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Supported Loving toolkit
Supporting trans people with learning disabilities
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This toolkit explores how to support trans people with a learning disability based on research, community experiences and the law.
This toolkit explores how to support trans people with a learning disability based on research, community experiences and the law.
Trans people are "people who move away from the gender they were assigned at birth, people who cross over (trans-) the boundaries constructed by their culture to define and contain their gender" (Stryker, 2008).
Many people with a learning disability are trans. However, there are often assumptions that trans and/or gender divergent people with a learning disability don’t exist or their gender identity and expression is because they lack capacity to make decisions (Keates et al., 2022). Trans people with a learning disability argue that these perspectives are harmful and patronising.
'Gender reassignment' is a protected characteristic under the Equality Act. Gender reassignment means proposing to undergo, undergoing or having undergone a process to reassign your gender. This means you do not have to have had any kind of gender affirming healthcare or legal recognition to be protected from discrimination (EHRC, 2023).
Discriminatory abuse is a category of abuse in the Care Act statutory guidance (DoHSC, 2024:14.17). This refers to any form of abuse which is carried out because of a person's differences or perceived differences. It can include verbal abuse, harassment, deliberate exclusion, or denying or providing substandard services. Therefore, transphobia within services is a safeguarding issue that social care providers should be actively working to prevent.
Unfortunately, research suggests that trans people with a learning disability experience significant abuse both from members of the public and the staff that support them (Dinwoodie et al., 2020). Being trans is not a mental illness; however, discrimination and gender dysphoria (discomfort or distress related to the mismatch between their identity and the gender they were assigned at birth) can cause low self-esteem, anxiety, depression and social isolation (Brandon- Friedman et al., 2020).
Gender affirming healthcare is not necessarily part of every trans person’s journey. However, for those who need it, it can help alleviate gender dysphoria, improve mental health and wellbeing, and is associated with lower rates of suicidal ideation, substance use, and psychological distress (Almazan and Keuroghlian, 2021). Gender affirming healthcare can include speech and language therapy, hormones and different forms of surgery. In the UK this is accessed through a GP referral to a gender identity clinic. However, there are currently very long waiting lists of up to 5 years or more (Zaccaro and Fagg, 2023).
Family support and affirmation of gender identity can mitigate discrimination experienced by trans people (Brandon-Friedman et al., 2020). Social transition (changing how people present in terms of names, pronouns, hair, clothes and grooming practices) can also be associated with significant mental health benefits (Pollitt et al., 2017). Research highlights the importance of peer support and being supported to engage with LGBT community and culture (although these may not always be accessible) (Smith et al., 2024).
What are the most common challenges faced by people in this area?
Coming out can be complex and people with a learning disability can anticipate discrimination from staff and family. Responses to people with a learning disability coming out as trans can range from verbal and emotional abuse (Dinwoodie et al., 2020), risk aversion where staff discourage the expression of identity, to staff not having the confidence or language to talk about gender identity or change their practice (Smith et al., 2024). These responses may negatively impact mental health, can leave the person with a learning disability more isolated and normalise abuse and hate crime.
When someone first comes out as trans, it is important to respond with sensitivity and understanding. Remain calm and ask non-judgemental open questions, such as ‘how can I support you?’ and ‘what pronouns would you like me to use for you?’ Do not rush individuals into making any decisions and be led by them. Some people may not be ready to come out in all environments, so may want you to use different names and pronouns in different settings. It is important to respect this as outing someone without their consent can be very dangerous and can significantly damage your working relationship.
Training can help educate staff on trans inclusive practice and help give staff the skills and confidence to have supportive discussions regarding gender identity and expression. Training and organisational policies can help staff be clear about their role in preventing discriminatory abuse and aware of how to support someone experiencing hate crime and discrimination.
Research suggests that peer support groups for LGBT+ people with a learning disability can promote confidence and belonging (Elderton et al., 2014). People with a learning disability would like their staff to understand the importance of pride and support them to access the LGBT+ community (Smith et al., 2024).
Family support can positively impact the mental health of trans people (Brandon- Friedman et al., 2020). However, often family members are not supportive of trans people’s gender identity and expression. Many trans people can develop a chosen family of supportive friends and loved ones to compensate, but this may not necessarily be an option for trans people with a learning disability who don’t have access to the LGBT+ community.
Consider whether the way the individual’s family members express their lack of support could be considered a safeguarding concern and whether you need to raise this – for example if they repeatedly refuse to use their name and pronouns and this is having a significant impact on the person you support’s mental health. Speak to the person you support and ask them how they want to be supported in relation to their family. For example, they may not want you to challenge their family as they are not ready to come out to them yet or they may want you to role model how they want to be treated.
Family members and staff can often share concerns about the capacity of trans people with a learning disability to make decisions. This can often be associated with assumptions that people with a learning disability are not LGBT and are not able to make decisions regarding their lives (Keates et al., 2022).
Under the Mental Capacity Act 2005, mental capacity is decision specific. Gender identity and expression involve a wide range of decisions that may be taken over a lifetime (for example, name changes, clothing decisions, gender affirming healthcare and legal recognition), so it is not possible to say that someone lacks mental capacity to be trans. Someone may have capacity to make some decisions – such as a name change – but lack capacity to make others – such as consent to surgery – and these decisions should be considered . If mental capacity assessments are required for these particular decisions, then they should be conducted by the relevant professionals.
All practicable steps must also be taken to support someone to make a decision before they are deemed to lack capacity. Therefore, if there are concerns about someone’s capacity to make a particular decision related to trans identity then they should be provided with accessible information and support to explore the risks and benefits of this decision.
Do's and don'ts regarding support in this topic area
Do
- be led by the person you support in how they want to be supported
- help the trans people you support access peer support and the wider LGBT community
- with the consent of the person with a learning disability, ensure that their name and pronouns are correctly reflected in documentation. Consider that they may want to be open about their trans identity to some people and not others.
Don't
- assume that someone cannot be trans because they have a learning disability
- wait until someone comes out as trans before ensuring that there is a trans-inclusive environment in your service
- out someone without their consent. This can be very dangerous and even life threatening
- use someone's dead name (eg “I’m working with Tim who used to be called Tina.”) unless there is a specific reason to do so.
Case Study
Sarah was assigned male at birth but came out as a trans woman a few years ago. She still sees her family but they will only use her deadname (the name she was given at birth), refer to her as a man and do not believe that she has mental capacity to make decisions.
Sarah’s keyworker speaks to her about how she wants to manage her relationship with her family. Sarah says that she would still like a relationship with her family but when they refer to her as a man, this negatively impacts her mental health and recently she has been self-harming. With Sarah’s agreement, her keyworker makes a safeguarding referral to the local authority under the category of discriminatory abuse. Sarah and her keyworker discuss what outcome she would like to achieve from this referral. Sarah would like her family to have some support to understand her gender identity.
Whilst waiting for this referral to be considered, Sarah’s staff support her to have an appointment with her GP where she discusses her mental health and her wish for gender affirming healthcare. Sarah’s GP refers her to a gender identity clinic and gives her some information about the risks and benefits of gender affirming healthcare. Sarah’s GP explains that mental capacity is decision specific and a mental capacity assessment regarding gender affirming healthcare may be completed by staff at the gender identity clinic but this will be their assessment to make and not her families’.
Whilst Sarah is waiting for these referrals to be considered, her staff support her to access a local LGBT support group and attend a local Pride event. With Sarah’s agreement, her staff inform her family that they will be referring to her as Sarah and using she/her pronouns as she has changed her name by deed poll. This is her wish and they believe that she has capacity to make this decision.
Top tips
What would be the most important advice/ take away for readers?
- Each trans person’s journey is different and that is ok. Ask the person you are working with how they want to be supported.
- Similarly, if someone does not want to access gender affirming healthcare then that does not make them any less trans.
- Use supervision as a space to explore your personal views and potential biases so they do not impact the support you provide.
Autor's note:
"Lorne Power, Doctoral Local Authority Fellow, NIHR303070 is funded by the NIHR for this research project. The views expressed in this publication are those of the author(s) and not necessarily those of the NIHR, NHS or the UK Department of Health and Social Care."
Resources
References
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