The Human Rights Campaign estimates that over two million people make up the transgender community across the United States, and three out of ten people know someone transgender. The transgender experience has a complexity that spills into many aspects of a person’s life, including how they view themselves and the world. In this feature article, I aim to separate the varying layers that come with this experience to provide better understanding and appreciation.
Gender Identity: What does it mean?
To understand the experience of being transgender, let’s first iron out a few terms. When we refer to gender identity, we are referencing the internal experience of gender, which goes further than man or woman; gender identity also includes agender, nonbinary, genderqueer, and other identities. Those who are cisgender identify with the gender assigned to them at birth. Nonbinary does not fit under the label of male or female and typically indicates that they fall in between the two binary genders or entirely outside of those lines. Gender expression refers to how a person demonstrates their gender; this could be in dress styles, behavior, mannerisms, and more.
Transgender is an umbrella phrase used to describe people who identify themselves differently than their birth sex by a doctor based on the body’s appearance. Despite some misconceptions, transgender is not used to describe sexual orientation (who you find attractive) but how you feel on the inside.
When discussing a transgender experience, we cannot leave out the biology and psychology that play a pivotal role in a person’s ability to find peace and acceptance in their identity.
Gender identity development is present as early as the age of two years old, and many transgender individuals recall feeling a sense of disconnect between how they felt and what they saw in the mirror. This feeling can be challenging to navigate; how they process this disconnect can be severely impacted by the level of acceptance in their support systems and how they can or cannot express themselves. Transgender individuals often face several other mental health challenges, such as depression, anxiety, and suicidality, due to the fear of being stigmatized or rejected.
For transgender individuals, Gender Dysphoria plays a significant role in their decision to transition. Gender dysphoria is a DSM V Psychological Diagnosis referring to the distress a person feels from the juxtaposition of their assigned sex and their gender identity. This process often begins in childhood but can also present later in life. The criteria vary within different age groups and are differentiated below:
In children, the criteria of incongruence in gender must be present for six months and must be associated with impairment of social functioning and distress:
- The insistence that they are the other gender or a strong desire to be an alternative to their assigned gender.
- Preference for cross-dressing to the attire of a gender different than assigned.
- Preference for cross-gendered roles in make-believe play and toy games and activities targeted to the opposite gender and rejection of toys targeted to the assigned gender.
- Strong preference for playmates of the other gender.
- Strong desire to match the experienced gender’s primary and secondary sex characteristics.
- Rejection or dislike of one’s sexual anatomy.
In adolescents and adults:
- Desire to change or prevent primary and secondary sex characteristics due to the incongruence between assigned and experienced gender.
- Longing for the primary and secondary attributes of the other gender.
- Desire to be treated as the desired gender.
- Possessing typical feelings and reactions of the gender outside the assigned gender.
Why is this label important?
For clients under eighteen, parental consent is required to receive gender-affirming care, and age requirements can vary depending on the state. Many insurance companies will not cover gender-affirming healthcare without a formal diagnosis of gender dysphoria by a medical/mental health professional.
While several treatments are used to make physical changes to adapt to a person’s gender identity, it is crucial to recognize that this is not the only method used to affirm gender identity. While some explore some additional surgeries and hormone therapies, treatment begins with the open-ended exploration and expression of gender identity. Some techniques can include adopting new pronouns or names that match their identity. Additional gender affirmations also have the legal assurance of changing the name and gender markers on government identification.
As one explores this, it is often helpful to work with a therapist to understand any learned biases or fears and to process how the person felt to express themselves freely. It is also vital that the therapist has no preconceived notions or outcomes defined around which gender the person explores.
IMPORTANT: Methods to force a person to conform to cisgender expression, also commonly referred to as gender identity conversion, are unethical and can cause severely adverse outcomes in the person’s mental health. Societal and family rejection significantly impact the mental health of a transgender person. We will address methods to support a loved one who is transgender in the social factor section of this blog.
One common form of gender-affirming care is hormone replacement therapy (HRT). This type of care includes using hormones to produce physical changes to the body that typically happen during puberty. In feminizing hormone therapy, estrogen provides secondary sex characteristics such as breasts, and additional medication blocks testosterone production. In masculinizing hormone therapy, testosterone stops the menstrual cycle and slows the ovary’s ability to produce estrogen. Testosterone also allows secondary sex characteristics such as facial and body hair and shoulders broadening. Each of these can be done independently or with additional gender-affirming surgeries. HRT is crucial in the biological transition process, impacting physical appearance, voice, and overall well-being. However, it also brings its own set of challenges, including medical supervision and potential health risks.
Gender Affirming Surgeries
Gender-affirming surgeries, also known as (GAS) are used in those looking to pursue their gender identity further than that of just hormone replacement therapy. The Center for Transgender Medicine and Surgery has a wide range of services targeting different body areas, from the face to the genitalia.
Feminizing surgical procedures include:
- Breast augmentation– a fairly common technique used to insert breast implants.
- Facial feminization surgery– includes reshaping of different areas of the face, including the jawline, chin, nose, brow bone, and hairline changes.
- Orchiectomy- Involves removal of the testicles in hopes of eliminating testosterone production.
- Tracheal Shave-removal of cartlidge on the thyroid that is responsible for the protrusion of the Adam’s apple
- Vaginoplasty-creating a vagina using the existing genital tissue. It requires a stay in the hospital and aftercare with a recovery time of approximately three months.
- Voice feminization surgery- shortens the vocal cords to produce a higher pitch. It is required to have vocal coaching and speech therapy before surgery.
Masculinization surgeries include:
- Chest Masculinization- removal of the mammary and fat tissue in the chest to create a more masculine appearance; most can resume regular activity after three months.
- Metoidioplasty- procedure releasing the ligament that holds the clitoris in place to create a penis-like structure with the ability to erect. Some methods can also include the creation of a scrotum with testicular implants. Recovery can take up to eight weeks.
- Phalloplasty- a procedure used to make a penis out of skin elsewhere on the body and can also include closing the vaginal opening and lengthening the urethra. Multiple techniques are typically required.
- Hysterectomy- removal of the uterus and ovaries with a recovery of up to four weeks.
While requirements can vary based on state and legislation, some prerequisites are described by Mt. Sinai in New York City, a hospital informed by the World Professional Association of Transgender Health (WPATH) and the Endocrine Society.
- Any prospective surgery candidates will require an evaluation to ensure they are medically healthy enough to undergo this procedure.
- Candidates will verify their insurance and become informed over a few weeks, including the insurance company’s requirements to qualify for coverage.
- Requirements typically include recommendation letters from a health care provider, including social workers, primary care providers, mental health professionals, or psychiatrists who work with transgender care. Typically, a separate letter is required for each procedure (e.g., face, chest, and genitals) and must verify the presence of gender dysphoria.
- Meetings begin with the surgeon as the person discusses goals and plans for surgery outcomes, risks, and recovery.
- Post-operative care, including mental health, is planned during this preparation, as recovery and processing can take time.
Social Factors and Challenges in the transgender community
Sharing the experience of being transgender can influence how a person can connect with their peers. According to studies conducted by Pew Research, how much a person shares about their gender can be a bit of a gamble and leave them feeling like they are taking a risk; this can be in terms of safety and acceptance and vary depending on whether the person is “passing” as one of the binary genders. This experience differs for everyone as some welcome questions and conversations, while others find it draining.
Language and Pronouns
Terms are regularly changing as we become more informed over time. It is essential to address language as it can play a significant role in a person feeling seen, understood, and respected. When speaking to someone who isn’t cisgender, be mindful and willing to listen and ask questions such as “What are your name and pronouns?” Terms may change over time as a person learns more about themselves. Be aware that misgendering or calling someone by their dead name can be harmful and embarrassing for the person. Here are some tips when you are in a situation where you are unsure of a person’s pronouns:
- Ask, don’t assume.
- If you make a mistake and misgender someone or use the wrong name, apologize, correct, and do better next time. Don’t make excuses, and don’t make it about your guilt.
Stigma, Discrimination, and Violence
While we have seen increased representation in the media and pop culture, transgender individuals still face stigmas such as being socially deviant, sexually predatory, and mentally ill. These nonaccepting views have emerged in public policy and politics that attempt to ban others from learning about trans communities. The Human Rights campaign also cites that the transgender community has higher rates of violence against them than the average person.
Such intolerance exists in education, employment, housing, and especially gender-affirming health care. Transgender patients often inform their providers and teach them if the opportunity allows.
Tips to be a support to a loved one who is exploring gender identity or is transgender
- Believe them: There are challenges around them and fear of rejection. Be someone who understands who they are.
- Start Learning: You need to be someone other than an expert to be supportive. Several LGBTQIA communities can provide psychoeducation, answer your questions, and help you understand some of the challenges they may face.
- Know what questions to ask and what to say- Coming out can be a lengthy process; some good considerations are:
- What their pronouns are
- If they want you to share this information
- If they wish to have others corrected if they say the wrong pronoun
- Let them know that you appreciate them trusting you
- Support Groups– Many support groups are available to you as a loved one to help you relate to other family members in your positions and help you process the change your loved one is experiencing.
- Don’t over apologize- As you understand your loved one’s identity, you will likely make mistakes. It is like learning a new language: you will only get it right sometimes. You do not need to create a scene to correct your mistake; that makes it about you. Correct yourself and work on it.
- Practice makes perfect!
A transgender experience is layered and complex, with several important considerations that impact how they feel seen in the world. Understanding the biological, psychological, and social factors influencing this community is vital to creating a more inclusive and empathetic society. It highlights the need for comprehensive healthcare, mental health support, and anti-discrimination measures to improve the lives of transgender individuals. By recognizing and addressing these factors, we can work towards a more equitable world where everyone can live authentically without fear of prejudice or discrimination. The terms, phrases, and information on this topic are growing, so always be open to learning additional perspectives.