What Is Transgender?

A person is considered to be transgender if their gender identity is not what would be expected for their assigned sex at birth. Gender identity refers to an individual's sense of themselves as male, female, non-binary, or different gender identity. People whose gender identity is what would be expected for their assigned sex at birth are referred to as cisgender.

Transgender is an adjective, not a noun. Transgender people should be referred to by the gender by which they identify. Someone with a male identity who was assigned female at birth is a man, or a transgender man. Someone with a female identity who was assigned male at birth is a woman, or a transgender woman.

Meaning of Transgender

Individuals have both a sex and a gender. Sex refers to an person's biology and gender to a person's identity. Although many people are only familiar with binary sexes and genders (man/woman, male/female), both sex and gender exist on a spectrum. It is important to understand both sex and gender to understand the meaning of transgender.

Biological Sex

Discussions of biological sex often focus on chromosomes—labeling XY individuals as male and XX as female. However, there are other combinations of chromosomes, and sexual development can also be affected by certain health conditions.

Individuals whose biology falls between male and female may be referred to as intersex or has having differences or disorders of sexual development.

Assigned Sex at Birth

At the time of birth, most infants are categorized as either male or female. This categorization is usually based on the appearance of their external genitalia, although it can be more complicated in some cases.

Assigned sex at birth, or recorded sex at birth, refers to the determination of whether infants' bodies appear to be male or female. It is this sex that is recorded on the birth certificate.

Gender Identity

Gender identity refers to a person's conception of themself as male, female, non-binary, or another gender. Children begin to label themselves as male or female when they are as young as two or three years old.

A child's understanding of gender, and themselves as gendered beings, grows and changes over time, moving from being highly structured and stereotypical (all doctors are boys, even though my mom is a doctor) to being more nuanced and flexible.

Most individuals will develop a gender identity that is concordant with what is expected based on their sex assigned at birth. That is to say that most people assigned female at birth will grow up to identify as girls or women, and most people assigned male at birth as boys or men.

In contrast, individuals are transgender if their gender identity is not what would be expected for their assigned sex at birth. They may identify as the other binary gender. They may also identify as non-binary, agender, or another gender entirely.

In recent years, a growing number of transgender individuals have identified as non-binary rather than as the other binary gender. This may reflect changing clinical guidance that for many years only allowed individuals to affirm their gender, or transition, if they were doing so to become a heterosexual member of the "opposite sex."

Some transgender individuals have a stable gender identity from as early as three to five years old. Others may not recognize or affirm their gender until they are older.

For many, puberty is a highly salient time when they start to feel increasing discomfort with their bodies. However, some transgender individuals may not recognize or affirm their gender until much later in adulthood.

History

Gender diverse individuals have been reported across thousands of years and many cultures. Many cultures have their own words to describe individuals whose gender identity and/or expression is not what would be expected from their assigned sex at birth.

These individuals may or may not consider themselves to be transgender. Some, such as the hijras of India identify as a third sex or gender. In 2014, the supreme court in Indiahijras, transgender people, eunuchs, and intersex people as a 'third gender' in law; it is important to understand that gender diversity can take on many forms.

Relevant Terminology

Terminology is constantly changing in the discussion of transgender people and transgender health. Important terms include:

• Affirmed name: The name people use that reflects their gender identity
• Cisnormativity: The assumption that all, or almost all, individuals are cisgender. Although transgender-identified people comprise a fairly small percentage of the human population, many trans people and allies consider it to be offensive to presume that everyone is cisgender unless otherwise specified.
• Cross-sex hormone therapy or gender affirming hormone therapy: The use of androgens or estrogens to help individuals develop physical characteristics associated with their affirmed gender
• Gender affirming care: Medical and mental health care that respects and affirms individuals' gender identity
• Gender binary: The notion that all gender can be categorized as either male or female
• Gender dysphoria: Discomfort associated with having a body that does not reflect ones gender identity
• Gender expression: The way that someone presents themselves in a gendered way, can include clothing, physical appearance, and behaviors
• Gender spectrum: The idea that gender is a spectrum that includes both male to female and that people can exist in the places between
• Medical transition: Medical care to help someone change their body to reflect their gender identity, possibly including hormone therapy and/or surgery
• Misgendering: Referring to a person in a way that does not accurately reflect their gender
• Non-binary: Identifying as neither male nor female
• Pronouns: Words used to refer to people that are often gendered. Common pronouns include he/him, she/her, and they/them. When a person's gender isn't known, they can be referred to by gender-neutral pronouns such as they/them rather than assuming their gender
• Social transition: Making changes, such as name, pronouns, or presentation, in order to live in the world in a way that reflects gender identity.
• Transfeminine: Someone whose gender is more female than would be expected, includes non-binary individuals who were assigned male at birth and transgender women
• Transmasculine: Someone whose gender is more male than would be expected, includes non-binary individuals who were assigned female at birth and transgender men
• Transsexual: This term is not widely used in the community. However, some medical professionals use this term to refer to transgender individuals who are interested in medical and surgical gender affirmation.

Transgender Health Care

Standards of care for transgender health care are primarily published by the World Professional Association of Transgender Health (WPATH), although growing numbers of other medical organizations have started to publish their own standards.

Care Prior to Puberty

Prior to the onset of puberty, no medical treatment is needed or appropriate for transgender youth. The standard of care is to support children in their identity and allow them to socially transition, if doing so is appropriate.

When transgender youth reach puberty, there are two options for medical treatment. The more conservative, and more common option in the United States, is the use of puberty blockers. These are drugs that block the body from releasing sex hormones and prevent the development of gendered secondary sexual characteristics.

Puberty blockers are entirely reversible. Therefore, after being on them for up to several years, individuals can choose to discontinue them and go through puberty in their assigned sex at birth or start taking cross-sex hormone therapy and go through a single puberty in their affirmed gender.

Gender Affirming Hormone Therapy

Cross-sex hormone therapy, or gender affirming hormone therapy, uses sex hormones to help initiate feminization or masculinization of the body—as appropriate.

Because androgens are stronger in their mechanism of action than estrogens, it is easier for transmasculine individuals to develop masculine characteristics than for transfeminine individuals to develop feminine characteristics and get rid of masculine characteristics that already exist.

The notable exception of this is that testosterone cannot reverse breast growth, and many transmasculine individuals who transition after puberty choose to undergo chest reconstruction surgery to remove their breasts.

Gender Affirming Surgery

Gender affirming surgery has also been referred to as sex reassignment surgery, although that term has gone out of fashion. Gender affirming surgeries include a variety of options that can reshape the body to conform more to gendered expectations. These include chest surgeries, facial surgeries, and genital affirmation surgeries to create either masculine or feminine genitalia.

It is important to know that not all transgender individuals are interested in gender affirming medical or surgical interventions.

Others require extensive medical or surgical care in order to feel comfortable functioning in the world. It is for this reason that transgender medical and surgical procedures are considered to be medically necessary.

The determination that gender affirming surgery is medically necessary was formalized during the Obama administration when a National Coverage Determination that had permitted Medicare to exclude transgender care was overturned. Since then, many states have passed laws requiring insurers to cover transgender care.

Transgender Discrimination

The National Transgender Discrimination Survey is the largest survey ever to look at the experiences of transgender Americans. It has been performed twice—first in 2008-09 and then in 2013. The first report, Injustice at Every Turn, reflected the experience of 6450 respondents. The second report discussed more than 27,000.

Both reports described pervasive experiences of discrimination across every facet of life. Transgender individuals reported mistreatment in schools, in housing, at work, and in the world at large.

Discrimination took the form of everything from verbal harassment to sexual assault, and many individuals were forced to leave school or jobs as a result of those experiences.

Transgender individuals also reported many experiences of discrimination in health care. Many individuals were denied access to gender affirming medical and surgical care.

Perhaps even more disturbing, numerous people reported being denied access to emergency care and general medical care as well as verbal and physical harassment in healthcare spaces.

Because of this, many transgender people report avoiding medical care, for fear of experiencing additional discrimination or abuse. Others report avoiding care because they lacked financial or other resources.

Discrimination is even worse for transgender people of color, who may experience bias based on both their skin color and their gender identity. The United States Transgender Survey found that Latino/a/x, American Indian, multiracial, and Black respondents were more than three times as likely as the U.S. population to be living in poverty.

A Word From Verywell

Gender diversity is a normal part of a functioning society and has been reported throughout history. Although transgender individuals have an increased risk of certain negative health outcomes, research suggests that this does not reflect any inherent issue with being transgender. Instead, it reflects the minority stress related to being part of a society that may not be accepting.

Indeed, research suggests that one of the most important factors associated with the health of transgender people is access to an affirming environment and desired medical care. This is particularly true for transgender children and adolescents, who have been shown to do as well as their cisgender peers when their families are supportive and accepting.

While not all transgender individuals are interested in medical or surgical affirmation, all people need health care at some point during their lives. Therefore, it is important to make all healthcare facilities safe and affirming for people of diverse genders. Lack of access to affirming health care is a risk factor for health concerns for transgender people of all ages.