Gender

Introduction

Few fitness-for-duty considerations exist for transgender/gender diverse (TGD) law enforcement officers (LEOs). Gender diversity is part of the human experience, not a medical condition, and not a reason to request a fitness-for-duty examination (FFDE).

In the United States (U.S.), the inadequate education and training that medical providers often receive renders them ill-prepared to offer culturally sensitive care to TGD persons. Many TGD persons describe negative experiences with health care (Appendix E), including harassment and discrimination in health care settings as well as encountering providers without knowledge of gender-related health. These experiences prompt many to avoid health care needs and perpetuate health disparities. Therefore, the goal of this document is to provide an overview of gender health, increase the competency of public safety medical providers, and promote a gender-affirming approach to the assessment of TGD LEOs.

According to data collected by the International Transgender Community of Police and Sheriffs (TCOPS – www.TCOPS-International.org):

• As of February 1, 2021, 6,000 transgender or gender-questioning law enforcement contacts were identified between 1998 and 2021.
• There have been 3,600 known contacts from transgender or gender-questioning LEOs in the U.S., and 2,400 known contacts from transgender or gender-questioning LEOs outside the U.S.
• Since 1974, 420 LEOs are known to have transitioned or attempted to transition genders while employed at their respective agencies.
• There were 49 known candidates hired in the U.S. who had already transitioned prior to applying to law enforcement.
• Although the exact number is unknown, candidates have been denied employment due to their TGD status.

TGD LEOs represent a heterogeneous group of persons with different experiences and transitioning goals. Many, but not all, experience gender dysphoria distress that arises from the incongruence between an individual’s gender identity and assigned sex at birth (see Appendix C).

The issues that pertain directly to the fitness-for-duty evaluation of TGD LEOs are found in the body of this document. Extensive information related to the health, well-being, and lived experience of TGD LEOs, which may aid in assessment, can be found in the appendices:

• Appendix A – Glossary
• Appendix B – Medical
• Appendix C – Behavioral Health
• Appendix D – Personal Statements from TGD LEOs
• Appendix E – Uniform and Grooming Standards for Transgender Officers
• Appendix F – Policy Statements from Other Organizations
• Appendix G – Cultural Competency — Inappropriate Questions

Throughout this chapter, when no specific reference is noted, then the statement is a consensus of the Public Safety Medicine Task Group.

Medical

Extensive knowledge gaps remain among providers in the evaluation and care of TGD patients. To better understand some of these issues, see Appendix B.

1. Pre-placement exams
   . These should not be any different from other applicants or officers. See chapter on Initial Exams.
   . While not strictly a medical issue, physical fitness standards should be defined by one’s job and not by one’s gender. TGD applicants and LEOs should meet the same physical fitness standards and medical requirements as non-TGD LEOs and applicants.
2. Periodic exams should not be conducted any differently from other applicants or officers.
3. Protective gear issues
   . Gender-affirming hormones (i.e., estrogen and testosterone) and surgical procedures will cause changes in body habitus, musculature, and body fat. Together, these changes can compromise fitting of protective gear.
   . Medical providers should advocate for appropriately fitting gear as needed for all LEOs (Appendix F).
4. Screening and surveillance programs
   . While there are a few medical screening programs for LEOs (e.g., respiratory, lead, etc.), and none of these would be affected by TGD status.
5. Wellness programs
   . Routine screening for cancer should be organ based. That is, if an individual has an organ and meets accepted criteria for screening, screening should be conducted as recommended for the general population.
6. Physical effects of transitioning
   The police physician should be aware of the following issues which may affect an LEO’s ability to perform essential job tasks during or after transitioning.

• • Changes in ability to qualify with a weapon due to changes in body habitus
  • Changes in upper body strength
  • Overall strength and endurance which might impact physical ability testing and defensive tactics training

mm7. Post-operative return to work
mmm. The following time frames are approximate to help guide the police physician to work with the surgeon on appropriate return to work.

*When performed alone
**Hand and/or physical therapy likely required; variable based on stages of procedures

1. Following initiation of medication treatments
   1. The following are medications that might be prescribed to TGD LEOs by the medical provider overseeing their transition. Refer to the Medication Chapter for guidance on any monitoring that may be needed.
   2. There is no need for routine restrictions when starting medications.
   3. Feminizing therapy:

• Estradiol — oral, transdermal patch
• Estradiol valerate (intramuscular)
• Spironolactone
• Finasteride
• Medroxyprogesterone (Provera)
• Micronized progesterone
  • Masculinizing therapy
• Testosterone
• Testosterone cypionate/enanthate IM/SC
• Testosterone gel (1%, 1.62%)
• Transdermal patch
• Testosterone implants
• Testosterone Topical Solution (Axiron)

Behavioral Health
There are known contextual (e.g., environmental, social, cultural, political) factors critical to the competent assessment and care of TGD LEOs. A more comprehensive review of these essential considerations is contained in Appendix C.

1. The mental health needs of TGD LEOs, like non-TGD LEOs, varies widely. When evaluating mental health symptoms, the provider should use the Mental Health Chapter regardless of TGD status.
2. Experiences of stigma, discrimination, and social and economic marginalization often negatively impact mental health (e.g., depression, anxiety, and suicidality).
3. TGD people encounter high rates of trauma, victimization and harassment in many settings including the workplace.
4. Being TGD is not a medical or psychological condition and thus is alone unrelated to duty fitness. Pathologizing these stressors (e.g., invalidation, marginalization, oppressions) may cause additional harm.
5. Gender Dysphoria
   • Gender Dysphoria can present with varied symptoms in different persons. It can present physically (discomfort with one’s body or presentation) or socially (discomfort with being misgendered or identified as a different gender)
     1. According to DSM-5 “In order to meet criteria for the diagnosis, the condition must also be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.”
     2. TGD LEOs who are determined to have significant distress or impairment (e.g., suicidality, panic attacks, depression) may require restrictions and a fitness-for-duty evaluation (see Mental Health Chapter).
     3. TGD LEOs who do not show significant distress or impairment will not require restrictions.
   • Providers should not assume that a TGD person has Gender Dysphoria (Appendix C). Such a prejudgment can undermine assessment and intervention.

References
Coleman E, Bockting W, Botzer M, Cohen-Kettenis P, DeCuypere G, Feldman J, et al. Standards of Care for the Health of Transsexual, TGD, and Gender-Nonconforming People, Version 7. Int J TGDism. 2012;13(4):165-232.

Hembree WC, Cohen-Kettenis P, Delemarre-van de Waal HA, et al. Endocrine treatment of transsexual persons: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2009;94(9):3132-54.

WPATH Clarification on Medical Necessity of Treatment, Sex Reassignment, and Insurance Coverage for TGD and Transsexual People Worldwide [Internet]. [cited 2014 Jan 21]. At: http://www.wpath.org/

Gómez-Gil E, Zubiaurre-Elorza L, Esteva I, Guillamon A, Godás T, Cruz Almaraz M, et al. Hormone-treated transsexuals report less social distress, anxiety and depression. Psychoneuroendocrinol. 2012;37(5):662-70.