Transgender people are people who feel that their gender identity is different from the gender associated with their assigned sex at birth/assigned-sex-at-birth (ASAB). When a transgender person chooses to undergo a process to align with their desired gender, this is called gender transitioning.
There are many ways to do this. Individuals may go through social transition by changing their name and pronouns or medical transition by change their bodies through hormone therapy or surgery. People who wish to transition may undertake one, all, or none of these steps.
Sex is assigned at birth based on what genitals you were born with, while gender refers to how someone feels inside and expression through behavior and appearance as well as pronoun usage are a couple of ways people might communicate their gender. Pronouns and expression do not necessarily have to “align” with each other or gender, however.
People who feel like their gender assigned at birth does not line up with the gender they identify with may experience gender dysphoria. They may not be uncomfortable with their body because society genders them incorrectly because of their body type and appearance.
When someone experiences body dysphoria, they feel like their body is wrong. Gender dysphoria is when someone feels like their body is wrong because the images of different genders are cissexist (the assumption that only cisgender identities and expressions are normal) and not inclusive of transgender bodies, making it hard for transgender individuals to see themselves as beautiful or handsome (and therefore deserving of love) and/or for the world to gender them correctly (seeing someone as a man, woman, or an androgynous being).
Misgendering means referring to someone with a word such as pronouns or names that does not correctly reflect the gender with which they identify.
Gender dysphoria may begin to become more prevalent during puberty. Some children may experience it even earlier (when they are 4 years old or younger).
Gender dysphoria is typically diagnosed by a mental health professional. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) provides one overarching diagnosis of gender dysphoria, with separate criteria for children and adolescents and adults. It defines gender dysphoria as a marked incongruence between the gender one identifies as and one’s assigned gender and this feeling has to last at least six months.
Under the DSM-5 criteria, gender dysphoria diagnosis in adults and adolescents starts by assessing if they have at least two of the following:
- A marked incongruence between one’s experienced/expressed gender and primary (external and internal genitalia) and/or secondary sex characteristics (muscle and breast development)
- A strong desire to be rid of one’s primary and/or secondary sex characteristics because of a marked incongruence with one’s experienced/expressed gender (or in young adolescents, a desire to prevent the development of the anticipated secondary sex characteristics)
- A strong desire for the primary and/or secondary sex characteristics of the other sex
- A strong desire to be of another gender (or some alternative gender different from one’s assigned gender)
- A strong desire to be treated as another gender (or some alternative gender different from one’s assigned gender)
- A strong conviction that one has the typical feelings and reactions of another gender (or some alternative gender different from one’s assigned gender)
The assessment of gender dysphoria in children begins with determining whether they have at least six of the following:
- A strong desire to be of a different gender or an insistence that one is a different gender
- A strong preference for wearing clothing typically associated with a different gender and strong resistance to wearing clothing typically for one’s assigned gender
- A strong preference for cross-gender roles in make-believe or fantasy play
- A strong preference for the toys, games, or activities stereotypically used or engaged in by a different gender
- A strong preference for playmates of a different gender
- A strong rejection of toys, games, and activities typically associated with one’s assigned gender
- A strong dislike of one’s sexual anatomy
- A strong desire for the physical sex characteristics that match one’s experienced gender
For both groups, in order to meet the diagnostic criteria of gender dysphoria, the condition must also be associated with clinically significant distress or impairment in social, occupational, or other important areas of functioning.
Transgender people may transition socially, which may include coming out to friends and family as transgender and changing their name to one that expresses their true gender and makes them feel comfortable. They may also ask people to use pronouns that match their desired gender and change their hairstyle or way of dressing.
They may want to change how they publicly express their gender, which is known as gender expression. This could mean changing their appearance, mannerisms, and the way they dress to express the gender they identify with.
Health care for transgender individuals starts with the same basics as cisgender individuals: annual physical exams, STI testing, and reproductive health care. For those who are considering medical transitioning, they may need hormone therapy or surgery, which will require additional medical appointments and screenings.
Hormone therapy helps people look more physically like the gender they identify as. Transmasculine individuals will take androgens that will deepen their voice, enhance their muscles, promote body hair, and enlarge their clitoris. Transfeminine people will take estrogen that will redistribute body fat, increase breast tissue, slow the growth of body hair, and lower testosterone. Physical changes, like breast enlargement, may take up to five years.
Sex Reassignment Surgery
Sex reassignment surgery is a procedure by which a transgender person’s physical appearance and functional abilities are changed to those of the gender they identify as. The procedure is now known as gender affirmation surgery because a shift in gender identity prompts transgender people to want such medical procedures.
Gender affirmation refers to an interpersonal, interactive process whereby a person receives social recognition and support for their gender identity and expression.
Many hospitals offer sex reassignment surgery through their department or center for transgender medicine.
Gender-affirming medical procedures include:
- Breast augmentation: Inserts a silicone or saline implant inside or beneath the breast to increase breast size.
- Chest masculinization: Removes breast tissues and contours the chest
- Facial surgery such as facial feminization surgery: Reshapes the nose, brow, forehead, chin, cheek, and jaw. An Adam’s apple can be reduced as well
- Metoidioplasty and Phalloplasty: Forms a penis
- Scrotoplasty: Creates a scrotum
- Vaginoplasty: Uses skin and tissue from a penis to create a vulva and vaginal canal
- Vulvoplasty: Uses skin and tissue from a penis to create all of the outside parts of a vagina, except for the vaginal canal
- Orchiectomy: Removes the testicles
Many insurance plans have removed restrictions that exclude transgender people. Transgender individuals are protected from public and private insurance discrimination under federal and state laws, including Medicare and Medicaid. But some insurance plans still make it hard to get coverage for gender transition-related health care, especially for surgeries.
If a transgender person’s medical treatment for gender transitioning is denied coverage or if their insurance plan has an exclusion for those services, they may need to explain to their insurance company why it is illegal discrimination to exclude medically necessary transition-related care. The National Center for Transgender Equality offers a step-by-step guide to help transgender individuals who wish to pursue transition care get coverage from their insurance providers.
Many transgender people seek therapy, especially in adulthood, to discuss their gender dysphoria and experiences with transphobia, which refers to prejudice against transgender people. Therapy and counseling can be a safe, supportive space for those with gender dysphoria explore and work through their feelings.
The Transgender Institute offers individual and group therapy for transgender youths and adults. It also provides a comprehensive list of and referral letters for transgender-friendly health care providers. Transgender individuals can also find a therapist who specializes in transgender therapy near them through the member directory of the World Professional Association for Transgender Health, which lists mental health professionals by state.
For those who don’t want to do in-person therapy, they can try Pride Counseling, which is a mobile app that connects users to licensed therapists who specialize in LGBTQ counseling. It charges $65 per week for unlimited chat, phone, and/or video therapy. The app is subject to strict local and federal laws, including HIPAA, that protect users’ privacy.
A lack of education, understanding, and compassion in society puts transgender people at risk of harassment and discrimination. Fifty-three percent of transgender people reported being harassed or disrespected in public. They are also more likely to experience harassment at work, bullying at school, homelessness, eviction, issues with health care, incarceration, and violence. In a 2015 survey, 10% of transgender youth revealed that they had been sexually assaulted and 47% were assaulted in their lifetime.
The Trevor Project offers a 24/7 hotline for transgender youths in crisis or in need of a safe space to talk. The Gay & Lesbian Alliance Against Defamation (GLAAD), a national organization that advocates for LGBTQ acceptance, has a comprehensive list of resources for transgender people on its website.
A Word From Verywell
For transgender individuals who are undergoing or are interested in gender transitioning, the process can be complex and overwhelming, but you are not alone. There are many organizations that can help, whether it’s getting insurance coverage for transition care or having someone to talk to about your feelings. Everyone’s transition is different, and there is no right or wrong way to do it.
For those who know someone who is transgender and/or considering transitioning, learning how to be supportive is the best way to be an ally. Educate yourself about gender and gender transitioning. Don’t hesitate to ask what a person’s correct pronouns and chosen name are. It’s an act of respect and everyone deserves to be addressed in the way they choose.