DEIJAB Toolkit: Transgender & gender-diverse care

Caring for transgender & gender-diverse (TGD) individuals: Frame of references

Capstone students: Bri Guillory, OTS, Boston University & Lili Rafalski, OTS, Emory & Henry College 08/11/2023

Transgender and gender-diverse (TGD) people are at a higher risk of experiencing mental health disorders, suicide, substance abuse, trauma, chronic health conditions, disability, and lower education and income levels compared to gender-majority populations and disproportionately affecting TGD of color (Bolding et al., 2022).

Working with TGD clients

Occupational therapy practitioners (OTPs) have the skills to work with TGD clients experiencing anxiety, depression, suicidal ideation, gender dysphoria, mistreatment in the workplace and/or schools, social rejection, and more. It is important to understand how someone’s minority gender status can affect their occupations. This topic provides a general overview of the various needs of transgender and gender diverse individuals. It not comprehensive or all-encompassing and encourages further discussion and research.

Frame of references

Below are a few examples of using a frame of reference that OTPs can use for guiding interventions.

Doing
- Synonymous with occupations that directly impact health.
- Supporting inclusive environments so TGD can perform gender-affirming occupations.
- Health and well-being are promoted when individuals are able to do meaningful occupations.
Being
- Referring to qualities that provide meaning and purpose to life.
- Assisting TGD individuals to fulfill desired occupational roles.
- Advocating for determinants of well-being such as housing, education, food, transportation, and economic policies.
Belonging
- Doing and being together enables the act of belonging, which stresses the importance of identity and community.
- TGD individuals experience belonging when families, friends, groups, communities, and societies accept them.
- Social connections and occupations that provide contact contribute to well-being.
Becoming
- Individuals are constantly changing, growing, developing, and evolving.
- Positive becoming demonstrates what people can contribute to their own growth and what they can offer their communities.
- By supporting TGD in occupations that they deem as self-actualizing allows them to participate in becoming.
References

Wilcock, A. A., & Hocking, C. (2015). An occupational perspective of health (3rd ed.). SLACK Incorporated.
“EHP framework is that ecology, or the interaction between person and the environment, affects human behavior and performance, and that performance cannot be understood outside of context” (Dunn et al., 1994, p. 598).
Establish or restore
- Identify the client’s skills and barriers to performance. The OTP can use this information to help improve the client’s skills and abilities.
- Teach the client and their families safe toileting post-gender-affirming surgeries.
Alter
- Alter the environment in which the client is performing a task that allows the client to use their skills.
- Assist the client in finding a job that aligns more with their skill set.
Adapt
- Adapt the context and task demands to support the client’s performance in the task.
- Provide more cues for donning<>doffing a binder.
Prevent
- Assist the client in preventing maladaptive performance in the environment.
- Utilize Cognitive Behavioral Therapy (CBT) to decrease maladaptive behaviors.
Create
- Create “circumstances that promote more adaptable or complex performance in context” (Dunn et al., 1994, p. 603). Does not assume the client has a disability.
- Plan gender-affirming tasks like grooming with proper cueing dependent on the client’s skills.
References

Dunn, W., Brown, C., & McGuigan, A. (1994). The Ecology of Human Performance: A framework for considering the effect of context. The American Journal of Occupational Therapy, 48(7), 595–607. https://doi.org/10.5014/ajot.48.7.595
This model concludes that gender variations are not disorders and the variations are usually caused by societal reactions to the individual rather than from within the person (Hidalgo et al., 2013).

The theoretical basis
1. “Gender identity or expression is not pathological.
2. Gender presentations are diverse and vary across cultures and require cultural sensitivity.
3. Gender identity can involve the integration of biology, development and socialization, and culture and context.
4. Gender can be fluid, not binary, can change over time, and is unique to the individual.
5. An individual's gender expression or identity is influenced more by negative cultural reactions to gender diversity than by the internal psychological disturbances within a child” (Keo-Meier & Ehrensaft, 2018, p.14).
If a client decides to change their gender, it is important to stay open to the idea that gender is fluid.

Affirm the client and be able to provide resources for them or admit when you are not knowledgeable about the topic.

References

Hidalgo, M. A., Petras, H., Chen, D., & Chodzen, G. (2019). The gender minority stress and resilience measure: Psychometric validity of an adolescent extension. Clinical Practice in Pediatric Psychology, 7(3), 278–290. https://doi.org/10.1037/cpp0000297

Keo-Meier, C., Keo-Meier, C., & Ehrensaft, D. (2018). Introduction to the Gender Affirmative Model. In the gender affirmative model: An interdisciplinary approach to supporting transgender and Gender Expansive Children (pp. 3–19). Essay, American Psychological Association.
Distal stress factors

Gender-based victimization
- A trans-masculine teenager has been kicked out of a store and called transphobic slurs.
Gender-based rejection
- A coworker avoids their trans-feminine coworker after learning that they are transgender and refuses to include them in social work outings.
Gender-based discrimination
- A non-binary person is denied on-campus housing since the dorms are only cis-gendered. They are required to choose one gender or live off campus.
Non-affirmation of gender identity
- A professor refuses to use a student’s chosen name and correct pronouns.
Proximal stressors

Negative expectations for future events
- A nonbinary person avoids going to see their provider for health maintenance to avoid discrimination they've experienced in the past.
Internalized transphobia
- A trans woman stays in an abusive relationship because she doubts she can find someone else to love her due to her gender identity.
Non-disclosure of one’s identity
- A trans man at a new job avoids answering questions about his past to prevent his coworkers from learning he is transgender.
Resiliency factors

Community connectedness
- A gender-fluid teenager feels more comfortable attending social events when other gender-expansive teens are there.
Pride
- A nonbinary person shares their experience using a binder for the first time on their Instagram.
References

Keuroghlian, A. S., Potter, J., Reisner, S. L., McDowell, A., & Streed, C. G. (2022). Health Disparities. In Transgender and gender diverse health care: The Fenway Guide. Essay, McGraw Hill.

Testa, R. J., Habarth, J., Peta, J., Balsam, K., & Bockting, W. (2015). Development of the gender minority stress and resilience measure. Psychology of Sexual Orientation and Gender Diversity, 2(1), 65–77. https://doi.org/10.1037/sgd0000081
The Kawa Model implements a metaphor of a river to explain one’s life experiences through self and context (Iwama et al., 2009).

The following structures can affect the shape, flow rate, and quality of the river (Iwama, 2009):

Mizu: Water
- Life flow & health: Dependent on the elements in the water mentioned below which can cause harmony or disharmony.
Iwa: Rocks
- Life circumstances: the client’s chronic and/or acute conditions.
Kawa Zoko: River walls and bottoms
- Environmental factors: the client’s access to healthcare, access to transportation, living environment, policies, social support system, etc.
Ryuboku: Driftwood
- Personal assets and liabilities: the client’s education level, socioeconomic status, values, personality, skills, etc.
Sukima: Spaces in between the rocks, driftwood, river walls, and bottom
- Occupations: the OTP can work with the client to find ways to break down negative rocks and river walls and bottoms through purposeful activities that incorporate the client’s abilities and assets (Iwama, 2009).
OTPs can assist with improving the client’s life flow by enhancing the harmony between all the elements mentioned above.

References

Iwama, M. K. (2006). The Kawa model: Culturally relevant occupational therapy. Churchill Livingstone.

Iwama, M. K., Thomson, N. A., Macdonald, R. M., Iwama, M. K., Thomson, N. A., & Macdonald, R. M. (2009). The Kawa model: The power of culturally responsive occupational therapy. Disability and Rehabilitation, 31(14), 1125–1135. https://doi.org/10.1080/09638280902773711
Trauma aware
- OTPs can understand the possible traumas, and terminology and seek more information to better inform their care for TGD clients.
Trauma sensitive
- OTPs can familiarize themselves with the trauma-informed care principles mentioned above and understand how their own personal trauma may impact their clients.
Trauma responsive
- OTPs should integrate trauma-informed care principles in all interactions with the clients and approach clients with compassion as past exposure to trauma is possible.
Trauma-informed
- OTPs should consistently examine their practice, provide education to other practitioners, and seek more knowledge in ways to continue to improve trauma-informed care.
References

Lynch, A., Ashcraft, R., Tekell, L., Atchison, B. J., & Suarez, M. (2021). Introduction to trauma and the role of occupational therapy. In Trauma, occupation, and participation: Foundations and population considerations in occupational therapy (pp. 1–18). Essay, American Occupational Therapy Association, Inc.

Missouri Department of Mental Health and Partners. (2014). Missouri Model: A developmental framework for trauma-informed. https://saintfrancisministries.org/wp-content/uploads/2019/04/MO-Model-Working-Document-february-2015.pdf
The four occupational injustices proposed:
1. Occupational alienation
  - The prolonged experiences of disconnectedness, isolation, emptiness, lack of sense of identity, and limited or confined expression of spirit, or sense of meaninglessness” (Townsend & Wilcock, 2004, p. 80).
  - TGD clients not being able to engage in meaningful occupations due to TGD-related discrimination.
2. Occupational deprivation
  - A prolonged exclusion from engaging in occupations that are meaningful due to contextual factors.
  - Policies preventing TGD individuals from working at a job that is meaningful to them.
3. Occupational marginalization
  - Limited choice and control of occupations due to certain injustices being normalized, standard, and expected.
  - TGD individuals not having access to a bathroom due to there only being binary bathrooms (women and men) and not gender-inclusive ones (all-gendered or non-gendered).
4. Occupational imbalance
  - Not having a healthy range of occupations that promotes healthy routines and social inclusion (Townsend & Wilcock, 2004).
  - A TGD parent may overwork to provide economic stability and safety to their family because they are worried about potential discrimination their family may face due to being TGD.
The four occupational rights proposed:
1. To experience meaning and enrichment in one’s occupations.
2. To participate in a range of occupations for health and social inclusion.
3. To make choices and share decision-making power in daily life.
4. To receive equal privileges for diverse participation in occupations.
It is important as OTPs, to recognize that clients are occupational and social beings. Individually and as members of particular communities their “occupational needs, strengths, and potential require differing forms of enablement to flourish” (Townsend & Wilcock, 2004, p. 80). OTPs can advocate for their client’s occupational rights.

References

Townsend, E., & A. Wilcock, A. (2004). Occupational justice and client-centered practice: A dialogue in progress. Canadian Journal of Occupational Therapy, 71(2), 75–87. https://doi.org/10.1177/000841740407100203
Person
- Mark is a 42-year-old transgender man who has diabetes mellitus II, depression, and anxiety.
Environment
- Mark lives in a single-story home with his partner and two toddler-aged children. Mark works from home as an engineer.
Occupation
- Mark inconsistently takes his medications to manage his diabetes, depression, and anxiety which affects his ability to produce at work and engage with his family.
Performance
- The intervention is focused on improving Mark’s medication management since it negatively impacts his function at work and social participation.
References

Christiansen, C., Baum, C., & Bass-Haugen, J., [Eds.]. [2005]. Occupational therapy: Performance, participation, and well-being [3rd ed.]. Thorofare, NJ: SLACK
Public policy
- Policies and laws can provide stress or resiliency factors for TGD individuals.
Environmental
- Social, cultural, and physical environments can provide resiliency or stress factors.
Organizational
- TGD-inclusive community organizations and school resources can help promote resiliency factors. Discriminatory policies and procedures exclude and alienate TGD individuals.
Interpersonal
- Teachers, family, coworkers, and friends can add to resiliency or stress factors.
Intrapersonal
- Physical and cognitive characteristics of the TGD individual that add to resiliency or stress factors.
References

Bronfenbrenner, U. (2000). Ecological systems theory. Encyclopedia of Psychology, Vol. 3., 129–133. https://doi.org/10.1037/10518-046

Keuroghlian, A. S., Potter, J., & Reisner, S. L. (2022). Transgender and gender diverse health care: The Fenway Guide. McGraw Hill
Person
- A non-binary young adult named Joe who was assigned female at birth (AFAB).
Occupational environment
- Joe is learning how to don and doff a shirt as well as proper toileting after post-gender-affirming top surgery and bottom surgeries. Joe does not have much support from their family but has friends that report that they will assist with Joe’s recovery.
Occupational participation
- Joe is very motivated and actively participates in therapy sessions with adapting dressing and toileting.
Press for mastery
- Joe is provided with surgical precautions and participates in performing the occupation with minimal to no assistance.
References

Schultz, S., & Schkade, J. K. (1992). Occupational adaptation: Toward a holistic approach for contemporary practice, part 2. The American Journal of Occupational Therapy, 46(10), 917–925. https://doi.org/10.5014/ajot.46.10.917
Safety

Interpersonal
- Maintain awareness of potential triggers of the client.
- Ask permission and be within line of sight during physical exams.
- Give the client autonomy and validate their expertise during therapy.
Institutional
- Create an inclusive, safe, and secure environment with a zero-tolerance policy towards stigma and discrimination.
- Advocate for gender-neutral bathrooms and be willing to change policies and environments that are gender binary.
Community and society
- Advocate for gender-affirming care.
Trustworthiness and transparency

Interpersonal
- Discuss confidentiality.
- Maintain a professional relationship.
- Use inclusive language with clients, families, other practitioners, and other stakeholders.
Institutional
- Allow for feedback about the client’s experience.
- Evaluate TGD-inclusiveness through a patient survey.
- Advocate for LGBTQIA+ trainings and bystander intervention trainings.
Community and society
- Finding additional organizations and resources that can help TGD clients find community.
Peer support

Interpersonal
- Refer TGD clients to TGD-sensitive trauma services.
Institutional
- Offer peer-led TGD-inclusive recovery groups and programming.
Community and society
- Work with community organizations with trauma-sensitive care experience for TGD individuals.
Collaboration and Mutuality

Interpersonal
- Understand power dynamics and encourage a collaborative, client-centered approach in sessions.
- Understand that the client’s symptoms and behaviors may be due to coping with trauma.
- Allow the client to lead an ADL routine that affirms their gender identity.
Institutional
- Hire TGD people in numerous roles for representation, safety, and inclusiveness.
Community and society
- Participate in community outreach to address the health needs of TGD individuals.
Empowerment, voice, and choice

Interpersonal
- Allow the client to choose options in care and avoid power imbalance.
Institutional
- Utilize feedback from TGD stakeholders for quality improvement.
- Advocate for institution-wide trauma-informed training.
Community and society
- Support TGD stakeholders in advocating their needs to insurance companies and policymakers.
- Awareness of cultural, historical, and gender acknowledgment
Interpersonal
- Be aware of TGD-phobic harm and implicit bias in healthcare and the intersectional identities of the client (e.g., do not push clients to wear gendered clothing, shave armpits, etc., just based on how you perceive their gender).
- Recognize that how the client may prefer to be addressed and present may differ from your expectations.
Institutional
- Provide institution-wide implicit bias, trauma-informed care, bystander, and TGD and racial minority training.
Community and safety
- Pass along best practices to other institutions, clinics, and hospitals.
Awareness of cultural, historical, and gender acknowledgment

Interpersonal
- Be aware of TGD-phobic harm and implicit bias in healthcare and the intersectional identities of the client (e.g., do not push clients to wear gendered clothing, shave armpits, etc., just based on how you perceive their gender).
- Recognize that how the client may prefer to be addressed and present may differ from your expectations.
Institutional
- Provide institution-wide implicit bias, trauma-informed care, bystander, and TGD and racial minority training.
Community and safety
- Pass along best practices to other institutions, clinics, and hospitals.
References

Centers for Disease Control and Prevention & Substance Abuse and Mental Health Services Administration. (2020). Infographic: 6 guiding principles to a trauma-informed approach. https://www.cdc.gov/cpr/infographics/6_principles_trauma_info.htm

Keuroghlian, A. S., Potter, J., Reisner, S. L., Grossman, S., Berman, S., & Potter, J. (2022). Basic principles of trauma-informed and gender-affirming care. In Transgender and gender diverse health care the Fenway Guide (pp. 116–117). Essay, McGraw-Hill

Working with TGD clients

Doing, being, belonging, becoming

Ecology of human performance (EHP)

Gender affirmative care model

Gender minority stress model

Kawa model

Missouri model framework for a continuum of implementation of trauma treatment for organizations and occupational therapy practitioners

Occupational justice framework

Person, environment, occupation, performance (PEOP) model

Socio-ecological framework

Theory of occupational adaptation

Trauma-informed care (TIC)