TONI Paynter, a 75-year-old transgender woman from Victoria, doesn’t ask for a lot when accessing health services.

“Just treat me with the same respect as you would any other human being,” is her simple message to GPs and other health service providers.

Toni, who transitioned about 15 years ago, recounted to MJA InSight the story of being in the crowded waiting room of a public hospital when her name was called by a nurse. When Toni stood up to present for her appointment, the nurse said, “at the top of her voice, ‘Oh, I thought you would be a woman’”.

“I went with the flow from there. I didn’t feel it was an appropriate place to correct her or educate her,” said Toni, who facilitates a mental health peer group at Uniting.

Dr Catherine Barrett, Director of  Alice’s Garage, said such instances of “misgendering” could be deeply traumatic for transgender people.

“For a lot of service providers, it might seem quite frivolous, ‘oh, I got your name wrong’. But having to battle every day for your gender identity and then to have that happen in health services can be [very disempowering and can erode trust in the service],” Dr Barrett told MJA InSight.

She said there was an increasing number of people who – with improved access to information and sometimes after divorce or the death of a spouse – were transitioning later in life. This often resulted in them having to contend with family conflict at the same time as managing the complexities of ageing.

In the MJA this week, Professor Carmelle Peisah, of UNSW Sydney’s School of Psychiatry, and co-authors, wrote that it was important to raise awareness in the medical community about recent “hard fought” legislative and policy changes to continue to make progress in supporting members of the lesbian, gay, bisexual, transgender and intersex (LGBTI) community as they age.

The authors wrote that many LGBTI elders had made themselves “invisible” throughout their lives as protection against discrimination and violence, and this invisibility was now extending to aged care service provision and medical research. They said that this perceived need to remain invisible had also meant that aged care providers were often unaware of their LGBTI clients.

The authors pointed to the Australian Government’s 2012 National LGBTI Ageing and Aged Care Strategy as a crucial starting point in raising awareness. This was followed by an expansion to the Aged Care (Living Longer Living Better) Act, which improves subsidised access to residential aged care for LGBTI elders, and an amendment to the Sex Discrimination Act to prevent Commonwealth-funded faith-based aged care providers from discriminating in their delivery of services on the basis of sexual orientation, gender identity or intersex status.

Under the national strategy, several organisations have been federally funded to deliver training across Australia to improve sensitivity and inclusiveness of LGBTI elders in residential aged care.

Co-author of the MJA article, Ms Samantha Edmonds, described the changes required as being like “turning the Titanic”.

“It’s a slow, steady turn – but it is changing, and it is getting better,” said Ms Edmonds, who is National Project Manager of Silver Rainbow (part of the National LGBTI Health Alliance).

Ms Edmonds said that LGBTI elders were often entering aged care services not knowing how they would be treated.

“You’re also being asked to live with the very people who have possibly abused you throughout your life,” she said, in an exclusive podcast. “So, people are going back into the closet … not showing affection to their partner, maintaining that it’s just a friend.”

Ms Edmonds said that LGBTI elders may also be reluctant to discuss their specific health needs, and just try to “blend in again”.

“It’s not to say there are not some really resilient and strong LGBTI people who are out there with quiet confidence, but … overall, that’s the common experience.”

Dr Barrett said that accessing home care services could also cause distress for LGBTI elders.

“They may feel that they have to ‘straighten up’ or ‘de-gay’ their home because they are worried that they will be discriminated against because of their LGBTI identities,” Dr Barrett said. “And that feels like a real violation for LGBTI elders because their home has been their safe space when the rest of the world has been so hostile.”

For people who are entering residential aged care, Dr Barrett said that the fears can be enormous.

“The fear is not just about LGBTI-phobic staff, it’s about LGBTI-phobic residents and volunteers, and the threat that their LGBTI identity may be gone forever.”

She said that this may also mean severing ties with their LGBTI community, and this can be a major issue in ageing.

The MJA article highlighted the importance of recognition of “family of choice” for LGBTI elders, where informal care networks, rather than families, provide support and important bonds.

Mr Russ Gluyas, coordinator of ACON’s ageing programs known as the LOVE (Living Older Visibly and Engaged) Project, said that the generation of LGBTI people now moving into ageing and aged care services had had very different historical experiences to younger LGBTI people.

“It’s those aged 70-plus who express some fear or anxiety and they think that they might have to go back into the closet with their aged care services. It’s not always the case, but it’s certainly the experience of many people that I have spoken to in my work that they won’t be able to be themselves if services can’t provide evidence of being LGBTI inclusive,” Mr Gluyas said.

“If there is no indication of inclusivity in [an aged care provider’s] policy and procedures, an LGBTI senior is probably not going to out themselves for fear of what the repercussions might be.”

He said that the LGBTI Ageing and Aged Care Strategy had improved conversations around these issues, but ignorance was still common.

“You can still go into numerous aged care organisations across Australia and hear ‘oh, there’s nobody like that living here’,” Mr Gluyas said. “That’s because they are probably fearful to disclose their sexual orientation or gender diversity [to the organisation] because of the quality of care they may then receive.”

Mr Gluyas said there was hope on the horizon with one aged care provider, Uniting, achieving Rainbow Tick certification.

“There are a very comprehensive set of criteria [to obtain Rainbow Tick certification] and Uniting has achieved this, continuing to implement positive changes,” Mr Gluyas said. “They are very much at the forefront of LGBTI inclusiveness and care.”

Dr Barrett said that finding an LGBTI-inclusive GP was like finding gold for LGBTI elders.

“The fact that [transgender] and gender diverse people, and gay people as well, have been pathologised in medicine, to find an LGBTI-inclusive GP in their older age, my goodness, the power is enormous,” she said. “We are talking about some people who have never been affirmed in their lives.”

Dr Barrett said that it was also important for the medical research community to recognise the often challenging health care needs of transgender and intersex elders.

“Intersex elders may have quite complex medical needs, and these need to be better understood, but there has been very little research in this area,” Dr Barrett said. “They may have had crude surgical interventions in their youth and now they may be having real physical problems because of the crude surgery … they have had a tough time.”

Dr Barrett highlighted the case of one intersex elder who has to see a paediatric endocrinologist in a children’s hospital.

“She has to sit and wait on the mini-chairs because there isn’t expertise around for what ageing means for her. There are similar issues for [transgender] and gender diverse people. We have tried to get a longitudinal study up about [transgender] and gender diverse and intersex ageing because there is not a pathway, there is not an evidence base.”

Mr Gluyas said that it was crucial that these conversations move beyond the LGBTI community and into mainstream networks.

“It’s a bit of a slow journey, but over the 5 years I have been with the LOVE Project, people have learnt to trust the work that we do and trust that we are in the space to have better and more open conversations,” Mr Gluyas said.

“That needs to be taken out into the broader community. We’re preaching to the converted if we stay in our community, so it’s really about being at forums, conferences, workshops and networks that aren’t specifically LGBTI, so we can increase the awareness of the importance of this.”

For 75-year-old Toni, accessing ageing and aged care services is not something she is looking forward to.

“I am desperately trying to avoid getting old,” she joked. “The whole aged care system tends to be very bureaucratic and clumsy and hard to navigate. I am constantly having to advocate for myself.”


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