Societal Transition, Medical Gender Affirmation, and Surgical Gender Affirmation

Gender Affirmation Support

Social Transition

Social transition has multiple components to it, some, all, or none of which may take place at any given time in a workplace environment.  The term social transition does not imply that any medical or surgical affirmation has taken place and is a process that may or may not be in step with other affirming care. One important thing to understand is that there may or may not be significant overlap in social transition between transgender, non-binary, and gender non-conforming people. Each individual is a different person.  Following are summaries of related topics.

Gender Expression

Gender expression includes how you look, what you wear, social behaviors, and mannerisms and is highly subjective in interpretation.  Different cultures, subsets of society, countries, systems of religious belief, and time periods have had radically different versions of traditional gender expression.  Before judging or commenting on an individual’s gender expression, it is very important to assume nothing about what their gender expression may be.  Fashion, behavior, and life experiences are so malleable that it would be folly to convince yourself that you know what someone is aiming for with their gender expression. A very important thing to understand is that gender expression is not coupled with gender identity. People can have a gender identity that does not strictly match their gender expression and that is because we are all people who have different personalities, preferences, and outward appearances. That said, gender expression is frequently a very powerful and affirming part of gender transition and takes many forms. If you want to support gender expression, there are some easy steps to take such as the following:

1. Do not shame people or single them out for their gender expression. Making light of someone’s method of expression may lead to a person not discussing anything further, modifying their gender expression to avoid future comments even if that gender expression is not preferred, feeling unsafe at work, or leaving their job.
2. Consider modification of dress codes to focus on inclusivity in attire, hair, makeup, and tattoos. Understand that rigid binary rules around appearance discourage gender diverse people in your workplace.
3. Cultivate an environment of understanding where people have education around gender diversity and are prepared to support it. Be willing to speak out and support individuals if and when people question their appearance, names, pronouns, etc. Without singling people out, showing appreciation in a non harassing manner for their gender expression also goes a long way towards inclusion.  Showing appreciation includes being kind and supporting gender identity and gender expression where relevant.  Including the individual in activities that interest them and in social circles which can often be the hardest part.

Understand that the degree to which an individual changes their gender expression is highly personal and that this expression may go through significant experimentation before someone decides on their typical appearance.  Most of us have experience with colleagues changing their hair, getting new tattoos, trying out a new outfit at work – all of these typical experiences apply when considering how to support a gender diverse person in the profession.

Gender Identity

Gender identity is your gender – for instance male, female, non-binary, gender non-conforming, gender fluid, genderqueer, or agender. This is a truth that someone knows about themselves and cannot be dictated to them or corrected. For many, the consideration of gender identity has taken a lifetime, and affirmation is a long awaited journey. Gender identity can be supported in many ways which are listed as rights within the Gender Identity Bill of Rights (GIBOR) such as use of correct names, providing correct information on websites, using correct pronouns, avoiding micro aggressions around gender, etc. Gender identity transition may be heavily staggered, and it may take quite some time for an individual to come out to themselves, their friends, their family, and the profession. Getting to the point of gender identity affirmation has often been a very fraught and sometimes perilous journey.  

One of the most important steps for members of our profession is to make an effort to accept, include, and welcome people for who they are. Social transition for gender identity may be substantially harder than social transition for gender expression. Many people can identify rock stars or actors or others who have flexed gender expression while seeming to ignore it – fewer can easily accept a gender identity and get it right by taking people at face value and supporting them from the beginning. 

In many workplaces, the first gender diverse person anyone has encountered is that person, and it is hard for anyone with a newly out gender identity to navigate explaining themselves to every coworker, classmate, client, teacher, etc. This may leave the individual feeling isolated and fatigued, not standing up for themselves, concerned about coming to work, and ultimately leaving an unsupportive space. 

Steps you can take to support individuals in gender identity transition include the following:

1. Be purposeful in your support.  This means committing to getting a series of things correct and making sure that others do the same. This may involve taking others aside and discussing missteps.
2. Support and advocate for a gender diverse member of your team not only when coworkers misstep, but also when clients or other individuals in the work space that are not part of your team question or ignore someone’s gender identity.
3. Be proactive. Provide education around gender diversity before you have a member of your team who needs that support or somehow do so discreetly if it is needed.
4. Work with intention on becoming a safe and brave space.
5. Educate yourself about gender diversity today to be prepared to immediately support a gender diverse individual on your team. Become familiar with definitions around transgender, non-binary, and gender non-conforming identity and listen to lived experience.  There are lots of places to obtain this information (e.g. Them Magazine, PFLAG, GLSEN, GLAAD, etc) but reading about advocacy is a good place to start.

Medical Gender Affirmation

Medical gender affirmation consists of hormone replacement therapy that may or may not include some degree of androgen blockade. No one makes the decision to pursue hormone therapy in a hasty manner, and many have spent years considering whether to do so. Hormone replacement therapy is a way to affirm personal gender identity and, in some cases, gender expression as this therapy helps to bring hormonal levels in line with that person’s gender identity. Hormone replacement therapy causes slow changes, in part because of dose escalation, and in part because an individual is essentially going through puberty, which takes years to modify a person’s body.  These changes may or may not be immediately apparent to those around the individual unless they are told and some individuals who do not feel comfortable in a setting may try to mask for as long as possible. This masking may be extremely detrimental to mental health and wellbeing, so we encourage you to develop a place in which people feel safe being themselves. 

Very few details of medical gender affirmation are necessary for the reader to understand how to support gender affirmation and education on  specific medication strategies are beyond the scope of this guide.  However, a mainstay of medical therapy is initial dose escalation and blood work rechecks followed by adjustment to a maintenance dose regime. 

You can facilitate medical transition best by making sure that gender affirmation is covered by your healthcare provider plan for employees and that this coverage makes medical therapy affordable. Although there are community transgender healthcare centers available, lower cost care may or may not come with the same degree of training in some areas and the consequences of poor management may be catastrophic. Once a person is on hormone replacement therapy (HRT), they will likely be on this medication for life, although the form and dose may be adjusted over time to fit the lifestyle of the individual.  This is why there is no one-size-fits-all drug or treatment and multiple options need to be considered.  

Another important concept is that ‘medical conscience’ can lead to difficulty in accessing care both because of willful ignorance or refusal to treat trans people on the part of medical personnel. This is an added and invisible stress that gender diverse people on HRT experience. It is also important to understand that non-binary and gender non-conforming people also access medical gender affirmation. 

Surgical Gender Affirmation

There are several things to understand about surgical gender affirmation. First, this is a deeply personal subject and many will not discuss it; asking is a significant invasion of privacy. Second, there are many people who do not elect any form of surgical gender affirmation. Finally, surgical gender affirmation comes in many different forms in part due to surgical techniques that vary and in part due to what an individual needs as part of their gender affirmation.  Because there is so much variation in procedures and because they achieve different endpoints, different gender affirmation journeys may take different recovery times. The exact details regarding surgical procedures are beyond the scope of this publication and regardless, is private information for the individual to decide how much to share or not share. 

A few items to contemplate around support of surgical gender affirmation include the following:

1. There is a direct connection between surgical affirmation and positive mental health. Time and again studies have shown the significant impact of both lack of access and improved access to gender affirming care.
2. For many people, surgical affirmation is also about safety. This is especially true regarding visible changes like top surgery, facial feminization, hair removal, etc.
3. Benefits need to cover all procedures that help provide positive mental health and improve safety, which means that gender diverse people need to directly advise on health care coverage, as well as hopefully suggesting practitioners that are known to provide transgender healthcare.
4. As with conditions that require multiple treatments, some of which must be adjusted over time, or pregnancy that requires a variety of appointments, gender affirmation needs a protected status to help include gender diverse people.
5. When leave is sought, the only information needed should be a doctor’s note that says that an employee will be out for necessary treatment and that the recovery period is x amount of time.
6. Gender affirmation leave as its own category similar to maternity leave should be considered.

Next Steps

• ALL steps taken for general employees to support a transitioning team member require that a) the team member is ok with applying this focus to gender diverse issues at a critical time for them; b) their safety is maintained throughout the process, and c) the work is ongoing, flexible and organic, continuing to evolve as issues and terminology change.
• Proactively prepare your practice by reading, understanding, and signing your support for the Gender Identity Bill of Rights (GIBOR), the GIBOR FAQs and the PrideVMC Allyship Guide.  Do this now, do not wait for a team member to raise the subject. One approach for workplace decision-makers:
  • Explain to your team that becoming even more inclusive as a workplace is one of your goals
  • Utilize the VMAE Journey Guide materials as they become available
  • Show the GIBOR overview video (with a pre-read of the GIBOR) at a staff meeting then facilitate a Q&A session that is based on helping people to understand the basic rights of gender diverse people without becoming a discussion of gender diverse people as a concept.
  • Ask all team members to read the GIBOR document prior to the next staff meeting
  • Provide a tool for team members to submit questions anonymously that will be read only by those in advocate roles.  These should never be shared directly with transitioning team members as many may be inadvertently harmful.
  • At the next staff meeting field any questions, invite all team members to sign on their individual support, and explain the workplace is signing on as an organizational signatory.
  • Sign the GIBOR – both for your workplace and as an individual signatory
  • If there is work to be done so that your workplace aligns with what is in the GIBOR, create an implementation plan with your team
  • Include the GIBOR in onboarding materials and periodic staff training
  • Invite all team members to share their pronouns on name tags and email signatures
• When a team member tells you they will be transitioning, your top priority should be to center your transitioning team member’s needs and thoughts every step of the way. Do not share this information with others. If you have questions, answer these in your own time without utilizing them as an information source.
• Listen to your team member to understand the support they need and then provide it. Be aware that being gender diverse is not a mental health issue and gender diverse people should not be referred to therapy or social services unless requested for other reasons.
• Create an internal and external communication plan with your transitioning team member if they say that this would be appreciated (this should never be mandatory) – this could include a statement in your practice e-newsletter or a letter (example letter) that is shared with all clients electronically and in person when they visit the practice.
• Read the Next Steps document section on ideas on how to better include gender diverse individuals in your organization and help them to belong.