terrific article in this weeks Journal of Pain and Symptom Management by Fliss Murtagh of King's College in London about the epidemiology of symptoms for patients with advanced renal failure who die without dialysis.  This study is important because while we know that patients with advanced renal failure have a limited life expectancy and the average age of initiation of hemodialysis is increasing, we know little about the alternatives to hemodialysis.  Specifically, we know nothing about symptoms affecting quality of life among patients who elect not to start dialysis (so called "conservative management" - is this the best label?).  This article provides a terrific counterpoint to the article in last years NEJM showing that nursing home residents who initiated hemodialysis tended to die and decline in function (see GeriPal write up here). 

The study authors followed patients with the most advanced form of chronic kidney disease (the new name for renal failu…

Survival from severe sepsis: The infection is cured but all is not well

Severe sepsis is a syndrome marked by a severe infection that results in the failure of at least one major organ system: For example, pneumonia complicated by kidney failure. It is the most common non-cardiac cause of critical illness and is associated with a high mortality rate.

But what happens to those who survive their hospitalization for severe sepsis? An important study published in JAMA from Iwashyna and colleagues provides answers and tells us all is not well. When the patient leaves the hospital, the infection may be cured, but the patient and family will need to contend with a host of major new functional and cognitive deficits.

Iwashyna examined disability and cognitive outcomes among 516 survivors of severe sepsis. These subjects were Medicare enrollees who were participants in the Health and Retirement Study. The average age of patients was 77 years.

When interviewed after discharge, most survivors were left with major new deficits in their ability to live independently. …