Gender transition in the workplace: An occupational therapy perspective

Abstract

BACKGROUND: This narrative review aims to describe the experiences of transgender people transitioning in their place of work. There are over 10,000 transgender individuals living and working in the UK. Currently there is limited research investigating the experience of changing gender in the workplace from an occupational perspective; considering activities of daily living and support currently offered to aid this transition.

METHOD: Quantitative and qualitative articles published from 2002–2013 were sourced using electronic databases, via email from the authors and from hand searches. Articles were included if they discussed the experiences of transgender people transitioning from one gender to another while in employment, pursuing a new career path or seeking work. Articles were excluded if they used generalisations from LGBT studies.

RESULTS: The findings show that successful transitioning in the workplace is a complex process requiring social and managerial support, environmental adaptation, legal guidelines, and a re-construction of how ‘gendered occupations’, such as self-care and job roles are carried out according to the social construction of the gender binary.

CONCLUSION: Future research is warranted on the occupational experiences of transgender people in employment. When considering the ‘gendered occupations’, changes in activities of daily living during transition, and the social/environmental adaptations required by all parties it is evident that an occupational perspective, such as that used by an Occupational Therapist, would be highly beneficial within this specialised area of vocational rehabilitation.

Keywords

Transgender employment vocational rehabilitation career occupation

1 Introduction

Gender is recognised to influence how a person chooses and participates in their career, where socially constructed cues signifying femininity or masculinity still exist, [1 –4]. For people with Gender Dysphoria who are undergoing transition these factors can make their journey more complex to navigate. According to the World Professional Association of Transgender Health (WPATH) [5], Gender Dysphoria refers to distress or discomfort caused by a discrepancy between the person’s gender identity and their assigned sex at birth. However, with appropriate intervention and support Gender Dsyphoria can be alleviated and individuals are able to find a gender role and expression that is comfortable for them, which may differ from that assigned at birth [5, 6]. Once a transgender identity as a trans-man or trans-woman is established, in the UK the individual may apply for a Gender Recognition Certificate, to live out the rest of their life in their new legally recognised gender [7]. This allows their previous identity to be protected and concealed.

In 2010, figures suggested that there were 12,500 transgender individuals receiving treatment for Gender Dysphoria within the UK population [8]. ‘Transitioning’ is a complex and challenging process, as individuals are required to follow a specific treatment pathway through Gender Identity Clinics (UK) to achieve their gender transition goals [6, 9]. As part of this process, individuals are required to undertake the ‘Real Life Experience’ whereby they must live in their preferred gender role for a period of 3 months before hormone treatment can begin, and from one to three years before surgery is considered [9, 10]. As part of this ‘Real Life Experience’ it is a mandatory requirement to continue full or part time employment or else treatment may be withdrawn and it is not possible to apply for a Gender Recognition Certificate [5 , 12].

Recently, in a British Broadcasting Corporation (BBC) television programme, transgender individuals were filmed while undergoing the reassignment process [13]. The surgeon discussed the economic benefits of ensuring people with gender dysphoria are given treatment like any other condition, as many people with the condition are of working age and cannot work when they are too self-conscious about their appearance. He went on to say that by being left untreated the risk of suicide is higher and the cost of a day in intensive care is far greater than the cost of reassignment surgery [13]. This Economic Model of Disability, whereby the ‘impairment’ is assessed in terms of economic consequences to the individual or the state [14], although not congruent with client-centred practice, suggests that ensuring transgender individuals are supported to continue working is beneficial for the economy as a whole.

As the person transitions from one gender to another, they must make the decision to transition at their current place of employment or alternatively seek employment elsewhere in their new gender identity. However, all previous employment history will be lost due to name changes and therefore they will be entering the job market with no references, no employment history and no record of ever working; therefore, it is preferable to maintain current employment [11]. In a broad online survey on the transgender experience conducted by the UK Home Office [15], the key findings indicated that employment was a main area of concern for transgender individuals, with around a third of the respondents selecting it as their main priority. Respondents identified that they had experienced difficulty gaining and retaining employment, with 66% identifying it as the most challenging aspect in their lives.

Many employers did not have policies to support transgender employees and 96% of the respondents said they had never been given any support in finding a job. As a result of these findings the Home Office launched the first ever transgender action plan to address the outcomes of the survey [16], which included strategies to inform the Department of Work and Pensions (DWP), Job Centre Plus and Her Majesty’s Revenue and Customs (HMRC) on how to update policy or support transgender people in the labour market. In January 2012 the UK Home Office released targeted guidance on employing Transgender individuals: ‘Advancing Transgender Equality: a plan for action’, available through JobCentrePlus [16, 17]. However, this guidance targets prospective employers, not current employers and only provides advice on pensions and taxes; therefore, this may do little to assist current employers.

On 17th June 2011 the UN Human Rights Council made amendments to the Human Rights Act to include transgender persons:

“all human beings are born free and equal in dignity and rights and that everyone is entitled to all the rights and freedoms set forth in that Declaration, without distinction of any kind, such as race, colour, sex, language, religion, political or other opinion, national or social origin, property, birth, or other status;”

Going on to say:

“Expressing grave concern at acts of violence and discrimination, in all regions of the world, committed against individuals because of their sexual orientation and gender identity”

Furthermore, the UK Equality Act [18] now explicitly offers protection for ‘gender reassignment’. However, it takes time for these policy changes to impact the day-to-day workplace environment.

This paper will review available literature to explore the experiences of transgender individuals in gaining, retaining and progressing through employment, identifying key issues and exploring common themes. The central knowledge base of occupational therapy focuses on how humans ‘do’ everyday life, within a disciplinary framework to analyse the complexity of ‘doing’. This understanding could be described as an ‘occupational perspective’ [19], because ‘occupation’ is the term used to describe collections of activities that provide structure and meaning. For example, working, taking care of one’s appearance, parenting or studying at school could all be described as ‘occupations’.

It is acknowledged that within the work-related research literature, the term ‘occupation’ typically is limited to job categories and work roles. However, it is important to distinguish the different usage of the word, because part of the aim of the study is to explore how the particular perspective of occupational therapy could enhance assisting transition in the workplace; by understanding the importance of changing occupations assigned to previous gender roles, the motivation that drives certain gender stereotypical occupations and by adapting new ways of participating within the work environment to assert a new gender role [20, 21]. It is recognised that there is a gender order which influences the distribution of work and resources as well as power, and occupations can be characterised by gender, often to the disadvantage of women [22]. It is hoped that the outcomes of the review could inform occupational therapy practice with transgender individuals in the workplace and also to provide an insight into the value of an occupational perspective for other professionals working in the field.

2 Method

It was identified early in the search strategy that the transgender community is closely linked in literature to lesbian, gay and bisexual (LGB) studies; therefore, a broad search of the literature was conducted; becoming progressively refined. Firstly, literature was searched within all available online Journals, through Google Scholar, Ingenta, Wiley online and Taylor and Francis online; the Cochrane library; and databases such as CINAHL, MEDLINE and ASSIA using the keywords ‘Occupational Therapy AND Sex, Gay, Lesbian, Transgender, and Sexuality’. The initial search produced 1,247 general results that were then refined using the keywords ‘transgender, transsexual AND work, vocational, occupation, career, employment’, and then further refined by limiting the date to within 10 years. A hand search of journals available to the authors was also conducted, books were located online, citation tracking occurred and lastly various authors of unavailable literature were emailed producing a further five results. In total 36 articles were considered for appropriateness through the use of a comparative matrix against the inclusion and exclusion criteria (written in English; transgender issues in the workplace were discussed; avoided generalisations from LGB experiences). A further methodological critique was carried out to determine the quality of the research in terms of transparency and rigour of method, sample size, potential bias, coding and theming and ethical issues. Furthermore, the studies were also considered against Finlay’s ‘5C’ criteria; Clarity, Credibility, Contribution, Communicative resonance and Caring [23]. This resulted in a total of nine articles selected for the purposes of the study.

The selected articles were spread between geographical locations, with five from the United States, one from Canada, two from the United Kingdom and one from Thailand. As the research covers three continents, UK policies and legislation on current healthcare requirements referred to may not be relevant to all participants or impact on how the transition is navigated. Four articles that were considered dated by current standards of research are, nonetheless, included as they are key studies within this field [24 –27]. Additionally, due to a lack of exploration or research within the field of Transgender issues it was common for researchers to utilise non-standardised interview questionnaires or modify research methods to meet the focus of the research objectives. Despite the limitations, all nine articles selected for this narrative review are unique and relevant for the purpose of exploring the focus of the enquiry. The issues raised with sourcing appropriate research highlight the need for more empirical research to be conducted on a topic that is becoming increasingly prevalent worldwide.

3 Review of literature

The final nine articles were further analysed using a four-stage analysis [28] to develop the themes that inform the basis of this narrative review: disclosure in the workplace; gendered spaces and self-esteem; gendered occupations; personal discrimination, and barriers and enablers of maintaining the same job.

3.1 Disclosure in the workplace

In the study of 5 transgender participants in Canada (a subsample of a larger qualitative study focusing on experiences of LGB women) [29], the qualitative interviews revealed that transitioning at work was a key cause for concern for participants. Preparation to transition became a full time occupation taking weeks, months or years involving activities such as, gathering information from the internet, participating in online forums and learning from the experiences of others. Participants approached Human Resources (HR) or senior staff members, armed with information to educate their employers before ‘coming out’ to colleagues; although a common theme from the studies revealed that many employers had never had this situation before and were unprepared to deal with it [26 , 30]. This is supported by the UK case study [26] where one to one interviews were conducted with employers and colleagues. It details how the manager and HR conducted internet searches to locate guidance or policy and in an interview they reported feeling “out of their depth, lacking in knowledge and isolated”.

In the Budge et al. qualitative study [30], interviews revealed that all participants had transitioned in their personal lives before transitioning at work due to the anxiety of how they would be received, and in some cases participants were so overwhelmed by hiding their gender identity within work, they attempted suicide. Hines used a narrative approach to explore the social world of 30 participants and gain insight into their stories [31]. This revealed that fear of job loss or discrimination is so great that some wait until they reach retirement age to transition.

Beagan et al. [29] found that those working within highly gender stereotyped environments found the process more challenging. For example, one participant worked as an electrical technologist with what she describes as ‘alpha type men’ and felt it was necessary to spend two months planning the disclosure with HR due to fear of discrimination. In support of these findings, one participant in the Budge et al. [26] qualitative study was quoted:

“It was really hard because I do work with all trades-people, and in trades there’s this big macho side you have to put on. So when I came back, nobody would look at you, and all of a sudden I was a total outcast”

This highlights how fear of disclosure is also strongly linked to the type of work environment, as studies found that those involved in the arts or in gender neutral vocations found the disclosure a simple process due to ‘open and supportive colleagues’ [25, 31]. To support this Brewster & Velez’s [32] quantitative study of over 263 transgender participants from 37 different states in America, revealed that explicit identity exposure in an initial supportive work environment resulted in increased job satisfaction for transgender individuals.

3.2 Gendered spaces and self esteem

A key issue identified from the studies within daily self-care activities, was deciding which bathroom to use at work. The main cause for this issue is that many employers fail to acknowledge the change in gender until genital surgery has been performed, creating a situation where individuals are forced to use a toilet facility that does not match the gender with which they associate. This also causes uncomfortable situations with colleagues with whom the facilities are shared. For example in the qualitative interviews by Beagan et al. [29], one participant said:

“The big issue was the washroom issue, females and males not wanting you to go into theirs”.

Similar situations occurred in the studies of Barclay and Scott; Budge et al. [26, 30], whereby neither male nor female colleagues wanted the participant to use their toilet and instead, individuals were made to use the accessible toilet. Furthermore, in the 2 case studies, work colleagues insisted they should not attend a social event, as there were no disabled facilities. Thus, direct discrimination against the transgender individual, impacted on leisure activities outside of the work environment. In these cases individuals felt pushed out of both gendered spaces and made to feel unwelcome by their destination gender.

In contrast to these findings Shilt & Connell, [25] showed that the majority of their participants were welcomed into ‘gendered spaces’ such as washrooms and changing rooms. However this only occurred once hormone therapy had commenced and they could ‘pass’ as their desired gender. Other examples of how individuals were welcomed into the destination gender and were shown ‘how to do things’ in the agreed gendered way included being invited to gossip and shown how to apply make-up, in a stereotypical ‘female’ manner. Shilt & Connell [25] discussed this process as a re-enforcement of the gender binary (the classification of sex and gender into two distinct, opposite and disconnected forms of masculine and feminine [33]), as participants were taken on as ‘gender apprentices’ in a masculine vs feminine enactment, as though to become male or female they must be shown how to do it properly by others.

All participants discussed how the reaction of colleagues regarding the issue of gendered space impacted on their self-esteem during transition. For those who had a negative experience, they felt directly discriminated against and excluded from their peer group. Conversely those who had positive experiences had feelings of inclusion and increased self-esteem. In all nine articles the success of transitioning in the workplace was linked to levels of self-esteem, as all participants valued their role within their workplace and acceptance of their new gender identity in this aspect of their lives was considered to be a high priority [26 , 30].

3.3 Gendered occupations

Beagan et al. and Suthrell [29, 34] discussed how choice in self-care occupations allows people to portray, project and affirm their chosen identity. In their studies, Budge et al. and Shilt [30, 24] explored how participation in self-care activities, such as dressing, became a key issue in the lives of participants. For example, MTF individuals spent time on makeup routines, choosing feminine clothing and shoes and hair styling, while FTM individuals adopted the role of protector towards women and similarly changed to more ‘masculine’ self-care routines.

The choice of how to present themselves to colleagues and employers was a way of informing others about their gender identity, seeking acceptance from others and attempting to ‘fit in’. Change in clothing often occurs before hormone therapy and/or surgery, it is the first identifiable marker of transgender status; therefore of great importance and significance to participants [30]. Some professions require a particular dress code, often determined by gender [35], which sometimes impacted on the vocational choices for transgender individuals. For example, within the study conducted by Shilt [24], a participant felt unable to pursue a career in law school until they transitioned, because wearing a dress and blouse was so far removed from their gender identity.

Colleagues and employers changed their perception of work tasks based on gender [25, 29]. For example, in the Budge et al. [30] qualitative study, participants describe how they are given ‘female occupations’ such as pruning flowers, and men would not allow them to do any of the hard labour that they were previously capable of doing. Similarly, in the findings of Shilt & Connell [25], colleagues imposed expectations of gendered occupations such as the MTF individual being included in social discussion of grandchildren, being shown how to manage their hair and makeup, or being taken to shop for clothes. Whereas, the FTM participants were required to lift heavy boxes and move office furniture; an activity they had never being required to carry out before. For some, this change in occupations was welcomed, although for others it was interpreted as being forced to ‘fit’ into a gender stereotype.

3.4 Discrimination and sexism

Brewster & Velez [32] found over 80% of respondents had experiences where they were ignored in the office or in meetings; had crude or offensive sexual remarks made about them; had colleagues avoid touching them; or colleagues made transphobic remarks about them. Within a sample of 263 participants this finding is significant. Qualitative studies revealed similar experiences; for example, in the UK case study by Barclay & Scott [26], the individual was informed by a senior member of staff that she was “an embarrassment to the organisation” and in addition to this, some colleagues refused to work with her and would intentionally use the incorrect name or personal pronoun. In the study by Budge et al. [30], two of the 18 participants were fired following their gender transition and felt that, although other reasons were given by their employer, it was in direct response to their transgender status.

Furthermore, the qualitative study by Shilt & Connell [25] found that following a male to female (MTF) transition, participants were surprised to find their productivity levels being doubted by their managers. Shilt & Connell [25] suggest MTF individuals become ‘outsiders within’ by experiencing how women are perceived and treated in the workplace [36]. Some participants felt at a disadvantage in their new female gender, as their ability to do their job was questioned. For example, one participant was forced out of her co-owned professional business by her business partner, who said:

“How can you expect to run a company when all you’re going to be thinking about is nail polish?”

In contrast, Shilt [24] explores female to male (FTM) transition and how FTM transgender participants describe the respect, authority and opportunity afforded to them as ‘men’. The participants recognise the idea of ‘male privilege’ and the experiences they recount offer a clear insight into the gender divide in the workplace. For example, one participant describes how they transitioned when working as an attorney for a law firm and an associate of the company was overheard commending the boss for firing the “incompetent woman” and hiring the “delightful new guy”, unaware they were the same person with the same skills and attributes for the job. Other participants described how they could work less but get rewarded. Many participants were able to pursue business ideas, gain promotions and made economic gains following their transition to the male gender [27].

Ocha interviewed 65 transgender participants employed as sex workers in Thailand [37]. The focus of these interviews was predominantly regarding their commercial sex services although participants discussed the difficulties in obtaining mainstream employment due to their transgender status. For example one participant was quoted saying:

“I experienced discrimination during a job application at a factory in Bangkok. When I submitted my identity card with the title ‘Mr’ one employer shouted at me ‘Hey toot (faggot) get out!”

However, participants felt welcomed and valued within the sex and entertainment industry, as it offered them a daily opportunity where they could assert their female gender, emphasising the importance of gender influence on choice of daily occupations and career. Following harassment, discrimination, job loss and abuse, many transsexuals, including those in the UK, fall into the market of transgender sex work [11 , 39]. Some Gender Identity clinics do not consider this a viable form of work relevant for their ‘real life experience’, although many will use this income to pay for surgery [40].

3.5 Barriers and enablers of maintaining the same job

Pepper & Lorah [27] described the positive aspects of transitioning in the current place of work as familiarity, financial stability, support from known associates or friends and knowing the job. This is supported by Budge et al. [26] who found that participants who transitioned in their place of work felt the familiarity of keeping the same job was reassuring as it offered security and allowed normal routines to continue, with one participant saying:

“I am respected for what I do; because I have been there forever ... ..It’s probably been the single best aspect of all of my transition, being able to keep my job”

However, a common theme in the studies where participants retained their current employment was misuse of personal pronouns and being addressed by their previous name [1, 29].

When seeking new employment almost all individuals change their name to match their desired gender. However, unlike a normal name change process the individuals seek to conceal their previous name as this will identify them as being transgender [26]. This causes many complications when attempting to seek or gain new employment because individuals lose all previous work experience, are unable to provide references, and if a Criminal Records Bureau check is required then it is necessary for them to contact the Bureau and ensure their previous identity is not revealed to their new employer [1]. It was a common theme within all the nine studies that many transgender individuals had difficulty navigating the legal aspects of their transition. For various reasons, the majority did not obtain a Gender Recognition Certificate providing them with legal protection, which is important for a job with a Genuine Occupational Requirement (where gender can be used as a determinant for employment)[12, 41].

4 Discussion and conclusion

Although every attempt was made to source information from the UK, seven of the articles were sourced from countries outside the UK (US, Canada and Thailand); highlighting the need for more UK-based research. In terms of generalisability across the globe, labour markets are dependent on varied economies, guidelines and policies are different and additionally cultures, values and beliefs within each society may present unique challenges.

However, all articles appeared congruent and were able to highlight common issues encountered by the global transgender community, which may indicate that regardless of the country, individuals transitioning in the workplace have similar experiences. The results of this review demonstrate that preparation for disclosure is considered to be a full time job for almost all participants in these studies. Individuals had spent a long time researching policies and procedures as well as seeking peer support. In many cases, individuals approached their line manager or HR department armed with this information and hoped that by going to the top they would be supported in their transition. However, this review has identified that many employers are unprepared for these situations, with no guidance or local policy to refer to.

The other main occupational concern focused on self-care, with individuals changing their routines and being taken on as ‘gender apprentices’; being shown how to ‘be men’ or ‘be women’, by engaging in activities such as shopping and make-up application [25]. Due to the complex social element of this interaction and the meaning it holds for the individual, it could be argued that this cannot simply be classified as ‘self-care’ [42]. It could be argued that by engaging in these ‘gendered occupations’, participants were being forced to be male or female, as Western society and culture requires citizens to be one or the other; constrained within the ‘gender binary’ [43]. This is evident in the terminology of the ‘transition’, as this stage is not seen as state of being but a passing through point [25]. There is, however, evidence of a move away from gender binaries, especially in the USA where a wider variety of gender options are emerging [44].

Throughout the nine studies, discrimination was experienced by participants through verbal harassment, occupational injustice, political injustice, or environmental exclusion. When considering these issues from an occupational perspective, it is clear that occupational deprivation and marginalisation occurred when participants were unable to engage in occupations of their preferred gender identity due to social exclusion or harassment [45]. Obtaining social acceptance in the workplace often resulted in participants over-compensating or spending a large proportion of their time adapting their daily occupations to keep the peace with others. Although this conditioning may occur over time it should still be considered as workplace harassment and is unacceptable practice [46]. Participants coped with these situations in various ways: through avoidance by waiting to retire, or escape by attempting suicide. Further exploration of the effects of this discrimination on the mental health of individuals is needed, although Markman [36] suggests careful consideration is needed when grouping mental health disorders with transgender issues.

As they transitioned, some participants found that their productivity and performance within occupations was questioned and gender stereotypes were imposed on them, causing a change in their daily activities, such as work responsibilities. Reinholdt and Alexanderson found that even within the same job women and men carried out different tasks according to their ‘gender marking’ [47]. For some, this change was welcomed as it was a chance to express their ‘true’ identity through their occupations, however for others it imposed restrictions upon what was perceived as acceptable behaviour.

It became clear within the study that the occupational experiences of trans-women are uniquely different from trans-men, with the latter appearing to make positive improvements to their social status and employment prospects. However, for men becoming women the challenge of negotiating the workplace was made increasingly difficult, firstly because of the male dominant professions they were employed in, but also due to the subtle suppression of women in the workplace, a phenomenon already pre-existent within the gender binary [48]. For example, in highly gendered work such as bus driving, the shift schedules may be structured around perceived male responsibilities which do not include childcare or other family commitments [49]; therefore, a trans-woman may encounter particular difficulties. Since the review was conducted we have seen a sexually ambiguous winner of the Eurovision Song Contest (Conchita) and increasingly high profile transitions such as Chelsea Manning and Caitlyn Jenner. It will be interesting to see how the increase in such diverse gender expressions may disrupt the gender binary, thereby changing the social context of transition [50].

Given the main occupational challenges for the individual that have been identified, occupational therapy could have a key role in facilitating a smooth transition in the workplace. Pollard & Sakellariou, [51] argue that occupational success for the client, alongside gains for society, should be the aim of all occupational therapy interventions. Using client-centred practice, the occupational therapist could tailor interventions to support individual transition requirements, such as the preferred gender expression which might or might not conform to the gender binary. More obvious contributions could be through individual grading and adapting of self-care routines, and occupational analysis of the job role [21 , 42].

However, the review has also highlighted that regardless of what the individual might do to prepare for transition, there are factors in the local, social and national contexts that remain barriers to participation in occupations [52]. Therefore, the skills of the occupational therapist as an advocate for occupational justice [42] may be required to navigate the workplace politics and legal issues. Of the eight Gender Identity Clinics in the UK, only one employs an occupational therapist, although their role is one of assessment, not vocational rehabilitation [53]. The presence of occupational therapy already in this area indicates that possibility of role expansion is a realistic recommendation. Lastly, on a larger scale and congruent with recommendations from the ‘Recovering Ordinary Lives’ document [54] occupational therapists can advocate for minority groups and aim to reduce occupational injustice through involvement in NHS clinical commissioning and add to the development of the UK evidence base through engaging in research on transgender transition.

In conclusion, this review has highlighted the key issues experienced by transgender individuals and has offered analysis of occupational challenges of transition in the workplace. The main barriers identified were: lack of up to date policy or guidance; lack of legal protection; lack of support or information for employers; the fixed Western culture of the gender binary and the dominance of male culture still in existence despite political progress and feminist movements [48, 55]. The complex process of changing gender identity in the workplace impacts how a person participates within their new roles, routines and occupations, while attempting to navigate a sometimes hostile social environment.

Conflict of interest

The authors have no conflict of interest to report.

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