The Psychiatrist : Clinical and Therapeutic Journal
Open Access

Growing research is delving into the risk factors for Alzheimer's Disease and Related Dementias (ADRD) within lesbian, gay, bisexual, transgender, queer, and LGBTQ+ communities. However, there is a notable gap in studies examining the risk and resilience factors of ADRD among transgender and non-binary (TNB) populations. Transgender and non-binary individuals, by definition, identify differently from the gender assigned to them at birth, while cisgender individuals identify with the gender assigned at birth [1]. The determination of gender assignment often relies on physical genital appearance at birth, although it may also consider chromosomal and hormonal levels. ADRDs encompass a wide range of experiences that require prioritization and comprehensive research.

Elderly individuals within TNB communities exhibit a heightened diagnosis rate of dementia and face earlier risks of ADRD compared to older cisgender adults. Contributing factors to this increased risk include comorbidities such as hypertension, diabetes, obesity, stroke, and mental health diagnoses. Moreover, heightened levels of discrimination and social marginalization experienced by TNB adults are linked to deteriorating mental health outcomes and adverse effects on physical health. One possible mechanism behind the elevated risk of ADRD is the acceleration of cognitive aging due to minority stress, which can manifest as subjective or objective cognitive decline. Meyer conceptualized prejudice and discrimination as unique, additive, chronic, and socially evolving/permanent minority stressors. TNB individuals encounter discrimination more frequently than cisgender individuals, including those within the cisgender LGBQ+ community. Daily social stressors linked to discrimination can evoke responses resembling traumatic reactions, triggering the autonomic nervous system repeatedly [2].

TNB individuals have a longstanding history of exposure to minority discrimination and stressors within healthcare models and systems. Their relationship with the current healthcare system is marred by prejudice, gatekeeping, provider bias, and inadequate training. Data from the National Transgender Discrimination Survey (NTDS) and the US Transgender Survey conducted between 2010 and 2015 revealed that one-third of TNB participants experienced knowledge gaps (50%) and harassment (28%) from healthcare providers. Negative interactions with providers, including treatment refusal (19%) and medical environment violence (2%), were also reported. Fear of discriminatory treatment led to 28% of TNB participants avoiding healthcare altogether. Additionally, 40% of older TNB individuals reported fears of discrimination and internalized stigma within healthcare systems and from providers. The prevalence of discriminatory experiences is highest among TNB individuals who are perceived as such, at 40.9% and 36.9%, respectively [3,4].

Discussion

The study investigated the correlation between Subjective Cognitive Decline (SCD) and various psychosocial factors, including mental health diagnoses, experiences of violence, and discrimination in medical settings, among older individuals identifying as transgender or non-binary (TNE). Approximately 16% of older TNE adults reported experiencing SCD, and even after accounting for factors such as age, education, and other psychosocial variables, those who reported poor or inadequate memory were more likely to report instances of discrimination in medical environments. These findings suggest that older TNE adults may encounter unique obstacles that hinder their access to healthcare or their ability to discuss memory-related issues with healthcare providers [5].

Despite changes in diagnostic practices reflecting shifts in healthcare providers' attitudes toward TNE identities, our study revealed significant instances of discrimination in medical settings among elderly individuals with TNE, particularly those experiencing SCD. Overall, TNE adults in our study were more than twice as likely to report medical discrimination compared to their cisgender LGBQ+ counterparts. Furthermore, older TNE adults who reported experiencing significant discrimination in healthcare settings were 5-8 times more likely to report memory loss or memory impartiality [6]. These findings underscore the importance of conducting targeted studies aimed at facilitating cognitive health screenings and discussions with healthcare professionals among older TNE adults experiencing SCD. Additionally, efforts to address medical discrimination in this population may play a crucial role in promoting dementia awareness, enhancing early detection of dementia, and reducing health disparities associated with SCD.

Despite the benefits of early dementia detection, including the initiation of care plans and treatments and the prevention of unsafe behaviours, discrimination in medical settings serves as a barrier to achieving these outcomes. Therefore, it is imperative to provide additional training for healthcare providers and implement systemic changes in healthcare environments to ensure that older TNE adults receive comprehensive and competent care as they age, regardless of their SCD status. Furthermore, policy initiatives aimed at addressing discrimination in medical settings are warranted [7,8].

It is important to acknowledge the exploratory nature of this study, and further research is needed to elucidate the complex interplay between psychosocial factors, discrimination, and SCD among individual TNE individuals. While the findings underscore the role of minority stress and provider training in shaping healthcare experiences, the specific contributions of this study may vary [9]. Additionally, the relatively small sample size of TNE participants over the age of 50, predominantly Caucasian and well-educated, may limit the generalizability of the findings to broader populations. Moreover, reliance on self-reporting represents a potential limitation, although studies have shown self-reporting to be effective in capturing cognitive decline as well as other medical conditions [10].

Conclusion

This study lays the groundwork for a more comprehensive understanding of Subjective Cognitive Decline (SCD) and its interplay with psychosocial factors in the transgender and nonbinary (TNE) population. Psychological and social determinants such as poor health, food insecurity, experiences of violence, and discrimination in medical settings have been identified as correlates of SCD. Further research exploring the intricate relationship between SCD and modifiable psychosocial factors influencing cognitive health among older TNE adults is crucial for mitigating health disparities within this demographic. Given the heightened prevalence of SCD and discrimination in healthcare among older individuals with TNE compared to the general population, addressing these disparities is imperative.

Discrimination in healthcare settings poses a significant barrier to accessing dementia diagnosis, care, and support services for TNE individuals. Combatting discriminatory practices within healthcare organizations and among healthcare providers is essential for improving healthcare delivery and promoting dementia diagnosis across diverse populations. This may entail prioritizing competency training in TNE healthcare delivery, updating research methodologies to include TNE participants, and fostering a diverse and culturally competent workforce in healthcare research and practice. Ultimately, shifting organizational culture towards inclusivity and equity is necessary to address the unique healthcare needs of TNE individuals and reduce health inequalities within this population.

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