Transgender

Every day you're seeing our existence debated. Transgender people are so very real. Transgender is an umbrella adjective describing people whose gender is other than the one they were declared to be at the time of their birth. Under the umbrella are trans men, trans women, and non-binary people.

Different types
To be absolutely precise, transgender is an adjective describing people who identify with a gender different from their assigned sex at birth. This includes genders within and outside the gender binary, in roughly equal proportions. In the past, transsexual was an adjective generally reserved for people who have physically transitioned to living with a different gender & sex than was assumed at birth, or who desire to do so. However, it is considered outdated and offensive by most trans people due to its dehumanising usage and how its often exclusionary (to non-op people). Almost everyone just uses the word transgender nowadays, and it is what people should use for trans people unless told otherwise by them. Crossdressers are not trans because they do not consider themselves a gender different to that assigned at birth, they just enjoy presenting as one.

Transgender people can be of any sexual orientation. A trans person can identify as straight, gay, bisexual, asexual, or anything.

While non-binary people do not identify as the gender they were assigned at birth, there is no consensus on whether or not non-binary people are ipso facto transgender. An individual non-binary person may or may not identify as transgender. Non-binary people may also experience gender dysphoria and even undergo medical transition.

Intersexuality, like sexual orientation, is also a concept related to, but independent of, transgender identity. An intersex person, assigned female at birth, who remains within the female gender role and identifies as female is cisgender (but is still considered a member of LGBTI+ community); an intersex person, assigned male at birth, who identifies with a third gender may be transgender.

Transitioning
Transitioning is the modification of one's body and/or social role to better represent one's gender identity. Medically speaking, trans people may take hormones, undergo genital/facial reconstruction, and opt for cosmetic procedures to correct their primary and secondary sex characteristics. This is sometimes more precisely referred to as medical transition or physical transition. Hormone replacement therapy (HRT) is one of the most common medical transitions for trans people. The goal of HRT is for the change in hormones to produce a change in secondary sex characteristics. Transfeminine people transitioning may take estrogen, progestogen, or antiandrogens, while transmasculine people transitioning may take androgens, particularly testosterone. A transitioning person may also take a gonadotropin-releasing hormone (GnRH) modulator. Young people who have not completed puberty yet may take puberty blockers, which postpone the puberty process, in hopes of giving them the opportunity to explore their identity further. Contrary to some claims, puberty blockers are considered completely safe.

Genital reconstruction, also known as gender confirmation surgery or gender reassignment surgery, was pioneered in the early 20th century. It is colloquially called "bottom surgery", as it concerns the bottom half of the body. The construction of a neovagina is called vaginoplasty, while the construction of a penis is called phalloplasty. Many transmasculine people seek to get a mastectomy (the removal of breasts), which is often called "top surgery".

Not all trans people want to undergo all procedures. A "non-op" trans person is a person who chooses not to undergo these kinds of surgeries. This is distinct from "pre-op", which generally describes a trans person who intends to seek such procedures in the future. Non-op trans people often still take hormones, because their secondary sex characteristics may be the source of dysphoria. For example, transmasculine people can opt to wear a binder (a garment that hides the breasts), and transfeminine people can wear breast forms. This may come regardless of when or if medical transition is sought.

Trans people typically also socially transition. Social transitioning is the process of transitioning in public and personal life. This may include changing their clothes, makeup, or hair, or using different names or pronouns. Some trans people change their name or seek to change the gender that appears on legal documents. It is considered extremely offensive to misgender a transgender person, which is to refer to them by the wrong pronouns or gender. It is also extremely offensive to deadname a transgender person, which is to refer to them by a pre-transition name they no longer use.

On the chance that someone who is transitioning decides that they don't want to transition at a given time, they may choose to detransition. Detransition usually sees the person stopping medical and social transitions, and may involve efforts to reverse the effects of medical transition. This may be caused by a range of factors, such as external pressure from family, the experience of transphobia, or further exploration and/or change of their gender identity.

As an inborn characteristic
While gender identity was originally given the tabula rasa approach by the medical professions, evidence has emerged in recent decades that it is, at the very least in significant portion and for many people, an inborn trait. Much of the scientific community now considers that both gender identity and sexual orientation are influenced by genetics and in utero hormonal conditions.

Genetics
A decently sampled 2008 study in Biological Psychiatry (an Elsevier journal published on behalf of the Society of Biological Psychiatry) analyzed the genes of transgender women (who were usually already in the process of gender transition), as compared to cisgender men. This study found that the trans women had longer androgen receptor (which are activated when binding androgens such as DHT or testosterone) repeat lengths; this is associated with less efficient testosterone signalling. The researchers for the 2008 study suggested that this difference may have a direct impact on the formation of gender identity.

A review of the scientific literature on biological origins of transgender status was published in Behavior Genetics, a Springer journal, in February 2018. Among other research, it considered twin studies. The authors suggested that while genetics provide a partial explanation for transgender status, other elements can also be a contributor, writing in their conclusion: This review of existing family and twin studies summarizes significant and consistent evidence for the role of innate genetic factors in the development of both cisgender and transgender identities, a negligible role for shared environmental factors, and a small potential role for unique environmental factors.

Commenting on the paper, neuroscience and genetics researcher Elyas Arvell wrote for Massive Science:

While heritability estimates varied widely between studies and age-groups, the review concluded that heritability of gender identity is comparable to other behavioral and personality traits, generally between 30% and 60%. This means that differences in gender identity can be explained at least partly, but not completely, by genetic differences. Some of the remaining variation can be attributed to unique environmental factors, like life experiences that differ from person to person.

One multicenter study with decent sample sizes, published in September 2018 by The Journal of Clinical Endocrinology and Metabolism (which is, in turn, published by the Endocrine Society), examined the associations between genetics (specifically, genes that deal with processing for sex hormones like estrogen and testosterone) and gender dysphoria. It found that certain alleles and genotypes were significantly over-represented in trans women with gender dysphoria, when compared to cisgender men. The authors concluded that gender dysphoria therefore "may have an

A small study, published in 2019 by Scientific Reports (a Nature journal), found through DNA analysis that 21 very rare variants in 19 genes in estrogen signaling pathways of the brain were present in transgender individuals with gender dysphoria. The paper represents preliminary evidence, especially compared with other studies mentioned above. Commenting on the study, geneticist Ricki Lewis wrote:

Would the selected rare gene variants show up among the participants, and if so, would that trend persist in a much larger group? Then those variants might be associated with some aspects of transgender identity. But it's a long way from association to correlation to causation. Some comments from readers of the Times piece [about the study] pointed out the small sample, but conducting a pilot study is how science works. Funding agencies aren't about to fork over the pounds or dollars for a large-scale investigation without a preliminary look-see.

Overall, there is considerable evidence that gender identity has a significant genetic component for many transgender people. The body of scientific research examining the matter, however, continues to expand.

Hormones
[One] theory regarding the biological basis of gender dysphoria is based on the fact that differentiation of the genitals and sexual differentiation of the brain take place in different periods of pregnancy. In fact, there are two critical periods in human development characterized by higher levels of testosterone in boys than in girls: midpregnancy and the first 3 months after birth. These peaks of testosterone, together with functional changes in steroid receptors, may be involved in the permanent programming and organization structures and circuits in a boy's brain. The sexual determination of the gonads and the formation of external genitalia take place months before the sexual differentiation of the brain in midpregnancy; the two processes might be quite independent from one another.

Prenatal diethylstilbestrol (DES) exposure might influence the formation of a transgender identity. DES is essentially a synthetic super-estrogen that many pregnant American mothers were prescribed throughout a considerable swath of the 20th century under the premise that it could reduce pregnancy complications (e.g. miscarriages and premature births). As it turns out, this can affect the child, and it is only rarely prescribed in recent decades. One early 2000s survey found that "DES sons" (people assigned male at birth, whose mothers took DES while they were in the womb) were significantly more likely to be transgender, gay, or intersex, relative to the general population.

Some research has suggested that transgender men are more likely — even if they have never undergone physical gender transition before — to have polycystic ovary syndrome (PCOS), a hormone condition, compared to the general population. While PCOS is typically quite distressing for cis women (it can, e.g., cause them to grow facial hair or experience reproductive problems), certain aspects of it can actually reduce gender dysphoria (or in fact even generate gender euphoria) for trans men.

Brains
Neuroscience studies of trans people increasingly suggest that gender identity is a biological phenomenon rather than a purely psychological one, as transgender individuals' brains have key structural differences, even before beginning hormone replacement therapy. Indeed, hormone therapy could have otherwise represented a confounding factor, and so, many transgender brain studies specifically recruit those who haven't begun receiving HRT (except studies specifically examining the effects of HRT on the brain). More precisely, tensor imaging studies suggest that while much of the brain structure of a transgender person matches their "biological sex", certain sections of the transgender brain may contain elements that are closer to the "biologically opposite sex".

As for what causes this? Scientists don't have a clear consensus, but the prevailing theory is that during development, a number of extremely complex systems are at play as the fetus grows, and something interferes with the whole process. Genes play a role, but only in the chance of developing along certain paths rather than defining those paths. Just as residual testosterone in the mother's womb appears to alter a developing fetus's future sexuality, various health conditions of the mother can impact the chance of a fetus developing a different brain structure. What's more, it appears that endocrine disrupting chemicals such as BPA (which is found everywhere these days) cause the "feminization" of male fetal brains. It's not unlikely that the rates of gender dysphoria have actually increased in recent years rather than just becoming more visible, due to our obsession with plastics and herbicides.

A 2016 review found that: "Untreated MtFs and FtMs who have an early onset of their gender dysphoria and are sexually oriented to persons of their natal sex show a distinctive brain morphology, reflecting a brain phenotype. These phenotypes are different from those of heterosexual males or females; the differences affect the right hemisphere and cortical structures underlying body perception." This is separate from the effects on brain chemistry of treatment with sex hormones, which causes "dramatic effects on the gray and white matter after short- to medium-term treatments but the long-term effects on the brain require evaluation". This indicates a biological basis without anything as reductive as having a male brain in a female body.

Homosexuality has also been associated with sex-atypical brain structures, so how does that factor into this? One 2017 paper in Scientific Reports offers some distinction. The authors wrote: "Our findings suggest that the neuroanatomical signature of transgenderism is related to brain areas processing the perception of self and body ownership, whereas homosexuality seems to be associated with less cerebral sexual differentiation." See also the above excerpt from the 2016 review.

Other traits
A number of other characteristics with a probable or certain inborn component are also associated with gender dysphoria and/or transgender identity, in some way or another. These include non-heterosexuality, autism, intersex conditions, and even (a group of connective tissue disorders).

Large surveys of transgender people in the United States have shown that they are significantly more likely to have a non-heterosexual sexual identity (lesbian, gay, bisexual, asexual, pansexual, queer, etc.) than the baseline. This holds true regardless of whether you interpret their answers based on their assigned sex at birth or their gender identity.

The autistic community and the transgender community also have a significant overlap. The cause for this overlap with autism isn't certain; one proposal is that it's an outgrowth of autistic resistance to identity restrictive social norms; if true, the actual transgender population may be undercounted. Cisgender non-heterosexuals also have overlap with the autistic community (and this constitutes multiple overlapping traits), and could also be undercounted if that theory is true.

An emerging body of evidence suggests that transgender people are more likely to have Ehlers-Danlos syndromes (EDS). This can cause complications for those seeking gender transition surgeries. A May 2022 study published in Plastic and Aesthetic Research examined the prevalence of these syndromes in patients seeking such surgeries. The authors concluded that the prevalence of EDS in their patient population was 2.6%, being "132 times the highest reported prevalence in the general population." Another 2022 paper, in SAGE Open Medicine, reported that of "the 166 total adolescents seen in [a] pediatric multidisciplinary Ehlers–Danlos Syndrome clinic during the study period, 17% reported gender dysphoria."

Two practitioners in transgender medicine (a general physician and a surgeon) have discussed their observations regarding a statistically significant EDS-transgender link within their patient communities. EDS patients are also more than seven times as likely as the general population to be autistic, according to a 2016 BMC Psychiatry paper, suggesting another set of multiple overlapping traits.

One Nature Reviews Urology paper estimated gender dysphoria incidence in intersex people at 8.5–20%, that being much higher than the general population. A 2022 paper suggested that Klinefelter syndrome (KS or XXY) may be several times more common among transgender women compared to the general population, though this study was limited by the fact that KS is generally under-diagnosed. Coming from the other direction, a small 2022 survey of KS patients found that they may have a significantly higher gender dysphoria prevalence.

Religious criticism
The American Religious right criticises transgender people regularly, often while remaining willfully ignorant about what being transgender is really like. The basic idea is that God has personally assigned everyone's sex (and with it their gender), and deviating from that is against God's plan. Thankfully, far from all Christians follow this restrictive teaching, and many more liberal Christian groups accept and welcome transgender people as the gender they are.

Unhappiness suffered by people under religious pressure to conform to a gender they feel does not suit them is typically either ignored or seen as a result of fallen human nature.

Pope Francis has criticised transgender people, claiming that being transgender "goes against God" and that increasing social acceptance of transgender people "negates traditional God-given values". On the related topic of transgender people, Roman Catholic archbishop of San Francisco, Salvatore Cordileone, also criticised Caitlyn Jenner's gender reassignment, motivating this with the tautological truth that "people are born either male or female".

Controversy over access to public toilets


When a person was assigned one gender at birth but presents as the other, a problem arises about use of public toilets &mdash; or what Americans unaccountably call bathrooms despite the universal lack of a bath in such facilities.

Some men protest that they don't want women dressed like men peeing alongside them in their toilets, ignoring the fact that such people, many of whom do not have the right equipment (many trans men do not undergo genital surgery, as the process is long and the results often unsatisfactory), and would not necessarily use urinals anyway but (and certainly already do) pee in private stalls. However, some trans men do use devices known as packers, which simulate a penis.

Women protesting the converse have a similar position, in that men posing as women could have sinister, exploitative or even illegal reasons for gaining access to toilets labeled Women. However, legislation is probably not a strong deterrent in this case.

Oddly, neither group complains about gay or bi men/women using the same facilities as them. This is a source of great puzzlement to trans people.

In the USA, state laws have been notably divided on the issue. Several states mandate that people must use the facilities that match the gender on their birth certificates. The standard-bearer for this extreme point of view is the State of North Carolina, which passed a so-called "bathroom bill" in March 2016, in a whirlwind legislative session that saw Democrats walking out in protest. At the other extreme, the megastore Target created a furor in April 2016 by declaring that its customers could freely choose which toilet to use. The Cooper Union, a small New York City university, also took an extreme position in the same month by removing all gender-specific signs from its toilets. The facilities that were formerly "Men's" were changed to “urinals and stalls", while former women’s rooms now carry the label "stalls only".

Coming as it did in the midst of an unusually contentious election primary season, this issue attained political "hot button" status very rapidly. There is no federal law on the issue, but in May 2016 the Justice Department declared that North Carolina's "bathroom bill" violates Title VII of the Civil Rights Act of 1964 and the White House sent a directive to all public schools requiring them to allow transgender students to use toilets matching their gender identity. Eleven US States filed a lawsuit challenging the directive. On 18 May, a declared "International Day against Homophobia and Transphobia", the governor of Texas, Greg Abbott, loudly dissented and signaled that his state will be the next North Carolina. Abbott tweeted "JFK wanted to send a man to the moon. Obama wants to send a man to the women's restroom." At the GOP's state convention, he added, "I want you to know, I am working with the governor of North Carolina, and we are going to fight back." In a further development, on 20 May, a bill was introduced in the Oklahoma State Legislature urging the state's congressional delegation to start an effort to impeach President Barack Obama over the issue. There was no official reaction from the White House, but pedestrians on Pennsylvania Avenue later that day could have sworn they heard laughter coming from the Oval Office.

Several further legal maneuvers  were made moot in February 2017 when President Donald Trump rescinded the Obama directive, arguing that the matter was not a federal concern.

Legal protections and status
Legal protections for trans people are controversial and depend on the area. In the US, 30 states still allow businesses to fire or evict people because of their gender identity. 31 states allow businesses to refuse service to trans people. 37 states still allow trans people to be denied credit. All 50 states allow name changes for trans people, as well as gender changes on driver's license. However, the requirements for a gender change depend on the state. Some may require sex reassignment surgery, while others only require a doctor's or psychologist's note. Some states even require a medical note for a name change.

Health issues
A Dutch study of 1100 young people found that transgender youth who received gender-affirming puberty blockers were significantly less likely to have emotional problems and suicidal thoughts than those who did not receive puberty blockers. The trans youth who received puberty blockers were similar to cisgender youth as far as mental health. Trans people who receive gender-affirming surgery show massively reduced levels of self harm such as smoking and suicidal thoughts. A study of 8000 transgender patients found that only 1% regretted having gender-affirming surgeries.

Notable transgender people
• 3

Days of significance

 * November 20th: Trans Day of Remembrance (TDOR). The day was dedicated in 1999 in honor of a trans woman named Rita Hester, who was murdered that day. It serves to commemorate the transgender people who are lost every year to murder and suicide.  The seven days before the event are Transgender Awareness Week.
 * March 31st: International Trans Day of Visibility (TDOV). This day celebrates all trans people, both living and dead.
 * December 28th: Trans Youth Awareness Day. Anniversary of Leelah Alcorn's death.

Health and medicine

 * Nguyen et al. (2018). "Gender-Affirming Hormone Use in Transgender Individuals: Impact on Behavioral Health and Cognition". Current Psychiatry Reports.
 * Bränström and Pachankis (2019). "Reduction in Mental Health Treatment Utilization Among Transgender Individuals After Gender-Affirming Surgeries: A Total Population Study". The American Journal of Psychiatry. American Psychiatric Association.
 * Turban et al. (2020). "Association Between Recalled Exposure to Gender Identity Conversion Efforts and Psychological Distress and Suicide Attempts Among Transgender Adults". JAMA Psychiatry.
 * Jackson et al. (2023). "Analysis of Mortality Among Transgender and Gender Diverse Adults in England". JAMA Network Open.

Biology and origins

 * Saraswat et al. (2015). "Review: Evidence supporting the biologic nature of gender identity". Endocrine Practice. The American Association of Clinical Endocrinologists and American College of Endocrinology.
 * Jenny Graves (2019). "How genes and evolution shape gender – and transgender – identity ". The Conversation.
 * Swaab et al. (2021). "Sexual differentiation of the human hypothalamus: Relationship to gender identity and sexual orientation". Handbook of Clinical Neurology, volume 181, chapter 31, pages 427-443.

Historical analyses

 * Robert Beachy (2014). "Gay Berlin: Birthplace of a Modern Identity". Vintage Books. Penguin Random House.
 * Susan Stryker (2017) "Transgender History: the Roots of Today's Revolution", 2nd edition. Seal Press.

Politics and society

 * Edward Schiappa (2021). "The Transgender Exigency: Defining Sex and Gender in the 21st Century". Routledge.
 * (2021). "Transgender Women Athletes and Elite Sport: A Scientific Review". Canadian Centre for Ethics in Sport.
 * Jack Turban (2021) "Trans Girls Belong on Girls' Sports Teams". Scientific American.

Religious views

 * "Resources: Faith Positions". Human Rights Campaign (HRC Foundation).
 * Zaharin and Pallotta-Chiarolli (2020) "Countering Islamic conservatism on being transgender: Clarifying Tantawi's and Khomeini's fatwas from the progressive Muslim standpoint". The International Journal of Transgender Health.
 * Ray Buckner (2022). "Many Paths to Freedom: Transgender Buddhism in the United States". The Revealer.
 * Jue Liang (2022) "Traditional Buddhist teachings exclude LGBTQ people from monastic life, but change is coming slowly". The Conversation.