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Transgender

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Trans-rights protestors in front of the Trump White House, 2017.
It's a social construct
Gender
Icon gender.svg
Spectra and binaries
Extremely influential people are spreading these myths and damaging rhetoric — every day you’re seeing our existence debated. Transgender people are so very real.
Elliot PageWikipedia[1]

Transgender, typically shortened to trans, is an umbrella adjective describing people whose gender is other than the one they were declared to be at the time of their birth based on observation of their physical sex characteristics. Under the umbrella are trans men, trans women, and any non-binary people who personally identify with the term. Although frequently tossed into the same category, being transgender is distinct from having any sexual orientation, as transgender people can identify as heterosexual, homosexual, bisexual, asexual, or anything in between. The opposite of transgender is cisgender, someone whose gender identity matches their assigned sex.

The number of transgender people in a population is difficult to pin down due to varying definitions of who counts as transgender, the large variety of questions used to ask about transgender identity, and younger people being more likely to admit to being transgender due to changing societal attitudes.[2] A 2022 study by the Williams Institute based in the UCLA School of Law estimated that about 0.5% of all United States adults, some 1.3 million people, and about 1.4%, or 300,000, of youth between 13- and 17-years-old identify as transgender.[3]

Being transgender comes with a variety of unique life challenges. Transgender people often experience gender dysphoria and thus seek potentially prohibitively expensive and time-consuming treatments such as hormone replacement therapy, gender transition surgery, and therapy.[4] They also frequently face transphobia, discrimination, and physical violence to the point of being over four times more likely to experience violent crimes than cisgender people.[5]

Different types

Transgender is an adjective describing people who identify with a gender different from their assigned sex at birth.[6] This includes genders within and outside the gender binary. 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 it's 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.[7] An individual non-binary person may or may not identify as transgender. Non-binary people may also experience gender dysphoria and 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 the LGBTI+ community); an intersex person, assigned male at birth, who identifies with a third gender may be transgender.

Transitioning

See the main article on this topic: Gender transition

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.[8] Contrary to some claims, puberty blockers are considered safe.[9] Research concerning their effects is limited, and they are not currently approved by the US FDA. [10]

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.[note 1][11] 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.[12]

Biological contributors to gender identity

While gender identity was originally given the tabula rasa approach by the medical professions, evidence has emerged that suggests, at the very least, that for a significant portion of people, it is significantly influenced by biological factors. Much of the scientific community now considers both gender identity and sexual orientation as influenced by genetics and in utero hormonal conditions.[6] Couple this with the non-existent efficacy of conversion therapy, the evidence seems to suggest that this phenomenon is far from a "choice".

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 trans women had longer androgen receptors (which are activated when binding androgens such as DHT or testosterone) at repeat lengths; this is associated with less efficient testosterone signalling.[13][14] The researchers for the 2008 study suggested that this difference may have a direct impact on the formation of gender identity.[15]

A review of the scientific literature on the possible biological origins of individual transgender status was published in Behavior Genetics, a Springer journal, in February 2018. Among other research, it considered twin studies.[16][note 2] The authors suggested that while genetics provide a partial explanation for transgender status, other elements can also be a contributor,[16] 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. Heritability estimates are consistent with other behavioral and personality traits, which generally fall in the range of 30−60%.[16][19]

Keeping in mind, of course, the general limitations to twins studiesWikipedia, and the technical meaning of heritability. The number "30–60%" is being applied to the statistical variance,Wikipedia not the trait itself (this common misinterpretation of heritability estimates often fuels notions of biological determinism).

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 oligogenic component".Wikipedia[20][21]

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.[22][23] The paper represents preliminary evidence, especially compared with other studies mentioned above. Commenting on the study, geneticist Ricki Lewis wrote:[24]

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.

One may notice an underdetermination of mechanism across various research in this regard; notice how none of this research states something as simple as there being a "transgender gene" or that the presence or absence of certain genes directly determines one's status as transgender. All this research suggests is that there is a marked statistical association, that could produce several plausible biochemical mechanisms — all of which could very well lead to the sort of perceptual and psychological experiences many transgender people report. This, of course, doesn't rule out the idea that the category or identity marker of "being transgender" is itself not socially constructed. It is possible that the conceptual category is socially and historically contingent, while the underlying phenomena that the individual experiences themselves are not. This just being another example of the map/territory distinction.

Overall, there is considerable evidence that genetics plays a notable role in gender identity. The body of scientific research examining the matter, however, continues to expand.[6][16] As well, the language used in some of the aforementioned research often conflates having gender dysphoria with being transgender, which are distinct phenomena. Regardless, it is of no controversy to suggest that for many trans people, the experience of gender dysphoria itself is still a causal factor in their decision to identify as transgender. It is just not the case that one has to have gender dysphoria, to be classified as, or to rightfully identify as, being transgender. However, some individuals reject this, even sometimes being transgender themselves (see: transmedicalism for that point of view).

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.
[6]

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).[25] 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.[26][27]

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.[28][29] 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.[28][30]

Brains

Neuroscience studies of trans people increasingly suggest that gender identity is in large part a biological phenomenon, as transgender individuals' brains have key structural differences, even before beginning hormone replacement therapy.[31][32] 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).[33] 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".[34]

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,[35] 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.[36]

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".[34] 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."[37] See also the above excerpt from the 2016 review. By one interpretation, this is consistent with transfeministWikipedia Julia Serano's description that her "brain expects her body to be female." She elaborates on her conception: that we have "subconscious sex and conscious (physical) sex [that] combine to form gender identity — and for the overwhelming majority of us, the two are the same."[38][note 3] Further, a 2019 study demonstrated a potential mechanism by which hormone replacement therapy can increase sense of body self-ownership in transgender people, and reduce anatomical markers for gender dysphoria in the brain.[39]

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 Ehlers-Danlos syndromesWikipedia (a group of connective tissue disorders). The overlap between these does not intrinsically suggest a shared innate root, but it is one possible explanation.

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.[40][41][42]:59

The autistic community and the transgender community also have a significant overlap.[43][44] 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.[45][46] 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.[47][46][48]

There is a suggestion, based on some research, 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."[49] 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."[50]

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.[51][52] 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.[53]

One Nature Reviews Urology paper estimated gender dysphoria incidence in intersex people at 8.5–20%, that being much higher than the general population.[54] 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.[55] Coming from the other direction, a small 2022 survey of KS patients found that they may have a significantly higher gender dysphoria prevalence.[56]

Discrimination

See the main article on this topic: Transphobia

Statistics

As with any other form of discrimination, prejudice against transgender people has a range of forms and levels of severity.

A report by the Williams Institute, published in April 2022, found that transgender college students in the US were significantly more likely (over 33%) to report "bullying, harassment, or assault" against them for their identity, and to report that "lifetime adverse treatment at school impacted their academic success" (about 25%). 32% reported that they had faced unfair treatment by teachers.[57]

The results of the 2015 U.S. Transgender Survey yielded a wealth of statistics on anti-transgender discrimination in the United States. Among other things, it founded that 10% had a family member act violently towards them for being transgender, 54% endured verbal harassment while in K-12 schooling, and 24% endured physical assault while in K-12 schooling. Respondents were more likely to be impoverished or homeless than the general population, with the fact that 8% had been kicked out of the house for being transgender being a probable contributor.[42] 2021 data collected by the United States Census Bureau found higher rates of food insufficiency among transgender people.[58][59]

The Office for Victims of Crime, a subdivision of the US Department of Justice, reported in 2014 that over half of transgender people have experienced at least one instance of sexual abuse or sexual assault.[60] Among transgender or nonbinary youth in particular, a 2019 study (based on 2017 data) found higher rates of sexual assault victimization than either cisgender girls or boys; the study also found an association between anti-trans restrictions on restroom or locker room access and sexual assaults, with that effect being especially pronounced on transgender girls although transgender boys experienced higher sexual assault victimization rates overall.[61] Another study by the Williams Institute, published in 2021, found that transgender people in the US were altogether over four times as likely to be the victim of a crime compared to cisgender people.[5] In England and Wales, too, transgender people are overall twice as likely to be the victim of crimes according to a 2020 report.[62] Another report the same year, by an anti-abuse charity, found that about eighty percent of transgender people in the United Kingdom faced violence, abuse, harassment, or some combination of these, with half reporting specifically anti-trans abuse of such nature.[63][64]

In the United Kingdom, about 34% of employers openly admit they are less likely to hire someone just by virtue of being transgender, according to a 2018 report; this is despite such discrimination being illegal in the UK.[65][66] This is one of the likely discrimination-related contributors to suicidiality across various countries, as lack of employment is associated with higher suicidality even in the general population; according to one study, transgender people were somewhat more likely to be unemployed in Australia as of 2018 (with a 19 percent unemployment rate, versus 5.5 percent in the general Australian population).[67] Similarly, the McKinsey Quarterly reported in 2021 that transgender people in the United States were 27 percent unemployed, versus an 18 percent unemployment rate among cisgender people. They also reported that transgender people who were employed were more likely to work lower wage jobs, such as in the food or retail industries.[68] This is somewhat corroborated by a 2021/2022 Human Rights Campaign study that found something of a wage gap between transgender and cisgender people.[69]

Religious opposition

See the main article on this topic: Transphobia § Among fundamentalist Christians

While some religious interpretations embrace or at least tolerate transgender people, others have a more negative view. The American religious right criticises transgender people regularly, often while remaining willfully ignorant about what being transgender is really like.[70] 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.[71]

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".[72] 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".[71] The Church has been somewhat mixed on the subject however, with for example, Francis writing in one 2024 letter: "Dignitas Infinita … refers not to transgender people but to gender ideology, which nullifies differences. Transgender people must be accepted and integrated into society."[73]

Controversy over access to public toilets

See the main article on this topic: Transphobia and public restrooms
This man was assigned female at birth. According to some people, he should be made to use the women's bathroom.

When a person was assigned one gender at birth but presents as the other, a problem arises about use of public toilets — 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.[74]

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.[75] 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.[76] 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".[77][78]

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[79] and the White House sent a directive to all public schools requiring them to allow transgender students to use toilets matching their gender identity.[80] Eleven US States filed a lawsuit challenging the directive.[81] 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."[82] 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.[83] 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[84][85][86] were made moot in February 2017 when President Donald Trump rescinded the Obama directive, arguing that the matter was not a federal concern.[87]

Legal protections and status

See the main article on this topic: LGBT rights § Transgender rights

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.[88] 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.[89][90] At least two studies suggested that the positive impact on mental health for gender dysphoric people may be significantly greater when they begin to physically gender transition earlier rather than later (assuming that they desired to),[91][92][93] which makes some intrinsic sense given what said condition even entails. Trans people who receive gender-affirming surgery show massively reduced levels of self harm such as smoking and suicidal thoughts.[94] A study of 8000 transgender patients found that only 1% regretted having gender-affirming surgeries.[89][95] One curious finding in some studies is that less exposure to anti-trans discrimination and better access to gender transition care actually results in lower likelihood for eating disorders among transgender people.[96]

Notable transgender people

Days of significance

  • March 31st: International Trans Day of Visibility (TDOV). This day celebrates all trans people, both living and dead.[119]
  • 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.[120]
  • December 28th: Trans Youth Awareness Day. Anniversary of Leelah Alcorn's death.[121]

Gallery

See also

External links

Further reading

Health and medicine

Biology and origins

Historical analyses

Politics and society

Religious views

Notes

  1. The existence of detransitioners has often been weaponized by transphobes. Detransition is a rare occurrence that is presented as if it were much, much more common than it is by some bad actors. However, it is a real thing that should be respected and supported.
  2. Past case reports tended to find that, in identical twin pairings where one sibling was transgender, the other would be as well at markedly higher rates than usual; this did not tend to be the case for non-identical twins.[17][18]
  3. See also: Intrinsic Inclinations Model.

References

  1. Elliot Page Is Ready for This Moment by Katy Steinmetz (March 16, 2021) Time.
  2. Meerwijk, Esther L.; Sevelius, Jae M. (2017). "Transgender Population Size in the United States: a Meta-Regression of Population-Based Probability Samples". American Journal of Public Health (American Public Health Association) 107 (2): e1–e8. doiWikipedia:10.2105/ajph.2016.303578. ISSN 0090-0036. 
  3. Allen, Jonathan (2022-06-10). "New study estimates 1.6 million in U.S. identify as transgender". 
  4. Maizes, Victoria; Low Dog, Tieraona (19 November 2015). Integrative Women's Health. Oxford University Press. p. 745. ISBN 978-0190214807. "Many transgender people experience gender dysphoriaTemplate:Snddistress that results from the discordance of biological sex and experienced gender. Treatment for gender dysphoria, considered to be highly effective, includes physical, medical, and/or surgical treatments [...] some [transgender people] may not choose to transition at all." 
  5. 5.0 5.1 "Transgender people over four times more likely than cisgender people to be victims of violent crime". 2022-12-21. 
  6. 6.0 6.1 6.2 6.3 Fisher, Alessandra Daphne; Cocchetti, Carlotta (2020-01-01). Legato, Marianne J.. ed (in en). The Plasticity of Sex. Chapter 8: Biological basis of gender identity. Academic Press (Elsevier). pp. 89–107. ISBN 978-0-12-815968-2. Retrieved 2023-03-31. 
  7. Are Non-Binary People Trans?. Duncan, Tracey Anne. Mic. October 26, 2021.
  8. Puberty blockers for transgender and gender-diverse youth. Mayo Clinic, 14 June 2023.
  9. Are Puberty Blockers Permanent? What You Should Know Before Treatment. Healthline, 25 April 2023.
  10. As more transgender children seek medical care, families confront many unknowns. Reuters, 6 Oct. 2022.
  11. An “Ex-Detransitioner” Disavows the Anti-Trans Movement She Helped Spark Urquhart, Evan. Slate, 1 Feb. 2021.
  12. Open access journal article Turban, Jack L.; Loo, Stephanie S.; Almazan, Anthony N.; Keuroghlian, Alex S. (2021-06-01). "Factors Leading to 'Detransition' Among Transgender and Gender Diverse People in the United States: A Mixed-Methods Analysis". LGBT Health 8 (4): 273–280. doiWikipedia:10.1089/lgbt.2020.0437. ISSN 2325-8292. PMID 33794108. 
  13. Open access journal article Hare L, Bernard P, Sánchez FJ, Baird PN, Vilain E, Kennedy T, Harley VR (January 2009). Society of Biological Psychiatry. "Androgen receptor repeat length polymorphism associated with male-to-female transsexualism". Biological Psychiatry (Elsevier) 65 (1): 93–6. doiWikipedia:10.1016/j.biopsych.2008.08.033. PMID 18962445. 
  14. (October 26, 2008). "Transsexual gene link identified". BBC News.
  15. Helen Carter (October 27, 2008). "Transsexual study reveals genetic link". ABC Science.
  16. 16.0 16.1 16.2 16.3 Open access journal article Polderman et al. (February 2018). International Gender Diversity Genomics Consortium. "The Biological Contributions to Gender Identity and Gender Diversity: Bringing Data to the Table". Behavior Genetics (Springer) 48: 95–108. doiWikipedia:10.1007/s10519-018-9889-z. PMID 29460079. 
  17. Heylens, Gunter; De Cuypere, Griet; Zucker, Kenneth J.; Schelfaut, Cleo; Elaut, Els; Vanden Bossche, Heidi; De Baere, Elfride; T'Sjoen, Guy (2012). "Gender identity disorder in twins: a review of the case report literature". The Journal of Sexual Medicine 9 (3): 751–757. doiWikipedia:10.1111/j.1743-6109.2011.02567.x. ISSN 1743-6109. PMID 22146048. 
  18. Diamond, Milton (2013). "Transsexuality Among Twins: Identity Concordance, Transition, Rearing, and Orientation" (in en). International Journal of Transgenderism 14 (1): 24–38. doiWikipedia:10.1080/15532739.2013.750222. ISSN 1553-2739. 
  19. Elyas Arvell (credited as Elysa Carr) (December 8, 2019). "Irresponsible scientific research and media portrayals are hurting trans people. Do better". Massive Science.
  20. Open access journal article Foreman et al. (September 2018). Oxford Academic. "Genetic Link Between Gender Dysphoria and Sex Hormone Signaling". The Journal of Clinical Endocrinology & Metabolism (The Endocrine Society) 104 (2): 390–396. doiWikipedia:10.1210/jc.2018-01105. PMID 30247609. 
  21. (October 3, 2018). "Written in DNA—study reveals potential biological basis for transgender". Hudson Institute of Medical Research.
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  47. Bertelli, Marco O.; Azeem, Muhammad Waqar; Underwood, Lisa; Scattoni, Maria Luisa; Persico, Antonio M.; Ricciardello, Arianna; Sappok, Tanja; Bergmann, Thomas et al. (2022). Bertelli, Marco O.; Deb, Shoumitro (Shoumi); Munir, Kerim et al.. eds (in en). Autism Spectrum Disorder. Cham: Springer International Publishing. pp. 391. doiWikipedia:10.1007/978-3-319-95720-3_16. ISBN 978-3-319-95720-3. Retrieved 2022-06-08. "Persons with [autism spectrum disorder] and/or other neurodevelopmental problems are more likely than the general population to have transgender identity, non-heterosexual sexual orientation, and other gender non-conformities." 
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  49. Open access journal article Najafian, Alireza; Cylinder, Isabel; Jedrzejewski, Breanna; Sineath, Craig; Sikora, Zbigniew; Martin, Leigh H.; Dugi, Daniel; Dy, Geolani W. et al. (2022-05-13). "Ehlers-Danlos syndrome: prevalence and outcomes in gender affirming surgery - a single institution experience" (in en). Plastic and Aesthetic Research 9 (5): 35. doiWikipedia:10.20517/2347-9264.2021.89. ISSN 2347-9264. 
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  76. Target takes stand on transgender bathroom controversy Robert Mclean in CNN Money, 20 April 2016. The statement read We welcome transgender team members and guests to use the restroom or fitting room facility that corresponds with their gender identity.
  77. New York College Decides To Make ALL Bathrooms Gender-Neutral Blake Neff in Daily Caller, 1 April 2016
  78. No More Men's or Women's Rooms Josh Logue in Inside Higher Ed, 31 March 2016. "I cannot change the outside world and how it treats transgender and gender-nonconforming people, but I can change the Cooper Union environment to help everyone feel safe when they are inside our buildings." (said Bill Mea, Acting President)
  79. Justice Department says North Carolina anti-LGBT law violates Civil Rights Act Matthew Teague in The Guardian, 4 May 2016
  80. U.S. Directs Public Schools to Allow Transgender Access to Restrooms Julie Herschfeld and Matt Apuzzo in New York Times, 12 May 2016. The directive was not legally binding, but it included an implied penalty for non-compliance in terms of reduced or terminated federal subsidies. The State of Texas stands to lose $10 billion.
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  82. Texas poised to be the next bathroom battleground in transgender fight Tom Dart in The Guardian, 18 May 2016
  83. Some in Oklahoma statehouse urge Obama impeachment over bathroom rule --Heide Brandes in Reuter's, 20 May 2016 (retrieved 23 May)
  84. Forth Worth judge blocks Obama transgender guidelines --Texas Tribune , WFAA 8:43 AM. CDT August 22, 2016
  85. Supreme Court to hear transgender school bathroom case --BBC News, 28 October 2016
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  87. Trump Rescinds Rules on Bathrooms for Transgender Students --New York Times, 22 February 2017
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  100. "I just want you all to know that I am a transsexual man who transitioned 23 years ago. This is not a representation of us all. Many of us transsexuals are also appalled and upset at the hate and anger coming from transgender agenda. It saddens us😢❤️". Archived from Buck Angel on Twitter. (Original link).
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