CPD: Transition period – supporting employees through gender transitioning

The process of gender transitioning is complex and not undertaken lightly. As Dawn Wyvern explains in the first of a two-part series, occupational health professionals therefore can play an important role in supporting employees who choose to transition, as well as helping employers understand what it will mean in terms of time away from, and returning to, work.

It’s by no means a scientific observation, but there do seem to be many more transgender people in the workplace these days. Is this because there are more people transitioning or is it because being transgender is now more acceptable, as well as opportunities to access the surgery required to transition being more readily available?

Opinions differ but, whatever the reason, there is a strong possibility that, as an OH practitioner, will come across a transgender person in your workplace and may be required to support them.

This article is the first of two exploring issues relating to being transgender. I am myself transgender and therefore this article aims to provide an overview of the “what, why and how” elements of supporting transgender individuals within the workplace.

My second article in the series will build on this foundation and consider the legal requirements in relation to supporting an employee as they transition into their preferred gender.

As with all things, the medical guidelines and support for those who are transgender are dynamic areas and prone to revision and progression. However, it is hoped that the information explored here will be helpful to practitioners in supporting a transgender person in the workplace.

Being “transgender” – some clarification

According to the World Health Organization, transgender people have a gender identity or gender expression that differs from the sex they were assigned at birth (WHO, 2016).

The term “transgender”, often shortened to “trans”, is an umbrella term covering a range of gender identities (Oliven, 1974). It refers to people whose gender identity is the opposite of the sex they were assigned at birth: trans men being men nominated female at birth and trans women being women nominated male at birth.

Other identity terminology refers to people who are not exclusively masculine or feminine and who identify as non-binary, gender-queer or including bi-gender, pangender, gender-fluid, or a-gender.

When discussing transgender issues, it is important to differentiate between transgender and non-transgender people. The opposite of transgender is “cisgender”, the term describing persons whose gender identity or expression matches their sex assigned at birth (NHS England, 2019).

Some people identify as belonging to a third gender, or categorise transgender people as a third gender (WHO, 2016). Such gender identities are seen in other cultures around the world including the ‘mahu’ in Hawaii and hijra in India. These people stand outside of the male/female binary order (Mahapatra, 2014).

The term transgender includes transvestites, cross-dressers, drag queens and drag kings, and other forms of gender nonconformity, but is distinguished from intersex (The United Nations Office of the High Commissioner for Human Rights, 2015).

However, not all transgender people elect to undergo surgery or take medication to develop secondary sexual characteristics. They may choose to live in their preferred gender role, whilst others may desire medical assistance to transition from one gender to another and identify as “transsexual” (Gov UK, 2010) because of gender dysphoria. This is the distress a person experiences when there is a mismatch between their gender identity and their sex assigned at birth (Oliven, 1974).

Being transgender is independent of sexual orientation (Anon, 2013); sexual preferences are unrelated to gender and often misunderstood when gender is confused with sexuality.

Many transgender people choose not to obtain a gender recognition certificate or to permanently change their gender, preferring to live with a different name to the one they were given at birth.

A range of reasons underpin such a decision and employers and others should support this in the same way as transgender individuals undergoing surgery (Gov UK, 2010 and NHS England, 2019).

Some statistics about transgender identity

The following statistics can assist in understanding the transgender population in the UK.

• In 2018-19, approximately 8000 adults and children were referred to gender identity clinics (GICs) (NHS, 2020).
• The number of those under the age of 18 years being referred to GICs has quadrupled in the last four years (Hartley, 2020).
• There is up to a three-year waiting list for first appointments across the five national GICs (House of Commons Women and Equalities Committee, 2015).
• In 2018-19, three times as many people assigned female at birth were referred to the Tavistock GIC compared to those assigned as male at birth (Hartley, 2020).
• Although 41% of transgender people (TGs) will try to end their life by suicide before the age of 30, this number is more than halved after commencing hormone treatment (McNeil et al, 2012, Powers 2019).
• Only 2% of all post-op TGs have regrets – most of these are because of complications from surgery (Powers, 2019).
• Many TGs suffer from mental illnesses, which improve during transition (House of Commons Women and Equalities Committee, 2015).

Too much choice? What am I?

An overview of the complexity of transgender has been presented. However, there are numerous differences on where, within the transgender spectrum, individuals feel most comfortable.
In illustration, 26 choices were included on a form sent to schools by the Children’s Commissioner in 2016, asking the students to identify their gender preference (Boult, 2016).

The gender preferences offered included: boy, girl, tomboy, female, male, young woman, young man, trans girl, trans boy, gender fluid, a-gender, androgynous, bi-gender, non-binary, demi-boy, demi-girl, gender-queer, gender-nonconforming, tri-gender, all-gender, in the middle of boy and girl, intersex, not sure, rather not say, and “other”.

As we are all unique, are labels necessary? For myself, I would prefer to be simply listed as identifying as a member of the trans community.

Self-Identification is an important area for support. Being able to express who you are without any constraint from “labels” is important, but it is important to respect a label that an individual identifies with and complying with their terminology.

Having a name that a person is comfortable with and equates to their preferred gender is an important point in self-identification.

It’s a lifestyle choice, isn’t it?

Being transgender is not a choice. Rather, it is something in the person’s make up that is part of them from an early age.

We can ask ourselves some very simple questions to illustrate what our options are or individual make up.

Such questions include asking: what colour are your eyes, can you choose your eye colour? You can wear contact lenses and hide your true eye colour. However, your true eye colour will always remain unchanged.

Are you left or right handed? Your dominant hand is innate. But it is possible to train yourself over time to be able to use the dominant and non-dominant hands equally.

What is your sexuality? Can you choose what you find attractive? As discussed above, when discussing sexuality, you can deny your deepest feeling, but this will still be there.

When it comes to gender, is it possible to choose your inner gender? The feeling of being in the wrong gender is always there if you are transgender.

So, gender identity is not a choice, we are all unique and have different make up (Powers, 2019). Self-identity awareness may come from an early age when you know you need to do something but it is put on hold. Alternatively, there may be a realisation in middle age when you just have to follow the call. It is not a choice – but it is often held back.

Many individuals know they are different at an early age; some are able to take steps then, but others hesitate hoping that they will be able “to fit in”, often from parental expectations and peer pressure (House of Commons Women and Equalities Committee, 2015; Mermaids, 2020).

Understanding transgender transitioning

The NHS has established a series of GICs specialising in the treatment and management of transgender transitioning within the UK.

These centres triage those wishing to commence hormone therapy and support those who wish to have gender confirming surgery. In view of this, national guidelines have been developed to guide these individuals through the process (NHS, 2020; House of Commons Women and Equalities Committee, 2015).

These are often seen as a hindrance to the transgender population and not “best practice”, as the waiting time is often very slow from the point of being referred to the point of attending their first appointment.

There is a further delay from the point of being seen in the GIC to commencing surgery (House of Commons Women and Equalities Committee, 2015).

Obviously, this waiting time increases stress and anxiety at a time when the individual is hoping for support and progression. The original “Harry Benjamin” standards of care protocols set this precedent but tended to focus on a purely psychological basis (Powers, 2019).

Recently the WHO has removed transgender from its list of psychiatric “disorders” and the need for psychiatric evaluation is no longer required for those who wish to transition (WHO, 2019).

NHS England Gender Dysphoria Clinical Programme has produced a set of transition flow charts. These standardise the treatment pathways for the transgender individuals and, as NHS England explained at the time, were “formed through a process of extensive stakeholder engagement and public consultation”. (NHS England, 2019). The pathways, however, are often seen as obstructive to those who are transitioning and a constant source of frustration (House of Commons Women and Equalities Committee, 2015).

An outline of the route to transitioning provided by NHS England

The individual has an awareness of the need to transition. Awareness comes at various ages and realisation takes time. The individual may need to overcome family and social factors, prior to being able to commence their transition.

They, first, undertake a visit to their GP, who refers to the GIC. There is now a wait for an appointment with the GIC. Two to three years (24-36 months) was the timeframe in 2019-2020 (NHS, 2020).

If the individual is below the age of puberty, the GIC may fast-track them to commence a medication regime to slow the onset of puberty. This is to defer the development of secondary sexual characteristics, which will be detrimental to their transition, so as to allow time for the individual to make a more informed choice of their options prior to commencing hormones (Mermaids, 2020).

During this time, some people may start transitioning by changing their name via deed poll; this is the legal document that proves a name-change. The person will then commence a “real life experience” of living and working in their preferred gender for a period of at least two years.

The day of the official name-change is generally taken as day one for that experience. At this point, they have their professional and civil documents changed to adopt their new name.

A transgender woman may undertake hair removal at this point, if they have not done so already. They may also need to “come out” at home and at work as part of a social and visible transition (Anon, 2020).

After a period of time, the person will attend their first GIC appointment, where they will discuss how they feel and explore their gender identity, obtain a background history. Treatments are rarely commenced at this appointment.

After a further period of time, usually six to eight months, they will attend their second appointment at the GIC.

Provided there are no medical red flags and the individual is deemed psychologically stable, hormones are recommended and a letter confirming this is sent to their GP in order that they can prescribe them.

Access to speech therapy and hair removal services is arranged at this point. Regular hormone and liver function tests are arranged, with medication levels being adjusted as required (Anon, 2020).

Following a period of two years of real life experience (to recap, living in their preferred gender), the GIC will make a referral for surgery. This involves two further assessments by two different doctors (NHS England, 2019; NHS 2020).

The use of hormones will have a profound change in secondary sexual characteristics for both genders (Powers, 2019). These include:

• For a male to female transition. These are skin changes, breast growth, mood swings, fat redistribution, and loss of muscle mass.
• For a female to male transition. The development of body hair, voice changes, increase of muscle mass, an increase of libido, cessation of menstruation and possibly male pattern baldness (Powers, 2019).

Accessing surgery can be complex. NHS waiting lists are long and there are a number of prerequisites, such as having a body mass index below 30, good management of hypertension and diabetes, as is the case for other elective surgery.

For male to female surgery, the removal of hair from the genital region is often required before surgery can be undertaken, as the tissue may be used to construct parts of the new anatomy.

The approximate timeline for surgery and recovery includes a minimum of a six-month wait after the GIC visits for the first surgical assessment. After that, there is often a two- to 12-month wait for the first surgical intervention.

Male to female surgery includes vaginoplasty, breast augmentation, facial surgery, tracheal shave, and laryngeal surgery.

Vaginoplasty requires an eight- to 10-week recovery period, but recovery periods for the other surgical interventions is procedure-dependant.

Dilation is a lifelong requirement to maintain patency of the constricted vagina. For the first few months post-operatively, this will be required for up to three hours per day (Powers, 2019).

Female to male surgery can include “top surgery” to remove breast tissue and construct a male-shaped chest.

There is further genital surgery, including scrotoplasty and metoidioplasty/phalloplasty to fashion a new phallus and scrotum after clitoral growth has been stimulated following the use of testosterone.

Removal of female organs of reproduction is also necessary, and includes a total hysterectomy. Recovery times are again dependant on the type of procedure (Powers, 2019; Anon, 2020).

After gender realignment surgery, a period of time is required for maintenance of the new gender anatomy, including, as touched on above, dilation for male to female and stretching of phallus skin for female to male.

Completion of gender-affirming surgery is often seen as the end of the transitioning process. However, it is worth being aware that there are often ongoing areas that will always require some attention, such as family acceptance and relationships (House of Commons Women and Equalities Committee, 2015).

Implications for occupational health

As this article has highlighted, the process of transitioning is complex and not undertaken lightly. Occupational health (OH) professionals have an important role to play in supporting clients who choose to transition from the gender they were assigned at birth.

There will be both physical and psychological challenges for the worker. Equally, the person’s line manager and HR professionals are likely also to welcome advice from their OH service in terms of regarding the impact on their employee’s health, time off from work, their ability to work, and how their health and transitioning might impact on them generally in the workplace.

In the second article in this series, which will appear in next month’s edition, I will consider the legal considerations of transitioning. This is an important area for occupational health practitioners, line managers and HR staff to be considering – and fully understanding – in order to ensure that they are confident they are treating their transgender staff, fairly, sensitively.

References
Anon (2013). “Sexual orientation, homosexuality and bisexuality”. American Psychological Association.

Anon (2020). “Female to Male Transsexuals: Gender Reassignment and FTM Surgery Guide”. Available online at: https://www.femaletomale.org

Anon (2020). Mascara and Hope. Available online at: https://mascaraandhope.tumblr.com

Boult A (2016). “Government asks schoolchildren to define their gender”. The Daily Telegraph, January 2016. Available online at: https://www.telegraph.co.uk/news/uknews/12127280/Government-asks-schoolchildren-to-define-their-gender-and-gives-them-24-options-to-choose-from.html

The Equality Act 2010. London: HMSO.

Hartley E (2020). “Why do so many teeenage girls want to change gender?”. Prospect Magazine, March 2020. Available online at: https://www.prospectmagazine.co.uk/magazine/tavistock-transgender-transition-teenage-girls-female-to-male

T455 The General Guide for all Users Gender Recognition Act 2004. HM Courts and Tribunals Service, 2019. London: HMSO.

House of Commons Women and Equalities Commitee, 2015. Transgender Equality First Report of Session 2015-16. London UK: House of Commons.

Mahapatra D (2104). “Supreme Court recognizes transgenders as ‘third gender’”. Times of India, April 2014. Available online at: https://timesofindia.indiatimes.com/india/Supreme-Court-recognizes-transgenders-as-third-gender/articleshow/33767900.cms

McNeil J et al (2012). “Trans Mental Health Study”. Available online at: https://www.gires.org.uk/wp-content/uploads/2014/08/trans_mh_study.pdf

Mermaids (2020). Mermaids Transgender Support. Available online at: https://mermaidsuk.org.uk/parents/

NHS England (2019). “NHS England Gender Dysporial Clinincal Programme”. Available online at: https://www.england.nhs.uk/commissioning/spec-services/npc-crg/gender-dysphoria-clinical-programme/

NHS (2020). “Gender Identity Clinic: what happens when you are referred”. Available online at: https://gic.nhs.uk/referrals/what-happens-when-you-are-referred/

The United Nations Office of the High Commissioner for Human Rights (2015). “Free & Equal Campaign Fact Sheet: Intersex”. Available online at: https://www.unfe.org/wp-content/uploads/2017/05/UNFE-Intersex.pdf

Oliven J F (1974). “Clinical sexuality: A Manual for the Physician and the Professions”. Lippincott, pp.110; 484-487.

Powers W (2019). Available at: https//PowersFamilyMedicine.com

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WHO (2016). “Growing recognition of transgender health”. Bulletin of the WHO , 94(11), pp.685-860. Available online at: https://www.who.int/bulletin/volumes/94/11/16-021116.pdf

WHO (2019). “WHO ICD classification of Diseases.” Available online at: https://www.who.int/classifications/icd/en/