Transgender experiences of occupation and the environment: A scoping review

ABSTRACT Background: ‘Cisnormativity’ refers to the Western cultural belief that gender (man/woman) mirrors sex (male/female). This review considers the occupational experiences of people whose gender identity differs from what is expected based on their sex at birth, gender identities operationalised as ‘transgender’. Method: A scoping review was conducted to examine the subjective experiences of occupation for transgender people and the enabling and/or restrictive features of the environment. Forty-one studies were reviewed, using inductive and deductive thematic analysis methods. Results: Three major themes relating to occupational experiences were identified: a) doing difference: gender expression and transition, b) recognisably different: macroaggressions and transphobia, and c) responding to difference: adaptation and identity affirmation. Environmental barriers were reported at a higher frequency than enabling features and pertained to social, physical, cultural and institutional factors. Conclusions: While occupation enables expression of transgender identities, cisnormative ideology shapes participatory norms in Euro-Western contexts. Occupational opportunities are unequal for transgender people, with the policing of binary gender restricting opportunities for inclusion and participation. This review functions as a critical starting point for broader conceptual thinking on occupation, resistance and identity-management for people who are transgender.

A foundational belief of occupational science is that well-being is achieved and sustained through occupation (Stewart, Fischer, Hirji, & Davis, 2015), and that it contributes to life satisfaction following disease or illness (Boyce & Fleming-Castaldy, 2012;Ekelman et al., 2017). Conversely, disengagement from meaningful occupation is associated with increased stress, physiological changes and decline in health (Blank, Harries, & Reynolds, 2014;Lokk, Arnetz, & Theodell, 1993). One of the foundational ways in which occupation is proposed to relate to well-being is through enabling expression of individual and collective values, tenets of one's identity.
A basic characteristic of identity and fundamental division of society (West & Zimmerman, 1987) is the gender categories of man and woman. One's gender category is assumed from one's sex at birth and, in Euro-Western contexts, is the binary distinction that divides labour and dictates practices of self-care, including clothing choice and public bathroom use. Unlike sex, which is based on biological criteria, gender is expressed by a series of acts of doing (Connell, 2009). Arguably, being perceived as a 'man' or a 'woman' is not a pre-determined state but rather is expressed through one's occupational engagement, by what one does or does not do (Beagan & Saunders, 2005).
Two analyses have considered the centrality of occupation in sustaining and reproducing differences between girls and boys, women and men. The first, a historic occupational account of dressing and grooming practices, considered the regulation of the body through, for example, the routine association of pink with femininity, blue with masculinity (Goodman, Knotts, & Jackson, 2009). Here, normative Western judgements of dress function to perpetuate a mimetic relationship between sex and gender, whereby gender expression mirrors sex or is otherwise restricted by it (Butler, 1990). The second, a qualitative phenomenological analysis, considered the bodyfocused occupations of 'cisgender' Canadian men, that is, people assigned male at birth who identify as men (Beagan & Saunders, 2005). The regulation and disciplining of the masculine body was achieved through vigilant efforts to sustain muscle mass, reduce body fat, and conceal 'feminine' dietary practices (Beagan & Saunders, 2005, p. 165). This literature suggests that gender is expressed and made intelligible through occupation.
However, there are limits to the occupational performance of gender. In Western society, gender is governed both ideologically and institutionally. 'Cisnormativity' refers to the cultural belief that all people identify with their sex assigned at birth and perform the gender associated with their assigned sex throughout their lifespan (Stryker & Aizura, 2013). The pervasive nature of this ideology results in the marginalisation of non-gender conforming people within Euro-Western physical environments, information systems and administrative policies (Bauer et al., 2009;Namaste, 2000;Vermeir, Jackson, & Marshall, 2018). Institutionally, gender identities that do not conform to cisnormativity are mediated and discursively constructed by medicine and psychiatry (Harwood, 2013;Stryker, 2008). For instance, the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) includes 'Gender Dysphoria' (GD) as a mental health diagnosis. In this framework, nonnormative gender identity is associated with psychological distress and occupational impairment, and is consequently in need of treatment (American Psychiatric Association [APA], 2015).
Given both the centrality of occupation to wellbeing and the need to develop more inclusive perspectives on occupation (Whiteford & Hocking, 2012), this review considers the occupational experiences of people with non-normative gender identities, specifically people who are transgender. Transgender denotes a range of gender subjectivities and presentations that fall across, between or beyond the categories of cisgender man and woman (Hines & Sanger, 2010), including individuals formerly diagnosed as transsexual and those who define as female-to-male transman (FtM), male-to-female transwoman (MtF), non-binary and genderqueer (Strauss et al., 2017). This heterogeneous categorisation includes people who engage in medical transition and those who may alter their gender expression solely through selfdefined pronouns, name change and dress.
A scoping review was conducted to examine transgender participants' subjective experiences of occupation and the environment for transgender participants. The objectives of the review were to describe the occupations central to the construction and expression of transgender identities, and to explore the enabling and/or restrictive features of the environment in facilitating occupation. By considering the experiences of transgender people, this review seeks to broaden occupational science's understanding of how gender influences people's engagement in occupation.

Reflexive statement
The research team comprised two white, cisgender academics (one cisgender woman, one cisgender man) with experience in qualitative research, one white cisgender doctoral student who identifies as a lesbian, and a white, queeridentified transgender honours candidate. All researchers have a social and political interest in gender issues, and are variably positioned both inside and outside the transgender community.

Scoping review
Scoping reviews enable mapping of the broad research landscape, summarising evidence and identifying research gaps. This method is not discipline specific, permitting consideration of subjective experiences beyond the limited accounts offered within occupational science literature. In contrast to other types of reviews, a scoping review does not consider the quality of studies as a basis for inclusion; rather, the objective is to sample for breadth. The scoping review was conducted between April and July 2018 applying the method of Arskey and O' Malley (2005). The scoping review proceeded according to Arskey and O'Malley's (2005) five-stage framework: (1) identification of the research question, (2) identification of relevant studies, (3) selecting studies, (4) charting data, and (5) collating, summarising and reporting results.

Identification of the research question
Two research questions were devised to ensure the breadth and depth of topic coverage: 1) What aspects of occupational experience have been researched? 2) What role does the environment play in enabling or restricting occupation?

Study identification and selection
As the current research is concerned with subjective experiences of occupation, only qualitative studies were reviewed. Qualitative research enables inquiry into the form, function and meaning of occupation from an individual's perspective. Following consultation with a health science librarian, qualitative articles were initially identified using the following search terms: occupation or occupations AND transgender. In a series of subsequent searches, specific occupations and their synonyms were coupled with the search phrase 'AND transgender'. Specifically, the terms self-care, employment, education, parenting or child rearing, domestic work or house work, religion, leisure or physical activity and transport were used. Electronic search of Web of Science, Scopus, CINAHL, Pubmed, PsycNET and LGBT Life was conducted. Combined, this search strategy yielded 175 potentially eligible articles. To ensure comprehensive identification of related papers, we conducted backward and forward searching of citations, resulting in the inclusion of an additional 27 articles. The study identification process is depicted in Figure 1, with 41 articles included in the review.
Inclusion/exclusion criteria were applied as detailed in Table 1. Notably, only research conducted in English-speaking nations of the Western world were considered. This criterion acknowledges the ways in which the construction of gender varies in different social, historical, political and geographic locations (Namaste, 1996). Additionally, only those studies that utilised interviews and/or focusgroups were included, as these methods best enable ethical collaboration with transgender participants in academic research (Vincent, 2018;Zappa, 2017).

Charting the data and reporting results
Key information was extracted and tabulated using an Excel spreadsheet. The following categories of information were recorded: author (s)/year of publication, research location, sample characteristics, study design, aspects of occupational experience and features of the environment (see Table 2).
Following completion of this indexing task, participant responses pertaining to occupational experiences or environmental influences were extracted, verbatim, from the 41 original articles. The first and second authors read all extracted text to increase familiarity. Individual responses were assigned initial codes generated from the grouped data. Lines of text were assigned initial codes based on their content and meaning. Initial codes were then grouped into broad study themes using inductive and deductive analysis methods. Features of the environment appeared to align with features of The Canadian Model of Occupational Performance and Engagement (CMOP-E) (Townsend & Polatajko, 2007) which was introduced as a conceptual framework to guide further analysis. Themes were refined by the research team to ensure they effectively summarised the literature through discussion of the identified codes and their interrelationships.

Results
Reflecting a recent focus on transgender identities within media and popular culture, the majority of studies were published between 2016-2017, with only three studies meeting inclusion criteria published prior to 2009. The majority of publications were by authors from the United States, returning 27 articles. Five articles came from the United Kingdom, while the remaining articles were by authors from Canada, Ireland, Australia, Finland, Sweden and the Netherlands. A total of 374 transgender participants aged 18 years or older were involved in the studies and variably identified as male, female, MtF, FtM, non-binary and genderqueer.     Experiences of individuals who had engaged in medical transition were more commonly reported than those who had not. Similarly, most participants identified with a gender binary (i.e., MtF, FtM) than those who eschewed fixed categorisation through non-binary or genderqueer identification. With exception of four studies that purposively sampled for persons of colour (Koken et al., 2009;Rood, Maroney, et al., 2017;Wallace, 2010), the majority of participants were white.
The following sections will outline themes regarding occupational experiences of people who identify as transgender and aspects of the environment. Consistent with the purpose of a scoping review, this section offers an overview of evidence and research gaps.

What aspects of occupational experience have been researched?
To consider how occupation relates to the construction of transgender identities, categories of occupational experience were developed inductively from the qualitative data itself. Three themes of occupational experience were developed: a) doing difference, b) being recognisably different and c) responding to difference.

Doing difference: Gender expression and transition
The centrality of dress in the construction of transgender identities was a recurrent theme. Participants demonstrated agency in expressing their gender identity through dress, enabling presentation as more masculine or feminine (Abelson, 2016;Budge et al., 2010;Connell, 2010 (Connell, 2010). Practices of chest binding among participants assigned female at birth were detailed (Jones et al., 2017;Mullen & Moane, 2013). Participants also described avoiding sport-specific clothing that exacerbated a feeling of incongruence with one's gender identity, most notably swimwear (Elling-Machartzi, 2017;Jones et al., 2017). Decisions regarding dress reflected the participant's felt safety in each setting, including place of work (Budge et al., 2010;Connell, 2010;Mizock et al., 2017;Ozturk & Tatli, 2016) and on public transport (Lubitow, Carathers, Kelly, & Abelson, 2017).
Participants engaged in occupations intended to suppress or accentuate aspects of gender expression, including dieting and exercise relating to weight loss (Algars, Alanko, Santtila, & Sandnabba, 2012). Exercise variably functioned to control and punish the "wrong body" (Elling-Machartzi, 2017, p. 262) and to support hormone treatment and surgical outcomes (Elling-Machartzi, 2017;Jones et al., 2017). Voice training was central to transfeminine expression for participants assigned male at birth who sought medical transition (Mullen & Moane, 2013;Pryor, 2015), as one participant commented, "[having a deeper voice] is the one thing that really does out me" (Pryor, 2015, p. 446). Reflecting the often-times cost prohibitive nature of cosmetic surgery, illicit silicone injection was an occupation of transition, intended to augment physical appearance and gender expression (Wallace, 2010).

Recognisably different: Microaggressions and transphobia
All studies reported instances of transphobia, defined as overt rejection, harassment and violence, and a more subtle form of discrimination  (Mizock et al., 2017). Experiences of overt and covert familial rejection including threat to life, being kicked out of home and persistent misgendering were perceived as normative (Dispenza et al., 2012;Koken et al., 2009;Levy & Lo, 2013;Mullen & Moane, 2013;Nadal et al., 2012;Von Doussa, Power, & Riggs, 2015). Similarly, transphobic encounters with health-care providers who are typically presumed to be trusted and non-judgmental were detailed (Bauer et al., 2009;Hines 2007;Hoffkling, Obedin-Maliver, & Sevelius, 2016;Samuels, Tape, Garber, Bowman, & Choo, 2018;Vermeir et al., 2018). As one stark example of overt discrimination, participants reported having their anatomy scrutinized or mocked when accessing acute and primary health care (Samuels et al., 2018). What the narrative data on family and health-care provider experiences suggests is a rupture in traditional networks of care for people who are transgender. Discrimination and harassment were further perpetuated by employers and work colleagues (Brown et al., 2012;Budge et al., 2010;Mizock et al., 2017;Ozturk & Tatli, 2016;Pitcher, 2017;Pryor, 2015), peers in tertiary learning settings (Johnston, 2016;Pryor, 2015) and religious community members (Levy & Lo, 2013;Wolff, Kay, Himes, & Alquijay, 2017). At the extreme, transgender participants experienced verbal and physical assault when using public transport (Lubitow et al., 2017). Together, these examples attest to how the persistent and oftentimes violent policing of binary gender impacts everyday occupational experiences for people who are transgender.

Responding to difference: Adaptation and identity affirmation
Threat of violence and discrimination meant that participants engaged in new actions and occupations to protect themselves; participants reported vigilant surveillance when in public spaces (Jones et al., 2017;Lubitow et al., 2017) and the carrying of mace (Pryor, 2015). Participants avoided physical settings where transphobia was perceived as most likely, including acute health care settings (Hoffkling et al., 2016;Samuels et al., 2018), public changing facilities (Jones et al., 2017;Woodford, Joslin, Pitcher, & Renn, 2017) and certain public transit routes (Lubitow et al., 2017). Participants ceased engaging in occupations, such as swimming, team sports (Elling-Machartzki, 2017;Jones et al., 2017;Mullen & Moane, 2013;Semerjian & Cohen, 2006) and participating in formal religious ceremonies (Levy & Low, 2012;Wolff et al., 2017), despite previous demonstrated interest. In instances where participants' physical appearance was perceived as cisgender, an adaptive strategy was to not disclose one's transgender identity, a strategy used to promote personal safety and social acceptance (Abelson, 2016;Lykens, LeBlank, & Bockting, 2018;Rood, Maroney et al., 2017;Sevelius, 2009). However, as the tools for concealing one's gender history (namely access to hormones and surgery) were inaccessible or undesirable to all, alternate strategies were required to avoid victimization, most notably for people of colour (Abelson, 2016;Lubitow et al., 2017). These adaptive strategies included the act of praying alone rather than attending formal religious ceremonies (Levy & Lo, 2012), engaging in fitness occupations that could be completed in the privacy of one's home (Elling-Machartzki, 2017;Johnston, 2016;Jones et al., 2017), self-employment (Mizock et al., 2017), reskilling to avoid transphobic work settings (Brown et al., 2012;Budge et al., 2010;Panter, 2017) and assuming an educational role with health care providers to enhance cultural sensitivity (Pietzmeier et al., 2017;Samuels et al., 2018).
Discursive recasting and risk taking were additional strategies used to manage gender identity. In a study of transmasculine experiences of the pap test, participants recast the test as an act of routine maintenance of a masculine connoted machine (Peitzmeier et al., 2017). Through discursive recasting, the test was viewed as gender congruent, thereby offsetting feelings of identity-threat and discomfort when seeking sex-based services. Pertaining to the experiences of transgender men who have sex with cisgnder men, inconsistent condom use was reported in a bid to "make it better" for non-transgender sexual partners (Sevelius, 2009, p. 406). Here, engaging in occupations that posed a risk to health were central to identity affirmation as male within delineated sexpower relationships.
What role does the environment play in enabling or restricting occupation?
Participants' subjective experiences of the environment aligned with the broadly defined categories in CMOP-E, with restrictive features reported at a greater frequency than enabling features. A discussion of each sub-category ensues.
Cultural environment A culture of cisnormativity pervaded all environmental sub-categories, shaping opportunities for occupational engagement. Cisnormativity functions to produce idealised subjectivities as reflected in social attitudes, the physical design of buildings and institutional practices. This Euro-Western cultural ideology also functions to protect particular kinds of knowledge, most evident in literature on transgender parenting and pregnancy (Hoffkling et al., 2016;Von Doussa et al., 2015). As one stark example of this, pregnant transgender men reported difficulties navigating informational systems unable to account for a man needing services traditionally ascribed to female only patients (Hoffkling et al., 2016).
Contrary to offline environments, participation in social networking sites, such as gender diverse Facebook and message boards, enabled the formation of inclusive cultural environments (Cannon et al., 2017;Levy & Lo, 2013;Wolff et al., 2017). In these stratified virtual spaces, transgender identities and expression are celebrated as normative, enabling transgender space and identity making in ways restricted offline. Within digital spaces and through occupations of care, most notably information exchange, participants legitimise and validate gender identities rendered impossible or unimagineable offline.
Pertaining to enabling features of the social environment, online networks offered critical opportunity for community contact, identity affirmation and information exchange (Cannon et al., 2017;Hines, 2007;Mullen & Moane, 2013;Wolff et al., 2017). These sociocultural environments enable a means of connecting socially marginalised participants, thereby alleviating feelings of isolation (Cannon et al., 2017;Wolff et al., 2017). Through an emphasis on shared experience, reciprocity and trust (Hines, 2007), online social networks provided a safe space for self-expression and belonging (Cannon et al., 2017). Critically, these networks enabled the dissemination of information and resources pertaining to hormone therapy, surgery and health, reflecting dissatisfaction with community methods of care perceived as unable to meet their needs (Bauer et al., 2009;Hines, 2007;Lykens et al., 2018;Mullen & Moane, 2013;Wolf et al., 2017).
Protective features of the physical environment included having access to gender-neutral bathrooms (Singh, Meng, & Hansen, 2013;Woodford et al., 2017) and dormitory arrangements (Pryor, 2015;Wolff et al., 2017). Ensuring privacy in health settings when there is a requirement to disclose one's transgender status (Samuels et al., 2018) was also noted as protective. Large venues promoted a feeling of safety through anonymity, most notably in the context of religious worship (Wolff et al., 2017) and the conduct of university classes (Pryor, 2015).

Institutional environment
Finally, legal and administrative challenges were a recurrent theme of the analysis. Pertaining to participation in sport, transgender participants felt they did not fit within a binary system of participation, particularly when participants engaged in medical transition (Elling-Machartzki, 2017;Jones et al., 2017;Mullen & Moane, 2013;Singh et al., 2013). This is epitomised by a transmasculine participant: "It is too aggressive for me to play on the male football team … I have a fear of getting broken … And female football, obviously I can't do that anymore" (Jones et al., 2017, p. 233). A similar feeling of erasure was felt in regard to participants' legal name status. The inability to change one's preferred name within university systems resulted in participants' legal name being visible on university emailing systems, online class lists and degrees (Pryor, 2015;Singh et al., 2013;Woodford et al., 2017). Participants faced scrutiny when accessing health services, especially when inconsistencies between medical records and insurance documentation were observed (Nadal et al., 2012;Samuels et al., 2018;Vermeir et al., 2018). This presented significant financial obstacles, including prohibitive out-of-pocket costs for preventative screening (Pietzmeier et al., 2017) and barriers to accessing gender affirming medical services when participants initiated medical transition (Singh et al., 2013).

Discussion
Transgender identities are not typically recognised in Euro-Western society as they transgress a cisnormative ideology. As such, experiences of exclusion, discrimination and harassment were commonly reported by transgender participants, shaping their occupational experiences. Various adaptive strategies were employed to enable occupational participation. These included practices of medical transition, dress, diet and exercise intended to suppress or accentuate expression of one's gender, and avoidance of normatively gendered spaces and settings where transphobia was perceived as most likely. Participants made strategic decisions regarding disclosure of their transgender identity, with the option of concealing their gender history noted to enhance safety. Conversely, some identity-affirming occupations posed health-risks, including illicit silicone injection and inconsistent safe sex practices.
The results support a transactional, social justice view of occupation. Currently, Western social, physical and institutional environments lack sufficient nuance to enable equitable occupational participation. Specifically, these environmental sub-domains reflect a tendency to view and design society on the basis that everyone identifies with and will perform the gender that matches their sex assigned at birth. Transphobic social attitudes, the binary structure of team-based sports, bathrooms and inflexible administrative and health systems are a consequence of cisnormative cultural ideology. The subsequent policing of binary gender creates situations of occupational injustice for people who are transgender. Adopting a social justice lens (Wilcock & Townsend, 2000), the findings of this review indicate that occupational opportunities are unequal for transgender participants, with cisnormativity and transphobia restricting inclusion and participation.
While providing insights into patterns of occupation for people who are transgender, several limitations of the reviewed articles are of note. Firstly, the majority of studies were conducted in the United States. Greater insight to the experiences of transgender people in, for example, the United Kingdom, Australia and New Zealand is required to advance a culturally situated understanding of transgender experience. Secondly, few authors reported on their role as researchers or their investment in selfother representations. Researcher reflexivity is essential when coproducing qualitative data with transgender participants, protecting against misinformation. Similarly, due to the historic pathological positioning of gender diverse people, strategies to reduce misrepresentation are imperative (Vincent, 2018). Strategies such as including community involvement in project formulation and member checking were inconsistently employed across the included studies.
Pertaining to the review, neither the selection of databases, search terms nor inclusion of papers was exhaustive, however this review is a critical first step in exploring this topic. While providing insights into the contextualised experiences of transgender people, knowledge could be strengthened by including educational and sociological databases and additional search terms. Future reviews could consider including different methodologies, such as quantitative research, and integrate a structured assessment of strengths and weakness. Indeed, as occupational scientists conduct further studies into the subjective experiences of transgender participants, especially those with a vision to inform transgender-inclusive practices, quality appraisal will be important for future reviews. Finally, while a team based approach to data analysis was used, to enhance dependability greater reflection on researcher assumptions and biases, particularly in the selection of examples, is recommended. This is necessary to protect against insider blindness when conducting research into minority group experiences, particularly granted the first author's status as a member of this minority group.
With these limitations in mind, this study is an important first step in discussion of transgender experiences of occupation and the environment. Further to providing an overview of occupational experiences, several conceptual insights have been gleaned. Firstly, occupation enables transgender people to negotiate the discordance between gender identity and gender expression. Expression of gender identity through, for example, hormones, surgery, name change and/or dress, functioned to conceal transgender identity, to fit in to a binary framework, or as a conscious strategy to destabilise a naturalised gender binary. Thus, participants engaged in occupation in flexible ways to achieve and sustain idiosyncratic gender expression.
Secondly, while previous research has suggested that ways of doing gender were perceived as natural and invisible for cisgender men (Beagan & Saunders, 2005), the current review indicates that falling outside gendered social conventions can result in hyper-visibility, necessitating vigilance to physical and identity threat. This finding confirms that gender is a social and cultural organising principle in Euro-Western contexts, with invisibility contingent on the hypervisibility of people who do not conform to gender expectations (Hines & Sanger, 2010). Ultimately, we are all influenced by and involved in the creation of gender(s).
In the current analysis, certain forms of privilege were noted to mitigate experiences of transphobia, including economic resources, white privilege and level of support from intimate networks. However, such privilege was not available to all participants, suggesting people experience being transgender differently. In instances where socio-demographic data were available, the majority of participants identified as white, FtM or MtF participants of the Western world. Yet, transgender men of colour report new risks of harassment in gaining maleness in social interactions (Schilt, 2006), while transgender women of colour experience the highest rates of discrimination, incarceration and violence among the transgender population (Grant et al., 2011;Westbrook, 2016), demonstrating the importance of adopting an intersectional lens. The finding that person-level factors create particular experiences of the social world prompts occupational scientists to adopt a sophisticated understanding of intersectional identities (Collins & Bilge, 2016). This may be illuminated in future research by considering occupational strategies of resistance to cisnormative social expectations and environments by transgender participants of diverse racial and gender identities.

Summary
This review provides preliminary insight to the subjective experiences of occupation and the environment for people who are transgender. Occupation enables the construction and expression of transgender identities, with occupational possibilities shaped by the systematic policing of binary gender in Euro-Western contexts. Continuing research is needed to consider empowerment-directed processes to decrease real or potential occupational injustice for people who are transgender.