(Return to) work and health

Work can be considered as one of the determinants of self-worth and a means of social participation and fulfillment. There is a strong association between worklessness and poor health in terms of higher morbidity and mortality [1]. During the last decade, a lot of attention has been given to “return to work” (RTW) research within several psychological and medical settings. An RTW-process is considered a process in which, through assistance and interventions, the worker resumes work after a period of (sickness) absence [2–8]. Ideally, the worker will return to their previous job, with accommodations if required. However, at times it may be necessary to proactively explore alternate or suitable new work during the convalescence period of the worker [2–8].

Emic approaches of RTW research [3–5, 9–11] have already shown a beneficial effect of RTW or work resumption on several levels. On the micro level, returning to work promotes quality of life, community integration and participation of the worker. On the meso level, the company benefits by reducing the costs of recruitment, training, productivity loss, and absenteeism. And on the macro level, society has less expenditure on health care and unemployment costs. There is evidence that vulnerable groups have the same desires as other people and want to participate in society by means of having a job [3–5, 9–11].

Transgender people and gender-affirming care

Transgender people or persons—an umbrella term for people whose gender identity (GI) or gender expression differs from the sex they were assigned at birth [12]—can be considered vulnerable as they often face difficulties in accessing employment [13–15] and sustainable work [13, 16, 17]. Within gender-affirming care (GAC), some trans individuals choose gender-affirming medical interventions (GAMI) to align their body with their gender [18]. Surgical aspects of GAMI or gender-affirming surgery (GAS) are inevitably accompanied by (several) temporary absences at work, followed by different RTW processes. Even for those not choosing GAMI, the social coming-out process might result in a temporary absence from work. It is therefore not surprising that the “going-back-to-work” process of trans people during social and/or medical transition is met with multiple challenges and the need for support.

The biopsychosocial model and identity-based model

Occupational health professionals have, among others, the task to assist in the return to employment of those who have been absent. As suggested by the International Classification of Functioning (ICF) biopsychosocial model [19–22], not only biological factors must be taken into account in the dynamic RTW process but also psychological and social factors. For trans people, it is important to consider the overarching theme of gender. Gender is often understood as a socially determined construct and encompasses the set of roles, expectations, and norms that we ascribe to different sexes. In the identity-based model [23], gender variance is understood as inherent to human diversity but in our daily society, trans and gender diverse persons still experience social stigma and less legal protection with associated negative health consequences [24].

Work experiences of transgender people

Within the transgender health literature, a small body of evidence has focused on negative and positive workplace experiences. Negative experiences (discrimination, micro-aggressions, lack of social support, structural inequalities, etc.) are associated with poor work outcomes and diminished well-being through maladaptive coping mechanisms [24–30]. Yet, a variety of effective strategies (coping methods with strategies, such as identity-based, cognitive, interpersonal and advocacy-related ones) can be utilized to facilitate transitions at work or buffer the effects of discrimination as reported by transgender participants in some qualitative studies [30–33]. Furthermore, other qualitative and quantitative research [26, 27, 34, 35] clearly demonstrates that positive experiences in a supportive and inclusive work climate go hand in hand with higher levels with respect to job performance, satisfaction, and general well-being.

Objectives and aims

This study is part of a larger project in which it is the goal to optimize RTW counselling for trans people during transition. As the basis for this research setup, our objective was to investigate the international literature on RTW (experiences) by way of a systematic review, and this will be followed by a mixed-methods design with quantitative data and qualitative data of RTW experiences. We searched the literature, using an occupational lens, for the availability of objective RTW outcomes, such as employment status and type, number of work resumptions, as well as (return to) workplace experiences and support during socio-medical transition of transgender employees. This review explores the intersectionality of RTW, transgender people, and transitioning at work (TAW) and may therefore also be useful to (occupational) health professionals seeking guidance on key issues noted among transgender people as well as on assistance in the RTW process.

Search strategy

The search strategy was based on the PICOT (population, intervention, comparison, outcome and time) framework [37, 38]. However, due to the absence of a specific comparator and the obsolete timeframe of during or after transition, the search strategy was derived in terms of the participant, intervention, and outcome (PIO). The complete search string was constructed of the combination of four search groups: transgender, gender dysphoria, gender confirmation surgery, and RTW. For each search group, frequently used (old) synonyms, related terms, and database-specific vocabulary were applied. The PubMed database and syntax were used as a starting point for construction and validation. A single database-specific search string example can be found in “S1 Text,” and search concepts along with specific database terms can be found in Table 1. The search strategy was evaluated by the standards set by the PRESS 2015 Guideline statement [39].

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Table 1. Search terms.

https://doi.org/10.1371/journal.pone.0259206.t001

For the purpose of this review, online databases, such as Medline, Embase, ProQuest, Scopus, Web of Science, EBSCOhost, CINAHL, and Epistemonikos, were systematically explored from January 2019 until March 1, 2021 for publications in the fields of medicine, psychology, and sociology. Additionally, other meaningful and gray literature interfaces (i.e., Zotor, OTseeker, and Open Grey) were thoroughly examined within the same time period. References to key articles were manually searched, and their eligibility was examined. Search results were exported in Endnote X8.2 for each database and subsequent deduplication was performed. Two reviewers (JVdC and HVS) screened the titles and abstracts using Rayyan software [40] and performed a full text evaluation. At all stages, in the case of disagreement, a third reviewer (LB) was consulted. There was no blinding for the journal title, study author, or institutions.

Eligibility

To ensure a comprehensive overview of the topic of RTW in an adult transgender population, all study designs (qualitative, quantitative, and mixed method) with primary or secondary data concerning transgender adults and RTW in English, Dutch, French, and German, but only originating from Europe and Anglo-Saxon countries (USA, UK, Australia), were considered eligible.

The researchers omitted children, teens, adolescents, informal workers, sex workers, HIV-related focus, intersex persons, and persons with dual-role transvestism (2021 ICD-10-CM Diagnosis Code F64.1 [41]) from this review. Informal and sex workers were excluded due to the study’s focus on legal and protected work environments and the regulated process of RTW in occupational (health) care and the emphasis on specific RTW outcomes. Intersex people and persons with dual-role transvestism, who are not defined within the transgender spectrum [12], were also omitted from this review.

Interventions within GAC, such as therapy, procedures, and surgeries, were eligible. No exclusion criteria were implemented in terms of, e.g., type, timing, frequency, or dosage of the intervention. Articles with outcomes not associated with transgender adults and (return to) work (experience) were excluded.

RTW was defined as any work resumption on the part of full-time and part-time, employees, laborers, or self-employed individuals at the previous workplace (same or different job) or in another company or organization (same or different sector). RTW could be eligible as a dichotomous variable (yes or no), a rate or proportion, number of RTW attempts, or time to RTW or number of sick days. No limitations were set on the follow-up period in which RTW can occur in the selected studies nor was a specific assessment tool for RTW upheld as an inclusion criterion. RTW experiences of TP, especially those involving facilitators and barriers to RTW, were established based on qualitative data.

The researchers only performed a screening and full-text evaluation of publications released between November 1, 2006 and March 1, 2021. The year 2006 was chosen as a starting date due to the meeting held in that year, which resulted in the Yogyakarta Principles [42]. These principles triggered developments in the political and social landscape, such as the European Gender “Recast” Directive (2006/54/EC) [43] for the application of human rights in terms of sexuality and GI. It is thus reasonable to assume that this publication and the following directive affected the (return to) work experiences of transgender employees.

Data extraction & data synthesis

A synthesis of the included articles was performed independently and entailed the following characteristics: author, place and year it was published, the topic, methods used in data collection, participants, most important or work-related outcomes, and work-related key findings.

Thematic analysis

Qualitative data from qualitative and mixed-methods studies were each separately analyzed by two independent reviewers (JVdC, HVS) in their own narrative. General themes or domains were identified, and testimonies and topics were summarized into subthemes. Similarities in overarching themes and discrepancies were discussed, whereas a third reviewer (LB) was consulted when consensus could not be reached.

Quality appraisal

Two reviewers (JVdC, HVS) independently performed the quality assessment. The QualSyst tool [44] was used for the assessment of the overall quality of quantitative and qualitative studies with a liberal cut-off for the summary score of 0.55. The Mixed Methods Appraisal Tool or MMAT [45] was applied for mixed-method studies. Disagreements were resolved by consulting a third reviewer (LB).

Selection of relevant studies

The flowchart (“Fig 1”), based on PRISMA reporting guidelines [36], depicts the study identification and selection process. The literature research identified 14,592 articles, and ten additional articles were manually searched; following deduplication 10,401 articles remained. For 97 remaining articles, a full-text evaluation was performed and 77 of those were excluded. The articles (77) that were excluded during the full-text evaluation and their reason of exclusion can be found in “S1 Table”. Twenty studies were included for further research.

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Fig 1. PRISMA flow diagram.

An overview of the literature search and study selection [36] *reasons for exclusion: some studies were excluded for multiple reasons.

https://doi.org/10.1371/journal.pone.0259206.g001

Study characteristics and data synthesis

Detailed characteristics of the 20 included studies are listed in the data extraction/evidence table (“Table 2”). The study design included quantitative studies (n = 8), qualitative studies (n = 7), and mixed-methods studies (n = 5). The majority (n = 9) of the studies were conducted in Europe (Belgium, France, Denmark, Germany, Italy, Sweden, the Netherlands) and the USA (n = 6); the remaining studies were conducted in the UK (n = 2) and Australia (n = 2) or were international (n = 1). Eighteen studies were written in English, one study was written in both English and French, and one report was drawn up in Dutch.

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Table 2. Study characteristics and data synthesis of (return to) work-related outcomes.

https://doi.org/10.1371/journal.pone.0259206.t002

Quality of evidence

The QualSyst score ranged from 0.68 to 0.91 (M = 0.71) for quantitative studies [28, 34, 46, 50, 53, 54, 58, 59] (see “Table 3”) with an average summary score of 0.77 (SD = 0.08); overall, a score closer to 1 indicates a better quality. For the qualitative studies [26, 35, 48, 52, 56, 57] (see “Table 4”), the overall summary score (QualSyst tool) ranged from 0.19 to 1.0 (M = 0.85, x = 0.70, SD = 0.27): only two studies, with a very distinct study design (report of HR organization, single interview) were of very low (0.19) [52] to low quality (0.50) [57], while the remainder were of good to very good quality. Because of their information value, these two studies were included.

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Table 3. Quality analysis of quantitative studies with the QualSyst tool.

https://doi.org/10.1371/journal.pone.0259206.t003

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Table 4. Quality assessment of qualitative studies with the QualSyst tool.

https://doi.org/10.1371/journal.pone.0259206.t004

Three [17, 47, 51] out of five mixed method articles assessed through the MMAT, generated a variety of “No” or “Can’t tell” on the statements related to the separate parts of their qualitative and quantitative study design, the integration of data and its output, or possible divergences and did not sufficiently adhere to the quality criteria of each tradition of the methods involved. Two studies [16, 55] were overall of very good quality in their mixed methods design, as summarized in “Table 5”. Based on the guidelines of MMAT [45], none of the mixed-method articles were excluded.

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Table 5. Quality assessment of mixed method studies with the MMAT.

https://doi.org/10.1371/journal.pone.0259206.t005

Quantitative results

Qualitative results: A thematic analysis of (return to) work experiences

During the thematic narrative analysis of (return to) work experiences from the qualitative data of twelve studies, two overarching main themes emerged: coming out (CO) at work and transitioning at work (TAW) (see “Table 6”).

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Table 6. Thematic analysis of (return to) work experiences.

https://doi.org/10.1371/journal.pone.0259206.t006

Preparation

Budge et al. (2010) [48] and Brewster et al. (2014) [26] observed that a majority of transgender employees felt the need to prepare themselves for their transition. There were different measures and several decisions to make concerning when and how to disclose and present to others.

Outcome expectations

The lack or presence of organizational awareness and support is a decisive factor for employees with respect to (non)disclosure (of transgender history) and TAW [17, 35]. Several studies have indicated that transgender employees who expected little or no support at the workplace hid their transgender identity and waited as long as possible to come out at work. They anticipated harassment, discrimination or stigmatization from their supervisors, coworkers, and clients due to disclosure [26, 35, 48, 55, 57]. All transgender employees in general feared that they would lose their job, be passed over for promotions, or be demoted [17, 55, 56] which often led them to postpone their disclosure and transition although some TM tended to invest in disclosure because of work seniority [55]. Avoidance of disclosure as well as negative anticipation caused for many symptoms of distress, such as anxiety, depression, and suicidal ideation [48, 52, 55]. A disclosure disconnect between private and work life can also cause extra strains on (psychological) well-being [31].

In contrast, organizational support and acceptance in creating an inclusive work climate made CO easier than expected. Diversity management integrating GI as a significant category, organizational policies and guidance to support and value gender and sexual minorities were essential keys to facilitate disclosure decisions of transgender employees [35, 55].

Transgender persons perceived specific sectors as more supportive, such as the care and creative sectors [55]. Sectors such as industry, construction, and services had a nonsupportive reputation, which inhibited TP in these sectors from coming out at work [35].

Reactions from management and HR

Reactions from coworkers

The reception of trans employees by the workforce during their transition period was a recurrent theme. These interpersonal relationship experiences were characterized by three main topics: discrimination and policing gender and also the display of genuine support.

Transition plan

When transitioning at the current workplace or when discussing policy implementation and good practices, several articles focused on a transition plan. Within this domain, six elements were recurrently discussed as a necessity (to be included): the regulation of administration, modes of communication throughout the organization, the importance of cooperation between several actors, health-related factors, the agreements and application of work adjustments, protection of the transgender employee, and their job security. Studies emphasized that a unique tailored transition plan was a clear way to help guide managers and their workforce to support the employee [17, 57] as some transgender employees sometimes felt constrained by too much control provided by the plan and insufficient flexibility towards their changing needs throughout their transition [35].

Coping mechanisms

During their TAW, employees reacted in different ways. These were categorized as the following: taking action and seeking support, avoidance and palliative reactions, emotional coping, and overcompensation mechanisms.

Transgender employees, with a more active coping mechanism, did not refrain from addressing coworkers regarding their awareness of transgender issues or their behavior while they also tried to remain flexible and patient towards their colleagues. Some felt empowered by this and did not have to struggle as much during their TAW. Others focused on the importance of changing a work culture and augmenting diversity and equality. While for some activism seemed natural or a given, organizations should not automatically expect such an investment from a transgender employee. Some trans employees chose to get things off their chest through their social support network, while others sought the help of counsellors, lawyers, union representatives, and the transgender community. This was a dynamic process from before the disclosing of their GI to discussing matters of rights, policies during transition, up to career issues post-transitioning [26, 48, 55].

Positive coping mechanisms were reinforced by positive reactions from the work environment [26], but these actions could also be part of a back-up plan together with the training of new skills and the prospect of a job mutation or turnover [26, 48].

Some transgender employees tried to overcompensate for their transgender status by working overtime or being extra grateful for being employed [48]. Many trans employees reported distress, feeling insecure, having anxiety, or feeling depressed [16, 26, 48, 55], which was predominantly related to negative reactions from their surroundings but not necessarily so [16, 55]. Some described being in a negative spiral that ended in sanctions, demotions, job loss, or even suicidal ideation [47, 48, 53, 55].

Appearance and personality

From the qualitative data, a great deal of the experience of TAW took place at the level of appearance and personality. Transition meant becoming their true self on the exterior as the interior. For most TP the association of their GI with their visible physical characteristics, as perceived by others, was a source of distress and anxiety, while for others the feeling of “being free” dominated [26, 35, 48]. Nearly all were tied up with their gender expression (e.g., through clothing, hairstyle, make-up, composure) and/or chosen steps in transgender health care (GAC). Generally, as the age of transition was higher for TW and due to male body characteristics, they were frequently confronted with their gender history by reactions from others [26, 48, 49, 52]. For some, this resulted in the beginning in a misconception that femininity should be characterized by external female traits [52]. Other TP chose to undo binary thinking at work through “gender blending” [49]. TM in specific sectors (e.g., working-class culture, transportation, construction) were also challenged in their behavior (e.g., be an “authentic” man). Apart from physique and behavior, many TP also displayed previously hidden interests and personality traits during their transition and afterwards (e.g., engaging in training, new social experiences, job tasks, asking for a posting that better suited their true self) [16, 26, 48, 56].

Personal career choices

In nearly all studies, trans employees decided their career pathways based on their perceptions, experiences, and personality. These career choices entailed turnover, compromising, and accommodating for less through education, by going the extra mile at work, or being a model employee, being absent from work, or being unemployed.

Many transgender persons choose the way of turnover between jobs (within the same company), organizations, or sectors based on changing interests more in harmony with their true identity, or based on a transgender-friendly environment (e.g., work culture in specific sectors, diversity policies, legislation in specific geographic regions) or to have a clean break from their gender history [16]. Some preferred to extend their skills by following post-graduate education [25, 26] or specific job training programs [16]. Through turnover to jobs in the public sector or extended education, trans employees often settled for less on the level of income; many would even quit their job to be able to transition in a more comfortable way or because of the very gendered work environment they were in. Some would prefer to take a career break or take an extended (un)paid leave during their transition. When organizations were deemed transgender friendly, or when employees felt a sense of loyalty towards their job/employer, or were invested due to work seniority, some would work extra hours, try to be an amiable and supportive colleague, or be extra productive, whereas others would invest in raising awareness through trans activism within the organization and help establish policies.

(Return to) work outcomes

Our first research question entailed the procuration of an overview of objective RTW outcomes, such as number of sick days during or after gender affirming care (GAC), time to RTW, and RTW attempts. Unfortunately, apart from a short mention of absenteeism in Vennix [16], such precise data remained elusive. As such, we focussed our quantitative synthesis on more general work-related outcomes, such as employment rates, turnover, age of transition, and objective career-related outcomes following disclosure and TAW.

Employment rates were in general lower, with up to one third working part-time and unemployment being much higher than the general population of each country. This was even more true for trans women (TW) than for trans men (TM) [28, 50, 51], but unemployment rates should also be mirrored in the transition phase and chosen steps in GAC. More transgender people (TP) were also either students, on disability, on welfare pensions, or retired, although the proportion of TW versus TM therein was mixed [16, 54, 58]. Countries with a strong social security system, such as Denmark, Sweden, or Belgium [46, 50, 53, 54], included more TP on social welfare or sickness funds. Parallelwise, this could be attributed to insufficient protective legislation, reported discrimination, and a negative work environment, lack of awareness of the labor market and in organizations, administrative difficulties, and mental health conditions.

Only a minority of studies disclosed the job titles or sectors in which their participants, before and after transition, were active. Nevertheless, our results showed a shift among TM from white-collar (WC) jobs [28] or the health sector [16] and TW in government or public sector jobs [16, 28] a decade ago to a recently more prevalent presence of TW in blue-collar jobs [56]. This could be attributed to a changing work culture, the sociopolitical landscape and more diversity management in otherwise “masculine BC jobs”. Turnover (TO) and TO intentions, which were also underreported, of trans employees in Belgium and the Lower Countries (17%) [16] were more in line with the general population (20% Belgium [61]), while US trans participants had a higher turnover (50% vs. 27% in 2018 for the general population [62]). The heterogeneity of (lacking) legislation, changes in work culture, the sociopolitical landscape, and a more diversity-oriented management as well as trends of involuntary part-time work [63] of TP may largely explain these observations.

Although the number of sick days, periods of long absences, and time to RTW are important factors throughout transgender health care, only one study [16] mentioned exact numbers for an average sickness absence, namely 2 weeks on yearly basis and 1 month after GAS. Psychosocial factors related to the transgender status of participants were herein an important contributor to sickness absence. According to the US Bureau of Labor Statistics, the overall absence rate was circa 3% in 2020 [64], while in Europe, average rates varied between 3% and 7% [65–67]. Higher absence rates in Europe can be explained by higher levels of unionization and social security laws that protect employees. Due to insufficient data, it is difficult to compare absenteeism or even short-term absences of TP with the general population.

Part-time employment (involuntary) along with prolonged education, living on unemployment or welfare benefits, discrimination and turnover to less lucrative jobs, cause TP to be more likely to suffer from economic stress [13, 63]. When mentioned, household income or socioeconomic status [26, 28, 55] of TP was mostly below the annual national average income [68, 69]. In general, trends showed a profitable gaining of income for TM as they “upgrade” to a “higher human capital” or a status quo when already working in good job positions pretransition, while TW lose their “male advantage” and earn one third less [28]. Socioeconomic concerns were a major instigator to delay transition of TW, which is reflected in an average older age of transition (≥ 10years) [16, 26, 28, 34, 46, 50, 55, 56], although two studies [54, 58] reported a smaller age gap of 4–5 years between TW and TM, which could be attributed to the long process of authorization to GAC in their respective countries (Denmark, Germany) at that time, wherefore TP would have been prompted to contact transgender health care services much earlier. As seen in Meyer et al. [58] and Bretherton et al. [59], a general younger trans population was also reached through social media for recruitment or as a way of pre-GAC information.

(Return to) work experiences

The second main goal of this review was mapping the experiences of trans people, when they (return to) work during and after transition, through a narrative thematic analysis. As with the quantitative data, we could only find two reports [16, 57] mentioning RTW, while in other articles we had to extract work experiences in general of TP, which we, as vocational experts, could indirectly relate to work retention or RTW.

Based on the results of our review, the experiences with the personal disclosure and support system, influences from current activism and legislation gave root to the perceptions, expectations, and motivations of the individual about CO and TAW. The importance of TP’s perceptions or expectations and actions therefore can be framed within stigma theory, already described by Goffman [70] in 1968 but still relevant, and within the division into three types by Link-Phelan [71], such as self-stigma, experienced stigma, and perceived stigma. All three types were found in our thematic analysis, whether it was a perception of negativism and the decision to quit their job or social isolation or taking time off work or being discriminated against by colleagues or managers. Such findings are in line with a recent meta-synthesis of social integration and well-being of TP [72].

Although TP are generally perceived as a vulnerable group and literature has a tendency to highlight negative aspects of CO and transitioning, for some the aspect of no longer living with a secret relieved their distress, empowered them, and boosted their confidence, which in turn influenced their behavior at work and coping. As such, they could break the vicious cycle of stigmatization. Positive thinking has been a focus in (organizational) psychology [73, 74] and is also an important personal factor to facilitate going back to work [75, 76] while motivation (autonomous or controlled by external factors, e.g., financial) plays an important role in the RTW process [77, 78] and should be evaluated, supported, and guided by (mental) health professionals.

Additionally support, which has been long known as a social determinant of health [79], on any level (emotional, instrumental, informational, appraisal) proved to be an essential protective factor against vulnerability, and the effects of distress and stigmatization or discrimination [72, 80]. Most studies looked towards coworkers, management, HR, and family for support and less towards other third parties. However, access to occupational health centers and health professionals could be helpful since stigmatization and experienced distress often lead to mental health problems and negative coping mechanisms (e.g., palliative coping through alcohol or illegal substance abuse) [53, 58–60, 72, 81]. One such negative coping mechanism and also a societal factor [25] was overcompensation through hard work, which in view of well-being (at work) and together with the high emotional/psychosocial load, puts TP at risk of an imbalance between demands/rewards (Karasek model [82]) and developing burnout in the end whereby the transgender employee can still lose their job if help is not undertaken.

A recurring theme that emerged from our analysis was the preparation stage wherein trans employees educated themselves about the applicable legal protection (country legislation, company policy) and looked towards trans-friendly organizations. Our results showed that there is still much to gain at the level of legislation. UK studies [17, 35, 57] have mentioned the limitations of their equality acts and the need to develop policies beyond the existing legislation, while in the USA, the governmental structure (federal vs. state) inhibits the development of equality for all regardless of their GI, although recent executive orders may indicate future improvements [83]. While in the European union only 13 of the 31 countries have protection for GI by national legislation [84], although some large organizations (e.g., the Belgian Railways) have shown a growing awareness for an equality and diversity policy [85, 86].

As highlighted above, as perceptions in our studies were mixed so were the outcome expectations at work, which is consistent with other (LGBTQIA) literature [87, 88]. The sequence of CO and communication of the intention to TAW, which was dependent on private disclosure experiences and work relationships, was firstly done with persons considered as “safe and trustworthy”, followed by a communication through different channels. These qualitative findings are in line with Law et al. [34] wherein disclosure behaviors were predicted by, amongst others, organizational supportiveness and private CO. CO was also positively related with job satisfaction and commitment and negatively with work anxiety, but all were mediated by coworkers’ reactions (support vs. negative) [34]. In distinction with other countries, besides Belgium and the Netherlands [16], the occupational physician (OP) was rarely the first contact person, although health professionals are generally early in the disclosure sequence [89]. This could be attributed to the different role company doctors play in different countries [90–97] and partly to the general negative experiences with health care professionals [98–101], although company doctors are not specified in these reviews. This leads us to understand that although there are systems available at work for trans employees, there is an additional gap in the literature about the role of OP’s in the transition.

TAW was colored by reactions from the work environment, knowledge of transgender issues, and implementation of policies, career expectations, and the existence of a transition plan. Law et al. [34] already mentioned the importance of reactions in the work environment, especially among coworkers, as a mediator between disclosure and work outcomes. Martinez et al. [87], in their study on authentic identity expression, also placed a hierarchy onto this mediator role. The degree and support expressed by supervisors set an example for other personnel’s attitudes and may be critical in the trans employee’s well-being [87], which was also highlighted by Marvell et al. [57], wherein managers are key to an inclusive work environment. On the other hand, oppositional behavior by colleagues to improve the current work climate towards TP can also have a relational value for them and enhance work outcomes and general well-being [102]. As such, different actors of the organization and the organization can also be viewed as pivotal in the RTW process and the employee’s motivation to go back to work.

Knowledge of trans issues, as well as employment law and policies, form the basis of an inclusive work environment, and data therein were mixed. It is clear that there is a need for continuous education and training for HR personnel and managers among others to familiarize themselves with terminology and show competence and empathy towards (undisclosed) TP and, if necessary, to enlist help of legal experts. This should be accompanied by a genuine effort on the part of the organization to publicize their culture of diversity since public relations towards society is crucial to make sure that TP can comfortably apply for jobs, CO, and TAW. Furthermore, the correct implementation of diversity and antidiscrimination policies are essential, as some industries still have a (perceived) transphobic culture [16] despite having had diversity training in place. The collaboration with trans employees, derived from our results, within organizations and on a societal level could prove very fruitful on a micro, meso and macro level and is in line with the call of Beauregard et al. [103] for more transgender voices in the workplace.

Negative career outcomes or prospects were common in all of the included studies. Participants voiced their fears of dismissal, missed job opportunities and demotions, personal negative job effects (e.g., concentration), binary thinking in job expectations with the male gender as the higher position on the labor market, and cissexism or struggles on the level of infrastructure (such as dressing rooms, toilets), gender policing and discrimination by coworkers, and professional isolation. This was highlighted by Gut et al. [17] in an international survey, wherein about one quarter was demoted or fired in light of their GI, and half reported negative reactions from their work surroundings in the absence of diversity training. Although most studies in transgender (health) literature have the tendency to focus on the negative, for good reason, there were in general more positive experiences of TAW than expected, and supportive coworkers [17] and managers [17] influenced morale and a positive work culture.

From our results, the general feeling is that work adjustments and flexibility were not proficiently applied. Work adjustments are one of the core rules of RTW management after a work absence for psychosocial and medical reasons [104, 105]; therefore, it sounds very logical that an enhanced work participation through flexible adaptations can only benefit the employee and employer during TAW and diminish involuntary or unwanted work absences. Graded RTW, flexible working hours, teleworking, workplace changes, alterations in workload and job tasks, and job crafting (physical and/or task and/or cognitive) have been proficient in many psychosocial and health issues [106–114]. Job crafting refers to employees redesigning work tasks to fit their motives, passions, and strengths [112, 115, 116] which arises more frequently as employees in general experience different needs and regulatory foci at work [117], which based on our results should be added as an option to the transition plan.

Strengths and limitations

To our knowledge, this is the first systematic review conducted on the intersectionality of RTW, transgender people, and TAW, thereby shining a light on the importance of a sustainable work resumption, the prevention of turnover, and retaining valuable productive workers. With our review, we have shown a clear gap in knowledge about RTW data, experiences, and a lack of possible job re-entry interventions.

By including diverse study methodologies, we were able to analyze a heterogeneous sample of research data, although there is still a publication bias to consider. Since we focused solely on Western studies, it is not clear if these results and the gap of knowledge concerning RTW of transgender persons are transferable to other non-Western countries.

The quality of quantitative and qualitative studies was good overall, while the mixed-methods studies were generally of a low quality (see Results section), but as stated by the MMAT recommendations [45], we did not exclude any of the studies on the basis of their quality assessment.

While most included studies involved TP in general, a select number of qualitative studies focused on either TW or TM, and in some studies specific GIs (gender fluid, nonbinary persons) were underrepresented. This can also be explained by the fact that, although included in our search string, studies solely focused on nonbinary persons but those who did not choose any steps in GAC with possible work absences or for whom there was no mention of TAW with possible work absences were discarded. Furthermore research focused on this subgroup has also just undergone a recent expansion [23, 118], and only in recent years has GI been explicitly mentioned beyond the binary when describing study populations.

We are aware of an existing selection bias and confirmation bias, as the majority of the authors of this systematic review are, apart from one sexually fluid orientation (JVdC), Caucasian, heterosexual, cisgender persons with an expertise in the occupational/vocational field. By having our manuscript co-authored by an expert (JM) in gender studies and TG health, we aimed to reduce this concern. Furthermore, throughout all studies, participants were recruited through clinics, conferences, or online. This is not uncommon in transgender research literature, as people will instinctively participate in studies by way of perceived safe spaces. The differences in definitions of transgender persons, inherent to the sociopolitical landscape, and mostly small but different sample sizes and methods, make comparisons difficult. Finally, the lack of quantitative data also prohibited us from performing a meta-analysis of RTW outcomes.

Future research and practical implications for (occupational) health professionals and vocational experts

Future TG research would benefit from collecting information on objective work outcomes, such as sick days, career breaks, unpaid leave, and RTW patterns, through surveys and interviews at a (inter)national level. In addition, by evaluating the medical and professional history, personality, motivation, work environment characteristics, work relations, barriers and support for organizations and third parties, in particular occupational health professionals, can provide new insights for optimal guidance of trans employees in their chosen path.

Within studies involving participants identifying under the umbrella transgender term, the risk of homogenization persists, even with an emic approach. Future RTW research should refrain from only conducting studies of transgender people as one group but should focus on diverse samples prioritizing those who have been identified by prior research as higher on the intersectionality scale and who are more vulnerable. Leaning on a larger body of evidence, a more diverse and tailored RTW assistance can be achieved. In addition to the fact that more objective variables should be collected in this group, more in-depth knowledge of the experiences of transgender people is needed. Therefore, mixed and qualitative research, by means of, e.g., in-depth interviews or diary studies, is necessary to help us better understand (nonbinary) transgender people’s RTW outcomes.

A joint effort and shared responsibility of all stakeholders involved is required. Organizations should work alongside occupational health centers for assistance in policy and transition plans, while clinical professionals and counsellors should refer to their occupational colleagues who have more accurate insight into labor laws and the inner workings of the organization to which their trans client belongs. Occupational health centers, on the other hand, should provide a RTW expert and counsel equality/diversity experts, while also building on self-awareness and self-reflection.

Based on the results of this systematic review and our expertise in occupational health, we aim to create a RTW model and develop tools for health professionals to improve counselling and job retention for TP.