Challenging Norms: The Impact of Transgender and Gender-Diverse Realities on Work and School Participation

Occupational therapy practitioners recognize that health is supported when individuals fully participate in home, school, workplace, and community life (American Occupational Therapy Association [AOTA], 2020b). Thus, disruption to occupation in these settings is potentially significant for the estimated 1.6 million transgender individuals in the United States when confronted with discrimination while undergoing gender affirmation (or transitioning; Herman et al., 2017). The term transgender or trans refers to individuals whose gender identity and expression are different from cultural expectations of the sex they were assigned at birth (Human Rights Campaign, 2023). A related term, gender diverse, may be used to describe individuals who do not conform to binary gender categories, such as male–female or man–woman (American Psychological Association, 2015). Transgender and gender-diverse (TGD) individuals often adopt new routines for basic activities of daily living and face numerous challenges, even mistreatment, while attempting to introduce their changing outward appearance (Beagan et al., 2012; Parr & Howe, 2021) and improve authenticity. Authenticity is the ability to be one’s true self in daily life (Kernis, 2003; Martinez et al., 2017). Education and work are recognized as core life occupations (AOTA, 2020b), so conflict at school and in the workplace should be of high concern to practitioners. Furthermore, the Occupational Therapy Practice Framework: Domain and Process (4th ed.) acknowledges that gender identity is a personal factor reflecting the “essence” of an individual and “who they are” (AOTA, 2020b, p. 11).

TGD individuals often experience significant challenges in the workplace. In Budge et al. (2017), participants expressed fear that disclosing their TGD identity at work could lead to unfair treatment or losing their job. According to the 2015 U.S. Transgender Survey, 15% of respondents reported experiencing verbal or physical abuse or sexual assault at work because of their gender affirmation status (James et al., 2016). More than 75% of respondents reported taking actions to avoid workplace mistreatment, such as masking their gender affirmation or, in some cases, quitting their job (James et al., 2016). A lack of workplace protections places TGD individuals at increased risk of being denied promotion or opportunities for career advancement and affects their work volition (capability to make career choices; Tebbe et al., 2019). The lesbian, gay, bisexual, and transgender (LGBT) community did not gain employee rights until 2020 when the U.S. Supreme Court ruled that LGBT employees were protected in the workplace under the Civil Rights Act of 1964 (Pub. L. 88-352; Totenberg, 2020). Even with federal employee rights, TGD individuals as employees have a greater likelihood of personal dissonance when their outward manifestation of gender is discrepant with their inner gender identity (Martinez et al., 2017). The extent to which TGD employees have matched their outward appearance to their identity has been associated with higher job satisfaction, organizational fit, and less discrimination, and this relationship is mediated by the extent to which TGD employees feel others at work perceive them in a manner consistent with how they perceive themselves (Martinez et al., 2017).

Similar to the workplace, the school environment can be exclusionary and damaging for TGD youth. TGD students are more likely to report a hostile school environment, bullying, and higher rates of truancy than non-TGD students (Day et al., 2018). Kelley et al. (2022) reported that a supportive school environment is strongly related to TGD students’ well-being. A supportive school environment has been shown to reduce the risk of suicidality among LGBT adolescents (Ancheta et al., 2021).

Building on previous research, this study aimed to evaluate TGD individuals’ comfort with how others perceive their gender identity at work and school, the impact on coming out or outness, and mistreatment at work or school. Understanding these issues can inform the occupational therapist’s role in helping TGD individuals navigate discrimination and unfair practices to allow improved and more equitable occupational participation.

This study examines a subset of participants who were enrolled in the Study of Transition, Outcomes and Gender (STRONG). STRONG is a retrospective– prospective cohort study to assess the health status of TGD individuals (Quinn et al., 2017). Although most data for STRONG were collected from electronic health records, an important component was a cross-sectional survey of detailed participant-reported information. Among the larger adult cohort of 6,456 TGD members of Kaiser Permanente health plans (56% assigned male at birth [AMAB], 45% assigned female at birth [AFAB]) in Georgia, Northern California, and Southern California, 2,136 were invited to complete the survey (Owen-Smith et al., 2018; Quinn et al., 2017). AMAB and AFAB determinations have been described in previous articles (Quinn et al., 2017; Roblin et al., 2016). Briefly, text strings from electronic medical records (EMRs) were manually reviewed for transgender status and physical sex assigned at birth, and a validation study was completed that compared EMR results and survey reports of physical sex assigned at birth. Cohort and survey participant demographics are sociodemographically diverse and broadly representative of the communities in the corresponding areas (Koebnick et al., 2012; Owen-Smith et al., 2018; Quinn et al., 2017). Emory University served as the coordinating center. All activities were approved by the institutional review boards of the four institutions.

We want to disclose our collective identities in acknowledgment of any potential impact these may have had on the research. The author group includes educators and researchers in medicine, occupational therapy, public health, and large, integrated health care systems. We identify as cisgender, and the LGBT community is represented. Four of us identify as women, and four identify as men. In addition, other identities include Asian American–Filipina, Asian, Caucasian, White, Black, and Latinx.

The primary dependent variables included outness and mistreatment at work or school. Outness assesses the degree of disclosure of one’s gender identity to different people in one’s social network (Brewster et al., 2012; Whitehead et al., 2016). Survey respondents indicated whether they were (1) ever out to an employer or (2) treated unfairly at work or school or fired from a job (mistreatment). Responses to the first measure were grouped into “no” or “yes” categories from the following response options: “no,” “yes–some,” “yes– most,” “yes–all,” and “does not apply.” For the mistreatment outcome, response options for the larger question “During the past 12 months, have any of the following things happened to you because someone knew or assumed you were transgender?” were “no,” “yes,” “does not apply–don’t know.” Respondents who indicated “does not apply” or “don’t know” were excluded from the regression analyses.

The primary independent variable was high social affirmation, referring to gender affirmation from others, which has been shown to be a significant source of social support for TGD individuals (Sevelius, 2013). High social affirmation was determined on the basis of responses to the survey question, “Assuming gender and gender expression are continuums, how do you think others perceive you on the scales below?” The question solicited responses on a scale ranging from 0% to 100% for four continuums: (1) maleness, (2) femaleness, (3) masculinity, and (4) femininity. Desired scores were captured by a similar but separate question soliciting where on these continuums they wanted others to perceive them. High social affirmation was assigned to participants whose scale scores were equal to or exceeded their desired scores (To et al., 2020).

The second independent variable was “comfort with how others perceive own gender identity,” which was captured by the statement, “I am generally comfortable with how others perceive my gender identity when they look at me,” with response options on a 5-point scale: strongly disagree, somewhat disagree, neither agree nor disagree, somewhat agree, and strongly agree. To create a dichotomized outcome, responses were categorized as strongly disagree/somewhat disagree and somewhat agree/strongly agree, excluding respondents who indicated neither agree nor disagree from the logistic regression analyses.

Frequency distributions were calculated for demographic variables (Table 1). Affirmation predictor and outcome variables were compared between AMAB and AFAB groups, and χ² tests were calculated. Test results were considered significant if p < .05.

Crude and adjusted odds ratios (ORs) and 95% confidence intervals (CIs) using logistic regression were calculated to assess the association between social affirmation and comfort with how others perceive their current gender expression and the outcomes of outness and mistreatment in the workplace. Adjustment for potential confounders known to be associated with workplace climate includes age, race–ethnicity, income, and education level (Ewton & Lingas, 2015; Gyekye & Salminen, 2009; Nunez-Smith et al., 2009). Statistical analyses were performed with SAS (Version 9.4).

Of the 2,136 individuals invited to participate in this survey, complete responses were received from 696. Of these, 67 (9.6%) self-identified as nonbinary. The final sample included 350 individuals AMAB and 346 individuals AFAB. Demographic characteristics are presented in Table 1. Overall, 44% of participants were younger than age 35 yr. Individuals AFAB were generally younger, with nearly 60% younger than age 35 yr compared with 28% of participants AMAB. Most participants were non-Hispanic White (56%), had completed at least some college or more (85%), and were employed for wages at the time of the survey (56%). Participants identified as students (15%), self-employed (12%), retired (11%), not working (17%), and homemakers (3%), or they did not report their occupation (7%). Of the 106 who identified as students, 52 were exclusively students. Participants were able to choose multiple occupations.

Between AMAB and AFAB groups, significant differences were found in social affirmation level and comfort with how others perceived their gender identity (Table 2). Nearly two-thirds of participants AFAB reported high social affirmation compared with only one-third of participants AMAB (p = .0001). Although the majority of individuals AFAB and AMAB agreed that they felt comfortable with how others perceived their gender identity, the proportion of participants was higher in the AFAB group (73% vs. 61%; p = .001). There were no significant differences between the AMAB and AFAB groups, respectively, in outness to employers (51% vs. 54%; p = .44) or perceived mistreatment (17% vs. 18%; p = .79).

Table 3 details the associations between the predictor variables and mistreatment at work or school. Overall, those with high social affirmation were 57% less likely to experience mistreatment than those with low social affirmation (95% CI [0.38, 0.86]). Similarly, those who agreed that they felt comfortable with how others perceived their gender identity were 53% less likely to experience mistreatment than those who disagreed (95% CI [0.32, 0.87]). These patterns were generally consistent in fully adjusted regression models and within AMAB and AFAB groups.

More than half of the respondents reported ever telling their employer about their gender identity (52%). When examining associations between the predictor variables and outness in the workplace, there was considerable variation within the AMAB and AFAB groups. Individuals AFAB who agreed they felt comfortable with how others perceived their gender identity were significantly less likely to be out to their employers than individuals AFAB who disagreed (OR = 0.45, 95% CI [0.20, 0.97]; Table 4). Findings from the fully adjusted regression model were comparable with the crude result. However, no associations were found between the predictor variables and outness in the workplace among individuals AMAB. Overall, we found no significant associations between social affirmation and outness.

The results of this study indicate that the transitioning experience is, unfortunately, different for individuals AFAB and AMAB. Two-thirds of individuals AFAB reported high social affirmation compared with only one-third of individuals AMAB. In addition, individuals AFAB reported greater overall comfort with how others perceived their gender identity. These findings are consistent with those of other studies that have found the transitioning experience to be more positive for individuals AFAB. Individuals AFAB reported newfound respect, authority, and opportunities for promotion, whereas employees AMAB indicated that their abilities and productivity levels were suddenly in question (Schilt & Connell, 2007). In addition, individuals AMAB have been found to demonstrate impaired occupational identity (subjective view of themselves in an occupational role) and competence (ability to take action and achieve an occupational goal) compared with their cisgender female counterparts as a result of fewer opportunities for social interaction, less support from coworkers, and feeling less physically and emotionally safe (Bar et al., 2016; Cole & Tufano, 2019).

One notable finding is the association between comfort with others’ perception of their gender identity and authenticity or outness at work or school. Authenticity includes the extent to which TGD individuals feel others perceive them in a manner that matches their perception of themselves (Kernis, 2003; Martinez et al., 2017). Greater authenticity is positively related to feelings of self-worth and healthy psychological functioning (Goldman & Kernis, 2002). In this study, individuals AFAB who agreed they felt comfortable with how others perceived their gender identity were significantly less likely to be out to their employers than individuals AFAB who disagreed, indicating that they were less likely to self-disclose their transitioning status.

The impact of social affirmation at work and school should not be minimized. Participants who reported high social affirmation were found to be less likely to report mistreatment than those who reported low social affirmation. In addition, those who were comfortable with how others perceived their gender identity were less likely to report mistreatment than those who were not comfortable. In this study, about 17% to 18% of respondents AMAB and AFAB reported mistreatment at work and school. This finding is in alignment with previous research indicating that TGD individuals report psychological distress and discrimination when they disclose their preferred gender identity (Becerra-Culqui et al., 2018; Ewton & Lingas, 2015). Broadly, lack of sensitivity and acknowledgment of gender identity have been noted to contribute to lower care-seeking behavior or the willingness to access primary and preventive health care services among TGD and sexual and gender minority groups (Lombardi, 2001; Whitehead et al., 2016). To cope with discrimination-related anxieties, TGD patients often delay seeking care or instead follow health advice from friends and others (Lewis et al., 2019). TGD individuals in nonsupportive environments may additionally feel the need to use covering strategies or take other actions to hide their true gender identity (Brewster et al., 2012). These actions can include deciding not to attend TGD social events, avoiding contact with people known to be TGD, and disassociating oneself from issues pertaining to gender identity. Avoiding these activities can in turn reduce social support and impair mental wellness and quality of life (Brewster et al., 2012).

We view the findings of this study as a call to action for practitioners to be aware of ongoing discrimination against TGD individuals and the need to serve as allies and advocates. Seemingly simple activities such as changing clothes for high school gym class or entering a public restroom can be fraught with anxiety for TGD individuals, a population that has faced a history of institutionalized persecution (Mezey, 2020). Although the U.S. Supreme Court’s 2015 ruling in Obergefell v. Hodges ensured marriage rights and benefits for all LGBT individuals, subsequent years have seen aggressive efforts to restrict LGBT rights, particularly for TGD individuals. Numerous states have enacted bathroom laws that bar TGD individuals from using public bathrooms in alignment with their gender identity (Mezey, 2020), and more than 320 anti-LGBT pieces of legislation have been introduced in state legislatures. Of those, 130 target TGD youth specifically and aim to ban TGD athletes from participating in public high school sports or prohibit them from seeking gender-affirming care (Berg-Brousseau, 2022). Eight states now ban TGD public high school athletes despite the fact that only 0.7% of youth ages 13 to 17 yr in the United States are TGD (Crary, 2021; Herman et al., 2017). Advocating for occupational justice at work and school will help TGD individuals more fully engage in work and education occupations and potentially bolster them emotionally from an outside world that continues to demean them, restrict their rights, and scapegoat them as a population.

A strength of this study is its use of questions related to social affirmation, which were proposed and considered high priority by a STRONG stakeholder advisory group. A limitation of this study is that we did not complete a separate analysis for survey respondents who self-identified as nonbinary. We asked respondents to identify the gender terms they use to describe themselves, and they were able to check more than one category, for example nonbinary and transman or nonbinary and transwoman. These categories were not mutually exclusive; thus, we did not pursue describing this group separately.

Another limitation is that survey questions associated with the predictor and outcome variables solicited responses for different time periods. Social affirmation and comfort with others’ perception of one’s own gender identity solicited responses based on the time of the survey. In contrast, the outcomes of ever out to an employer and being treated unfairly at work or school or fired from a job in the past 12 mo pertained to past experiences. However, given that 33% of individuals AMAB and 65% of AFAB had high social affirmation at the time of the survey, we can consider that this proportion had the same or less social affirmation before the time of the survey or in the past 12 mo. Thus, we can infer that the study results were biased toward no association when there could be an association or toward a stronger one. This holds true for the results associating outness and unfair treatment at work or school with comfort with how others perceive one’s own gender identity.

The results of this study indicate that TGD individuals can participate in work or school without negative consequences when they feel recognized as their desired gender and supported by others. A supportive environment for LGBT individuals improves self- esteem, decreases depressive symptoms, and reduces the risk of suicide (Ancheta et al., 2021; Wilkerson et al., 2017). The discrimination experienced by TGD individuals in their work and school environments should serve as a call to practitioners to advocate for this vulnerable population. The AOTA 2020 Occupational Therapy Code of Ethics holds practitioners responsible for upholding the rights of others and preventing harm (AOTA, 2020a). Occupational therapy practitioners can work toward this goal by helping clients to improve relationships with coworkers and schoolmates, manage stress and psychological demands, and access programs in the community that offer support for TGD individuals. Examples of possible interventions include the following:

• ▪ helping clients to create efficient habits and routines for self-care and self-presentation when the client identifies this as a goal (Beagan et al., 2012; Munson & White, 2015; Phoenix & Ghul, 2016)

• ▪ teaching clients how to seek and summarize information to better inform employers and coworkers, prepare for gender affirmation, and navigate workplace policies (one helpful tool is the Human Rights Campaign Foundation’s [2016] “Transgender Inclusion in the Workplace: A Toolkit for Employers”)

• ▪ guiding clients in researching community and national LGBT resources

• ▪ partnering with clients to develop communication strategies with coworkers, teachers, and classmates to manage self-disclosure

• ▪ helping clients explore and build support networks with individuals with shared experiences (Beagan et al., 2012; Phoenix & Ghul, 2016).

Practitioners may also want to consider their own workplaces and advocate for more inclusive practices that will benefit current and future employees as well as clients. Employees of inclusive workplaces report greater job satisfaction and career optimism and improved physical and psychological well-being (Martinez et al., 2017; Shore et al., 2011). In addition, organizations that cultivate an inclusive environment have greater retention of a diverse workforce and lower costs incurred from employee turnover (Aysola et al., 2018). One useful resource to begin the conversation is AOTA’s (2021) Affirming Gender Diversity and Identity Code policy.

TGD individuals encounter exclusionary practices in everyday life. This discrimination may cause harmful effects on participation in two occupations, school and work, that involve many years of an individual’s life. This study evaluated TGD individuals’ comfort with how others perceive their gender identity at work and school, the impact on outness, and the level of social affirmation they report. Higher levels of social affirmation and comfort with how others perceive their gender identity were both linked to less mistreatment. Furthermore, we found that individuals AMAB may be in more need of intervention and support because they report significantly lower levels of social affirmation at school and work compared with individuals AFAB. These findings shine light on a much-needed area of focus for practitioners and researchers. Occupational therapists must take an active role in working with TGD individuals to improve their gender affirmation experience, help them be treated in an equitable manner, and achieve their occupational goals in educational and employment settings.

This research was supported by the Patient- Centered Outcome Research Institute (Contract AD-12-11-4532), the Eunice Kennedy Shriver National Institute of Child Health and Human Development (Grant R21HD076387), and the California State University, College of Health, Human Services, and Nursing’s Research, Scholarship, and Creative Activity Awards Program. A stakeholder advisory group consisting of 12 members made several important contributions to the project at various stages of study design, planning, and implementation. In particular, the study survey was designed and pilot tested using input from the group. One full day of an in-person stakeholder advisory group meeting was dedicated entirely to the review and refinement of the study survey. Specific to the current analyses, the stakeholders felt that a meaningful measure is the “passing status,” which was expressed as the difference between the extent to which the participants wanted others to perceive them (desired score) and the extent to which they thought others actually perceived them (current score) as a person of their gender identity.