Transgender issues and later life

Factsheet 16 February 2015 Transgender issues and later life About this factsheet This factsheet provides information about later life for transgender (or trans) people. The main focus is on growing older for those who transitioned at a younger age and live their lives permanently in their affirmed gender. But it also provides information for people in later life who are seeking gender reassignment. The factsheet covers a range of social, care, legal and financial issues. It has a glossary and details of where to go for further information and support. The information given in this factsheet is applicable in England and Wales. Different rules may apply in Northern Ireland and Scotland. Readers in these nations should contact their respective national offices for information specific to where they live see section 18 for details. If you need further information or advice, see section 18 for details of how to order other Age UK factsheets and information materials. You will also find the telephone numbers for Age UK Advice there. If you need more detailed advice tailored to your personal circumstances or representation, it is often best to find a local service offering this. Age UK Advice can give you contact details for a local Age UK (or in Wales Age Cymru), or you could contact one of the independent organisations listed in section 17. Factsheet 16 February 2015 1 of 35

Inside this factsheet 1 Recent developments 3 2 What is transgender? 3 3 Trans Identities 3 3.1 Transvestite or cross-dressing people 4 3.2 Gender variant or gender non-conforming people 4 3.3 Transsexual people 4 3.4 Sexual orientation of trans people 5 4 Transitioning in later life 5 5 The transitioning process 6 5.1 The FtM trans man s transition 8 5.2 The MtF trans woman s transition 9 6 The limits of transitioning in later life 10 7 Getting older 10 7.1 Being a healthy older FtM trans man 11 7.2 Being a healthy older MtF trans woman 11 8 The longer term prognosis 12 9 Your rights 13 9.1 The Gender Recognition Act: the basics 13 9.2 Gender recognition and existing marriage 14 9.3 The Equality Act 2010 14 9.4 Hate crime 16 10 Financial issues 17 11 Care services 17 11.1 Care in the home 19 11.2 Sheltered housing and residential care 20 11.3 Making a complaint about your care 21 12 Mental capacity and making decisions 22 13 Wills and intestacy 23 14 Bereavement and registration of death 23 15 The partners of trans people 24 16 Glossary 25 17 Useful organisations 28 18 Further information from Age UK 33 Factsheet 16 February 2015 2 of 35

1 Recent developments The Marriage (Same Sex Couples) Act 2013 (England and Wales) and amendments to the Gender Recognition Act mean that people can change their legal gender without having to end their marriage. See Section 9. The State Pension age for women (including trans women with a Gender Recognition Certificate) is gradually increasing from 60 and will reach 65 by November 2018. State Pension age for both men and women will then increase to 66 by October 2020. See Section 10. Note: The glossary in section 15 explains common terms including those used in this factsheet. 2 What is transgender? Transgender, or trans, is an umbrella term that embraces many different gender presentations and lifestyles. A trans person crosses the conventional boundaries of gender in the clothes they wear and how they present themselves. They sometimes become fully bodily reassigned in their preferred gender role, male to female (MtF) or female to male (FtM). A trans person may or may not receive hormone therapy, have gender related surgical procedures or obtain legal recognition of their change of gender. In this factsheet we will be similarly inclusive but the focus is on trans people living permanently in their affirmed gender or who are seeking to do so. They are likely to face particular difficulties with family and friends, in employment and with government bodies and health and care providers, among others. 3 Trans Identities Trans people may identify and present as transvestites (or cross-dressers), as other gender-variant or gender non-conforming people, or as transsexual. Factsheet 16 February 2015 3 of 35

3.1 Transvestite or cross-dressing people Transvestite or cross-dressing trans people enjoy wearing the clothing of the opposite sex, often for relatively short periods of time, for sexual enjoyment or personal comfort. They are usually male. Trans people who cross-dress are usually comfortable with the gender they were assigned at birth and do not wish to change it. But for some, crossdressing is a preliminary stage before they decide that they are transsexual and decide to seek to live permanently in their preferred gender role. 3.2 Gender variant or gender non-conforming people Gender variant /gender non-conforming people are those whose preferred gender expression differs from society s expectations, given their birth sex. However they do not necessarily wish to pursue physical changes. Gender queer individuals may identify as between genders, as neither man nor woman, but do not necessarily wish to pursue physical changes. 3.3 Transsexual people Many transsexual people report identifying as a member of the opposite sex from a very early age. They often feel they were born in the wrong body. At some time in their life, perhaps after many years of cross-dressing publicly or in private, many will seek medical advice. This may depend on their personal and social circumstances, their family support and their degree of motivation. The medical term is gender dysphoria discomfort or distress caused by a mismatch between a person s gender identity and their biological sex assigned at birth. However some trans people and organisations prefer the term gender variance. At this stage they can decide if and how they wish to pursue transition. Do they wish to have hormone therapy, surgery and/or legal recognition of change of gender? None is a prerequisite for transition though many people will proceed to pursue some, if not all, of these. Transition is not a standard or pre-determined process individuals approach it in different ways according to their circumstances and preferences. Factsheet 16 February 2015 4 of 35

Those who change from female to male (FtM) are usually referred to as trans men; that is, they are now men but with a transsexual history. Similarly, those who change from male to female (MtF) are usually referred to as trans women; that is, they are now women but with a transsexual history. However, having opted to live in their preferred gender, few people with a transsexual history wish to be referred to as trans, transgender or transsexual. They are more likely to wish to be referred to as men or women. 3.4 Sexual orientation of trans people Some trans people identify as heterosexual in their affirmed gender role, while others identify as lesbian, gay or bisexual (LGB). It is also possible for a trans man or trans woman to experience a change of sexual orientation once transition has been completed. For example, a trans woman who was attracted to women before surgery may be attracted to men after surgery. However, this varies greatly from person to person, and the sexual orientation of many transsexuals does not change. 4 Transitioning in later life You may be asking yourself if you are trans or where you sit on the trans spectrum. For example, is the desire to dress occasionally in clothes of the opposite sex simply about enjoyment, or does it indicate something more? Though many trans people have an inkling early in their life, some may find themselves asking such questions later in life. Retirement from work or the death of a partner, for example, may suddenly provide the first real opportunity to think about and act on this. Older people have successfully transitioned and are living part time or permanently in their preferred gender role. There can be advantages as well as risks in taking this step. It can be an opportunity to resolve long standing conflicts and uncertainties that threaten mental health and well-being. When work and social responsibilities change, the social and economic impacts can be less. As people age their physical appearance can become more gender neutral, so it takes less to achieve the appearance of their preferred gender. Factsheet 16 February 2015 5 of 35

Achieving gender reassignment is not easy. The psychological implications should not be underestimated and these will be addressed as part of your assessment. The process will take several years, involve several doctors and if you decide to have surgery, probably involve more than one operation. Even after having the full surgery available to you (and not everyone is able to have all the possible operations), as a transsexual person you will require long term hormone therapy and monitoring for possible side effects. Note: If you live in England you can find information on gender dysphoria and the gender transition process on the NHS Choices website: search either gender dysphoria or transgender health ; look on NHS Direct Wales if you live in Wales (their website has an A-Z encyclopaedia section where you can find information on gender dysphoria). See section 17 for contact details. 5 The transitioning process Gender transition is likely to take several years. It starts with obtaining a diagnosis and receiving appropriate counselling, then making decisions about if and when to commence hormone therapy, begin living in your preferred gender and undergo surgery. Note: You may wish to contact a support group that provides information for individuals with gender identity issues and ask if they also offer the opportunity for you to meet people who have transitioned. The Gender Trust website lists details of support organisations across the UK. See section 17 for contact details. Assessment A visit to your GP is the first step, though typically she or he may not have experience of trans issues. Most GPs are unlikely to have seen many (if indeed any) trans people during their medical career. Factsheet 16 February 2015 6 of 35

Note: Before visiting your GP, you may like to read a document available on the NHS Choices website - Gender dysphoria: a guide for General Practitioners and other healthcare staff. This document has been written for the NHS in England though the vast majority of the general information will be equally as applicable for those living in Wales. www.nhs.uk/livewell/transhealth/documents/gender-dysphoria-guide-forgps-and-other-health-care-staff.pdf Your GP can refer you to a specialist team at one of the NHS Gender Identity Clinics (GICs). The clinics offer expert support and help, as well assessment and diagnosis, for people with gender dysphoria. A diagnosis of gender dysphoria can usually be made after an in-depth assessment carried out by two or more specialists. This may require several sessions, carried out a few months apart. It may involve discussions with people you are close to, such as members of your family or your partner. The assessment is to determine whether you have gender dysphoria and what your needs are. It may also involve a more general assessment of your physical and psychological health. Developing a treatment plan If the assessment suggests you have gender dysphoria, staff at the GIC will work with you to agree an individual treatment plan. This will include any psychological support you may need, a discussion on the risks and benefits of hormone treatment as well as any surgical treatment you may want to consider. When taking hormone therapy you will need regular check-ups to see if the treatment is working and identify any signs of associated health problems. Staff will also discuss preliminary timescales for treatment. Genital surgery (but not hormone therapy) is subject to completion of what is known as social gender role transition (previously known as real life experience or RLE) This involves living and presenting constantly in all aspects of life in your preferred gender for at least 12 months. This period has to be properly evidenced. Only then can lower surgery be authorised with the approval of two separate recognised gender specialists. The process may seem long and hard but a period of psychological adjustment is essential to a person s future success in their new role. Factsheet 16 February 2015 7 of 35

There are two ways to pursue gender transition in the UK the NHS route and the private route. It is possible to pursue gender transition using a combination of the two but this would need to be discussed with NHS staff. NHS clinics cannot work in parallel with private clinicians, so following your initial assessment you will need to decide if you would like each part of your treatment to be undertaken within the NHS or privately. The NHS route is free but demand is high and capacity is limited by the number and location of the Gender Identity Clinics. 5.1 The FtM trans man s transition Hormone therapy means taking the hormones of your preferred gender: a trans man (female to male) will take testosterone (masculinising hormones). The type, intensity and rate of reaction to hormone therapy varies considerably from person to person and depending on the type of medication being taken. The following list indicates the physical and emotional changes a FtM trans man may experience: beard and body hair growth. male pattern baldness may develop. the clitoris increases slightly in size. libido may be heightened. muscle bulk increases. the voice deepens, but not usually to the pitch of other men. in pre-menopausal women, periods will stop, although there may be some breakthrough bleeding requiring adjustment of dosage. some individuals develop acne. Breasts will not reduce in size but after about a year of living in his new gender role the FtM trans man may choose to undergo a bilateral mastectomy, which removes the breast tissue, reduces the nipple size and contours a masculine-looking chest wall. Factsheet 16 February 2015 8 of 35

Hormone therapy may be all the treatment needed to enable a trans man to live with his gender variance. Surgery to create a penis (phalloplasty) and construct a scrotum (scrotoplasty) along with testicular implants is also possible. Surgical techniques have greatly improved over the years. However, limitations of FtM genital surgery mean there are likely to be circumstances in which a man will have to disclose his past. 5.2 The MtF trans woman s transition Hormone therapy means taking the hormones of your preferred gender: a trans woman (male to female) will take oestrogen (feminising hormones). The type, intensity and rate of reaction to hormone therapy varies considerably from person to person and depending on the types of medication being taken. The following list indicates the kinds of physical and emotional changes an MtF trans woman may experience: reduction in sexual appetite. fat may be distributed on the hips. the size of the penis and testicles may be slightly reduced. some trans women find that erections and orgasm are harder to achieve. muscle bulk and power may be reduced. breasts may feel tender and lumpy and may sometimes increase modestly in size. the growth of facial and body hair may become weaker. This is regarded by many trans women as helpful in supporting the hair removal process using electrolysis and/or laser treatment and other hair removal techniques. male pattern baldness may be slowed or stopped, but is not necessarily reversed, so a trans woman is likely to need some supplementary support such as a wig or a hair transplant. The voice will not rise in pitch and the trans woman may well need speech therapy to help her achieve a more female tone. She may have more pronounced emotional ups and downs than previously experienced. Factsheet 16 February 2015 9 of 35

Hormone therapy may be all the treatment needed to enable a trans woman to live with her gender variance. However, if an MtF trans woman chooses to undergo genital surgery, such as vaginoplasty (construction of a vagina), this generally takes place between one and three years after starting to live in her new gender role. 6 The limits of transitioning in later life All the above stages are possible for older people. However the older a person is, the more they need to be aware of the limits and potential impacts and risks of hormone therapies and the various possible surgeries. Important issues that form part of a GIC assessment include: general physical fitness, including for example a history of high blood pressure or circulatory or cardiac problems whether you smoke or have been a smoker your weight, particularly if you are overweight. As there are less arduous alternatives that do not involve major surgery, it is important for people transitioning in later life to consider specialist counselling to support them to live in their new gender role while retaining their original genitals. 7 Getting older Your experience will vary according to the age at which you transitioned and when that was. If you are now 60 and transitioned when you were 20, you will have had a different life and faced different issues from someone who is now 60 but transitioned when they were 55. Knowledge is improving as trans people age but there are still unanswered questions about what later life and health will be like for trans people. We are only now seeing the first generation of trans people in their 60s and over who have taken hormone therapy for 30 years or more. Individuals are living with gender reassignment surgeries performed using the very different techniques of the 1960s and 70s. Factsheet 16 February 2015 10 of 35

More data needs to be collected and monitored to understand what it is like to have an older trans body. The experiences of older trans men and older trans women will be different. 7.1 Being a healthy older FtM trans man Annual health checks are strongly recommended as a minimum. Issues to consider, and to discuss as appropriate with the relevant health professional include: osteoporosis risk side effects associated with testosterone therapy vaginal health (if you still have a vagina) safe sex whether or not to undergo a hysterectomy need for smear tests if you have not had a hysterectomy risk of urethral stones, if you have had genital reconstruction breast cancer (even when trans men have their breasts removed, not all potentially cancerous glands are removed) the state of any silicone testicular implants and/or penile prosthetics. If you sense, see or feel anything peculiar about your body, it is important to get this checked promptly. Most trans men find they pass less easily as they get older. They tend to appear smaller in stature than ever. They may find that what has been their natural speaking voice for many years starts to develop an effeminate tone. You can discuss any concerns at your health check. 7.2 Being a healthy older MtF trans woman Annual health checks are strongly recommended as a minimum. Issues to discuss as appropriate with the relevant health professional include: the effects of oestrogen replacement therapy lifestyle issues - smoking cessation, diet and exercise Factsheet 16 February 2015 11 of 35

blood pressure oestrogen, testosterone and prolactin (hormone) levels prostate health (the prostate is not removed when you have lower surgery) dilation and douching advice if you have had vaginoplasty (plastic surgery performed to create a vagina) the health of your neo-vagina breast self-examination and mammograms the state of any silicone breast implants. The important thing to remember is that if you sense, see or feel anything peculiar about your body, to get this checked promptly. Trans women may find they pass more easily as they get older. This is because as women age and their oestrogen level drops, they tend to develop more masculine features. Note: A leaflet Transsexual people and osteoporosis is available from the National Osteoporosis Society. See section 17 for contact details. 8 The longer term prognosis Studies indicate that the longer term prognosis for the transsexual person is good. A review of a number of studies carried out over a 20-year period found that 96% of people who had gender reassignment surgery were satisfied. Research by the organisation Press for Change suggests that the vast majority of transsexual people enjoy much happier lives following surgery. However it is important to be aware that personal finances can be affected (see section 10). There is also a greater risk of relationship breakdown and becoming a victim of harassment or assault. There is Equalities legislation to tackle discrimination and protect rights, in particular the Equality Act 2010 (see the following section). Factsheet 16 February 2015 12 of 35

9 Your rights 9.1 The Gender Recognition Act: the basics The Gender Recognition Act 2004 (GRA) is one of the most significant legal changes for trans people. It came into force in April 2005. The GRA affords full legal recognition to a transsexual person's acquired gender. It recognises a transsexual person as someone who is living permanently in their acquired gender role and intends to do so for the rest of their life. Surgical procedures are not a prerequisite. What gender recognition means The GRA enables transsexual people to apply to a body called the Gender Recognition Panel, for 'gender recognition'. If successful they will receive a Gender Recognition Certificate (GRC). Those born in the UK will also be given a new birth certificate. On receiving a GRC, the trans person must be treated as their new sex for all legal purposes. A GRC gives the trans person enhanced privacy rights. This means that great care must be taken by all official bodies to ensure they do not disclose that the person is trans without their express permission. The GRA allows trans people to be recognised in their new gender for all legal purposes, including marriage and civil partnership, and gives them legal protection from others who disclose their status without their permission. Note: You can find out about how to apply to the Gender Recognition Panel for a GRC on the government website: www.gov.uk/apply-gender-recognitioncertificate/changing-your-gender A right to privacy Section 22 of the Gender Recognition Act provides high levels of privacy protection. It makes it a criminal offence for any individual who has obtained the information in an official capacity to disclose that a person has a Gender Recognition Certificate. Factsheet 16 February 2015 13 of 35

Official capacity includes all service providers, government agencies, local authorities, membership groups and associations, employers and the police (except in rare circumstances). Disclosure may only be made with the trans person s express permission. Note: It is important to ensure you put in writing, to any individual who knows your medical history, the limits you are placing on further disclosure. If you have privacy problems, contact Press for Change. See section 17. 9.2 Gender recognition and existing marriage The Marriage (Same Sex Couples) Act 2013 (England and Wales) and amendments to the Gender Recognition Act mean that from 10 December 2014 people may now change their legal gender without having to end their marriage, including civil partnerships that have been converted to a marriage, provided the applicant's spouse consents by making a statutory declaration. The necessary forms are available via a link on the Gender Recognition Panels website. See link above. 9.3 The Equality Act 2010 The Equality Act 2010 provides a legal framework to protect the rights of individuals and advance equality of opportunity for all. Gender reassignment is a specific category for which the Act provides protection against discrimination, harassment and victimisation. Gender reassignment is described as a person intending to, going through or having gone through the process of re-assigning his/her sexual characteristics (in full or in part). This protection is specifically for transsexuals and it applies equally to people intending to live permanently in their preferred gender role. Factsheet 16 February 2015 14 of 35

Employment rights The Equality Act 2010 makes it unlawful for an employer to discriminate against a worker on the grounds of gender reassignment, or to treat them less favourably. This includes protection from harassment, both by the employer and by colleagues. The Act also provides specifically that employers must treat absence from work for procedure related to gender reassignment in the same way as absence for sickness, injury or any other reason acceptable to the employer for staff absence from work. People can bring a claim at an Employment Tribunal if they are being discriminated against on these grounds. The Equality Act 2010 also contains positive action provisions for employers, to encourage people from groups with different needs or with a past track record of disadvantage or low participation (including trans people) to apply for jobs. Customers and service users You are protected against discrimination, harassment and victimisation in the provision of goods, facilities and services, under the Equality Act 2010. This applies to both the public and private sectors. For instance: It is unlawful for a publican or shopkeeper to refuse to serve you because you are trans. It is unlawful for a leisure centre to refuse to permit you to use their facilities because you are trans. It is unlawful for a housing association to refuse you accommodation, or to offer housing of lesser quality or on different terms, because you are trans. These are only examples. The law applies to most circumstances with only a handful of exceptions, for example, where the service is single sex, such as ante-natal care. Note: For advice and support about discrimination and human rights contact the Equality Advisory and Support Service. See section 17. Factsheet 16 February 2015 15 of 35

Public bodies The Public Sector Equality Duty is an important part of the Equality Act 2010. Its aim is to encourage public bodies to go beyond the elimination of unlawful discrimination, harassment and victimisation. They must consider how they can positively contribute to the advancement of equality and foster good relations between different groups. The duty applies to private bodies carrying out public functions, as well as to local or national Government bodies. An example could be a hospital offering a trans man the first appointment of the day for a hysterectomy. This would avoid him the embarrassment of being one man among many women in the waiting room. They could also make arrangements for him to have his details registered in a private area. Private clubs and other associations A private club or other association cannot discriminate against, harass or victimise an existing or potential member or an associate because they are trans. So, for example, it cannot refuse membership or grant membership on less favourable terms by applying different conditions or fees. 9.4 Hate crime If you are the victim of a crime you believe to be motivated by prejudice or hate, you should report it as a hate crime. The police define transphobic hate crime as: Any criminal offence which is perceived, by the victim or any other person, to be motivated by a hostility or prejudice against a person who is transgender or perceived to be transgender. Hate crimes may involve physical attacks, verbal abuse, domestic abuse, harassment, damage to your property, bullying or graffiti. Reporting such an offence as a hate crime can help ensure it is treated in the most appropriate and effective way. There are a number of safe and discreet or anonymous ways to do so, including online and through third parties. The True Vision website has more information: www.report-it.org.uk/home See section 17 for details. Factsheet 16 February 2015 16 of 35

10 Financial issues Trans people may have extra financial issues to consider in later life. For example, obtaining a Gender Recognition Certificate (GRC) can result in changes to benefit qualifications and affect a trans person s tax liabilities, pension benefits and credit status. You should seek professional advice from an independent financial advisor in advance of any legal change of gender and take proactive steps to protect your interests as much as possible. Your local Age UK (or in Wales your local Age Cymru) can explain about benefit entitlements; information about national insurance payments and tax credits is available from HM Revenue and Customs (HMRC); the Financial Conduct Authority (FCA) authorises independent financial advisers and any proposed or current lender should tell you what credit reference agency they use and how to contact them. See section 17. Pensions In the past one advantage for a trans woman applying for gender recognition was their eligibility to receive the State Pension at the age of 60. For trans men the rules were reversed: when awarded a Gender Recognition Certificate (GRC), a 60 year old trans man s State Pension entitlement ceased (though any pension payments already received are not claimed back). The State Pension age for women (including trans women with a GRC) is gradually increasing from 60 and will reach 65 by November 2018. State Pension age for both men and women will then increase to 66 by October 2020. See Age UK s Factsheet 19, State Pension for more information on the state pension and proposed changes. 11 Care services Many people who underwent treatment in the 1960s and 1970s are now facing all the ordinary issues that come with ageing, as well as some that are unique to trans people. Factsheet 16 February 2015 17 of 35

The 1990s and 2000s have seen a large increase in the number of people pursuing gender transition and reassignment, many of them in their middle or older ages. This means they are 'older people but young in terms of their experience of living and being in their new gender. We are also increasingly seeing disabled people undergoing gender reassignment who would not have been able to access services or treatments in the past. Therefore, for the first time, there is an ageing trans population. Consequently, it is increasingly common for health and social care professionals to be working with a trans client who may have complex social or bodily needs relating to their gender reassignment treatments. Seeking advice from a multi-disciplinary team on how to meet the client s needs would appear to be common sense, but the privacy rights now afforded to trans people mean that they must get the client s permission before discussing the matter in any way that might identify the client. Transgender personal care issues When approaching a care agency or local authority for an assessment of your needs or if considering hospital tests or treatment, it is important to be mindful of the issues you face daily to manage a trans body and your personal privacy needs. It is helpful to ask yourself the following questions and be ready to raise any concerns you may have prior to engaging with health and care services. Trans women Do I still look masculine when undressed? Do I still have a penis? Do I have breasts? Do I need to shave regularly? Do I need my own room in which to dilate and douche? What do I need in order to maintain my hormone regime? Do I need to maintain my hair, e.g. a wig, hairpiece or weave? Factsheet 16 February 2015 18 of 35

Trans men Do I still look feminine when undressed? Do I have no penis, or do I still have breasts? Do I need to take special care of my penis or metoidioplasty, e.g. catheterisation? 11.1 Care in the home You can receive care services provided by, or on behalf of the social services department of your local authority. You can also make your own arrangements with an independent care agency. These organisations should have accessible equality, anti-bullying and confidentiality policies. Do not be frightened to ask for a copy. If they do not include trans people in their remit ask how to contact the right person to discuss how trans people should be included. Assessment Your local authority has a legal duty to carry out an assessment of anyone living in its area who may need community care services, once it becomes aware of this need. Then based on its eligibility criteria, it must make a decision as to whether to provide services. The assessment should take into account all your needs psychological, social and cultural, as well as personal care and domestic. In England see Age UK s Factsheet 41, Local authority assessment for community care services provides further information. In Wales, see Age Cymru s Factsheet 41w, Local authority assessment for community care services in Wales. Means testing Services arranged by the local authority are generally means tested, which means you may have to make a financial contribution. In England Age UK s Factsheet 46, Paying for care and support at home, and Factsheet 6, Finding help at home provide further information. In Wales see Age Cymru s versions of these factsheets 46w and 6w. Factsheet 16 February 2015 19 of 35

Personalisation and direct payments The Government s personalisation policy aims to give service users more choice and control over the services they receive. If eligible for financial help from your local authority to provide services, you now have the option to receive direct payments so that you can arrange services yourself or with support from a third party. This may be very important to you because it means you can arrange the assistance you need to meet personal and other care needs. You may choose to recruit a personal assistant someone you feel comfortable with, who can respond to your individual needs and preferences and offer continuity of care. In England see Age UK s Factsheet 24, Self-directed support: direct payments and personal budgets for further information. In Wales see Age Cymru s Factsheet 24w, Direct payments for community care services in Wales. 11.2 Sheltered housing and residential care There has been no significant research into the care of older trans people in sheltered or residential accommodation. When facing decisions about sheltered housing or residential care, the trans person and/or their carer should ensure they do plenty of research and visit all the establishments they might consider. As with care services, these organisations should have accessible equality, anti-bullying and confidentiality policies. Ask to see a copy of their policies. If they do not include trans people in their remit, ask how to contact the right person to discuss how trans people should be included. In England see Age UK s Factsheet 29, Finding care home accommodation and Age UK s Factsheet 10, Paying for permanent residential care. In Wales see Age Cymru s versions of these factsheets 29w and 10w. Age UK s Information Guide, Housing options may also be helpful for people in both nations. Factsheet 16 February 2015 20 of 35

11.3 Making a complaint about your care NHS services If you have a concern or problem with your GP practice or NHS service such as hospital care, raise it with the health professional concerned or their manager. An informal discussion may be able to resolve your problem without needing to use the formal NHS complaints process. In England see Age UK s Factsheet 66, Resolving problems and making a complaint about NHS care for further information or contact your local Healthwatch. See section 17. In Wales see Age Cymru s Factsheet 66w, Resolving problems and making a complaint about NHS care in Wales, or contact your local Community Health Council see section 17 for contact details. Local authority services If you have a concern or problem with social care arranged or provided by the local authority, first try to resolve the issue informally. Speak with your social worker or their line manager. If this proves unsatisfactory, you can make an official complaint using the local authority complaints procedure. See Age UK s Factsheet 59, How to resolve problems and make a complaint about social care for further information. This factsheet contains information which is relevant to England only. At the present time there is no direct equivalent to this factsheet by Age Cymru in Wales. However Factsheet 41w, Local authority assessment for community care services in Wales contains a section on making complaints about social care. Privately arranged care If you have a concern or problem with care services that you arranged privately, you should use the agency or care home s own complaints process. If you remain dissatisfied, you can take your complaint to the Local Government Ombudsman. The Local Government Ombudsman provides a direct service for people in England funding their own social care at home or in a residential setting. Factsheet 16 February 2015 21 of 35

There is not currently an equivalent Ombudsman service for people in Wales who arrange and fund their care privately. Recent legislation in Wales the Social Services and Well-being (Wales) Act 2014 is set to rectify this situation, though the change won t be implemented until April 2016. See the section on making a complaint about social care in Factsheet 41w, Local authority assessment for community care services in Wales. See section 17 for contact details. 12 Mental capacity and making decisions It is a good idea to consider writing a document known as an advance statement. Here you can record your beliefs and preferences. You can also use it to describe how you would like to be cared for should you, in the future, be unable to make or communicate preferences and decisions for yourself. This could include, for example, describing what type of clothing you wish to wear or if you are a trans man with size 4 feet, requiring care staff to only purchase male footwear for you. Trans people should also endeavour to ensure that someone is going to act in their best interests. In the above case, this would mean ensuring only men s slippers are purchased for you. You can make a Lasting Power of Attorney (LPA). This is a legal document in which you appoint a relative or someone you trust to be your Attorney. Your Attorney must make best interests decisions on your behalf, should you no longer have the mental capacity to make or communicate decisions for yourself. There are two types of LPA. You can make an LPA that addresses property and financial affairs and/or one that addresses health and welfare issues. See Age UK s Factsheet 22, Arranging for someone to make decisions about your finances and welfare for further information Factsheet 16 February 2015 22 of 35

13 Wills and intestacy Making a will Just like everyone else, trans people should write a will to ensure their property and other assets go to those they would prefer to have them on their death. You should make sure you are fully and clearly identified in your will, if you use two names or have only recently begun to live permanently in your new gender role. See Age UK s Factsheet 7, Making a Will for more information. Being the beneficiary of a will In terms of being a beneficiary of a will, it is important as a trans person to keep some evidence of your past identity, including your gender as registered at birth. If you have a Gender Recognition Certificate this will provide the link. If not, you should keep some other paperwork, such as your change of name, to ensure you can rightly benefit from a will. 14 Bereavement and registration of death Most deaths are registered by a relative of the person who has died. The registrar normally only allows someone else to do it, such as someone present at the death, if no relatives are available. The registration must be made with the Registrar of Births, Marriages and Deaths for the district where the death occurred and is based on the details provided by the informant. Where problems arise with regard to a trans person, it is generally because of uncertainty about what to do when stating the deceased s sex. Sometimes relatives register the death of the trans person in their birth gender, no matter how long a person has permanently lived in their preferred gender. However, if they had a Gender Recognition Certificate, then their affirmed gender should be stated when registering their death. If a trans person has been living permanently in their affirmed gender role, it is generally considered perfectly acceptable to put down their sex as that of the gender they lived in. Factsheet 16 February 2015 23 of 35

If an error is made in registering a death, the law allows for details to be changed or added. Corrections should be arranged with the office where the death was registered, although the paperwork will need to be sent for authorisation to the Corrections and Re-registration Section at the General Register Office. Note: You should contact the General Register Office if you are uncertain about registering a trans person s death, for example because you are not sure whether they had gender recognition, or were living permanently in their preferred gender, or you are concerned that someone else has registered a trans person s sex on death incorrectly. See section 17 for contact details. 15 The partners of trans people If you are the partner of a trans person, watching what is happening to your loved one as they come to terms with their gender issues, whether or not they decide to pursue transition, can be very distressing. You may feel that your hopes for the future have come crashing down. You may feel a sense of loss and emotional confusion as well as anger and hurt. It can also affect your sense of who you are if you were a loving wife to a handsome man, do you now become the lesbian partner of a masculine-looking woman? All sorts of questions arise. Do you stay or do you go? How and what do you tell people including relatives and friends? What do your children and grandchildren call your partner. How do you address each other in public? How do you refer to each other? How do you appear together in public and are you prepared to do so? How do you want your partner to present themselves in public and how do you advise them tactfully on what, for example, it is appropriate for an older woman to wear? If a salary is lost, or the neighbours refuse to speak, it becomes a serious family matter. On top of all this partners may have to witness or help their partner deal with comments or discrimination or, at worst, outright instances of transphobia. See section 9.4. Hate crime. Given that partners are more than likely to have such feelings and experiences and suffer such losses, they will often need their own independent support mechanisms to help them cope, to decide what they really want to do and, ultimately, whether to stay or go. Factsheet 16 February 2015 24 of 35

There are support organisations such as Depend and Women of the Beaumont Society (WOBS) that provide support for family and friends. See section 17 for contact details. 16 Glossary A-gendered: a person who feels their gender identity is neutral, or that they have no gender at all. Affirmed gender: describes the post transition gender role. Bi-gendered: a person who feels that his/her gender identity includes both male and female elements. Bilateral mastectomy: the removal of some breast tissue from both breasts and the reconstruction of the chest wall to resemble a male chest. Body image: the internal perception of one's body, including not only what the body looks like, but feelings and sensations, the perception of one's own voice, and so on. Transsexuals usually have an internal body image that is at odds with their actual body until this is altered via hormones and surgery. Breast Augmentation (BA) / Augmentation Mammoplasty (AM): enlargement of the breasts, usually with implants. Butch: a certain sort of masculine appearance often used to refer to butch lesbians as opposed to femme lesbians. Cisgendered man/genetic male: a man born with male anatomy, as opposed to a man born with female anatomy (a trans man). Cisgendered woman/genetic female: a woman born with female anatomy, as opposed to a woman born with male anatomy (a trans woman). Cross dresser/transvestite: a person who wears the clothes of the opposite birth sex group for personal and/or sexual pleasure. Cross-gender living: living in the gender role of the opposite anatomical sex group. Drag: the art/performance of dressing up in the clothes of the opposite sex to provide entertainment; sometimes used to make a political statement. Factsheet 16 February 2015 25 of 35

Drag king: rarely do drag kings identify as men, they identify as women who choose to dress up as men for certain social occasions. They are not trying to imply they are men. Drag queen: rarely do drag queens identify as women, they identify as men who choose to dress up as women for certain social occasions. They are not trying to imply they are women. Endocrinology: the field of medicine concerned with hormones, including the sex hormones oestrogen and testosterone. FFS or Facial Feminisation Surgery: involves various surgical and nonsurgical procedures to feminise the face of trans women such as facelifts, tracheal shaves (reduction of the Adam s Apple), botox and fat injections. FtM: female-to-male trans person, a trans man. Gender: the social differences between women and men that have been learned, are changeable over time and have wide variations both within and between cultures. The term is often used to differentiate from sex which refers to biological differences. Gender dysphoria: the term used by psychiatrists and psychologists to describe a person s condition of feeling unwell or unhappy with their gender as assigned at birth, in terms of both their social role and their body. Gender identity: a person's internal sense of being male or female. Gender identity disorder (GID): the same as gender dysphoria (above) and gender variance both of which have now largely replaced the term GID. Gender/sex reassignment/confirmation/realignment treatment: terms used for the medical treatments including hormone therapies and surgical procedures to change a person's appearance to nearer that of the opposite birth sex group. Gender recognition: a process whereby a transsexual person's affirmed gender is recognised in law, or the achievement of the process. Gender Recognition Act (2004) (GRA): the UK law that allows transsexual people to obtain gender recognition. Gender Recognition Certificate (GRC): a certificate provided to those who have been successful in their application for gender recognition. Factsheet 16 February 2015 26 of 35

Gender Recognition Panel (GRP): a group of lawyers and doctors appointed to consider applications for gender recognition. Gender role: how a person expresses himself or herself in terms of traits commonly associated with masculinity and femininity. Gender variance: the same as gender identity but preferred by some as more neutral and less associated with mental illness. Hysterectomy: the surgical removal of the womb and cervix. Metoidioplasty (also called genitoplasty): the process whereby, when the clitoris has enlarged after testosterone hormone therapy, the clitoral hood is released so enabling the clitoris to be more forward and upright and to resemble a micro penis. MtF: male-to-female trans person, a trans woman. Non-op: a person who does not desire surgery, or does not need surgery to feel comfortable with his or her body. Orchidectomy: the surgical removal of the testes. Oopherectomy: the surgical removal of the ovaries. Penectomy: the surgical removal of the penile tissue the precursor to the creation of a new vagina. Phalloplasty: the surgical creation of a penis like piece of flesh, though it is not a penis inasmuch as it is not erectile tissue and cannot have sexual sensation in itself. Sometimes the urethra can be successfully extended through it so that urine may be passed standing and sometimes erectile implants can be placed in it so that penetration of a sexual partner can be achieved. Post-op/pre-op transsexual: having had/awaiting gender-confirmation surgeries. Non-op is the correct term if a person doesn t intend to pursue gender confirmation surgery. Scrotoplasty: the surgical creation of an apparent scrotum. SRS (Sex Reassignment Surgery) or GRS (Gender Reassignment Surgery) or GCS (Gender Confirmation Surgery): surgery to bring the external and internal genitalia into alignment with the trans person s self-perception. Factsheet 16 February 2015 27 of 35

Trans person/people/man/woman: inclusive terms that embrace many different gender presentations and lifestyles. Transgender: an umbrella term that defines a community that includes transsexual people, transvestites (or cross-dressers) and other groups of gender-variant or gender-non-conforming people. It has also been used to refer to people who express gender in non-traditional ways, but continue to identify as the sex of birth. Transition: the process of beginning to live full time as the opposite sex and changing the body, through hormones and sometimes surgery. Transsexual (female to male, male to female): a person who experiences a profound sense of incongruity between his/her psychological sex and his/her anatomic sex. Vaginectomy: the surgical removal of the vagina and the closure of the vaginal opening. Vaginoplasty: the surgical creation of a vaginal opening and canal. 17 Useful organisations National support organisations Beaumont Society A self-help body run by and for the transgender community, offering support for members of the transgender community, their partners, family and friends. Tel: 01582 412 220 (24 hour) Email: enquiries@beaumontsociety.org.uk Website: www.beaumontsociety.org.uk Community Health Councils (CHCs) in Wales CHCs are a statutory and independent voice in health services in Wales. They work to enhance and improve the quality of local health services. Each CHC runs a Complaint Advocacy Service. Tel: 0845 644 7814 Email: enquiries@waleschc.org.uk Website: www.nhsdirect.wales.nhs.uk/localservices/communityhealthcouncils/ Factsheet 16 February 2015 28 of 35