Home ⟩News ⟩USC Chan Magazine ⟩Fall 2022 / Winter 2023

Daily Affirmations

Occupational therapist Nora Dixon leads new Lifestyle Redesign® program for supporting transgender and gender expansive clients.

By Mike McNulty ’06, MA ’09, OTD ’10

“There was just one website that we referred people to if they wanted to learn more about gender confirmation surgery — that was it,” says Assistant Clinical Professor Nora Dixon MA ’20, OTD ’21 with a cringed half-smile. “Education is only one piece of occupational therapy’s really, really large scope, and we could do much better.”

For Dixon, who uses she/her pronouns, the mismatch between current capability and emerging need was too obvious to ignore. She was a doctoral resident at the USC OT Faculty Practice, the home of Lifestyle Redesign® occupational therapy, in 2020 and 2021 when issues surrounding transgender rights and visibility started gaining attention in national media, sports and political dialogues.

As Dixon learned more about both Lifestyle Redesign and best practices to support trans populations, she and her faculty mentors quickly realized they could, and should, do more.

According to the most recent analysis by the UCLA School of Law’s Williams Institute using data from the Centers for Disease Control and Prevention’s Behavior Risk Factor Surveillance System and Youth Risk Behavior Survey, approximately 1.3 million U.S. adults (0.5 percent of the adult population) and approximately 300,000 U.S. teenagers aged 13 to 17 (1.4 percent of that age population) are transgender. Those rates are on the rise. The institute’s estimate of the number of transgender youth doubled from its previous 2017 estimate.

So Dixon dug into the literature and took a course on OT-specific considerations after lower body surgery. While there are a number of conceptual papers — Dixon has predominantly relied upon nursing and primary care medicine sources — gender-affirming approaches have yet to be fully explored in occupational therapy.

“Lifestyle, identity, roles and routines are such an integral part of occupational therapy, but there isn’t much [literature] about OT when you’re sitting one-on-one, side-by-side with a trans client,” Dixon says.

Dixon also realized that providing truly responsive, client-centered care would require her to confront and dismantle her own privilege and positionality.

“It’s because of the hard work and endless advocacy of the trans community that a cisgender person like me is even able to work this area,” Dixon says. “I have really leaned in on the idea of trying to use my privilege for good, while amplifying those voices with the most to offer and the most at stake.”

She began connecting with other USC health care providers in 2021, including Patty Pinanong, clinical assistant professor of family medicine at the Keck School of Medicine and the founder of USC Student Health’s Gender-Affirming Care Team. Dixon hosted an in-service for Pinanong and Student Health providers, and she says their encouragement validated her conviction to build a new comprehensive Lifestyle Redesign program for this population.

“Dr. Pinanong got the ball rolling — she told her colleagues at Keck about our program, I did an in-service there, and it really started catching on — and she’s such a great champion for OT,” Dixon says. “I was just in awe of how this program emerged very quickly over the course of a year because everyone was so ready for change.”

Enabling euphoria

The American Psychiatric Association’s Diagnostic and Statistical Manual defines gender dysphoria as the psychological distress that results from an incongruence between one’s sex assigned at birth and one’s gender identity. Feelings of dysphoria often begin in childhood, although some people may not experience it until after puberty, and some never experience incongruence or dysphoria. But for those who do to a clinically significant extent as demonstrated by distress in, or impairment to social, job-related or other functional domains, occupational therapy can focus on finding ways to help alleviate its symptoms.

“I’m happy to help educate clients about gender dysphoria, but most people already know way more about it than I ever will as a cis woman,” Dixon says. “So from the very start of the therapeutic process, I address my privilege and power differential and remind people that they are the expert on their own experience, and I’m just the expert on lifestyle modifications.”

Lifestyle Redesign is a type of occupational therapy that guides clients through the process of creating habits and routines that are personally meaningful and health-promoting. Together, clinician and client review basic principles of healthy lifestyles, identify individualized health and behavioral goals and customize plans to achieve them. Changing behaviors is a non-linear, complex process that takes time, which is why clinicians like Dixon help support clients’ physical, mental, cognitive and emotional well-being every step of the way.

In that sense, Dixon says that Lifestyle Redesign for Gender Affirmation is unique because it approaches gender as an occupation, rather than as a status or condition. During Lifestyle Redesign sessions, Dixon and her clients work to identify concrete activities, habits and routines that help diminish perceptions of gender dysphoria, while building a plan to more frequently or more easily engage in those which enhance gender euphoria.

“We pinpoint specific triggers that increase dysphoria and then problem-solve solutions to promote euphoria,” she says. “From that perspective, we take a very similar approach to health coaching and wellness promotion.”

Occupations that can contribute to dysphoria include bathing and personal hygiene, interacting with one’s anatomy, sexual activity and grooming and dressing. Occupational therapists help clients identify, structure and promote safe access to affirming routines, whether those occur daily, such as appearance-related routines, or whether they are one-time milestones, such as filing court documents to legally change one’s name and gender identity.

For example, Dixon recalls a client who needed to self-administer weekly testosterone injections, which the literature suggests is a challenging occupation because it typically occurs only once a week and because using a syringe makes many people anxious.

“I came into the session with the assumption, ‘OK, let’s dig into these barriers,’” Dixon says. “But it turns out that the client’s barrier was not ‘I hate needles,’ it was ‘Oh, this is what dysphoria feels like.’ So we took a full one-hour session to discuss, connect and explore the layers of occupations and their experiences. That’s the depth of care we can offer in occupational therapy, which just isn’t available in a 20-minute office consultation with a physician or surgeon.”

That depth of care is already making a real-world difference.

“My injections went very well after finding strategies to build the habit,” says Dixon’s client, who prefers to remain anonymous. “After our sessions, I felt like I had the key and the solution. I have decreased the blame in my brain, and I have tools to stay in the present.”

Dixon typically writes plans of care lasting between 10 and 14 one-hour sessions. To guide those sessions, she uses the Canadian Occupational Performance Measure (COPM), a semi-structured interview that fosters open dialogue on issues of importance to the client. Interviewees are asked to rate their performance and satisfaction in identified areas using a 10-point scale, where 1 indicates poor performance and low satisfaction and 10 indicates very good performance and high satisfaction. Longitudinal changes to those scores reflect subjective improvements in clients’ chosen occupations and routines.

“One client identified COPM goals around stress management, surgery preparation and surgery recovery, and after about three months working with me in Lifestyle Redesign, they had statistically significant increases in measured performance and satisfaction,” Dixon says.

“I felt really happy to have OT as a component of my recovery and an additional source of support because I encountered so much uncertainty after things didn’t go as planned after my surgery,” says another of Dixon’s clients. “I felt very well understood and supported during OT, with creative suggestions and strategies for healing and continuing daily activities after surgery.”

While the majority of Dixon’s referrals to date have been for postsurgical care as clients relearn and readjust to their activities of daily living, occupational therapy can also address a much broader range of occupational performance. Before surgery, for example, Lifestyle Redesign can help clients mentally prepare, emotionally regulate, align social support systems and visualize how daily occupations will be impacted and how they might respond.

“As clinicians, we meet people where they are at and where they are going from here,” Dixon says.

Duty and dance

In late 2021, the American Occupational Therapy Association’s Representative Assembly approved and published “Affirming Gender Diversity and Identity,” a document outlining the profession’s commitment to the care, safety and inclusion of gender-diverse clients and colleagues. It also outlines occupational therapy practitioners’ ethical duty to actively develop, maintain and update continuing competence for providing high-quality, gender-affirming care.

Dixon acknowledges that may sound daunting for some practitioners. But she emphasizes that gender-affirming practices don’t need to be complicated in order to make an impact.

“Have your pronouns visible; use a person’s name, not their dead-name; use gender-neutral language across all clients; learn to use neopronouns,” Dixon says. [Editor’s note: Neopronouns are word creations that can function as gender-neutral pronouns, such as xe or xim]. “So my first piece of advice to any provider is to look at all those small tangible things that add up in big ways.”

Dixon’s second piece of advice is to intentionally build partnerships with other allies in your professional networks.

“My experience shows that other health care professionals are ready to support your efforts, whether that’s just one person or a whole team,” Dixon says.

Those efforts will continue to be valued as the trans and gender non-conforming population looks likely to keep growing. They are also necessary because, according to Dixon, gender is not so much an endpoint to be reached as it is a component of identity to be continuously expressed and experienced.

“There’s a big misconception that people feel completely euphoric post-surgery because they have either a new body part or an eliminated body part,” she says. “While surgery can help mitigate dysphoria, it doesn’t ‘resolve’ it — there’s no end to a person’s transition because it’s all very much a dynamic, ongoing process.”

With the efforts of occupational therapy practitioners and support from cis and trans colleagues alike, that process is one in which Lifestyle Redesign occupational therapy will continue playing a vital role.

“The literature and the stakeholders I have spoken with don’t view transitioning as, ‘I started as this, and I ended up as this,’” Dixon says. “Instead, it’s like a continuing dance with gender and all the ways it’s expressed and how others perceive it.”

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USC Chan Division of Occupational Science and Occupational Therapy
1540 Alcazar Street, CHP 133, Los Angeles, CA 90089-9003

ACOTE accreditation | NBCOT certification

The USC entry-level master’s degree program (cost of attendance) is accredited by the Accreditation Council for Occupational Therapy Education® (ACOTE®) of the American Occupational Therapy Association (AOTA). The USC entry-level doctorate in occupational therapy (OTD) degree program (cost of attendance) is accredited by ACOTE®. View our program’s ACOTE® standards public data. ACOTE® c/o the American Occupational Therapy Association, Inc.®, 7501 Wisconsin Avenue, Suite 510E, Bethesda, MD 20814, (301) 652-AOTA, www.acoteonline.org.

Professional program graduates are eligible to apply for the national certification examination administered by the National Board for Certification in Occupational Therapy, Inc.® (NBCOT®), nbcot.org. All states require licensure to practice; a felony conviction may affect a graduate’s ability to sit for the NBCOT® OTR certification examination or attain state licensure. Program results from the NBCOT® can be found online at www.nbcot.org/Educators-Folder/SchoolPerformance.