Aging can be emotionally, physically, and financially challenging for just about anybody.
But transgender elders face some extra, heart-wrenching questions in the last chapters of their lives. Their predicament was discussed in several workshops this week at the 15th annual Philadelphia Trans Health Conference at the Convention Center.
"Is there a legal form that would require my family to bury me as I desire?" an older woman wearing a neat bob and a conservative dress asked Thursday at one of the sessions.
Another spoke haltingly through tears of her fear of facing death without her family. "My kids and I are not talking," she said. "It scares me."
Workshop leaders and participants talked about people who are afraid to trust doctors because of past discrimination, who feel they must go back into the closet or risk being seen as a "freak" when they enter senior housing, who struggle to maintain their identities at the end of life.
Estrangement from families - and a lack of potential caregivers - is a big concern. Some are isolated from the broader trans community because their generation's goal was to pass as cisgender - as someone whose sense of gender conforms with their biological sex.
Then there's money. Job discrimination and high medical costs may leave transgender people with especially tight budgets.
The conference, which continues through Saturday, was expected to draw at least 4,000 participants, a combination of trans men and women, their families and friends, and professionals who work with them.
"This is the biggest conference like this in the world," said Dane Menkin, a nurse-practitioner at Philadelphia's Mazzoni Center, which sponsors the event.
The conference transformed the Convention Center into a place where common conceptions of gender could safely be upended. Name tags had a line for participants to specify their preferred pronouns. Bathrooms within the conference bounds, even the ones with multiple stalls, were gender-neutral. Lots of clothing and hair was creatively androgynous, especially among the younger attendees who dominated the event.
Physical health risks from years of taking hormones - testosterone for trans men and estrogen for trans women - do not appear to be a big problem in aging, Menkin said. While research is inadequate, he said, places like Mazzoni, which cater to the LGBTQ population, are not seeing higher rates of cancer among trans patients. Heart disease risk is similar to that of other people with their chosen gender.
But like so much of the U.S. population, trans men and women are prone to weight gain and its attendant health risks. Menkin said counseling on exercise and diet, along with using the lowest possible doses of hormones, is a big part of trans health.
Rutgers New Jersey Medical School was also hosting a transgender health conference on Friday in Newark. It is aimed at mental health providers and was expected to draw more than 200 people, said Petros Levounis, chair of the department of psychiatry at Rutgers University.
Levounis said transgender patients often mistakenly attribute psychological problems to hormones. Most of the time, he said, there problems have nothing to do with gender or hormones.
On the plus side, he said, he has seen "incredible happiness" in patients who choose to transition later in life.
One of the presenters in Philadelphia, the Rev. Moonhawk River Stone, an interfaith minister and counselor from Niskayuna, N.Y., specializes in working with trans clients. He addressed the trans woman who wanted so badly to reconnect with her children.
"The only family that I have doesn't talk to me, too," said Stone, who is in his 60s. "I think there is nothing worse than a severed relationship."
He decided that he had to move forward. "I made a decision to actively grieve my family and that, if I was dead to them, they were dead to me." But he still hopes things will change.
Like other workshop leaders, he strongly encouraged trans men and women to put their wishes in writing, and choose a substitute decision-maker.
Katherine Whitehead, a palliative care physician at Toronto Grace Health Centre, spoke about end-of-life care. She noted that people who can't talk freely about their sexual identity should be of special concern to doctors, as they also may not be able to talk about their illnesses. She also spoke of treating patients whose families refused to accept them or their partners, and how that creates "disenfranchised grief."
Whitehead said it is very important for some trans patients to maintain their gendered appearance even at the end. She thinks medical personnel should help them with that.
She gets it, she said. Her mother wears "really, really blue eye shadow and has her hair done like Marie Antoinette once a week. If she dies with her hair down and her makeup off, she's not going to die as herself."