Caring for transgender and gender diverse individuals: ADLs and IADLs

Relevance

• Regular bathing or showering is crucial for an individual’s physical health and wellness.
• It is important to honor the principles of consent in all treatment contexts, but especially in more personal occupations such as bathing and showering.
• Following gender-affirming surgeries, TGD individuals may have limitations in mobility due to precautions, pain, or weakness. These limitations may impact participation in their ability to engage in bathing or showering. As with any occupation, consider the use of AE/AD to overcome existing barriers.
• Some post-op recommendations may prohibit one’s ability to engage in bathing/showering following GAS. An OTP must ensure optimal hygiene is achieved within post-op recommendations to facilitate optimal post-surgical wound healing.

Considerations for OTPs

• Bathing and showering may cause dysphoria for TGD individuals.
  • Specific Recommendations for Managing Dysphoria While Bathing or Showering
    • Wearing a bathing suit to cover specific body areas
    • Covering bathroom mirrors
    • Creating comforting or positive routines prior to or following bathing or showering
    • Using washcloth/loofah/exfoliating glove to avoid direct contact with body
• Considerations post-GAS
  • Recommended DME
    • Shower chair, tub transfer bench, long-handled sponge
  • Education
    • Safe showering and bathing
    • Teaching energy conservations strategies after bed rest restrictions are lifted
    • Incision care
    • Using an inflatable donut to relieve pressure from the surgical site
  • Considerations specific to post-op Vaginoplasty and Vulvoplasty (Steuer & Walker, 2023)
    • Do not submerge the incision site completely under water until cleared by the surgeon, it can get wet by running water down them
    • “Dab dry and apply ointment to exterior incisions before applying a menstrual pad with underwear” (p. 10).
    • Educate on using the long-handled sponge to prevent straining and pressure around the surgical area

Relevance

• Dressing is a personal choice, one must negotiate between expression of self and/or identity and the context in which this is done.
• TGD individuals may engage in binding. Binding is the process of donning tight clothing, sports bras, binders, tape, or other materials to flatten out the appearance of one’s chest and/or other anatomical features.
• TGD individuals may engage in tucking. Tucking is the process of donning a gaff, tight undergarments, or tape to minimize the appearance of the penis, scrotum, and testicles.
• TGD individuals may engage in packing. Packing is the process of using materials to create the appearance and/or feel of having a penis.

Considerations for OTPs

• Engaging in unsafe binding or tucking practices may lead to musculoskeletal, integumentary, cardiovascular, and/or reproductive system changes (OHSU Doernbecher Children’s Hospital, 2020; Peitzmeier et al., 2016). The OTPs' role is to consider the factors around binding and providing recommendations and/or interventions for wearing schedules, garment modifications, garment recommendations, and garment management.
  • Specific Recommendations for Binding Safety
    • Taking 20-minute breaks from binding throughout the day
    • Limiting wear of binders to 10 hours per day
    • Taking “days off” from binding
    • Do not sleep or exercise in a binder
    • Remove binder in instances of pain or if experiencing breathing challenges.
    • Consider binding garments or materials with environment and occupation, utilizing more loose garments or materials when possible.
    • If utilizing tape, daily skin checks are necessary
  • Specific Recommendations for Tucking Safety
    • Taking regular breaks from tucking
    • Untucking in instances of pain or numbness
    • Checking for broken or irritated skin prior to tucking
    • Consider adapting tucking garments or materials with environment and occupation, utilizing loose methods when possible
  • Specific Recommendations post GAS (Steuer & Walker, 2023)
    • Educate clients against excessive trunk forward flexion, utilize crossed-leg body dressing instead (figure 4 technique)
    • Train client on LB dressing DME if needed (i.e., sock aid, shoe horn, etc.)
    • Advise dressing in loose-fitting clothing
• Consider the sensory preferences and/or sensitivities of TGD individuals and how binding, tucking, packing, or other gender affirming dressing practices may impact sensory regulation.

Relevance

• Body image concerns (i.e., body hatred, body dissatisfaction, body aversion) is one of the primary factors for eating disorders among TGD individuals (Keuroghlian et al., 2022).
• Acute care: Post-head and neck surgery recovery may require a postoperative liquid diet (Keuroghlian et al., 2022).
• Providers performing gender affirmation surgeries usually require a certain body mass index (BMI) for GAS (Brownstone et al., 2021).

Considerations for OTPs

• Education
  • Understanding the unique TGD barriers to care and GAS surgical considerations.
• Post-operative surgical considerations
  • Some GAS may require a postoperative liquid diet, and swelling may cause difficulties with feeding & swallowing (Keuroghlian et al., 2022).
• Consider
  • TGD clients with eating disorders may be caused distress by meeting requirements for GAS and body image concerns due to potential gender dysphoria.
• Supporting clients
  • OTPs can support TGD individuals by promoting mindfulness or meditation, building healthy habits and routines, promoting community connections, and encouraging healthy hobbies (Lock & Pépin, 2019).

Relevance

• The completion of ADLs and IADLs often requires functional mobility. Being active in one's environment allows for participation in work, leisure, social activities, and education.
• Following gender-affirming surgeries, TGD individuals may have limitations in functional mobility due to precautions, pain, or weakness.

Considerations for OTPs

• Education
  • Recognize the impact surgery has on functional mobility in the acute care setting, home environment, and community.
• Promoting mobility post-GAS
  • Preventative strategies for blood clots, generalized weakness, and safe mental health strategies.
  • Safe functional mobility with lines, leads, catheters
  • Functional mobility while adhering to precautions/limitations, avoiding pain.
  • Teaching modified techniques for functional mobility at home (Steuer & Walker, 2023).
• Mental Health
  • Inability to participate in desired occupations can have a negative impact on mental health.
• DME, AE/AD, and modifications
  • Regardless of the reason for functional mobility limitations, OTPs can work with TGD clients to adapt their environment, use equipment or tools, or modify approaches.

Relevance

• TGD individuals may want to minimize or maximize the appearance of facial or other body hair to be consistent with their gender identity.
• Following gender-affirming surgeries, TGD individuals may have limitations in mobility due to precautions, pain, or weakness. These limitations may impact participation in personal hygiene and grooming tasks such as shaving, brushing hair or teeth, applying makeup, etc.

Considerations for OTPs

• Asking for consent
  • As with dressing and bathing, consent needs to be acquired prior to engaging in removing or altering body hair, cosmetic application, nail care, and all other aspects of personal hygiene and grooming.
• Ways to affirm gender identity during personal hygiene and grooming
  • Provide the client with opportunities and the space to share which aspects of grooming and personal hygiene they engage in to affirm their identity.
    • This includes ensuring personal beliefs, assumptions, and biases are not present in your practice. Consider self-reflection and engaging in implicit bias assessments to establish self-awareness.
      • A moment of reflection: Are you deciding which occupations your client may engage in before meeting them? You may be depriving a client of participation in cosmetic application, nail painting/care, and hair care practices as a result of existing assumptions, biases, and/or personal beliefs.
• Considerations post-op
  • Consider the environment, a client may not want to utilize mirrors while engaging in these tasks to reduce or minimize dysphoria.
  • A client may be advised against engaging in facial grooming or shaving post-op, leading to potential unwanted growth of facial hair which may contribute to experiences with dysphoria. The client may benefit from wearing gloves or other garments while engaging in facial hygiene tasks to reduce the interaction with/ sensation from facial hair.
  • Following a procedure an individual may be unable to engage in affirming hair care including washing, cutting, or styling. Consider the use of wigs, hats, hair wraps, or covers to facilitate euphoria and minimize dysphoria.

Relevance

• A person’s sexuality influences and impacts their needs, desires, roles, expression, social relationships, and personal identity (Lynch & Fortune, 2019).
• Initiation and engagement in sexual activities are one of the ways individuals engage in sexuality.
• TGD individuals who are transitioning medically with hormone therapy experience changes in desire, arousal, and lubrication. These changes can interfere with initiating and engaging in sexual activities due to a lack of lubrication, low desire, reduced arousal, and/or fluctuating mood changes.

Considerations for OTPs

By recognizing the potential disparities and cultural sensitivities associated with TGD individuals' sexuality, OTPs can create a more inclusive and supportive therapeutic environment that looks beyond sex and focuses on the pleasure and sexuality of an individual.

• Proactive education for OTPs
  • Familiarizing oneself with the commonly used terminology when addressing the sexual activity of TGD individuals *see the Glossary in the webpage as a reference*.
• Fostering a safe environment
  • Providing clients the opportunity and space to explain unfamiliar terms and activities to promote a client-centered approach and improve rapport between the practitioner and client (Coleman et al., 2022).
• Asking for consent and establishing safety
  • Provide recommendations on communication
    • Establishing safe words, actions, and boundaries
  • Promote safe sex practices
    • Getting tested regularly for STDs
    • Birth control options for clients with a uterus and ovaries
• Ways to affirm gender identity during sexual activity pre-op:
  • Education
    • Clients can potentially use makeup, binders, breast prosthesis, and assistive aids (i.e., dildos, strap-ons, vibrators, wands, etc.)
    • Provide visualization techniques for reducing body dysphoria
  • Medical transition considerations
    • Scheduling sexual activities, alternatives to low endurance sexual activities (like breathwork or sensual touch to reduce mood changes/irritability), use of lubricants, vaginal estrogen creams/moisturizers for transmasculine individuals
• Ways to affirm gender identity during sexual activity post-op:
  • Neurosensory re-education (Peters et al., 2022)
    • Consider utilizing visualization and mirroring
    • Education on touch-based alternatives for pleasure & intimacy
  • Education
    • Provide information on safe positioning and body mechanics to minimize pain (gravity eliminated vs. against gravity)
    • Education on the use of moisturizers and lubricants
  • Top surgery considerations
    • Chest expansion exercises, breathing, and touch-based alternatives for pleasure & intimacy
  • Post vaginoplasty & vulvoplasty considerations (Steuer & Walker, 2023):
    • External self-stimulation: typically 4 weeks post-op
    • Receptive anal or vaginal intercourse: typically after 6 weeks depending on the surgeon
    • Habit training- dilation
      • Helps maintain the vaginal canal depth and width
        • 2x a day for at least 30 minutes 1-3 weeks post-op

Relevance

• OTPs have a role in providing education on toileting post-gender-affirming surgeries (GAS).
  • Toileting can look very different for a client after a GAS and safe toileting techniques are needed.
• OTPs have a role in providing care to TGD clients within pelvic floor therapy. TGD individuals may have pelvic floor issues unrelated to GAS. However, it is essential to note that receiving pelvic floor therapy pre and post-GAS is recommended by many surgeons (Grace Physical Therapy & Pelvic Health, 2020; Jiang, et al., 2019; Manrique, et al., 2019).
• Lack of access to toileting and/or safe toileting environments can lead to lower urinary tract symptoms, urinary tract infections, kidney infections, and bladder infections (Hardacker et al., 2019)

Considerations for OTPs

• Considerations post vaginoplasty or vulvoplasty
  • Education on postoperative peri-care with a peri-bottle which the individual can use after removing their urinary catheter (Walker et al., 2021)
  • Education on healthy routines “wiping front to back after urinating, urinating after sexual activity” (Walker et al., 2021, p. 5).
  • Education on “avoiding the valsalva maneuver during defecation” (Steuer & Walker, 2023, p. 10).
  • Education on performing “pelvic floor tilts for bowel movement ease and directing the flow of urine” (Steuer & Walker, 2023, p. 10).
• Considerations post phalloplasty
  • Education on one-handed techniques due to weight-bearing precautions on the donor's arm
  • Education on abdominal precautions, energy conservations, and phallus positioning to manage circulation and pain (Walker et al., 2021).
• Considerations for stand-to-pee devices
  • Education on use and cleaning.
• For all bottom gender-affirming surgeries:
  • Acute care: cover precautions, education on health routines, practice safe toileting, and provide recommendations for long-term care.
  • Remember to use inclusive language, ask for consent, and practice cultural humility
• Pelvic floor therapy:
  • Pelvic floor therapists can assist TGD clients who may have urinary and/or bowel issues due to trauma and/or GAS.

Relevance

• Providing formal or informal care for others is a meaningful occupation (OTPF-4; AOTA, 2020).
• TGD individuals may experience ostracization from their family and friends due to transphobia which can hinder their ability to care for others (Adan et al., 2021).
• GSM older adults often receive care from their chosen family (e.g., friends and partners who are not related to the individual), who do not have legal recognition.

Considerations for OTPs

• Do not make assumptions
  • Sometimes TGD individuals can experience rejection from their family members and they may have a chosen family that they care for and also receive care from.
  • Sometimes families may look different than expected, do not make assumptions about parents, legal guardians, or family structure
• Implications for client interactions
  • Use inclusive language, practice cultural humility, and ask relevant questions toward the client’s care
• Support and advocacy
  • OTPs can advocate for clients who wish to social transition and assist parents or guardians in understanding the benefits of allowing their child to transition socially (AOTA; OTPF-4, 2022).
  • Affirm TGD client’s chosen family and understand that providing care to their chosen family builds community and provides a sense of joy, understanding, and shared cultural knowledge (Sumerau et al., 2023).

Relevance

• Many transgender individuals are confronted with unique issues and obstacles in parentage, custody, and divorce cases (Minter, 2018).
• A TGD person can become a parent by being the birthing person (i.e., preserving either an egg or sperm before undergoing medical transitions), impregnating a partner, through assisted reproduction, through marriage, adoption, or by raising a child (Minter, 2018).
• “Transgender parents still face considerable bias in child custody cases” (Minter, 2018, p. 410).

Considerations for OTPs

Child rearing is a meaningful occupation and it is important that OTPs are aware of the state laws regarding using assisted reproduction.

• Communication
  • It is essential that OTPs do not inflict their own potential biases on their TGD clients or ask intrusive questions that are not relevant to the intervention.
  • Using appropriate gender-inclusive language (i.e., child, parent)
• Awareness of potential barriers and supports in child rearing for TGD individuals (Minter, 2018)
  • Potential barriers
    • Despite Obergefell v. Hodges (2015), transgender parents can still face biases in child custody cases.
    • Many TGD people can face financial stress due to discrimination in the workplace based on their gender identity and/or paying for gender-affirming medical treatments which can lead to difficulties in paying child support (Coleman et al., 2022; James et al., 2016; Minter, 2018).
  • Potential supports
    • Experienced counselors can help rebut misinformation and negative stereotypes
    • Depending on the state, there can be legislative supports in place for TGD families

Relevance

• A person may have transitioned medically and/or socially but legal documents (i.e., driver’s license and state identification cards) may not reflect their authentic gender.
• Some states do not provide nonbinary gender alternatives in government documentation. This can be distressing to those who identify as nonbinary. They may choose not to engage in driving if their license does not reflect their authentic gender identity.
• TGD individuals can face violence (verbal and/or physical) and discrimination when using public transportation (i.e., buses, planes, trains, etc.) (Lubitow et al., 2017; Reisner et al., 2015; Shakibaei & Vorobjovas-Pinta, 2022).
• Not being able to use public transportation or drive based on discrimination due to someone’s identity can cause occupational alienation, deprivation, and marginalization. In addition to potential adverse emotional and physical symptoms (Reisner et al., 2015).

Considerations for OTPs

• Resources
  • OTPs can help their TGD clients find community transportation services that may be safer for the client (i.e., through the local LGBTQIA+ centers or other community organizations).
• Post Vulvoplasty and Vaginoplasty considerations
  • Educate clients on using a donut pillow and sitting in a reclined position to relieve pressure off the perineum (Steuer & Walker, 2023).
    • 1-6 weeks postoperative can only sit for 5 min increments at a time to keep pressure off the surgical site (Steuer & Walker, 2023).
    • 6 weeks post-operative they can sit up to 30-min increments at a time to keep pressure off the surgical site (Steuer & Walker, 2023).
• Mental health considerations
  • TGD clients can experience occupational imbalance and deprivation for not being able to use public transport or fear of using public transport due to potential discrimination and harassment which can negatively impact their mental health.
  • OTPs should utilize trauma-informed care, gender-inclusive language, and cultural humility to affirm clients and prevent inflicting more harm.

Relevance

• Many TGD individuals are at risk of low education and income levels compared to cisgender individuals due to discrimination they may face in the workplace (Bolding et al., 2022; Howard et al., 2019; Moore & Dukes, 2019).
• TGD individuals can face unique financial obstacles when trying to access care
• Financial management is a meaningful occupation and involves using fiscal resources and planning long-term and short-term goals (OTPF-4; AOTA, 2020).

Considerations for OTPs

• Consider the unique health disparities TGD clients can face
  • TGD individuals can face unique financial insecurities due to potential workplace discrimination, medical transition bills, and potential discrepancies in insurance and medical records that may cause the individual to pay for services out-of-pocket. This may restrict them from receiving gender-affirming care (Nadal et al., 2012; Peitzmeier et al., 2017; Pryor, 2015; Samuels et al., 2018; Singh et al., 2013; Vermeir et al., 2018).
  • If a TGD client desires to medically transition and they can not due to financial insecurities this may exacerbate mental health issues (Coleman et al., 2022; Owen-Smith et al., 2018)
• Mental health considerations
  • TGD individuals may be unable to pay for medical transitioning it is essential that OTPs:
    • Support their social transition (i.e., inclusive language and affirm their identity and pronouns)
    • Help clients find resiliency through finding resources and/or a job that will help pay for their medical transitioning and other bills
    • Practice trauma-informed care and cultural humility

Relevance

• In 2020, 5.3 million LGBT adults (nearly half of LGBT adults in the U.S.) were religious (Gallup Daily Tracking Survey 2020; Conron et al., 2020)
• For LGBTQ people, “mainstream religions have been (and continue to be) significant contributors to oppression and suffering” (Beagan & Hattie, 2014, p. 472)
• Significant lack of research that explores LGBTQ identities at the intersection of religious and spiritual occupations (Beagan & Hattie, 2014) and a further lack of research exploring religious and spiritual expression for TGD people
• LGBTQ people who are religious or spiritual in non-affirming environments can experience identity conflict, as well as loss of family, community, and/or friends, which negatively impact health and wellness and require transition and adaptation (Beagan & Hattie, 2014)

Considerations for OTPs

• Trauma-informed practice is best practice
  • Educate yourself on religious and spiritual trauma
  • Recognize how different faith traditions have contributed to shame, condemnation, oppression, trauma, and alienation for LGBTQ+ people across history and the lifespan
  • Respect TGD clients’ level of comfortability in discussing or addressing religious and spiritual occupations
• Do not assume TGD client levels of religiosity (Gallup Daily Tracking Survey 2020; Conron et al., 2020)
  • 40% of LGBT adults ages 18-34 years are religious, and 65% of LGBT adults ages 65+ are religious
  • 71% of Black LGBT adults are religious
  • 54% of LGBT adults in the South are religious
• Identify if your setting has a chaplain
  • Assuming an affirming chaplain, how can you work together to support your TGD clients religious/spiritual wellness? How can you work together to support your TGD clients’ participation in religious/spiritual occupations?
• Recognize religious and spiritual diversity
  • Similar to gender identity, a person’s religious, nonreligious, and/or spiritual affiliations influence occupational choice, meaning, and identity (Beagan & Hattie, 2014)
  • Research interfaith approaches/dialogue to improve care for TGD clients of various religious and nonreligious traditions, beliefs, and practices
• Recognize differences in meaning-making
  • Assessing client religiosity
  • What an OTP might consider a “secular” activity (e.g. dressing or grooming) could hold spiritual value for a client
• Generational shifts in religious identities
  • People of all identities can experience change in their religious or spiritual identity across the lifespan
• Explore guides for professionals in pastoral care (e.g., chaplains) to brainstorm ideas for skilled documentation
• Recognize the existence of theologies from the margins to refer to clients when appropriate
  • Liberation theologies
  • Queer theologies
  • Womanist and feminist theologies

Relevance

• Safety and emergency maintenance can include safety from oneself. Many TGD individuals experience mental health challenges, including increased risk for self-injurious behaviors and suicidal ideation/actions (James et al., 2016, Kidd et al, 2023).
• Safety and emergency maintenance also includes navigating personal safety in day-to-day life and across various locations. Nearly fifty percent of TGD individuals have experienced harassment or violence from others (James et al., 2016; Kidd et al, 2023). 19 states have passed anti-LGBTQ+ laws specifically targeting gender-affirming healthcare thus far in 2023 (ACLU, 2023).

Considerations for OTPs

• Recommendations specific to safety from oneself:
  • Educating about harm reduction and proposing alternatives for self-injurious behaviors that provide similar but less dangerous or risky sensory input. For example, for an individual who scratches their skin, suggest a sensory brush, compression garment, or hot/cold items to provide different sensory input.
  • Educating TGD clients about healthy coping skills and resources they can access in times of mental health-related crisis.
• Recommendations specific to personal safety:
  • Supporting the individual in identifying what safety means to them in relation to their TGD identity and interactions with others.
  • OTPs must educate themselves on local and state laws specific to TGD individuals, especially those that may impact gender-affirming healthcare. OTPs must advocate against policies and legislation with negative impacts on gender diversity (AOTA, 2021).

Relevance

• TGD individuals can face discrimination and violence when shopping due to transphobia. Because of this, they may avoid shopping, hide their true identity in order to shop, or partake in limited shopping.
  • This can cause mental and physical health problems (i.e., malnutrition, depression, anxiety, etc.) if TGD individuals are unable to shop for items they want and/or need.
• Many clothing companies are binary and gendered which can further exacerbate feelings of gender dysphoria and/or not belonging (Jones et al., 2023).

Considerations for OTPs

OTPs have a role in helping their clients find ways to participate in meaningful occupations like shopping.

• Affirming shopping
  • OTPs can help their TGD clients navigate shopping safely through brands, sites, and stores (online and/or in-person) that provide inclusive and affirming clothing (Jones et al., 2023).
  • OTPs should consider that shopping may cause anxiety due to gender-related rejections the client may have experienced. It is essential to practice cultural humility and a client-centered approach.
• Resources and safe precautions
  • OTPs can help their TGD clients find LGBTQIA+ resources and support groups in their area that may partake in group shopping activities or provide recommendations to safe stores
• Implications for practice
  • Utilizing frame of references such as Gender Minority Stress (Testa et al., 2015), the PEOP Model (Christiansen et al., 2005), the socio-ecological framework (Bronfenbrenner, 2000) can provide guidance on ways to promote engagement in shopping.